LUNG CANCER the new Staging System G.KIROVA TOKUDA HOSPITAL SOFIA

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1 LUNG CANCER the new Staging System G.KIROVA TOKUDA HOSPITAL SOFIA

2 STAGING SYSTEM Provides standardized nomenclature for exchanging information Groups patients according to the biologic behavior of their tumors Aids stratification of patients on the basis of different treatment strategies Enables evaluation of treatment strategies Defines patients prognosis

3 MAIN CHANGES 7 th Edition 9 new classifications 6 main changes Мх elimination Parallel anatomic and prognostic staging

4 9 new classifications MAIN CHANGES 7 th Edition Melanoma GI carcinoma GIST Appendix carcinoma Neuroendocrine tumors: stomach, bowels, appendix, lung Intrahepatic cholangiocarcinoma Merkel cell carcinoma Sarcoma uteri Suprarenal cancer 6 big Esophagus Stomach Lung Skin Cervix Prostate

5 MAIN CHANGES 7 th Edition Elimination of category Мх смх could not exist (could not be proved) рмх does not exist рм0 does not exist (except after autopsy) см0 = clinically without metastasis; cm0 instead pm0 in case of negative biopsy result from an existing lesion см1 = clinically proved metastasis рм1 = pathologically proved metastasis (p.ex. cut biopsy)

6 MAIN CHANGES 7 th Edition Esophagus Stomach 6 big Lung Skin Cervix Prostate

7 TREATMENT POLICY Primary methods of lung cancer staging Clinical (non-invasive and minimally invasive) Pathological Clinical vs pathological staging (level of agreement 35% vs 55%) Lung resection as the only curative treatment for lung cancer The goal of the preoperative evaluation is to not preclude patients from attempting surgical resection Pathological staging as a reference standard Lopez-Encuentra et al; Comparison between clinical and pathological staging in 2994 cases of lung cancer; Ann Thor Surg 2005;79:

8 2 nd, 3 rd and 4 th Editions of TNM classifiation (lung cancer) American Join Committee on Cancer Union Internationale Contre le Cancer 2155 cases; MD Anderson Cancer Center; Texas І stage Т 1-2 N 0 М0 ІІ stage Т 1-2 N 1 М0 Clifton F. Mountain ІІІ А stage ІІІ Б stage ІV stage Т 1-3 N 2 М0 Т 3 N 0-1 M0 any Т N 3 M0 Т 4 any N М0 any Т any N М1

9 4 th Edition ТNM classification (lung cancer) N1 N2 Tsuguo Naruke Naruke map Mountain-Dressler ATS map

10 5 th Edition ТNM classification (lung cancer) th Edition TNM classification (lung cancer) pts North Am; Improvement in grouping of pts with similar prognosis Limitations Selected population of pts One geographic region No results validation 5319 pts Stage Occult carcinoma Tх N0 M0 Stage 0 Тis N0 M0 Stage І А T1 N0 M0 Stage І В T2 N0 M0 Stage ІІ А T1 N1 M0 Stage ІІ В T2 N1 M0 T3 N0 M0 Stage ІІІ А T1 N2 M0 T2 N2 M0 T3N1-2 M0 Stage ІІІ В any T N3 M0 Т4 any N M0 Stage ІV any Т any N M1

11 7 th Edition ТNM lung cancer 2009 International Staging Project on Lung Cancer Peter Goldstraw International Association for the Study of Lung Cancer (IASLC)

12 The IASLC Lung Cancer Database Summary of Cases Contributed to Project ( ) Total cases submitted 100,869 Excluded from analyses 19,854 Outside of time frame 5,443 Incomplete survival data 1,505 Unknown histology 2,468 Incomplete stage information 7,720 Recurrent cases and other exclusions 1,603 Carcinoids, sarcomas and other histologies 1,115 Included in analyses 81, pts fulfilled the inclusion criteria 20 countries; Asia, Europe, N.America, Australia 45 different databases Small Cell Lung Cancer (and mixed SCLC/NSCLC) 13,290 Non-Small Cell Lung Cancer 67, Clinical Trial Surgical Series Updated from: Goldstraw P, Crowley JJ. The International Association for the Study of Lung Cancer International staging project on lung cancer. J Thorac Oncol 2006; 1: Surgical Registry

13 The IASLC Lung Cancer Database Clinical Stage Distribution by Continent, Non-small Cell Lung Cancer 53,646 Cases I II III IV Europe Australia N. America Asia Cancer Research and Biostatistics (CRAB) Seattle, Washington, USA Internally validated by geographic region and type of database Externally validated by being tested against the Surveillance, Epidemiology and End Results registries Surgery + Chemo 4% Chemotherapy 21% Surgery 36% Surgery + Chemo + RT 3% Chemo + RT 12% Surgery + RT 4% RT 11%

14 NSCLC changes T Size Simultaneous nodule N New LN map M Malignant pleural effusion SCLC staging strategy Carcinoid tumors New preoperative functional assessment WHAT S NEW?

15 T descriptors <2cm = T1a 5y sv 77% 2-3cm = T1b 5y sv 71% 3-5cm = T2a 5y sv 58% 5-7cm = T2b 5y sv 49% >7cm = T3 5y sv 35% Tumor sze - A 2cm cutpoint subdivides T1a and T1b - A 5cm cutpoint subdivides T2a and T2b Rami-Porta R et; J Thor Oncol 2007;2:

16 T2a vs T2b (cut-point 5cm) T1a vs T1b (cut-point 2cm)

17 T descriptors Satelite nodules Previously: T4 Previously: M1 The presence of satellite nodules in the same lobe as the primary tumor is now T3 The presence of an ipsilateral nodule in a different lobe is now T4

18 N descriptor No changes have been made in the N descriptor as defined in the previous TNM staging system IASLC International Staging Committee has developed a new node map: - UPPER ZONE: stations 1 to 4 - AORTOPULMONARY ZONE: stations 5 and 6 - SUBCARINAL ZONE: station 7 - LOWER ZONE: stations 8 and 9 - HILAR ZONE: stations 10 and 11 - PERIPHERAL ZONE: stations 12 to 14

19 Survival analysis by the number of involved nodal zones: Single N1 (48%) Multiple N1 or single N2 (35%/34%) Multiple N2 (20%) Multilevel N2 disease not recommended for primary surgical resection Sakao Ann Thor Surg 2006

20 M descriptors The M descriptor defines the extent of spread to distant sites: Mo: No distant metastasis M1a: Separate tumor nodules in a contralateral lobe or tumor with pleural nodules or malignant pleural dissemination. M1b: Distant metastasis

21 M1a nodule in contralateral lung Previously: T4 M1a pleural metastases Previously: T4

22 M1b distant (extrathoracic) metastases Previously: M NB! Paraneoplastic syndrome is not accepted as a metastatic process and is not a contraindication for surgical treatment

23 SCLC Veterans Administration Lung Study Group (VALSG) IASLC IASLC/UICC, 7 th edition histology at initial presentation; adequate staging information at baseline; adequate follow-up cases

24 VI vs VII Edition

25 CO-MORBIDITIES Decreased performance status was associated with an increased mortality and was shown to be an independent significant factor in determining survival PE Cardiac diseases Lung diseases Emphysema COOPD Second primary tumor preliminary cardiologic screening systematic measurement of the diffusing capacity for carbon monoxide (DLCO) A Charloux et al; Lung function evaluation before surgery in lung cancer patients: how are recent advances put into practice? A survey among members of the European Society of Thoracic Surgeons (ESTS) and of the Thoracic Oncology Section of the European Respiratory Society (ERS)

26 Conclusions The revised staging system Is more accurately correlated with survival when compared with the prior staging system Is more closely reflected trends in both definitive and paliative treatment The Future Follow up of the present data basis 8th Edition 2016 Prospective analysis (prognostic information based on the tu biology and tu genetics; implication of imaging) 9th Edition 2023

27 All treatment decisions in oncology practice are based on the available prognostic data

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