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C. Herold
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IA05 - The Practical Use of the TNM Classifications for Thoracic Cancers (ID 291)
- Event: WCLC 2016
- Type: Interactive Session
- Track: Radiology/Staging/Screening
- Presentations: 4
- Moderators:H. Asamura, C. Herold
- Coordinates: 12/06/2016, 11:00 - 12:30, Hall C7
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IA05.01 - Lung Cancer Cases (ID 6524)
11:00 - 12:30 | Author(s): G. Lyons
- Abstract
- Presentation
Abstract:
The definition of staging in Lung Cancer is the determination of the anatomic extent of three tumor components: the primary tumor (T), the lymph nodes (N), and the metastases (M). Their accurate evaluation allows grouping patients in stages that is one, and perhaps the single most important, of several prognostic factors that guide the appropriate treatment option(s) to offer the patient. The clinical classification cTNM (Pre-treatment clinical classification), is based on evidence acquired before treatment The pathological classification pTNM (Post-surgical histopathological classification), is based on the evidence acquired before treatment, supplemented or modified by the additional evidence acquired from surgery and from pathological examination. A minimum number of tests is not required to define the extent of the disease, but it’s very clear that as more exhaustive the explorations more accurate and precise the staging will be. This may be strongly affected by the availability of physical and human resources, multidisciplinary work and adherence to clinical practice guidelines. After the changes proposed by the new IASLC-ATS-ERS lung adenocarcinoma classification and the IASLC proposals for revision of the T, N and M descriptors and stage groupings in the forthcoming (Eighth) edition of the TNM Classification for Lung Cancer, we must incorporate this new information into our clinical practice. (1, 2) The changes that The IASLC Staging Committee recommends for the T, N and M components and the resulting new stage grouping and their survival are summarized in table 1 and figure 1. The main changes in T components are the relevance of the size of the tumor for each cm, grouping of the involvement of the main bronchus or partial and total atelectasis or pneumonitis as a T2 descriptor and the reclassification of diaphragm invasion as T4. (3) N component remains without changes. (4) In M component a new M1b category includes patients with a single metastatic lesion in a single organ site and a new M1c category was introduce for patients with multiple lesions in a single organ or multiple lesions in multiple organs. (5) Some new stage groupings are proposed. The new size cut points of T1-N0-M0 tumors has been assigned to stage IA1, IA2, and IA3. The new stage IIIC (T3 and T4-N3-M0) reflects their worse outcome. Finally, stage IV disease has been divided into IVA (M1a, M1b) and IVB (M1c). The new IVA stage grouping should be used in trials analyzing patients with oligo-metastasis or pleural or pericardial disease. (2) For the newly described types of adenocarcinoma of the lung, The IASLC recommends incorporating the coding of AIS as Tis (AIS) and of MIA as T1mi into the traditional TNM classification. For part-solid tumors, the size of the invasive component should be used to assign a T category, but the whole tumor size should also be recorded. However, the measurements will be influenced by a number of observer-dependent and technical factors. It is important to perform the measurements for clinical staging on contiguous thin CT sections reconstructed with a high-resolution algorithm with multiplanar reconstruction. (6) For pathologic staging, attention should be given to the assessment of invasive and lepidic components. It can be helpful to correlate microscopic findings with measurements made on gross examination, particularly in inflated specimens or with CT findings. Patients who present with more than one pulmonary site of lung cancer may represent different patterns of disease as synchronous primary lung cancers, those with a separate solid tumor nodule(s) (intrapulmonary metastases), multifocal lung cancer presenting as multiple nodules with ground glass/lepidic features, and diffuse pneumonic-type adenocarcinoma. It is proposed that the T category of patients presenting ground glass/lepidic (GG/L) tumors be classified using the T category of the highest T lesion and in parentheses either the number of GG/L tumors or simply m for multiple (#/m). A single N and M category is assigned for all GG/L tumors combined. (7) Both clinical information (the presence of additional lesions identified by imaging) and the pathologic information (from resected lesions) should be used to determine the TNM classification. Lesions smaller than 5 mm or AAH are not counted. The pneumonic type of adenocarcinoma should be classified according to the size of the area of lung involved, or as T4 or M1a in the case of involvement of more than one lobe (i.e., either ipsilateral or contralateral). A single N and M category is assigned. In patients with separate tumor nodules (intrapulmonary metastases), it is proposed that the seventh edition classification of same-lobe nodules as T3, same side (different lobe) nodules as T4, and other-side nodules as M1a be carried forward. (8) It is easier to establish that two pulmonary foci of cancer are separate primary tumors than that they are metastatic from one another. Few features are sufficiently reliable by themselves, such as different histologic type and differences by a comprehensive histologic assessment of resected specimens or by matching breakpoints by DNA sequencing. Most criteria can be suggestive, but are associated with potential misclassification. These include biomarker patterns, imaging characteristics, and the presence or absence of nodal involvement. The fact that generally only biopsy specimens are available at the time of clinical decision making further adds to the uncertainty and difficulty of the assessment. A constellation of factors is better than any single factor; it is best to make a determination of separate primary versus metastatic lesions through a collective judgment of a multidisciplinary tumor board after taking into account all of the available information. (9) Synchronous primary cancers are classified with a T, N, and M category for each tumor; separate tumor nodules result in a T3, T4, or M1a category depending on the separate nodule’s location relative to the primary tumor. (10) Despite these proposals of staging, there will always be areas of difficulty and tumors that are challenging to classify. The prognostic value of clinical and pathological TNM staging in patients with SCLC was also confirmed, and the continued usage is recommended for SCLC in relation to proposed changes to T, N, and M descriptors for NSCLC in the eighth edition. (11) Table 1 Descriptors and T and M categories in the seventh edition and as proposed for the eighth edition. Figure 1 *Where there is a change, the resultant stage groupings proposed for the eighth edition are in bold, and the stage in the seventh edition is given in parenthesis. Figure 1 Overall survival by clinical and pathological stage according to the proposed eighth edition groupings using the entire database available for the eighth edition. Figure 2References: 1. Travis WD, et al. The New IASLC/ATS/ERS international multidisciplinary lung adenocarcinoma classification. J Thorac Oncol. 2011;6: 244–285. 2. Goldstraw P et al. The IASLC Lung Cancer Staging Project: Proposals for Revision of the TNM Stage Groupings in the Forthcoming (Eighth) Edition of the TNM Classification for Lung Cancer Journal of Thoracic Oncology, Vol. 11, Issue 1, p39–51 3. Rami-Porta R 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. Journal of Thoracic Oncology, Vol. 10, Issue 7, p990–1003 4. Asamura H et al. The International Association for the Study of Lung Cancer Lung Cancer Staging Project: Proposals for the Revision of the N Descriptors in the Forthcoming 8th Edition of the TNM Classification for Lung Cancer. Journal of Thoracic Oncology, Vol. 10, Issue 12, p1675–1684 5. Eberhardt W E.et al. The IASLC Lung Cancer Staging Project: Proposals for the Revision of the M Descriptors in the Forthcoming Eighth Edition of the TNM Classification of Lung Cancer. Journal of Thoracic Oncology, Vol. 10, Issue 11, p1515–1522 6. Travis WD, et al. The IASLC Lung Cancer Staging Project: Proposals for Coding T Categories for Subsolid Nodules and Assessment of Tumor Size in Part-Solid Tumors in the Forthcoming Eighth Edition of the TNM Classification of Lung Cancer. Journal of Thoracic Oncology, Vol. 11, Issue 8, p1204–1223 7. Detterbeck FC et al. The IASLC Lung Cancer Staging Project: Background Data and Proposals for the Application of TNM Staging Rules to Lung Cancer Presenting as Multiple Nodules with Ground Glass or Lepidic Features or a Pneumonic Type of Involvement in the Forthcoming Eighth Edition of the TNM Classification. Journal of Thoracic Oncology, Vol. 11, Issue 5, p666–680 8. Detterbeck FC et al. The IASLC Lung Cancer Staging Project: Background Data and Proposals for the Classification of Lung Cancer with Separate Tumor Nodules in the Forthcoming Eighth Edition of the TNM Classification for Lung Cancer. Journal of Thoracic Oncology, Vol. 11, Issue 5, p681–692 9. Detterbeck FC et al. The IASLC Lung Cancer Staging Project: Background Data and Proposed Criteria to Distinguish Separate Primary Lung Cancers from Metastatic Foci in Patients with Two Lung Tumors in the Forthcoming Eighth Edition of the TNM Classification for Lung Cancer. Journal of Thoracic Oncology, Vol. 11, Issue 5, p651–665 10. Detterbeck FC et al. The IASLC Lung Cancer Staging Project: Summary of Proposals for Revisions of the Classification of Lung Cancers with Multiple Pulmonary Sites of Involvement in the Forthcoming Eighth Edition of the TNM Classification. Journal of Thoracic Oncology, Vol. 11, Issue 5, p639–650 11. Nicholson AG et al. The International Association for the Study of Lung Cancer Lung Cancer Staging Project: Proposals for the Revision of the Clinical and Pathologic Staging of Small Cell Lung Cancer in the Forthcoming Eighth Edition of the TNM Classification for Lung Cancer. Journal of Thoracic Oncology, Vol. 11, Issue 3, p300–311
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IA05.02 - Mesothelioma Cases (ID 6525)
11:00 - 12:30 | Author(s): M.A. Hoda
- Abstract
- Presentation
Abstract:
Malignant pleural mesothelioma (MPM) is a highly lethal malignancy arising from the serosal lining of the pleural cavity [1]. In up to 80% of patients, asbestos is considered to contribute to the development of this tumor within about 20 to 40 years of exposure time [2]. The incidence of MPM is expected to increase dramatically over the next few decades. It has been estimated that 250 000 people will die of MPM in Europe in the next three decades, and 2500–3000 new cases are diagnosed each year in the USA [3]. The macroscopic appearance of MPM depends on disease stage. In early stage MPM, the cancer presents as multiple small nodules on the surface of both pleural linings. In advanced stages, the multiple small nodules form a tumor plate which surrounds the lung like a cage and in most cases invades the lung parenchyma, diaphragm and pericardium [4]. The establishment of the pathological diagnosis of MPM and the classification in three main histological subtypes (namely epitheloid, biphasic and sarcomatoid) is important and has an impact on therapy and prognosis. Epitheloid MPM is more therapy responsive and associated with better outcome compared to biphasic and sarcomatoid histotypes. Other very important simple prognostic factors for MPM are disease stage and lymph node involvement. Therefore an adequate staging of MPM patients is crucial for therapy decision-making. The currently widely used staging system is the one according to International Mesothelioma Interest Group (IMIG) established in 1996 [5]. Based on the TNM (tumor-node-metastasis) system for malignant tumors, this staging system describes: the extent and size of the primary tumor, lymph node involvement and distant metastases. By the different TNM descriptors, MPM can be classified and summarized in four different tumor stages (IMIG I-IV). Patients suffering from stage I-III are considered for surgery within multimodality protocols, while palliative systemic or local treatment is indicated for stage IV in accordance with the current classification. Butchart et al. [6]proposed in 1976 an alternative staging system, referred to as the Butchart Staging. Contrary to the IMIG system (based on lung cancer staging) the Butchart system is particularly set up for MPM. Therefore, several differences between both staging systems exist. However, the IMIG in collaboration with the International Association for the Study of Lung Cancer (IASLC) have proposed a new T, N and M descriptors for in the forthcoming 8[th] edition of the TNM classification for MPM with significant changes to the 7[th] TNM edition and proposals have been very recently published [7-9]. With regard to the T descriptor, a fusion of both, clinical and pathological T1a and T1b into a T1 was recommended [7]. Regarding the N descriptor, a summary of the clinical and pathological N1 and N2 categories into a single category with the classification into ipsilateral, intrathoracic nodal metastases (N1) was proposed [8]. No changes have been recommended for the M descriptor in the 8[th] edition of the TNM [9]. In this presentation, 4 patient cases of different stages of MPM patients will be presented and the newly proposed TNM descriptors and IMIG staging will be applied. Cases and changes in the staging system will be discussed together with the attending audience in an interactive manner. After the presentation, the participants will be able to understand and practically apply the forthcoming changes in the TNM system for staging of MPM patients. 1. Whitaker, D., J.M. Papadimitriou, and M.N. Walters, The mesothelium and its reactions: a review. Crit Rev Toxicol, 1982. 10(2): p. 81-144. 2. Lanphear, B.P. and C.R. Buncher, Latent period for malignant mesothelioma of occupational origin. J Occup Med, 1992. 34(7): p. 718-21. 3. Peto, J., et al., The European mesothelioma epidemic. Br J Cancer, 1999. 79(3-4): p. 666-72. 4. Rudd, R.M., Malignant mesothelioma. Br Med Bull, 2010. 93: p. 105-23. 5. Rusch, V.W., A proposed new international TNM staging system for malignant pleural mesothelioma from the International Mesothelioma Interest Group. Lung Cancer, 1996. 14(1): p. 1-12. 6. Butchart, E.G., et al., Pleuropneumonectomy in the management of diffuse malignant mesothelioma of the pleura. Experience with 29 patients. Thorax, 1976. 31(1): p. 15-24. 7. Nowak, A.K., et al., The IASLC Mesothelioma Staging Project: Proposals for Revisions of the T descriptors in the forthcoming Eighth edition of the TNM classification for pleural mesothelioma. J Thorac Oncol, 2016. 8. Rice, D., et al., The IASLC Mesothelioma Staging Project: Proposals for Revisions of the N Descriptors in the Forthcoming Eighth Edition of the TNM Classification for Pleural Mesothelioma. J Thorac Oncol, 2016. 9. Rusch, V.W., et al., The IASLC Mesothelioma Staging Project: Proposals for the M Descriptors and for Revision of the TNM Stage Groupings in the Forthcoming (Eighth) Edition of the TNM Classification for Mesothelioma. J Thorac Oncol, 2016.
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IA05.03 - Thymic Carcinoma Cases (ID 6526)
11:00 - 12:30 | Author(s): F. Detterbeck
- Abstract
- Presentation
Abstract not provided
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IA05.04 - Esophageal Carcinoma Cases (ID 6527)
11:00 - 12:30 | Author(s): T. Rice
- Abstract
- Presentation
Abstract not provided
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