Since its establishment in , the American Joint Committee for Cancer AJCC has undertaken the responsibility for developing clinically useful staging systems for various types of cancer. The task force on malignant bone tumors of the AJCC could not agree on a satisfactory system and recommended institutions with access to large numbers of patients, consistency in management, and long-term followups undertake this task [ 2 ]. In , a system for surgical staging of musculoskeletal sarcoma was proposed, studied, and adopted by the Musculoskeletal Tumor Society and subsequently by the AJCC [ 4 ]. This system was established initially at the University of Florida in based on the data collected from through by Dr. William Enneking. An ideal staging system should be practical, reproducible, and of prognostic significance.
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Since its establishment in , the American Joint Committee for Cancer AJCC has undertaken the responsibility for developing clinically useful staging systems for various types of cancer. The task force on malignant bone tumors of the AJCC could not agree on a satisfactory system and recommended institutions with access to large numbers of patients, consistency in management, and long-term followups undertake this task [ 2 ].
In , a system for surgical staging of musculoskeletal sarcoma was proposed, studied, and adopted by the Musculoskeletal Tumor Society and subsequently by the AJCC [ 4 ]. This system was established initially at the University of Florida in based on the data collected from through by Dr. William Enneking. An ideal staging system should be practical, reproducible, and of prognostic significance. Cancer staging is deemed critical for disease control in an individual patient and for the population at large.
As defined by the International Union Against Cancer, the objectives of cancer staging are 1 to aid in planning the course of treatment, 2 to provide insight into the prognosis, 3 to assist in evaluating the results of treatment, 4 to facilitate effective interinstitutional communication, and 5 to contribute to continuing investigation of human malignancies [ 7 ].
Historically, surgical resection has been the cornerstone for management of musculoskeletal sarcomas. Thus the most useful staging system would guide the nature of the surgical procedure.
It also should 1 organize the most significant prognostic factors into a system describing progressive degrees of risk to which a patient is subjected, 2 outline progressive stages of the disease having specific implications for surgical management, and 3 provide guidelines for use of adjunctive therapy. There are separate staging systems for benign and malignant mesenchymal tumors. The classification is based on radiographic characteristics of the tumor host margin. Well-demarcated borders are indicative of latent lesions whereas indistinct borders result from permeation into host bone and a more aggressive lesion [ 11 ].
For benign tumors, local aggressiveness and incidence of recurrence increase with increase in surgical grade. Metastases are rare for locally aggressive benign lesions but do rarely occur in giant cell tumor and chondroblastoma [ 8 , 12 ]. Enneking staging for benign musculoskeletal tumors based on radiographic characteristics of the tumor host margin. The Enneking surgical staging system for malignant mesenchymal tumors takes into account the surgical grade G, G1, G2 , local extent T, T1, T2 , and presence or absence of metastasis M0, M1 [ 4 ].
Stage III represents any tumor with distant metastasis. Stages I and II are based on surgical grade of the tumor. Each stage is further divided into two subcategories A, B based on the local extent of tumor. The stage of the tumor dictates the extent of surgical resection and margin. Enneking staging for malignant musculoskeletal tumors based on surgical grade, local extent, and presence or absence of metastasis.
A system for the surgical staging of musculoskeletal sarcoma. Clin Orthop Relat Res. In the Enneking staging system, a neoplasm is classified as either low G1 or high G2 grade. These tumors are characterized by low mitotic rates, low nuclear to cytoplasmic ratio, and limited pleomorphism.
Each lesion ultimately is assessed on histologic features; however, some tumors are high grade by definition, such as a dedifferentiated chondrosarcoma [ 3 ].
In addition to the histologic features, the staging takes into account the clinical and radiographic features.
This includes axial imaging to determine the anatomic confines of the primary tumor and the presence of metastasis. Local extent for any neoplasm refers to its containment in anatomic boundaries of a compartment.
Anatomic compartments have inherent barriers to tumor spread, including fascial planes and bone structures. Thus local extent determines the approach for surgical procedure and feasibility for desired surgical margins.
In general, a high-grade lesion is more likely to invade surrounding host tissue. This places the patient at greater risk of local recurrence and metastasis. The use of adjuvant therapies then is indicated to eradicate tumor cells that would remain after surgical resection. The AJCC has proposed their own staging system for soft tissue sarcomas in contrast to bone sarcomas [ 9 ].
Articulation with surgical procedure is limited when compared with the Enneking staging system because of lack of consideration to anatomic planes and compartments. The management of adult soft tissue sarcomas. Am J Clin Oncol. The Enneking surgical staging has been validated in two distinct situations: 1 intramurally by the University of Florida musculoskeletal oncology service patients [ 5 ] and 2 extramurally by a multicentric study 13 institutions conducted by the Musculoskeletal Tumor Society patients [ 5 ].
Difficulty in using the system was reported in 5. Almost all the reported problems were related to assessing compartmental containment of tumor. The probability of survival as a function of stage for intracompartmental and extracompartmental groups was similar [ 5 ]. The Enneking surgical staging system is based on the natural evolution of mesenchymal tumors and thus is not applicable to tumors originating in either the marrow or reticuloendothelial system.
Lesions originating in the skull also behave differently and thus cannot be staged or classified using this system. The size of the primary tumor has been implicated as an important prognostic factor for numerous soft tissue sarcomas [ 6 ]. Larger lesions may be more likely to metastasize and may benefit from adjuvant chemotherapy [ 10 ].
The Enneking surgical staging system does not consider this important factor. This parameter is accounted for in the AJCC staging system for soft tissue sarcomas, but this classification lacks consideration of anatomic boundaries. Ideally, a combination of the staging systems may provide a stronger instrument than either alone. For spinal column tumors, the Enneking surgical staging system does not take into account the presence of a continuous epidural compartment, neurologic implication of sacrificing the spinal cords and roots, and need for restoring spinal stability.
Use of this system along with the Weinstein-Boriani-Biagini WBB classification has been studied for spinal tumors and appears to be safe and feasible and to improve disease control and survival, although both systems show only moderate interobserver reliability and additional studies are warranted [ 1 ].
Classification is considered safe when prognostication outlined in the classification system corresponds and correlates with outcomes in clinical practice. It can improve disease control by providing a systematic approach towards treatment decisions. The Enneking surgical staging system is reliable, reproducible, and of prognostic importance for musculoskeletal sarcomas, especially for those originating in the axial skeleton.
It has been used widely for classification by orthopaedic oncologic surgeons around the world. However, this classification system is applicable only to mesenchymal malignancies. National Center for Biotechnology Information , U.
Published online Mar Scully , MD, PhD. Sean P. Author information Copyright and License information Disclaimer. Scully, Email: ude. Corresponding author. This article has been cited by other articles in PMC. History Since its establishment in , the American Joint Committee for Cancer AJCC has undertaken the responsibility for developing clinically useful staging systems for various types of cancer.
Purpose An ideal staging system should be practical, reproducible, and of prognostic significance. Enneking Staging System There are separate staging systems for benign and malignant mesenchymal tumors. Open in a separate window. Limitations The Enneking surgical staging system is based on the natural evolution of mesenchymal tumors and thus is not applicable to tumors originating in either the marrow or reticuloendothelial system.
References 1. An assessment of the reliability of the Enneking and Weinstein-Boriani-Biagini classifications for staging of primary spinal tumors by the Spine Oncology Study Group. Spine Phila Pa Developing of a clinical staging system for primary malignant tumors of bone: a progress report. Dedifferentiated chondrosarcoma: the role of chemotherapy with updated outcomes. J Bone Joint Surg Am. Soft-tissue sarcoma. J Am Acad Orthop Surg. History and international developments in cancer staging.
Cancer Prev Control. A systematic meta-analysis of randomized controlled trials of adjuvant chemotherapy for localized resectable soft-tissue sarcoma. Radiologic and pathologic analysis of solitary bone lesions. Part II: periosteal reactions. Radiol Clin North Am. Viswanathan S, Jambhekar NA. Metastatic giant cell tumor of bone: are there associated factors and best treatment modalities?
Wheeless’ Textbook of Orthopaedics
It does not classify skull tumors or marrow-originating tumors e. It is widely accepted and used by orthopaediac surgeons given its compartment-based classification. The differential diagnosis for bone tumors is dependent on the age of the patient, with a very different set of differentials for the pediatric patient. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys.
Enneking staging system
If you have symptoms of cancer contact your doctor. Read our information about coronavirus and cancer. The stage of a cancer tells the doctor how big it is and whether it has spread. The Enneking system is a surgical staging system.
Bone Tumor Staging Systems