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R. Rami-Porta

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    ED05 - The 8th Edition of the TNM Staging System (ID 268)

    • Event: WCLC 2016
    • Type: Education Session
    • Track: Radiology/Staging/Screening
    • Presentations: 4
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      ED05.01 - What’s New in Lung Cancer Staging? (ID 6443)

      16:00 - 16:25  |  Author(s): H. Asamura

      • Abstract
      • Presentation
      • Slides

      Abstract:
      The tumor, node and metastasis (TNM) classification for malignant tumors has been periodically revised in the International Union for Cancer Control (UICC) and American Joint Committee on Cancer (AJCC). As for lung cancer, the process of revision is quite unique compared with malignancies of other organs in that the corresponding professional society, the International Association for the Study of Lung Cancer (IASLC), has been playing a principal role in database construction, making revision agenda, simulation, and validation as a proposal to UICC and AJCC. The agenda articles have been already published for T, N, M, and stage grouping in the official journal of IASLC. In brief, the IASLC database included 77,156 evaluable patients diagnosed with lung cancer from 1999 to 2010, originating from 35 different databases in 16 countries of 5 continents. Among these, the data of 3905 patients were given by electric data capturing. In the T descriptors, new tumor-size groups were created: T1a 1-2 cm; T1c >2-3cm; T2a >3-4cm; T2b >4-5cm; T3 >5-7cm; and T4 >7cm. Endobronchial l ocation <2cm from the carina has better prognosis than any other T3 descriptor and will be classified as T2. Total atelectasis/pneumonitis will be classified as T2 because it has a T2 prognosis. Diaphramatic invasion will be T4. Visceral pleural invasion remains the same, and mediastinal pleura invasion, seldom used, disappears as a T descriptor. The N component remains the same, but the number of involved nodal stations has prognostic impact. Therefore, it was proposed to divide N1 into N1a (single station N1) and N1b (multiple station N1), N2 into N2a1 (single station N2 without pN1 involvement), N2a2 (single station N2 with pN1 involvement) and N2b (multiple station N2) for testing. For the M component, M1a (intrathoracic metastases) remains the same, but extrathoracic metastases are divided into single extrathoracic metastasis (new M1b) and multiple extrathoracic metastases in a single or multiple organs (M1c). Regarding stages, stage IA is divided into IA1, IA2 and IA3 to accommodate T1a, T1b and T1cN0M0 tumors; all N1 disease are stage IIB except for T3-T4N1M0 that are IIIA; a new stage IIIC is created for T3-T4N3M0 tumors; and stage IV is divided into IVA (M1a and M1b) and IVB (M1c). The 8[th] edition of the TNM classification of lung cancer defines new tumor-size groups, confirms the prognostic relevance of quantifying nodal disease, establishes a new category for single extrathoracic metastasis, and creates new stage groupings. Looking at these, the importance of the accurate measurement of tumor diameter and accurate counting of the swollen nodes and lesions of distant disease has been raised. In this way it improves our understanding of the anatomic extent of the tumor, enhances ,our capacity to indicate prognosis at clinical and pathologic staging, and increases the possibilities of research by facilitating tumor stratification for future clinical trials.

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      ED05.02 - Update on the Mesothelioma Staging System (ID 6444)

      16:25 - 16:45  |  Author(s): V. Rusch

      • Abstract
      • Presentation
      • Slides

      Abstract:
      The initial TNM staging classification for malignant pleural mesothelioma (MPM), published in the 6th edition of the UICC and AJCC staging manuals, was derived from analyses of small retrospective surgical series. It has been criticized for being insufficiently evidence-based and difficult to apply to clinical staging. To identify potential deficits in the MPM staging classification, the IASLC Staging and Prognostic Factors Committee (ISPC), in collaboration with members of the International Mesothelioma Interest Group (IMIG), initiated a large multinational database in 2009. This approach was modeled on methods used by the IASLC to revise the lung cancer staging system. Data were submitted on 3,101 patients from 15 centers on 4 continents, all of whom had some form of surgical management, and an initial analysis was published in 2012. Overall survival (OS) data largely supported continued use of the original MPM staging classification but identified several important areas for improvement, particularly for the T and N components. To address issues raised by this initial analysis, a second iteration of the IASLC MPM database was started in 2013 to inform revisions for the 8th edition of the AJCC / UICC staging systems. The data dictionary was revised to provide more granular information for the T, N and M descriptors and a new electronic data capture (EDC), housed at the biostatistical center CRAB (Cancer Research and Biostatistics, Seattle, WA, USA), was developed. Additional investigators who could provide valid information on patients with tumors staged clinically and managed non-surgically were recruited. Data to inform revisions for the 8th edition of the MPM staging classification originated from 29 centers on 4 continents and included 3,519 cases of which 2,460 passed the initial eligibility screen. As planned, this dataset included both patients managed surgically and non-surgically. OS examined for T categories according to the current 7th edition staging classification showed a clear difference between all clinically staged categories except for T1a versus T1b and T3 versus T4. Pathological staging failed to demonstrate a survival difference between adjacent categories with the exception of T3 versus T4. Performance improved with collapse of T1a and T1b into a single T1 category. Analyses suggested that all current T descriptors should be maintained. Tumor thickness and morphology were also significantly associated with OS. Consequently, a recommendation was made to collapse both clinical and pathological T1a and T1b into a T1 category. Because simple measurement of pleural thickness had prognostic significance, it was felt that this should be examined further with a view to incorporation into future revisions of the staging classification. With respect to the N categories (as defined in the 7th edition staging classification), there was no significant difference in OS between cN0, cN1 and cN2, likely reflecting the inaccuracies of current methods for clinical lymph node staging in MPM. For pathologically staged tumors, patients with pN1 or pN2 tumors had a worse OS than those with pN0 tumors but no OS difference was noted between those with pN1 and pN2. Exploratory analyses found that tumors with both pN1 and pN2 nodal involvement had a poorer OS than those with pN2 only. Consequently, a recommendation was made to collapse N1 and N2 into a new N1 category and to relabel the current N3 category as N2. Larger numbers of well staged cases are needed to determine whether this new N1 category should be subdivided in the future according to the number of involved lymph node stations. Of the 3,519 submitted cases, 84 were cM1 at diagnosis. Median OS for cM1 was significantly worse than for T4 or N3 (as defined in the 7th edition) supporting inclusion of only cM1 in the stage IV group. Exploratory analyses suggested a possible difference in OS for single versus multiple site cM1 but additional data are needed in the future to determine the validity of this finding. Candidate stage groups were developed using a recursive partitioning and amalgamation (RPA) algorithm applied to all cM0 cases. Based on these analyses, optimal stage groupings proposed for the 8th edition of the staging classification were: stage IA (T1N0), stage IB (T2-3N0), stage II (T1-2N1), stage IIIA (T3N1), stage IIIB (T1-3N2 or any T4) and stage IV (any M1). These new stage groupings are substantially different from what is currently used in the 7th edition. The IASLC database is the largest available multinational database in this rare malignancy and has provided the first evidence-based revisions of the TNM classification for MPM leading to substantial changes in the T and N components and the stage groupings. Continued efforts to accrue to this database will be important to inform further changes for the 9th edition of the staging classification.[1-7] Reference List (1) Rusch VW, The International Mesothelioma Interest Group. A proposed new international TNM staging system for malignant pleural mesothelioma. Chest 1995;108:1122-8. (2) Rusch VW, Giroux D, Kennedy C, Ruffini E, Cangir AK, Rice D, et al. Initial analysis of the International Association for the Study of Lung Cancer Mesothelioma Database. J Thorac Oncol 2012;7:1631-9. (3) Pass HI, Giroux D, Kennedy C, Ruffini E, Cangir AK, Rice D, et al. Supplementary prognostic variables for pleural mesothelioma: A report from the IASLC Staging Committee. J Thorac Oncol 2014;9(6):856-64. (4) Pass HI, Giroux D, Kennedy C, Ruffini E, Cangir AK, Rice D, et al. The IASLC Mesothelioma Database: Improving staging of a rare disease through international participation. J Thorac Oncol. In press 2016. (5) Nowak AK, Chansky K, Rice DC, Pass HI, Kindler HL, Shemanski L, et al. The IASLC Mesothelioma Staging Project: Proposals for revisions of the T descriptors in the forthcoming eighth edition of the TNM classification for mesothelioma. J Thorac Oncol. In press 2016. (6) Rice DC, Chansky K, Nowak AK, Pass HI, Kindler HL, Shemanski L, et al. The IASLC Mesothelioma Staging Project: Proposals for revisions of the N descriptors in the forthcoming eighth edition of the TNM classification for malignant pleural mesothelioma. J Thorac Oncol. In press 2016. (7) Rusch VW, Chansky K, Kindler HL, Nowak A, Pass HI, Rice DC, et al. The IASLC Malignant Mesothelioma Staging Project: Proposals for the M descriptors and for revision of the TNM stage groupings in the forthcoming (eighth) edition of the TNM classification for mesothelioma. J Thorac Oncol. In press 2016.

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      ED05.03 - The Thymic Epithelial Tumor Staging System (ID 6445)

      16:45 - 17:05  |  Author(s): K. Kondo

      • Abstract
      • Presentation
      • Slides

      Abstract:
      Thymic epithelial tumors are rare tumors. The clinical staging system for thymoma was introduced first by Bergh and associates in 1978 and later modified by Wilkins and Castleman (1), and was almost established by Masaoka and associates in 1981 (2). In France, multiple centers have adopted the Groupe d’Etudes des Tumeurs Thymiques (GETT) staging system (1). The Masaoka classification is the most widely accepted now and is an excellent predictor of the prognosis of thymoma (3, 4). And a modification of this classification was suggested by Koga et al. in 1994 (5) The International Thymic Malignancies Interest Group (ITMIG) has chosen to use the Masaoka-Koga stage classification system (1). There has never been an official TNM system classification of thymic epithelial tumor by American Joint Committee on Cancer/Union for International Cancer Control (AJCC/UICC) stage classification due to their relative rarity. Yamakawa and Masaoka presented a tentative TNM system classification of thymoma in 1991. Then Tsuchiya et al. (1994) in National Cancer Center Hospital of Japan, the WHO (2004) and Bedini et al.(2005) in National Cancer Institute of Italy proposed a TNM staging system (1). The ITMIG and the International Association for the Study of Lung Cancer (IASLC) simultaneously set out to accomplish a staging system for thymic epithelial neoplasms, and subsequently joined forces in 2010, partnering to create a Thymic Domain of the Staging and Prognostic Factors Committee (TD-SPFC), charged with the development of proposals to AJCC/UICC for the eight edition of the stage classification system. The ITMIG and IASLC assembled and analyzed a worldwide database of 10,808 patients with thymic malignancies from 105 sites. They made a stage classification that was tumor, node, metastasis (TNM) based, and applicable to thymoma as well as thymic carcinoma (6-9) (Tables). The T component is divided into 4 categories (Table 1). A tumor is classified in a particular “level” if one or more structures in that level is involved, regardless of whether other structures of a lower level are involved or not. The encapsulation of the tumor is not included, because this did not have a clinically significant difference of prognosis in the retrospective database. The T1 includes tumors that were classified as stage I or II in the Masoaka or Masaoka-Koga stage classification systems. The involvement of the pericardium pathologically is designated as T2, and several neighboring organs (potentially resectable) are included in the T3 category because they had similar prognosis. The T4 includes several organs with more extensive local invasion (potentially unresectable). The TD-SPFC decided to subcategorize T1 into T1a (no mediastinal pleural involvement) and T1b (involvement of the mediastinal pleura) to gain more prospective data for further testing, as there is a slight difference in cumulative incidence of recurrence in patients from Japan submitted by the Japanese Association for Research in the Thymus (6, 7). Lymph node involvement is common in thymic carcinoma (more than 27%) but is relatively uncommon in thymoma (2%) (4). The N component is divided into 3 categories (Table 1). No lymph node metastasis is classified as N0. Lymph nodes are assigned in 2 groups according to their proximity to the thymus: anterior (perithymic) (N1) and deep cervical or thoracic nodes (N2). The anterior region (N1) encompasses the space surrounding the thymus that is bordered by the hyoid bone and diaphragm craniocaudally, the medial edge of the carotid sheaths and mediastinal pleura laterally, the sternum anteriorly, the pericardium and great vessels posteriorly in the middle, and extending to the level of the phrenic nerves posterolaterally. The deep region (N2) describes the space distant to the anterior region within the mediastinum. It is situated posterior to the anterior mediastinum, anterior to the esophagus, and among the pulmonary hila; it extends into the neck on either side of the anterior cervical nodes. Involved nodes outside these regions are outside the N category and considered a distant metastasis (M1) (6, 8, 9). The M component is divided into 3 categories (Table 1). Absence of tumor outside the primary mass (or nodal metastases) is classified as M0. M1a is used to designate pleural or pericardial nodules. M1b designates pulmonary intraparenchymal nodules or distant metastases (6, 8). The TNM categories are organized into distinct stage groups as shown in Table 2. Stages I, II, IIIa, and IIIb are determined primarily by the T component. Stages IVa and IVb are determined by the presence of N1 or M1a disease for IVa and N2 or M1b disease for IVb (6-9). Figure 1 Figure 2 References 1. Detterbeck FC, Nicholson AG, Kondo K, Van Schil P, Moran C. The Masaoka-Koga Stage Classification for Thymic Malignancies Clarification and Definition of Terms. J Thorac Oncol. 2011;6: S1710–S1716. 2. Masaoka A, Monden Y, Nakahara K, Tanioka T. Follow-up study of thymomas with special reference to their clinical stages. Cancer 1981;48:2485–92. 3. Detterbeck FC, Parsons AM. Thymic tumors. Ann Thorac Surg 2004;77:1860-9. 4. Kondo K, Monden Y. Therapy for thymic epithelial tumors: a clinical study of 1,320 patients from Japan. Ann Thorac Surg 2003;76:878–84. 5. Koga K, Matsuno Y, Noguchi M, et al. A review of 79 thymomas: modification of staging system and rappraisal of conventional division into invasive and non-invasive thymoma. Pathol Int 1994;44:359–67. 6. Detterbeck FC, Stratton K, Giroux D, et al. The IASLC/ITMIG Thymic Epithelial Tumors Staging Project: Proposal for an Evidence-Based Stage Classification System for the Forthcoming (8th) Edition of the TNM Classification of Malignant Tumors. J Thorac Oncol. 2014;9: S65–S72 7.Nicholson AG, Detterbeck FC, Marino M, et al.,,The ITMIG/IASLC Thymic Epithelial Tumors Staging Project: Proposals for the T component for the Forthcoming (8th) Edition of the TNM Classification of Malignant Tumors. J Thorac Oncol. 2014;9: S73–S80 8. Kondo K, Schil PV, Detterbeck FC, et al. The IASLC/ITMIG Thymic Epithelial Tumors Staging Project: Proposals for the N and M Components for the Forthcoming (8th) Edition of the TNM Classification of Malignant Tumors. J Thorac Oncol. 2014;9: S81-S87 9. Bhora FY, Chen DJ, Detterbeck FD,et al., The ITMIG/IASLC Thymic Epithelial Tumors Staging Project: A Proposed Lymph Node Map for Thymic Epithelial Tumors in the Forthcoming 8th Edition of the TNM Classification of Malignant Tumors. J Thorac Oncol. 2014;9: S88–S96





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      ED05.04 - What’s New in Esophageal Cancer Staging? (ID 6446)

      17:05 - 17:25  |  Author(s): T. Rice

      • Abstract
      • Presentation
      • Slides

      Abstract:
      What’s New in Esophageal Cancer Staging? Thomas W. Rice, MD The 8th edition cancer staging manuals will be published later this year,[1,2] and the new staging recommendations will go into effect January 1, 2017. Staging cancer of the esophagus and esophagogastric junction for the 8th edition of the AJCC/UICC manuals was developed on a strong 7th edition foundation.[3,4] A greatly enhanced Worldwide Esophageal Cancer Collaboration (WECC) database, with a substantial increase in both numbers of patients (22,654) entered and variables (39) collected,[5-7 ]permitted a more dynamic and dependable Random Forest–based machine learning analysis. Random Forest analyses provided risk-adjusted survival estimates for all patients, from which distinctive and homogeneous stage groups with monotonically decreasing survival were identified.[8-10] Cancer Categories There were no major changes in cancer categories; however, there were some important refinements for T, N, grade, and location. Subcategorization of pT1 into pT1a and pT1b enhanced and improved Stage I grouping. Regional lymph nodes (N) were clarified in a new and simplified map. Undifferentiated cancers now require additional analyses to expose histopathologic cell type. If glandular origin can be determined, the cancer is staged as Grade 3 adenocarcinoma; if squamous origin can be determined or if the cancer remains undifferentiated after full analysis, it is staged as Grade 3 squamous cell carcinoma. Cancer location, not important for adenocarcinoma stage grouping, in conjunction with grade is necessary to subgroup only pT3N0M0 squamous cell carcinoma. The definition of the esophagogastric junction was revised; cancers involving the esophagogastric junction with epicenters 2 cm or less into the gastric cardia are staged as adenocarcinomas of the esophagus, while those with more than 2-cm involvement are staged as stomach cancers. Stage Groupings Pathologic Stage Grouping (pTNM) Historically, pathologic stage after esophagectomy alone has been the sole basis for all cancer staging, regardless of classification (c, yc, yp, r, and a). Today, pathologic stage has lost some of its clinical relevance for advanced-stage cancer as neoadjuvant therapy replaces esophagectomy alone. However, it remains important for early-stage cancers and as a key reference point. Dissimilar stage group composition and survival profiles necessitated separate staging groupings for adenocarcinoma and squamous cell carcinoma. Neoadjuvant Pathologic Stage Grouping (ypTNM) New to the 8th edition is stage grouping of patients with esophageal cancers who have had neoadjuvant therapy and pathologic review of the resection specimen (ypTNM). Drivers of this addition include absence of equivalent pathologic (pTNM) categories for the peculiar neoadjuvant pathologic categories (ypT0N0-3M0 and ypTisN0-3M0), dissimilar stage group compositions, and markedly different survival profiles. Grade and location play no role in neoadjuvant pathologic stage grouping. The groupings are identical for both histopathologic cell types. Clinical Stage Grouping (cTNM) Also new to the 8th edition is clinical stage grouping (cTNM) prior to treatment decision. Clinical staging is done typically in the absence of complete histologic cancer data, because clinical TNM categories are typically defined by imaging and examination of needle aspiration and biopsy specimens. Dissimilar stage group composition and survival profiles necessitated clinical stage grouping (cTNM) distinct from pathologic stage grouping (pTNM). There is separate clinical staging for adenocarcinoma and squamous cell carcinoma. How to proceed with TNM-8? 8th edition staging for cancer of the esophagus and esophagogastric junction are data driven and expanded from pathologic stage (pTNM) to include also pathologic stage after neoadjuvant therapy (ypTNM) and clinical stage (cTNM) before treatment decision. Critical evaluation of 8th edition staging, intensive data collection, in-depth analyses, and further consensus appraisal are necessary to proceed from the 8th to the 9th edition. References 1) American Joint Committee on Cancer Staging Manual. 8th ed. In press. 2) TNM classifications of malignant tumors. International Union Against Cancer. 8[th] ed. In press. 3) Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A, editors. American Joint Committee on Cancer Staging Manual. 7th ed. New York: Springer-Verlag; 2010. 4) Sobin LH, Gospodarrowicz MK, Wittekind C, editors. TNM classifications of malignant tumors. International Union Against Cancer. 7th ed. Oxford, England: Wiley-Blackwell; 2009. 5) Rice TW, Chen L-Q, Hofstetter WL, et al. Worldwide Esophageal Cancer Collaboration: pathologic staging data. Dis Esophagus. In press. 6) Rice TW, Lerut TEMR, Orringer MB, et al. Worldwide Esophageal Cancer Collaboration: neoadjuvant pathologic staging data. Dis Esophagus. In press. 7) Rice TW, Apperson-Hansen C, DiPaola LM, et al. Worldwide Esophageal Cancer Collaboration: clinical staging data. Dis Esophagus. In press. 8) Rice TW, Ishwaran H, Hofstetter WL, Kelsen DP, Blackstone EH. Recommendations for pathologic staging (pTNM) of cancer of the esophagus and esophagogastric junction for the 8th edition AJCC/UICC staging manuals. Dis Esophagus. In press. 9) Rice TW, Ishwaran H, Kelsen DP, Hofstetter WL, Blackstone EH. Recommendations for neoadjuvant pathologic staging (ypTNM) of cancer of the esophagus and esophagogastric junction for the 8th edition AJCC/UICC staging manuals. Dis Esophagus. In press. 10)Rice TW, Ishwaran H, Blackstone EH, Hofstetter WL, Kelsen DP. Recommendations for clinical staging (cTNM) of cancer of the esophagus and esophagogastric junction for the 8th edition AJCC/UICC staging manuals. Dis Esophagus. In press.

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    WS03 - IASLC Meets ESTI: Imaging in Lung Cancer Staging and Diagnosis (ID 361)

    • Event: WCLC 2016
    • Type: Workshop
    • Track: Radiology/Staging/Screening
    • Presentations: 4
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      WS03.01 - T Stage (ID 6765)

      08:00 - 08:56  |  Author(s): H. Prosch

      • Abstract
      • Presentation
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      Abstract not provided

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      WS03.02 - N Stage (ID 6767)

      08:56 - 09:52  |  Author(s): C. Schäfer-Prokop

      • Abstract
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      Abstract not provided

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      WS03.03 - M Stage (ID 6768)

      09:52 - 10:48  |  Author(s): N. Sverzellati

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      Abstract not provided

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      WS03.04 - Ultrasound- and CT-Guided Biopsies for the Diagnosis of Lung Cancer (ID 6766)

      10:48 - 11:44  |  Author(s): G. Mostbeck

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      Abstract not provided

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    PL03 - Presidential Symposium (ID 428)

    • Event: WCLC 2016
    • Type: Plenary
    • Track:
    • Presentations: 1
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      PL03.02 - Lung Cancer Staging – Changing the Clinical Practice (ID 6866)

      08:45 - 09:05  |  Author(s): R. Rami-Porta

      • Abstract
      • Presentation
      • Slides

      Abstract:
      Introduction At the time of the 17[th] World Conference on Lung Cancer, the 8[th] edition of the tumor, node and metastasis (TNM) classification of lung cancer will have been published by the Union for International Cancer Control, the American Joint Committee on Cancer and the International Association for the Study of Lung Cancer (IASLC) in their respective staging manuals. The innovations introduced, based on the analyses of the new IASLC database that includes 70,967 evaluable patients with non-small cell lung cancer and 6,189 with small cell lung cancer are described in the table. (1-9) These innovations will lead to some changes in clinical practice that are worth reflecting on. Table. Innovations introduced in the 8[th] edition of the TNM classification of lung cancer.

      Descriptor 8[th] edition
      T component
      >/= 1cm T1a
      >1 – 2cm T1b
      >2 – 3cm T1c
      >3 – 4cm T2a
      >4 – 5cm T2b
      >5 – 7cm T3
      >7cm T4
      Brochus <2cm from carina T2
      Total atelectasis/pneumonitis T2
      Diaphragm inasion T4
      Mediastinal pleura invasion -
      M component
      Metastases in thoracic cavity M1a
      Single extrathoracic metastasis M1b
      Multiple extrathoracic metastases M1c
      Other innovations in classification
      Second primaries One TNM for each
      Separate tumor nodules T3, T4 and M1a
      Multifocal adenocarcinomas with ground glass opacity/lepidic features Highest T (#/m) and global N and M
      Pneumonic type adenocarcinoma T3, T4 and M1a
      The T component Tumor size is a much more relevant prognostic factor than in previous editions and is now a descriptor in all T categories. Therefore, tumor size measurement should be carefully performed because small changes in size mean important changes in prognosis. (2) In part-solid tumors, only the solid/invasive part counts to measure tumor size. (7) The fact that adenocarcinoma in situ –Tis(AIS) – and minimally invasive adenocarcinoma –T1mi– have their own coding in the TNM classification will increase their awareness. (7) These, together with the smallest coded solid tumors, those of one cm or less in largest dimension –T1a– can become the base from which to study therapeutic options, such as sublobar resections, stereotactic radiotherapy, radiofrequency ablation; tumor biology, including tumor growth, tumor density and intensity of the standardized uptake value, as well as molecular profile and genetic signatures. Visceral pleural invasion and its two categories (PL1: invasion beyond its elastic layer; and PL2: invasion of the pleural surface) have been confirmed as important prognostic factors. (2) This means that pathologists should intensively investigate the identification of visceral pleural invasion, and, if it is not evident by the standard hematoxylin and eosine stains, elastic stains should be used, as recommended in the 7[th] edition of the TNM classification. (10) The N component Although there will be no changes in the N categories, the analyses for the 8[th] edition have shown that quantification of nodal disease has prognostic implications. This had already been evident in the 7[th] edition, when it was found that the number of involved nodal zones was prognostic. The analyses for the 8[th] edition have considered the number of involved nodal stations and have found that the more nodal stations involved, the worse the prognosis; and that the prognosis of tumors with involvement of multiple N1 stations was similar to that of tumors with single station N2 without concomitant N1 disease (skip metastases). (3) The findings of the 7[th] edition already raised the issue of indicating upfront resection in patients with tumors with single N2 zone involvement, because their prognosis was the same as that of tumors with multiple N1 zones. The question will be raised again in the light of the results of the 8[th] edition. However, in both occasions, the quantification of nodal disease derived from pathological staging of those tumors that had been resected and the resection had been accompanied by a properly performed systematic nodal dissection. This is difficult to replicate at clinical staging, the moment at which therapeutic decisions are made, unless a transcervical mediastinoscopic lymphadenectomy is performed. This lymphadenectomy has been found to be equivalent to that performed at the time of resection, either by thoracoscopic or open surgery, and is the only pre-resection test that can define single station or single zone N2 disease reliably. The M component There is no change in the metastasis within the thoracic cavity (M1a), but single extrathoracic metastases have better prognosis than multiple extrathoracic metastasis in one or in several organs, and different categories have been defined for them: M1b for single and M1c for multiple extrathoracic metastases. (4) The fact that single extrathoracic metastasis have their own category will facilitate the redefinition of oligometastatic and oligoprogressive disease, the establishment of therapeutic protocols with radical intention, and the investigation of all therapeutic modalities to eliminate the advance disease. However, clinical staging will have to be precise and will have to determine the number and the organ location of the metastatic deposits. The stages Some TNM subsets have moved from one stage to another and new stages and sub-stages have been created to accommodate groups of tumors with similar prognosis. (5) As it occurred with the 7[th] edition, the question of how to treat patients whose tumors have changed stage will be raised at multidisciplinary team meetings. Taxonomic changes do not necessarily mean an automatic change in therapy if the clinical trials performed to test therapeutic options did not include the tumors that are now included in the selected stages for study. Therefore, in the absence of results from clinical trials, clinical judgment will have to determine what the best options are for a given patient with a given tumor. Lung cancer with multiple lesions The 8[th] edition will provide a set of rules with the intention to classify lung cancers with multiple lesions in a homogeneous way. (8) It is our responsibility to follow the rules to collect prospective data uniformly and validate the given recommendations with international data. Conclusion The 8[th] edition will help us refine prognosis both at clinical and pathologic staging and stratify tumors in future clinical trials, but will require more attention from us at measuring tumor size, at determining nodal disease, at searching for metastases, and at using clinical judgment to indicate treatment. References 1. Rami-Porta R, Bolejack V, Giroux DJ et al. The IASLC lung cancer staging project: the new database to inform the eighth edition of the TNM classification of lung cancer. J Thorac Oncol 2014; 9: 1618-1624. 2. Rami-Porta R, Bolejack V, Crowley J et al. The IASLC lung cancer staging project: proposals for the revisions of the T descriptors in the forthcoming 8[th] edition of the TNM classification for lung cancer. J Thorac Oncol 2015; 10: 990-1003. 3. Asamura H, Chansky K, Crowley J et al. The IASLC Lung Cancer Staging Project: proposals for the revisions of the N descriptors in the forthcoming 8[th] edition of the TNM classification for lung cancer. J Thorac Oncol 2015; 10: 1675-1684. 4. Eberhardt WEE, Mitchell A, Crowley J et al. The IASLC lung cancer staging project: proposals for the revisions of the M descriptors in the forthcoming 8[th] edition of the TNM classification for lung cancer. J Thorac Oncol 2015; 10: 1515-1522. 5. Goldstraw P, Chansky K, Crowley J et al. The IASLC lung cancer staging project: proposals for the revision of the stage grouping in the forthcoming (8th) edition of the TNM classification of lung cancer. J Thorac Oncol 2016; 11: 39-51. 6. Nicholson AG, Chansky K, Crowley J et al. The International Association for the Study of Lung Cancer Lung Cancer Staging Project: proposals for the revision of the clinical and pathologic staging of small cell lung cancer in the forthcoming eighth edition of the TNM classification for lung cancer. J Thorac Oncol 2016; 11: 300-311. 7. Travis WD, Asamura H, Bankier A et al. The IASLC Lung Cancer Staging Project: proposals for coding T categories for subsolid nodules and assessment of tumor size in part-solid tumors in the forthcoming eighth edition of the TNM classification of lung cancer. J Thorac Oncol 2016; 11: 1204-1223. 8. Detterbeck FC, Nicholson AG, Franklin WA et al. The IASLC Lung Cancer Staging Project: summary of proposals for revisions of the classification of lung cancers with multiple pulmonary sites of involvement in the forthcoming eighth edition of the TNM classification. J Thorac Oncol 2016; 11: 539-650. 9. Detterbeck FC, Chansky K, Groome P et al. The IASLC Lung Cancer Staging Project: methodology and validation used in the development of proposals for revision of the stage classification of NSCLC in the forthcoming (eighth) edition of the TNM classification of lung cancer. J Thorac Oncol 2016; 11: 1433-1446. 10. Travis WD, Brambilla E, Rami-Porta R et al. Visceral pleural invasion: pathologic criteria and use of elastic stains. Proposal for the 7[th] edition of the TNM classification for lung cancer. J Thorac Oncol 2008; 3: 1384-1390.

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    PR03 - Press Conference: Accurate Diagnosis (ID 477)

    • Event: WCLC 2016
    • Type: Press Conference
    • Track:
    • Presentations: 1
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      PR03.01 - Lung Cancer Staging – Changing the Clinical Practice (ID 7209)

      10:30 - 10:30  |  Author(s): R. Rami-Porta

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      Abstract not provided

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