The 7th Edition AJCC Staging System for Eye Cancer: An International Language for Ophthalmic Oncology

The Ophthalmic Oncology Task Force1 has significantly changed the American Joint Committee on Cancer (AJCC) staging system for eye cancer. The 7th edition incorporates more clinically relevant, site-specific staging systems for primary cancers of the eyelids, eye, and orbit.2 All chapters now include detailed clinical and pathology guidelines for data acquisition and tissue processing, while collecting evidence-based biomarkers and prospective data points.In 2004, pairs of clinical and pathology specialists were assigned to review each of the 6th edition AJCC chapters for their clinical, pathology, and research utility. Each pair was charged with creating a new, evidence-based medical foundation for its staging systems. They were required to seek biomarkers (known risk factors) and up to 6 data points for evaluation as potential “future” biomarkers. Their initial drafts were reviewed by a second clinician and pathologist team of reviewers. Their comments and suggestions were discussed during periodic subcommittee teleconferences and face-to-face meetings. Then, each section was subjected to review by multiple additional specialists. During this 4-year process, the Ophthalmic Oncology Task Force grew to include 45 eye cancer specialists from 10 countries (including 3 official International Union Against Cancer [UICC; L'Union Internationale Contre le Cancer] representatives) who worked together to define a comprehensive, anatomically based TNM (tumor-node-metastasis)–based staging system for eye cancer. This peer-review system allowed for an evaluation, synthesis, and consensus for clinical practice parameters and pathology techniques and review.The following AJCC chapters are reviewed in 3 different papers published in this joint issue for ophthalmic pathology between the Archives of Pathology & Laboratory Medicine and the Archives of Ophthalmology.The evolution of the eyelid carcinoma staging system was particularly complex. From a clinical perspective, Ainbinder et al were expected to design a staging system that could be used by ophthalmologists, head and neck surgeons, Mohs surgeons, dermatologists, radiation oncologists, and pathologists. The authors were further challenged to describe site-specific implications of invasion of the eye, orbit, sinuses, and brain. This staging system now covers 58 histologic profiles, and includes new nodal and pathology-based biomarkers and unique multispecialty-based data points.2In contrast to eyelid tumors, lacrimal gland carcinomas are rare. In this issue, Drs Jack Rootman and Valerie A. White explain how independent multicenter studies and reviews of epithelial lacrimal tumor diagnosis pathology and treatment were used to shape the lacrimal gland carcinoma staging system.34 They brought this section into line with that used for the more diverse salivary gland neoplasias, while preserving the site-specific aspects of this more occult location. They emphasized the need for a uniform approach to pathologic analysis and classification. The biomarkers Ki-67 and NM23 were added as well as 6 pathology-related prospective data points.2Ocular adnexal lymphoma was revolutionary because it did not exist in the 6th edition. We thought it unreasonable to exclude the most common orbital malignancy from site-specific staging. We needed to know how site-specific factors (location, laterality, histopathology) affected local and systemic prognosis. This site-specific staging system was created by Coupland and colleagues,5 who were uniquely qualified for this task. As you will read, the clinical extent of disease of the ocular adnexal lymphomas was not adequately described by the Ann Arbor staging system. The 7th edition AJCC staging system for ocular adnexal lymphoma continues histologic subtyping according to the World Health Organization (WHO) lymphoma classification and will allow for a more precise description of disease extent and biomarker identification.The committee's aim was to make a useful TNM-based classification system for clinical care (for local and systemic risk assessment), research, and pathology. Each chapter was edited to conform to what is used throughout medicine, for other similar tumors, tumor registries, and world-wide cancer centers. The 7th edition brings ophthalmic oncology into the mainstream of cancer research.The 7th edition AJCC Staging System provides clinically useful definitions of tumor size, location, and metastatic disease for almost all eye cancers.2 The use of this common language will allow us to compare treatments on equivalently sized and “staged” tumors.6 Use of this staging system will improve participation in clinical trials and compliance with cancer center status.The Ophthalmic Oncology Task Force has undertaken an effort to promote the widespread use of the 7th edition, AJCC Staging System. It either has been or will be presented at all of the major national and international ophthalmologic, ophthalmic pathology, ophthalmic plastic, and ocular oncology subspecialty societies for its diffusion.The peer-reviewed ophthalmology journals Archives of Ophthalmology, American Journal of Ophthalmology, British Journal of Ophthalmology, Ophthalmology, and Ophthalmic Plastic and Reconstructive Surgery have recently added the classification to their instructions for authors. Largely adopted by the College of American Pathologists (CAP), it has been presented for approval by the American Association for Ophthalmic Pathology (AAOP). The 7th edition AJCC classifications have been adopted by the National Cancer Institute–sponsored Cancer Biomedical Informatics Grid (caBIG) initiative (http://cabig.nci.nih.gov/).Participants in the 7th edition AJCC ophthalmic oncology classification effort included core members of the AJCC and the UICC. These are large, broadly supported organizations. For example, the AJCC is supported by the American Cancer Society, American College of Radiology, American College of Surgeons (ACS), College of American Pathologists (CAP), United States National Cancer Institute (NCI), Centers for Disease Control and Prevention (CDC), American Society of Clinical Oncology (ASCO), American College of Physicians, American Society for Therapeutic Radiology (ASTRO), caBIG, American Head and Neck Society, American Society of Colon and Rectal Surgery, American Urological Association, National Cancer Institute of Canada (NCI-Canada), National Cancer Registrars Association (NCRA), National Comprehensive Cancer Network, North American Association of Central Cancer Registries, Society of Gynecologic Oncology, Society of Surgical Oncology, Society of Urologic Oncology, and the UICC.The UICC complements the AJCC by reaching additional cancer-related organizations in 103 countries including 27 in Africa, 74 in the Asia/Pacific region, 91 in Europe, 41 in Latin America/the Caribbean, 20 in the Middle East, and 40 in North America in addition to 5 purely international associations.The AJCC-UICC Ophthalmic Oncology Task Force demonstrated how 45 eye cancer specialists can work together to create a common language.6 As part of the AJCC, and in affiliation with the UICC, the 7th edition staging systems will be used by tumor registries and clinical cancer centers around the world.The members of the 7th Edition, AJCC-UICC Ophthalmic Oncology Task Force include Col Darryl J. Ainbinder, MD; Daniel M. Albert, MD, MS; James O. Armitage, MD; James J. Augsburger, MD; Nikolas E. Bechrakis, MD; Maj John H. Boden, MD; Patricia Chévez-Barrios, MD; Sarah E. Coupland, MBBS, PhD, FRCPath; Bertil Damato, MD, PhD; Laurence Desjardins, MD; Ralph C. Eagle, MD; Deepak P. Edward, MD; Bita Esmaeli, MD; Paul T. Finger, MD (Chair); James C. Fleming, MD; Brenda L. Gallie, MD; Dan S. Gombos, MD; Jean-Daniel Grange, MD; Hans E. Grossniklaus, MD, MBA; Barrett G. Haik, MD; Col John B. Halligan, MD; J. William Harbour, MD; George J. Harocopos, MD; Leonard M. Holbach, MD; John L. Hungerford, MD; Martine J. Jager, MD, PhD; Zeynel A. Karcioglu, MD; Tero Kivela, MD; Emma Kujala, MD; Ashwin C. Mallipatna, MBBS; Col Robert A Mazzoli, MD; Hugh McGowan, MD; Tatyana Milman, MD; A. Linn Murphree, MD; Tim G. Murray, MD, MBA; Jack Rootman, MD, FRCS; Didi de Wolff-Rouendaal, MD, PhD; Andrew P. Schachat, MD; Stefan Seregard, MD; E. Rand Simpson, MD; Arun D. Singh, MD; Valerie A. White, MD, MHSc; Matthew W. Wilson, MD; Christian W. Wittekind, MD; Guopei Yu, MD, MPH.This work is supported by the American College of Surgeons, the American Joint Committee on Cancer (AJCC), the International Union Against Cancer (UICC), Springer, and The EyeCare Foundation.

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