LUNG CANCER: IASLC GLOBAL INITIATIVES
TUESDAY, SEPTEMBER 8, 2015 - 08:15-09:45
PLEN02.02 Revised (8th) Edition of TNM Staging System for Lung Cancer
Ramon Rami-Porta Thoracic Surgery, Hospital Universitari Mutua Terrassa, Terrassa/Spain
The changes introduced in the 7th edition of the tumour, node and metastasis (TNM)
classification for lung cancer derived from the analyses of the International Association
for the Study of Lung Cancer (IASLC) database. These analyses were conducted by
the members of the IASLC Staging and Prognostic Factors Committee (SPFC) and the
biostatisticians of Cancer Research And Biostatistics (CRAB). For the first time in the
history of the TNM classification for lung cancer, the 7th edition was based on a truly
international database of more than 80,000 evaluable patients collected in 45 different
sources in 20 countries and treated with all treatment modalities from 1990 to 2000. (1)
The changes recommended by the IASLC were accepted by the Union for International
Cancer Control (UICC) and by the American Joint Committee on Cancer (AJCC) and were
eventually published in their staging manuals. With this involvement of the IASLC in the
revision of the TNM classification for lung cancer, the IASLC became the most important
provider of data to the UICC and the AJCC for future editions of the classification. A
similar process was used for the revision of the 7th edition into the 8th edition. The IASLC
made an international call for submission of more data to the IASLC database. (2) The
resulting international contribution amounted to more than 77,000 evaluable patients
diagnosed with either non-small cell lung cancer (70,967 patients) or small cell lung
cancer (6,189 patients) from 1990 to 2010. They were submitted from 35 different
databases located in 16 countries in Europe, Asia, North and South America, and
Australia. (3) The different subcommittees of the Lung Cancer Domain of the IASLC SPFC
were in charge of analysing the data pertaining to the T, the N and the M component of the
classification, as well as the stages and the small cell lung cancer. For the T component,
the prognostic impact of the T descriptors was analysed in five different populations:
pT1-4N0M0R0, pT1-4anyNM0R0, pT1-4anyNM0anyR, i.e., including incomplete
resections, either microscopically incomplete, R1, or macroscopically incomplete, R2;
and cT1-4N0M0 and cT1-4anyNM0. Survival analyses were completed with univariate
and multivariate analyses adjusted by histological type, gender, region and age. The
main results showed that the capacity of tumour size to separate tumours of different
prognosis was greater than that shown in previous analyses, and that its influence could
be spread to all T categories; the role of visceral pleura invasion as a T2 descriptor
was confirmed; the prognostic impact of endobronchial location less than 2 cm from
the carina (T3 in 7th edition) and of total atelectasis/pneumonitis (T3 in 7th edition) was
found to be similar to that of their T2 counterparts; diaphragm invasion was found to
have worse prognosis than that of other T3 descriptors; and mediastinal pleura invasion
was found to be scarcely used as a T descriptor. (4) For the N component, the present N
descriptors (N0, N1, N2 and N3) were found to separate tumours of different prognosis
in clinically and pathologically (both in the R0 and any R populations) staged tumours.
The impact of tumour burden in the lymph nodes could also be assessed when survival
was analysed according to the number of nodal stations, but this could only be analysed
in the population of patients who had undergone tumour resection and systematic nodal
dissection, and could not be validated at clinical staging. (5) For the M component, the
7th edition M1a descriptors were validated, as all showed similar survival. However,
when the M1b descriptors were analysed in detail, single metastasis (one metastasis
in one organ) had better prognosis than multiple metastases in one or several organs.
(6) Table 1 shows the changes recommended by the IASLC SPFC based on the analyses
of the new IASLC database. The described changes implied some modifications in the
stage grouping, creating more stages for early and advanced disease, (7) and were
also applicable to small-cell lung cancer. (8) The IASLC recommendations emphasize the
prognostic impact of tumour size; simplify the T descriptors by combining some of them;
maintain the current N descriptors; separate tumours with single metastasis in a distinct
group; and establish more stage groupings to refine prognosis based on anatomic
extent of disease. They improve our capacity to indicate prognosis, which is one of the
objectives of the TNM classification, and, therefore, they should be implemented in the
8th edition of the TNM classification. Table 1
References
1. Goldstraw P, Crowley JJ. The International Association for the Study of Lung Cancer international staging project on lung cancer. J Thorac Oncol 2006; 1: 281-286.
2. Giroux DJ, Rami-Porta R, Chansky K et al. The IASLC Lung Cancer Staging Project: data elements for the prospective project. J Thorac Oncol 2009; 4: 679-683.
3. Rami-Porta R, Bolejack V, Giroux DJ et al. The IASLC Lung Cancer Staging Project: the new database to inform the 8th edition of the TNM classification of lung cancer. J Thorac Oncol 2014; 9: 1618-1624.
4. 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 eighth edition of the TNM classification for lung cancer. J Thorac Oncol 2015;10:990-1003.
5. Asamura H et al. J Thorac Oncol 2015; in preparation.
6. Eberhardt WEE et al. J Thorac Oncol 2015; in preparation.
7. Golstraw P et al. J Thorac Oncol 2015; in preparation. 8. Nicholson AG et al. J Thorac Oncol 2015; in preparation.
Keywords: TNM classification, lung cancer, lung cancer staging
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