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G. Lyons
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IA05 - The Practical Use of the TNM Classifications for Thoracic Cancers (ID 291)
- Event: WCLC 2016
- Type: Interactive Session
- Track: Radiology/Staging/Screening
- Presentations: 1
- Moderators:H. Asamura, C. Herold
- Coordinates: 12/06/2016, 11:00 - 12:30, Hall C7
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IA05.01 - Lung Cancer Cases (ID 6524)
11:00 - 11:30 | Author(s): G. Lyons
- Abstract
- Presentation
Abstract:
The definition of staging in Lung Cancer is the determination of the anatomic extent of three tumor components: the primary tumor (T), the lymph nodes (N), and the metastases (M). Their accurate evaluation allows grouping patients in stages that is one, and perhaps the single most important, of several prognostic factors that guide the appropriate treatment option(s) to offer the patient. The clinical classification cTNM (Pre-treatment clinical classification), is based on evidence acquired before treatment The pathological classification pTNM (Post-surgical histopathological classification), is based on the evidence acquired before treatment, supplemented or modified by the additional evidence acquired from surgery and from pathological examination. A minimum number of tests is not required to define the extent of the disease, but it’s very clear that as more exhaustive the explorations more accurate and precise the staging will be. This may be strongly affected by the availability of physical and human resources, multidisciplinary work and adherence to clinical practice guidelines. After the changes proposed by the new IASLC-ATS-ERS lung adenocarcinoma classification and the IASLC proposals for revision of the T, N and M descriptors and stage groupings in the forthcoming (Eighth) edition of the TNM Classification for Lung Cancer, we must incorporate this new information into our clinical practice. (1, 2) The changes that The IASLC Staging Committee recommends for the T, N and M components and the resulting new stage grouping and their survival are summarized in table 1 and figure 1. The main changes in T components are the relevance of the size of the tumor for each cm, grouping of the involvement of the main bronchus or partial and total atelectasis or pneumonitis as a T2 descriptor and the reclassification of diaphragm invasion as T4. (3) N component remains without changes. (4) In M component a new M1b category includes patients with a single metastatic lesion in a single organ site and a new M1c category was introduce for patients with multiple lesions in a single organ or multiple lesions in multiple organs. (5) Some new stage groupings are proposed. The new size cut points of T1-N0-M0 tumors has been assigned to stage IA1, IA2, and IA3. The new stage IIIC (T3 and T4-N3-M0) reflects their worse outcome. Finally, stage IV disease has been divided into IVA (M1a, M1b) and IVB (M1c). The new IVA stage grouping should be used in trials analyzing patients with oligo-metastasis or pleural or pericardial disease. (2) For the newly described types of adenocarcinoma of the lung, The IASLC recommends incorporating the coding of AIS as Tis (AIS) and of MIA as T1mi into the traditional TNM classification. For part-solid tumors, the size of the invasive component should be used to assign a T category, but the whole tumor size should also be recorded. However, the measurements will be influenced by a number of observer-dependent and technical factors. It is important to perform the measurements for clinical staging on contiguous thin CT sections reconstructed with a high-resolution algorithm with multiplanar reconstruction. (6) For pathologic staging, attention should be given to the assessment of invasive and lepidic components. It can be helpful to correlate microscopic findings with measurements made on gross examination, particularly in inflated specimens or with CT findings. Patients who present with more than one pulmonary site of lung cancer may represent different patterns of disease as synchronous primary lung cancers, those with a separate solid tumor nodule(s) (intrapulmonary metastases), multifocal lung cancer presenting as multiple nodules with ground glass/lepidic features, and diffuse pneumonic-type adenocarcinoma. It is proposed that the T category of patients presenting ground glass/lepidic (GG/L) tumors be classified using the T category of the highest T lesion and in parentheses either the number of GG/L tumors or simply m for multiple (#/m). A single N and M category is assigned for all GG/L tumors combined. (7) Both clinical information (the presence of additional lesions identified by imaging) and the pathologic information (from resected lesions) should be used to determine the TNM classification. Lesions smaller than 5 mm or AAH are not counted. The pneumonic type of adenocarcinoma should be classified according to the size of the area of lung involved, or as T4 or M1a in the case of involvement of more than one lobe (i.e., either ipsilateral or contralateral). A single N and M category is assigned. In patients with separate tumor nodules (intrapulmonary metastases), it is proposed that the seventh edition classification of same-lobe nodules as T3, same side (different lobe) nodules as T4, and other-side nodules as M1a be carried forward. (8) It is easier to establish that two pulmonary foci of cancer are separate primary tumors than that they are metastatic from one another. Few features are sufficiently reliable by themselves, such as different histologic type and differences by a comprehensive histologic assessment of resected specimens or by matching breakpoints by DNA sequencing. Most criteria can be suggestive, but are associated with potential misclassification. These include biomarker patterns, imaging characteristics, and the presence or absence of nodal involvement. The fact that generally only biopsy specimens are available at the time of clinical decision making further adds to the uncertainty and difficulty of the assessment. A constellation of factors is better than any single factor; it is best to make a determination of separate primary versus metastatic lesions through a collective judgment of a multidisciplinary tumor board after taking into account all of the available information. (9) Synchronous primary cancers are classified with a T, N, and M category for each tumor; separate tumor nodules result in a T3, T4, or M1a category depending on the separate nodule’s location relative to the primary tumor. (10) Despite these proposals of staging, there will always be areas of difficulty and tumors that are challenging to classify. The prognostic value of clinical and pathological TNM staging in patients with SCLC was also confirmed, and the continued usage is recommended for SCLC in relation to proposed changes to T, N, and M descriptors for NSCLC in the eighth edition. (11) Table 1 Descriptors and T and M categories in the seventh edition and as proposed for the eighth edition. Figure 1 *Where there is a change, the resultant stage groupings proposed for the eighth edition are in bold, and the stage in the seventh edition is given in parenthesis. Figure 1 Overall survival by clinical and pathological stage according to the proposed eighth edition groupings using the entire database available for the eighth edition. Figure 2References: 1. Travis WD, et al. The New IASLC/ATS/ERS international multidisciplinary lung adenocarcinoma classification. J Thorac Oncol. 2011;6: 244–285. 2. Goldstraw P et al. The IASLC Lung Cancer Staging Project: Proposals for Revision of the TNM Stage Groupings in the Forthcoming (Eighth) Edition of the TNM Classification for Lung Cancer Journal of Thoracic Oncology, Vol. 11, Issue 1, p39–51 3. Rami-Porta R et al. The IASLC Lung Cancer Staging Project: Proposals for the Revisions of the T Descriptors in the Forthcoming Eighth Edition of the TNM Classification for Lung Cancer. Journal of Thoracic Oncology, Vol. 10, Issue 7, p990–1003 4. Asamura H et al. The International Association for the Study of Lung Cancer Lung Cancer Staging Project: Proposals for the Revision of the N Descriptors in the Forthcoming 8th Edition of the TNM Classification for Lung Cancer. Journal of Thoracic Oncology, Vol. 10, Issue 12, p1675–1684 5. Eberhardt W E.et al. The IASLC Lung Cancer Staging Project: Proposals for the Revision of the M Descriptors in the Forthcoming Eighth Edition of the TNM Classification of Lung Cancer. Journal of Thoracic Oncology, Vol. 10, Issue 11, p1515–1522 6. Travis WD, 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. Journal of Thoracic Oncology, Vol. 11, Issue 8, p1204–1223 7. Detterbeck FC et al. The IASLC Lung Cancer Staging Project: Background Data and Proposals for the Application of TNM Staging Rules to Lung Cancer Presenting as Multiple Nodules with Ground Glass or Lepidic Features or a Pneumonic Type of Involvement in the Forthcoming Eighth Edition of the TNM Classification. Journal of Thoracic Oncology, Vol. 11, Issue 5, p666–680 8. Detterbeck FC et al. The IASLC Lung Cancer Staging Project: Background Data and Proposals for the Classification of Lung Cancer with Separate Tumor Nodules in the Forthcoming Eighth Edition of the TNM Classification for Lung Cancer. Journal of Thoracic Oncology, Vol. 11, Issue 5, p681–692 9. Detterbeck FC et al. The IASLC Lung Cancer Staging Project: Background Data and Proposed Criteria to Distinguish Separate Primary Lung Cancers from Metastatic Foci in Patients with Two Lung Tumors in the Forthcoming Eighth Edition of the TNM Classification for Lung Cancer. Journal of Thoracic Oncology, Vol. 11, Issue 5, p651–665 10. Detterbeck FC 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. Journal of Thoracic Oncology, Vol. 11, Issue 5, p639–650 11. Nicholson AG 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. Journal of Thoracic Oncology, Vol. 11, Issue 3, p300–311
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