III
T3
N0
M0
IVA
N1
T4a
N0-N1
IVB
T4b
Any N
IVC
Any T
M1
Beyond the factors used to assign T, N, or M categories, no additional prognostic factors are required for stage grouping.
As with all cancers, the overall frailty and comorbidities of the patient are important determinants of prognosis. MM has few defined disease-specific prognostic factors. The site of origin in the head and neck is one of the only clear prognostic factors. Disease in the oral cavity has a higher rate of cervical nodal metastasis than those arising in the paranasal sinuses. Overall 5-year survival is 15–30% for nasal cavity, 12% for oral cavity, and 0–5% for paranasal sinus disease.9-11 Other series have demonstrated slightly better outcomes, but the relative proportion of survival remains best for nasal cavity and worst for paranasal sinus.
Prasad and colleagues proposed a microstaging system for MM. They reported that findings of vascular invasion, polymorphous tumor population, and necrosis conferred a worse prognosis.12 Others, however, have not confirmed these findings and suggest high mitotic index and other findings are more salient. At this time, it appears that no clear prognostic factors exist for MM, although many promising candidates exist; collection of these data for future editions is advantageous.
In addition to the importance of the TNM factors, the overall health of these patients clearly influences outcome. An ongoing effort to better assess prognosis using both tumor and nontumor-related factors is underway. Chart abstraction will continue to be performed by cancer registrars to obtain important information regarding specific factors related to prognosis. These data then will be used to further hone the predictive power of the staging system in future revisions.
Comorbidity can be classified by specific measures of additional medical illnesses. Accurate reporting of all illnesses in the patient’s medical record is essential to assessment of these parameters. General performance measures are helpful in predicting survival. The AJCC strongly recommends the clinician report performance status using the Eastern Cooperative Oncology Group (ECOG), Zubrod, or Karnofsky performance measures, along with standard staging information. An interrelationship between each of the major performance tools exists.
0. Fully active, able to carry out all predisease activities without restriction (Karnofsky 90–100)
1. Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature; for example, light housework, office work (Karnofsky 70–80)
2. Ambulatory and capable of all self-care, but unable to carry out any work activities; up and about more than 50% of waking hours (Karnofsky 50–60)
3. Capable of only limited self-care; confined to bed or chair 50% or more of waking hours (Karnofsky 30–40)
4. Completely disabled; cannot carry on self-care; totally confined to bed (Karnofsky 10–20)
5. Death (Karnofsky 0)
Lifestyle factors such as tobacco and alcohol abuse negatively influence survival. Accurate recording of smoking in pack-years and alcohol in number of days drinking per week and number of drinks per day will provide important data for future analysis. Nutrition is important to prognosis and will be indirectly measured by weight loss of greater than 5% of body weight in the previous 6 months.14 Depression adversely affects quality of life and survival. Notation of a previous or current diagnosis of depression should be recorded in the medical record.15
The role of tobacco as a negative prognostic factor is well established. Exactly how this could be codified in the staging system, however, is less clear. At this time, smoking is known to have a deleterious effect on prognosis but it is difficult to accurately apply this to the staging system. Smoking history should be collected as an important element of the demographics and may be included in Prognostic Groups in the future. For practicality, the minimum standard should classify smoking history as never, less than or equal to 10 pack-years, greater than 10 but less than or equal to 20 pack-years, or greater than 20 pack-years.
Figure 1 shows 24-month follow-up of patients older than 18 years of age, diagnosed with MM of the head and neck, lip and oral cavity, pharynx, larynx, and nasal cavity and paranasal sinuses using the AJCC Cancer Staging Manual, 7th Edition. The cases were diagnosed in 2010–12. The curves indicate a reasonable hazard discrimination and distribution. They also suggest good prognostic discrimination.
Figure 1. 24-month follow-up of patients older than 18 years of age, diagnosed with MM of the head and neck, lip and oral cavity, pharynx, larynx, and nasal cavity and paranasal sinuses using the AJCC Cancer Staging Manual, 7th Edition. The cases were diagnosed in 2010–12.
There is no recommended histologic grading system at this time.