Evolution of Staging in Lung Cancer

Transcription

1 AATS Annual Meeting, Toronto, General Thoracic Session. Evolution of Staging in Lung Cancer Peter Goldstraw, Honorary Consultant Thoracic Surgeon, Royal Brompton Hospital, Emeritus Professor of Thoracic Surgery, Imperial College, London, UK. President, International Association for the Study of Lung Cancer.

2 Disclosures I received an honorarium for attending an Advisory Board for Siemens.

3 Pierre Denoix Surgical Oncologist, IGR, Paris. Director IGR Developed the TNM classification in a series of articles President of the UICC

4 History of the UICC and Cancer Staging. Union Internationale Contre le Cancer (UICC) founded in Paris 1934, now the Union for International Cancer Control. In 1954 accepted TNM as the basis for its Classification by Anatomical Extent of Disease UICC published 9 brochures with TNM proposals for 23 sites (lung in 1966). Proposals by consensus, not data driven.

5 TNM Staging for Lung Cancer : Brochures combined into the Livre de Poche, the UICC 1 st edition of TNM Classification of Malignant Tumours. Lung included under other sites. T1 T4, progressive involvement of lung tissue/bronchii. NX, N0 and N1 (intrathoracic nodes) included hilar or peripheral lymph nodes. M0 or M1a (pleural effusion cy +ve), M1b (palpable cervical nodes) or M1c (distant metastases). No stage groupings established at that time.

6 TNM Staging for Lung Cancer. American Joint Committee on Cancer Staging and End Results Reporting (AJC) founded 1959, became the AJCC in Re-focussed US participation away from the UICC structure with risk of a loss of uniformity. Accord between UICC and AJC reached at meeting in Toronto, November, Consultation agreed between the parties prior to future revisions.

7 Harmonization of Timelines UICC 1 st Edition nd Edition rd Edition 1978 revised 3rd Edition 1982 AJC/AJCC 1 st Edition nd Edition th Edition rd Edition th Edition th Edition th Edition th Edition th Edition th Edition th Edition 2009

8 TNM Staging for Lung Cancer. In 1973 the AJC Task Force on Lung Cancer asked Drs Mountain, Carr and Anderson to develop a database for the purposes of informing a TNM-based system for the classification of lung cancer.

9 A System for the Clinical Staging of Lung Cancer Collected 2,155 cases (1,712 NSCLC) diagnosed > 4 yrs Highest T category reduced to 3, incorporated pleural effusion. Highest No N category data increased presented to 2 to accomodate mediastinal nodes. M1 for cervical & contralateral nodes and distant metastases Many of the to T,N,M validate descriptors in use today any were incorporated: 3cm size, bronchoscopic limit, atelectasis/pneumonitis, pleural of these effusion, direct descriptors! invasion of chest wall/ diaphragm, mediastinum and contents, 0 and x categories. Aggregated data only for T, N and M categories, TNM subsets and stage groupings. Mountain CF, Carr DT, Anderson WAD, Am J Roentgenol, Rad Ther Nucl Med, 1974,120:

10 TNM Staging for Lung Cancer database: Stage Groupings developed, I, II and III. Stage I: T 1 N 0 M 0 T 2 N 0 M 0 T 1 N 1 M 0 Stage II: 7/18 TNM sets < 100 cases, as few as 24 cases, another 4 sets too few for analysis. T 2 N 1 M 0 Stage III: any T with N 2, any N with T 3, any T or N with M 1

11 TNM Staging for Lung Cancer : UICC 2 nd edition of TNM Classification of Malignant Tumours incorporated these proposals. 1977: AJC published 1 st Edition of its Manual for Staging of Cancer, incorporating the recommendations of its Task Force, Added VPI as T2 descriptor. 1983: AJCC published 2 nd Edition without change.

12 A New International Staging System for Lung Cancer. New database, , > 24 mo follow-up. 3,753 cases (2,749 treated at MD Anderson). Changes in Descriptors: Superficial tumours, invasion limited to bronchial wall added to T1, irrespective of bronchial location. Cytology ve pleural effusions ignored in allocating T category. old N2 divided into new N2 and an N3 category. old T3 divided into new T3 and a T4 category. T 1 N 1 M 0 moved to stage II Stage III divided into IIIA and IIIB Stage IV added Mountain, Chest, 1986;89:225s-233s.

13 These proposals formed the basis of the UICC 4 th Ed published in 1987 and the AJCC 3 rd Ed published in The AJCC published the 4 th Edition of a Manual for Staging of Cancer in There were no changes for Lung Cancer (Pleural Mesothelioma was added to a section on Thorax ).

14 Revisions in the International System for Staging Lung Cancer. Mountain data base expanded to 5,319 cases. Changes proposed to stage groupings: Stage I divided. IA - T 1 N 0 M 0. IB - T 2 N 0 M 0. Stage II divided: IIA T 1 N 1 M 0. IIB - T 2 N 1 M 0. Included T 3 N 0 M 0 in IIB. Mountain, Chest, 1997;111:

15 TNM Staging for Lung Cancer. 5th edition in 1997: Changes in descriptors. - satellite tumor nodule(s) in the ipsilateral primary-tumor lobe of the lung added to T4. - Separate metastatic tumor nodule(s) in the ipsilateral nonprimary-tumor lobe(s) of the lung also are classified as M1. No data presented to validate these proposals!

16 Mountain Database Relatively small dataset (5,319 in 1997). Insufficient to validate any of the descriptors. Some descriptors challenged from other databases. Increasingly historical (started in 1975). No Validation! Single centre, not International. Reflects one type of practise in the USA. Relevance to most of the World? Surgically orientated. Relevance to the vast majority of cancer cases?

17 IASLC Staging Project Pump-priming funds from IASLC. Global multi-speciality membership. Links to UICC, AJCC, JLCS etc. Philanthropic funding from Pharma. Data collection and analysis by CRAB. 100,000 cases. 46 sources in > 20 Countries. All modalities of care. Short accrual, stable staging algorithm. Extensive internal and external validation. All proposals published in JTO in advance.

18

19 Summary of Changes in 7 th Edition of TNM T1 and T2 sub-divided into a and b : 3cms retained, new cut-points of 2 cms, 5 cms Size > 7 cms now a T3 descriptor. Reclassify tumours with ATNs (pulmonary metastases) in ipsilateral lobe(s): T3 in lobe of primary T4 in other ipsilateral lobe(s). Retain validated N categories unchanged. Create M1a category for malignant effusions and contralateral pulmonary metastases. Create M1b for extra-regional disease.

20 Stage Groupings in 6th and 7th Editions of TNM = Change in Classification T and M descriptors N0 N1 N2 N3 6 th Edition 7 th Ed Stage Stage Stage Stage T1 (<= 2cm) T1a IA IIA IIIA IIIB T1 (> 2 3 cm) T1b IA IIA IIIA IIIB T2(> 3-5cm) T2a IB IIA IIB IIIA IIIB T2 (> 5-7cm) T2b IIA IB IIB IIIA IIIB T2 (> 7cm) IIB IB IIIA IIB IIIA IIIB T3 invasion T3 IIB IIIA IIIA IIIB T4 (same lobe nodules) IIB IIIB IIIA IIIB IIIA IIIB IIIB T4 (extension) IIIA IIIB IIIA IIIB IIIB IIIB T4 M1 (ipsilateral lung) IIIA IV IIIA IV IIIB IV IIIB IV T4 (pleural effusion) IV IIIB IV IIIB IV IIIB IV IIIB M1 (contralateral lung) M1a IV IV IV IV M1 (distant) M1b IV IV IV IV

21 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.

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

23 Future Revisions of TNM in Lung Cancer and other Thoracic Malignancies? Increasingly driven by prospective data. T size cut points will proliferate. Classification of ATNs will stratify by multiplicity. Prognostic impact of VPI will sub-divide by tumour size and depth of invasion. N classification will evolve, less emphasis on anatomical site, more on burden of disease, perhaps zones, number of nodes involved. TNM will remain anatomical extent of disease. Composite Prognostic Index will include increasing number of factors esp biologicals.

24 8 th Edition of TNM All proposals will be first published in JTO , free to members of IASLC. IASLC will submit proposals to UICC/AJCC late Publication presently scheduled for late 2016 (WCLC 2016 in Vienna). IASLC educational products available at WCLC Vienna, free/discounted for members. To be enacted January 2017.

25