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13th Annual Congress Turkish Thoracic Society Istanbul, May 2010

13th Annual Congress Turkish Thoracic Society Istanbul, May 2010. The 7th Edition of TNM for Lung Cancer. Peter Goldstraw, Consultant Thoracic Surgeon, Royal Brompton Hospital, Professor of Thoracic Surgery, National Heart and Lung Institute, Imperial College, London, UK.

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13th Annual Congress Turkish Thoracic Society Istanbul, May 2010

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  1. 13th Annual CongressTurkish Thoracic SocietyIstanbul, May 2010 The 7th Edition of TNM for Lung Cancer Peter Goldstraw, Consultant Thoracic Surgeon, Royal Brompton Hospital, Professor of Thoracic Surgery, National Heart and Lung Institute, Imperial College, London, UK.

  2. Turkish translations in preparation.

  3. TNM Atlas: Colour in Manual, Halftone in Handbook.

  4. What has changed in the 7th Edition? • First revision in 12 years, most radical since 1975! • The process of change: • IASLC now has a central role. • Based on IASLC International data base: • >100,000 cases. • Short accrual, stable staging algorithm. • 46 sources in > 20 countries around globe. • Treated by all modalities of care. • Intensive validation. • Proposals widely publicised in Journal of Thoracic Oncology.

  5. Summary of Changes to Descriptors (1). • T1 sub-classified: • T1a tumours ≤ 2 cms. • T1b tumours > 2 cms and ≤ 3 cms. • T2 sub-classified: • T2a tumours > 3cms and ≤ 5cms. • T2b tumours > 5 cms and ≤ 7 cms. • Reclassify T2 tumours > 7 cms as T3. • Reclassify T4 tumours due to additional tumour nodules in the primary lobe as T3. • Reclassify M1 due to additional tumour nodules in other ipsilateral lobe(s) as T4.

  6. Summary of Changes to Descriptors (2). • Retain current N classification. • Reclassify T4 tumours due to malignant pleural effusion as M1, create M1a category. • Reclassify M1 due to additional tumour nodules in the contralateral lung as M1a. • Reclassify M1 due to distant metastases as M1b.

  7. Stage Groupings in 6th and 7th Editions of TNM = Change in Classification

  8. Overall survival, expressed as a median survival time (MST) and 5-year survival, by clinical stage using the sixth edition of TNM (A) and 7th edition (B). Goldstraw et al. J Thorac Oncol 2007;2:706-714

  9. Overall survival, expressed as a median survival time (MST) and 5-year survival, by pathologic stage using sixth edition of TNM (A) and 7th edition (B) Goldstraw et al. J Thorac Oncol 2007; 2:706-714.

  10. Additional Recommendations: • Role of TNM in SCLC confirmed, and its use in SCLC re-emphasised in the 7th edition. • Carcinoid Tumours included for the first time in the 7th edition. • A New International Nodal Chart agreed, “the recommended means of describing regional lymph node involvement for lung cancers”. • A uniform definition of “Visceral Pleural Invasion” has been provided in the 7e. • Additional “Proposals for Testing”.

  11. After Hammar SP. Common Tumors. In:Pulmonary Pathology. 2 ed. New York: Springer-Verlag; 1994 p. 1138.

  12. IASLC Nodal Chart Reconciled “Naruke” and “Mountain/Dresler” Nodal Charts. “Oncologic” midline in superior mediastinum moved from the anatomic midline. Incorporating concept of “Nodal Zones”.

  13. Completeness of resection. R0:Complete Resection. All of the following are satisfied: a) Resection margins confirmed to be clear on microscopy. b) Six nodes/nodal stations removed/sampled for histological examination. These should include 3 nodes/stations from the mediastinum, one of which should be sub-carinal node #7 and 3 nodes/stations from the hilum or other N1 locations *. *If all resected/sampled lymph nodes are negative, but the number recommended is not met, classify as pN0. If resection has been performed, and otherwise fulfils the requirements for complete resection, it should be classified as R0.

  14. Completeness of resection • A new category,“R0(un)”, is proposed: • No macroscopic or microscopic evidence of residual • disease but either of the following reservations apply: • Nodal assessment has been based on less than the • number of nodes/stations recommended for resection. • ii) The highest mediastinal node removed/sampled • is positive. Rami-Porta et al, Lung Cancer, 2005;49:25-33.

  15. Additional Tumour Nodules. In most situations in which additional tumour nodules are found in association with a lung primary these are metastatic nodules, with identical histological appearances to that of the primary tumour. If limited to the lobe of the primary tumour such tumours are classified as T3, when found in other ipsilateral lobes are designated as T4 and if foundin the contralateral lung are designated M1a.

  16. Multiple Primary Tumours. Multiple tumours may be considered to be synchronous primaries if they are of different  histological cell types. Multiple tumours of similar histological appearance should only be considered to be synchronous primary tumours if in the opinion of the pathologist, based on features such as differences in morphology, immunohistochemistry and/or molecular studies, or, in the case of squamous cancers, are associated with carcinoma in situ, they represent differing sub-types of the same histopathological cell type. Such cases should also have no evidence of mediastinal nodal metastases or of nodal metastases within a common nodal drainage.

  17. “V” Classification. In the lung, arterioles are frequently invaded by cancers. For this reason the V classification is applicable to indicate vascular invasion, whether venous or arteriolar.

  18. What has been retained from 6th Edition ? • Prognostic importance of: • 3cm split point • Visceral pleural invasion • Bronchial extent • Atelectasis/obstructive pneumonitis • Invasion of adjacent structures, especially in T3/T4 split • Nodal categories N0-3. • Caveats regarding superficial bronchial tumour and “non-malignant” effusion.

  19. Prospective Data Set: Objectives. • Correct geographical and treatment biases in retrospective data base. • Validate or refute “not proven” descriptors. • Infrequent descriptors e.g. atelectasis, bronchial. • Inter-relationship VPI with size. • Local invasion e.g. T3-T4 split. • Validate or refute “proposals for testing”. • Expand project to include neuro-endocrine tumours, mesothelioma, thymoma, etc. Giroux DJ et al, JTO, 2009;4:679-683.

  20. If you are interested in participating: information@crab.org “IASLC Staging Project” in subject line. We have finalised the prospective data set, have developed a web-based system for data collection, have obtained funding for the next cycle and are selecting database partners. We hope that members of the IASLC and colleagues in Japan will continue to support this next phase of the project.

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