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THE NEW LUNG CANCER STAGE CLASSIFICATION. 강 창 현 서울대학교병원 흉부외과 서울대학교 의과대학. Communication. Evaluation. Staging. Treatment. Prognosis. Research. TNM based stage. AJCC (1977). UICC (1958). Collaboration since 1982. AJCC Cancer Staging Manual editions. References.
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THE NEW LUNG CANCER STAGE CLASSIFICATION 강 창 현 서울대학교병원 흉부외과 서울대학교 의과대학
Communication Evaluation Staging Treatment Prognosis Research
TNM based stage AJCC(1977) UICC(1958) Collaboration since 1982
References • T-descriptors JTO 2007 • N-descriptors JTO 2007 • M-descriptors JTO 2007 • Stage grouping JTO 2007 • Validation JTO 2007
References • SCLC (clinical staging) JTO 2007 • SCLC (pathological staging) JTO 2009 • Carcinoid tumors JTO 2008 • Additional prognostic factor JTO 2008 • IASLC nodal map JTO 2009
AJCC 7th edition • Based on staging project by IASLC • International multi-institute data • Internal and external validation
IASLC database Time Frame 1990 ~ 2000 Source of data 45 sources from 20 countries
Treatment modalities Surgery+ Chemo4% Surgery+ RT5% Tri-modality3% Chemo+ RT12%
Validation Internal External By Data source Geographical regions By SEER data 1998-2000 Literature review
Numbers analyzed • T descriptors 18,198 • N descriptors 28,371 • pN1 & pN2 2,876 • M descriptors 6,596 • SCLC (clinical) 8,088 • SCLC (Pathologic) 349 • Carcinoid tumor 513
T-descriptors • Cutpoints of tumor size • Malignant pleural effusion • Separate nodules • Other T2 descriptors • Other T3 descriptors • Other T4 descriptors
T1 learning set (n=2,284) T2 learning set (n=2607)
N-descriptors • Verification of N1, N2, & N3 • Location of involved LNs • Number of involved LN stations • Skip metastasis • Anatomical “zones”
Negative results • Peripheral specific LNs • Single specific LN zones • Presence of skip metastasisdid not had prognostic significance(except LUL with AP zone single metastasis)
Positive results? • N1a single N1 zone • N1b Multiple N1 zone • N2a Single N2 zone • N2b Multiple N2 zone
Overall disease burden, rather than anatomical location may have the most important influence on outcome
Suggestions • Six Nodal zones • Subdivision to 3 prognostic groups • N1a • N1b & N2a • N2b • No change of current N-descriptors
Discrepancy in nodal maps MD-ATS map(Mountain-Dresler modification of American Thoracic Society map) Naruke map(Japan Lung Cancer Society map) vs.
M-descriptors • Separate nodules • Same lobe • Same lung • Contralateral lung • Malignant pleural effusion • Distant metastasis • Site of interest (brain) • Single vs. multiple
Potential prognostic factors • Tumor characteristics • Patients characteristics • Laboratory parameters • Tumor biology
Changes in the 7th edition • Recommended for the classification of both NSCLC and SCLC and for carcinoid tumors • T classification • T1a (≤2cm) and T1b (>2-3cm) • T2a (>3-5cm) and T2b (>5-7cm) • T2 (>7cm) → T3 • Multiple tumor nodules in the same lobe → T3 • Multiple tumor nodules in the same lung → T4
Changes in the 7th edition • No changes in N classification • But new international nodal map was proposed • M classification • Malignant pleural or pericardial effusion → M1a • Separate tumor nodules in contralateral lung → M1a • M1b designates distant metastasis • MX designation has been eliminated
Limitations • Lack of detailed data in each descriptors • Too small numbers in specific category • Different lymph node maps • Biased distribution in treatment modality • Effect of treatment had not been considered
New IASLC Prospective project • Prospective data acquisition • International multi-institute study • Complete set of data • Including non-anatomical prognostic factors
Timetable • 2009-2010 Data collection • 2011-2012 Follow-up • 2013 Data analysis • Jan 2014 Submission of recommendations to UICC and AJCC • Jan – July 2014 Publication in JTO • 2016 Publication of 8th edition of TNM classification by the UICC and AJCC