Antonio ROSSI, MD
Division of Medical Oncology,
“S.G. MOSCATI” HOSPITAL, AVELLINO - ITALY
La classificazione TNM: cosa cam...
Thanks to…
Component of the
classification
Changes
T To subclassify T1 according to tumor size in
T1a: < 2 cm and
T1b: > 2 cm but <...
Antonio ROSSI, MD
Division of Medical Oncology,
“S.G. MOSCATI” HOSPITAL, AVELLINO - ITALY
Thank you for your kind attentio...
Some of the aims for adopting a global standard are to:
• Aid medical staff in staging the tumour helping to plan
the trea...
The history of Lung Cancer TNM
• 1968: I ed.
• 1974: II ed. (Mountain-proposal 1973)
• 1978: III ed. (minimal changes)
• 1...
TNM6: Further Limitations
 Patients who had undergone surgical treatment, not
representative of the entire population of ...
TNM7: IASLC Lung Cancer Database
Summary of Cases Contributed to the Project
Total cases submittedTotal cases submitted 10...
0
5000
10000
15000
20000
25000
30000
35000
40000
45000
Europe Australia N. America Asia
59%59% 8%8% 18%18% 15%15%
TNM7: An...
 Type of collection: Retrospective
 Study period: 1990-2000
Internal validation: comparing results by type of data
sour...
IASLC Staging Project
Treatment Modalities – 67,735 NSCLC
SurgerySurgery
42%42%
ChemotherapyChemotherapy
15%15%
RTRT
8%8%
...
When comparing overall survival between groups of patients defined by tumor
size, we found that survival differences were ...
•T1 Tumour 3 cm or less in
greatest dimension, surrounded
by lung or visceral pleura,
without bronchoscopic evidence
of in...
•T2T2 Tumour more than 3 cm but
not more than 7 cm; or tumour
with any of the following features:
•• Involves main bronchu...
•T3T3 Tumour more than 7 cm or
one that directly invades any of
the following: chest wall
(including superior sulcus
tumou...
•T4T4 Tumour of any size that
invades any of the following:
mediastinum, heart, great
vessels, trachea, recurrent
laryngea...
Rush V et al J Thorac Oncol 2009;4: 568–577
N Descriptors
• Reconciled “Naruke” and “Mountain-Dresler” Nodal Chart
• The a...
N1
N2
Proposed nodal zones with their nodal stations
Rush V et al J Thorac Oncol 2009;4: 568–577
Survival by N status
and number of involved N zones
Rush V et al J Thorac Oncol 2009;4: 568–577
Three distinct prognostic ...
M Descriptors
6,596 patients with sufficient
cM and /or pM information
•MxMx Presence of distant metastasis cannot be
asse...
T2N0
(> 5 < 7 cm)
T2N0
(> 7 cm)
T2N1
(< 5 cm)
T2N1
(> 7 cm)
T4N0
(same lobe
nodules)
T4N1-2
(same lobe
nodules)
T4N0-1
(ex...
Overall survival by clinical
stage
TNM6 TNM7
Goldstraw P et al J Thorac Oncol 2007; 2:706–714
Survival by clinical stage a...
Overall survival by pathologic
stage
TNM6 TNM7
Goldstraw P et al J Thorac Oncol 2007; 2:706–714
Survival by pathologic sta...
Proposed stage groupings
Goldstraw P et al J Thorac Oncol 2007; 2:706–714
criticism
• Database does not includes any data from Africa, SouthAfrica, South
America or Indian subcontinentAmerica or Indian subc...
Giroux DJ et al J Thorac Oncol 2009;24: 679–683
Lung Cancer staging:
what is the next step?
TNM7 - Therapeutic implications?
T and M descriptorsT and M descriptors N0N0 N1N1 N2N2 N3N3
66thth
editionedition
77thth
e...
TNM7 - Therapeutic implications?
T and M descriptorsT and M descriptors N0N0 N1N1 N2N2 N3N3
66thth
editionedition
77thth
e...
TNM7 - Therapeutic implications?
T and M descriptorsT and M descriptors N0N0 N1N1 N2N2 N3N3
66thth
editionedition
77thth
e...
TNM7 - Therapeutic implications?
T and M descriptorsT and M descriptors N0N0 N1N1 N2N2 N3N3
66thth
editionedition
77thth
e...
TNM7 - Therapeutic implications?
T and M descriptorsT and M descriptors N0N0 N1N1 N2N2 N3N3
66thth
editionedition
77thth
e...
TNM7 - Therapeutic implications?
T and M descriptorsT and M descriptors N0N0 N1N1 N2N2 N3N3
66thth
editionedition
77thth
e...
TNM7 & Adjuvant therapy
Complete resection and N0
IB (new): T2a (3-5 cm) = 5-y Survival 58%
IIA (new): T2b (5-7 cm) = 5-y ...
0
500
1000
1500
2000
2500
3000
3500
4000
Europe Australia N.
America
Asia
Limited
Extensive
TNM Only
IASLC Lung Cancer Dat...
Shepherd F et al J Thorac Oncol 2007; 2:1067–1077
TNM7: Small Cell Lung Cancer
TNM6 TNM7
Survival by clinical sixth editio...
TNM7: To date application in
clinical practice
• Effective January 2010, the 7th editions of the
American Joint Commission...
TNM7: Final Comments
• The IASLC Lung Cancer Staging System is the largest, validated,
internationally recognized system t...
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That's cool a rossi la classificazione tnm cosa cambia 24 settembre 2010

  1. 1. Antonio ROSSI, MD Division of Medical Oncology, “S.G. MOSCATI” HOSPITAL, AVELLINO - ITALY La classificazione TNM: cosa cambia?
  2. 2. Thanks to…
  3. 3. Component of the classification Changes T To subclassify T1 according to tumor size in T1a: < 2 cm and T1b: > 2 cm but < 3 cm To subclassify T2 according to tumor size in T2a: > 3 cm but < 5 cm (or tumor with any other tumor descriptors, but < 5 cm) and T2b: > 5 cm but < 7 cm To reclassify T2 tumors > 7 cm as T3 To reclassify T4 tumors by additional nodule/s in the same lobe of the primary tumours as T3 To reclassify M1 tumors by additional nodule/s in another ipsilateral lobe as T4 To reclassify T4 tumors by malignant pleural effusion as M1a N No changes M To subclassify M1 in M1a: separated tumor nodule/s in the controlateral lung; tumor with pleural nodules or malignant pleural (or pericardial) effusion; and M1b: distant metastasis Take-home message Changes for the 7th Edition of the TNM classification of lung cancer Goldstraw P et al JTO, 2007
  4. 4. Antonio ROSSI, MD Division of Medical Oncology, “S.G. MOSCATI” HOSPITAL, AVELLINO - ITALY Thank you for your kind attention But…
  5. 5. Some of the aims for adopting a global standard are to: • Aid medical staff in staging the tumour helping to plan the treatment • Give an indication of prognosis • Assist in the evaluation of the results of treatment • Enable facilities around the world to collate information more productively TNM: Uses and Aims
  6. 6. The history of Lung Cancer TNM • 1968: I ed. • 1974: II ed. (Mountain-proposal 1973) • 1978: III ed. (minimal changes) • 1987: IV ed. (Mountain-proposal – Chest 1986) • 1992: IV ed. rev. (no changes) • 1997: V ed. (last Mountain revision) • 2002: VI ed. (no changes) No.pts 2,155 3,753 5,319 Estimated 1.608.000 new cases of lung cancer worldwide with 1.380.000 the deaths in year 2008 (GLOBOCAN 2008) 5,319 = 0.00337% of 1.608.000 patients affected by lung cancer
  7. 7. TNM6: Further Limitations  Patients who had undergone surgical treatment, not representative of the entire population of patients affected by lung cancer  Patients collected in only one geographic region …this is why we needed an updated staging system for Lung Cancer
  8. 8. TNM7: IASLC Lung Cancer Database Summary of Cases Contributed to the Project Total cases submittedTotal cases submitted 100,869100,869 • Excluded from analysesExcluded from analyses 19,85419,854 • Outside of 1990-2000 time frameOutside of 1990-2000 time frame 5,4435,443 • Incomplete survival dataIncomplete survival data 1,5051,505 • Unknown histologyUnknown histology 2,4682,468 • Incomplete stage informationIncomplete stage information 7,7207,720 • Recurrent cases and other exclusionsRecurrent cases and other exclusions 1,6031,603 • Carcinoids, sarcomas and other histologiesCarcinoids, sarcomas and other histologies 1,1151,115 Included in analysesIncluded in analyses 81,01581,015 •Small Cell Lung Cancer (and mixed SCLC/NSCLC)Small Cell Lung Cancer (and mixed SCLC/NSCLC) 13,29013,290 •Non-Small Cell Lung CancerNon-Small Cell Lung Cancer 67,72567,725
  9. 9. 0 5000 10000 15000 20000 25000 30000 35000 40000 45000 Europe Australia N. America Asia 59%59% 8%8% 18%18% 15%15% TNM7: Answers to TNM6 Limitations 2009: VII ed. (forthcoming – 2007 IASLC proposal) No.pts 100,869 19,854 excluded from the analysis due to several reasons 81,015 = 5.0% of 1.608.000 patients affected by lung cancer 53% of these patients had undergone surgical treatment
  10. 10.  Type of collection: Retrospective  Study period: 1990-2000 Internal validation: comparing results by type of data source and geographical regions  External validation: Surveillance, Epidemiology, and End Results Program (SEER) database TNM7: Characteristics
  11. 11. IASLC Staging Project Treatment Modalities – 67,735 NSCLC SurgerySurgery 42%42% ChemotherapyChemotherapy 15%15% RTRT 8%8% SurgerySurgery + Chemo+ Chemo 4%4% SurgerySurgery + RT+ RT 5%5% ChemoChemo + RT+ RT 12%12% Tri-modalityTri-modality 3%3% No treatment detailsNo treatment details or best supportiveor best supportive care: 10%care: 10%
  12. 12. When comparing overall survival between groups of patients defined by tumor size, we found that survival differences were optimized at size cutpoints of 2, 3, 5, and 7 cm. These tumor size cutpoints were chosen on the basis of pathologic measurements from completely resected cases in the learning set and were then tested in the remaining pathologic and clinical data. T Descriptors Rami Porta T et al J Thorac Oncol 2007;2: 593–602 15,234 patients with sufficient pT descriptor information (M0)
  13. 13. •T1 Tumour 3 cm or less in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e., not in the main bronchus) •T1a Tumour 2 cm or less in greatest dimension •T1b Tumour more than 2 cm but not more than 3 cm in greatest dimension TNM Clinical Classification T Descriptors
  14. 14. •T2T2 Tumour more than 3 cm but not more than 7 cm; or tumour with any of the following features: •• Involves main bronchus, 2 cm or more distal to the carina •• Invades visceral pleura •• Associated with atelectasis or obstructive pneumonitis that extends to the hilar region but does not involve the entire lung •T2a Tumour more than 3 cm butT2a Tumour more than 3 cm but not more than 5 cm in greatestnot more than 5 cm in greatest dimensiondimension •T2b Tumour more than 5 cm butT2b Tumour more than 5 cm but not more than 7 cm in greatestnot more than 7 cm in greatest dimensiondimension TNM Clinical Classification T Descriptors
  15. 15. •T3T3 Tumour more than 7 cm or one that directly invades any of the following: chest wall (including superior sulcus tumours), diaphragm, phrenic nerve, mediastinal pleura, parietal pericardium; or tumour in the main bronchus less than 2 cm distal to the carina but without involvement of the carina; or associated atelectasis or obstructive pneumonitis of the entire lung or separate tumour nodule(s) in the same lobe as the primary. TNM Clinical Classification T Descriptors
  16. 16. •T4T4 Tumour of any size that invades any of the following: mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve, oesophagus, vertebral body, carina; separateseparate tumour nodule(s) in a differenttumour nodule(s) in a different ipsilateral lobe to that of theipsilateral lobe to that of the primaryprimary.. TNM Clinical Classification T Descriptors
  17. 17. Rush V et al J Thorac Oncol 2009;4: 568–577 N Descriptors • Reconciled “Naruke” and “Mountain-Dresler” Nodal Chart • The anatomic limits of the nodal stations are clearly defined • The concept of “nodal zones” has been introduced incorporating adjacent stations into larger aggregates (need to be further validated) • Supraclavicular zone now includes the low cervical, supraclavicular and sternal notch nodes • Identification of mediastinal line on the left paratracheal level • Enlargement of subcarinal space 38,265 patients with sufficient pN descriptor information (M0)
  18. 18. N1 N2 Proposed nodal zones with their nodal stations Rush V et al J Thorac Oncol 2009;4: 568–577
  19. 19. Survival by N status and number of involved N zones Rush V et al J Thorac Oncol 2009;4: 568–577 Three distinct prognostic groups:  Single zone N1  Multiple-zone N1 or single N2  Multiple-zone N2 (Need to be further validated)
  20. 20. M Descriptors 6,596 patients with sufficient cM and /or pM information •MxMx Presence of distant metastasis cannot be assessed •M0M0 No distant metastasis •M1M1 Presence of distance metastasis •M1a: separate tumor nodule(s) in a controlateralM1a: separate tumor nodule(s) in a controlateral lobe and tumor with malignant pleurallobe and tumor with malignant pleural involvement, effusion or nodule(s), or malignantinvolvement, effusion or nodule(s), or malignant pericardial effusionpericardial effusion •M1b: distant metastasis outside lung/pleuraM1b: distant metastasis outside lung/pleura
  21. 21. T2N0 (> 5 < 7 cm) T2N0 (> 7 cm) T2N1 (< 5 cm) T2N1 (> 7 cm) T4N0 (same lobe nodules) T4N1-2 (same lobe nodules) T4N0-1 (extension) T4 any N (pleural effusion) T4N0-1M1 (ipsilateral lung) T4N2-3M1 (ipsilateral lung) TNM6 Stage IB T2N0 (> 5 < 7 cm) Stage IB T2N0 (>7 cm) Stage IIB T2N1 (< 5 cm) Stage IIB T2N1 (> 7 cm) Stage IIIB T4N0 (same lobe nodules) Stage IIIB T4N1-2 (same lobe nodules) Stage IIIB T4N0-1 (extension) Stage IIIB T4 any N (pleural effusion) Stage IV T4N0-1M1 (ipsilateral lung) Stage IV T4N2-3M1 (ipsilateral lung) TNM7 Stage IIA Stage IIB Stage IIA Stage IIIA Stage IIB (T3) Stage IIIA Stage IIIA Stage IV (M1a) Stage IIIA Stage IIIB Stage groups in TNM6 and TNM7
  22. 22. Overall survival by clinical stage TNM6 TNM7 Goldstraw P et al J Thorac Oncol 2007; 2:706–714 Survival by clinical stage according to the sixth edition of TNM and by the newly proposed TNM stage based on the entire set of cases available for reclassification
  23. 23. Overall survival by pathologic stage TNM6 TNM7 Goldstraw P et al J Thorac Oncol 2007; 2:706–714 Survival by pathologic stage according to the sixth edition of TNM and by the newly proposed TNM stage based on the entire set of cases available for reclassification
  24. 24. Proposed stage groupings Goldstraw P et al J Thorac Oncol 2007; 2:706–714 criticism
  25. 25. • Database does not includes any data from Africa, SouthAfrica, South America or Indian subcontinentAmerica or Indian subcontinent • Under-represents cases from ChinaChina which is experiencing a rapid increase in lung cancer incidence and is the most populous country in the world • New TNM reflects more strongly prognosis than algorithm for treatment (i.e., stage IV with oligometastases and resectable primary lesion could receive a different treatment with respect to stage IV with multiple distant metastases) • New TNM does not offer information about biology and behaviour of the tumor; we are waiting for a better understanding of these aspects ...further Criticisms
  26. 26. Giroux DJ et al J Thorac Oncol 2009;24: 679–683 Lung Cancer staging: what is the next step?
  27. 27. TNM7 - Therapeutic implications? T and M descriptorsT and M descriptors N0N0 N1N1 N2N2 N3N3 66thth editionedition 77thth editionedition StadioStadio StadioStadio StadioStadio StadioStadio T1 (< 2 cm)T1 (< 2 cm) T1aT1a IAIA IIAIIA IIIAIIIA IIIBIIIB T1 (> 2-3 cm)T1 (> 2-3 cm) T1bT1b IAIA IIAIIA IIIAIIIA IIIBIIIB T2 (< 5 cm)T2 (< 5 cm) T2aT2a IBIB IIA (ex IIB)IIA (ex IIB) IIIAIIIA IIIBIIIB T2 (> 5 < 7 cm)T2 (> 5 < 7 cm) T2bT2b IIA (ex IB)IIA (ex IB) IIBIIB IIIAIIIA IIIBIIIB T2 (> 7 cm)T2 (> 7 cm) T3T3 IIB (ex IB)IIB (ex IB) IIIA (ex IIB)IIIA (ex IIB) IIIAIIIA IIIBIIIB T3 invasionT3 invasion IIBIIB IIIAIIIA IIIAIIIA IIIBIIIB T4 (same lobe nodules)T4 (same lobe nodules) IIB (ex IIIB)IIB (ex IIIB) IIIA (exIIIA (ex IIIB)IIIB) IIIA (ex IIIB)IIIA (ex IIIB) IIIBIIIB T4 (extension)T4 (extension) T4T4 IIIA (ex IIIB)IIIA (ex IIIB) IIIA (exIIIA (ex IIIB)IIIB) IIIBIIIB IIIBIIIB M1 (ipsilateral lung)M1 (ipsilateral lung) IIIA (ex IV)IIIA (ex IV) IIIA (ex IV)IIIA (ex IV) IIIB (ex IV)IIIB (ex IV) IIIB (ex IV)IIIB (ex IV) T4 (pleural effusion)T4 (pleural effusion) M1aM1a IV (ex IIIB)IV (ex IIIB) IV (ex IIIB)IV (ex IIIB) IV (ex IIIB)IV (ex IIIB) IV (ex IIIB)IV (ex IIIB) M1 (controlateral lung)M1 (controlateral lung) IVIV IVIV IVIV IVIV M1 (distant)M1 (distant) M1bM1b IVIV IVIV IVIV IVIV In yellow changing in classificationIn yellow changing in classification No treatment changes
  28. 28. TNM7 - Therapeutic implications? T and M descriptorsT and M descriptors N0N0 N1N1 N2N2 N3N3 66thth editionedition 77thth editionedition StadioStadio StadioStadio StadioStadio StadioStadio T1 (< 2 cm)T1 (< 2 cm) T1aT1a IAIA IIAIIA IIIAIIIA IIIBIIIB T1 (> 2-3 cm)T1 (> 2-3 cm) T1bT1b IAIA IIAIIA IIIAIIIA IIIBIIIB T2 (< 5 cm)T2 (< 5 cm) T2aT2a IBIB IIA (ex IIB)IIA (ex IIB) IIIAIIIA IIIBIIIB T2 (> 5 < 7 cm)T2 (> 5 < 7 cm) T2bT2b IIA (ex IB)IIA (ex IB) IIBIIB IIIAIIIA IIIBIIIB T2 (> 7 cm)T2 (> 7 cm) T3T3 IIB (ex IB)IIB (ex IB) IIIA (ex IIB)IIIA (ex IIB) IIIAIIIA IIIBIIIB T3 invasionT3 invasion IIBIIB IIIAIIIA IIIAIIIA IIIBIIIB T4 (same lobe nodules)T4 (same lobe nodules) IIB (ex IIIB)IIB (ex IIIB) IIIA (exIIIA (ex IIIB)IIIB) IIIA (ex IIIB)IIIA (ex IIIB) IIIBIIIB T4 (extension)T4 (extension) T4T4 IIIA (ex IIIB)IIIA (ex IIIB) IIIA (exIIIA (ex IIIB)IIIB) IIIBIIIB IIIBIIIB M1 (ipsilateral lung)M1 (ipsilateral lung) IIIA (ex IV)IIIA (ex IV) IIIA (ex IV)IIIA (ex IV) IIIB (ex IV)IIIB (ex IV) IIIB (ex IV)IIIB (ex IV) T4 (pleural effusion)T4 (pleural effusion) M1aM1a IV (ex IIIB)IV (ex IIIB) IV (ex IIIB)IV (ex IIIB) IV (ex IIIB)IV (ex IIIB) IV (ex IIIB)IV (ex IIIB) M1 (controlateral lung)M1 (controlateral lung) IVIV IVIV IVIV IVIV M1 (distant)M1 (distant) M1bM1b IVIV IVIV IVIV IVIV In yellow changing in classificationIn yellow changing in classification Adjuvant CT is already being considered
  29. 29. TNM7 - Therapeutic implications? T and M descriptorsT and M descriptors N0N0 N1N1 N2N2 N3N3 66thth editionedition 77thth editionedition StadioStadio StadioStadio StadioStadio StadioStadio T1 (< 2 cm)T1 (< 2 cm) T1aT1a IAIA IIAIIA IIIAIIIA IIIBIIIB T1 (> 2-3 cm)T1 (> 2-3 cm) T1bT1b IAIA IIAIIA IIIAIIIA IIIBIIIB T2 (< 5 cm)T2 (< 5 cm) T2aT2a IBIB IIA (ex IIB)IIA (ex IIB) IIIAIIIA IIIBIIIB T2 (> 5 < 7 cm)T2 (> 5 < 7 cm) T2bT2b IIA (ex IB)IIA (ex IB) IIBIIB IIIAIIIA IIIBIIIB T2 (> 7 cm)T2 (> 7 cm) T3T3 IIB (ex IB)IIB (ex IB) IIIA (ex IIB)IIIA (ex IIB) IIIAIIIA IIIBIIIB T3 invasionT3 invasion IIBIIB IIIAIIIA IIIAIIIA IIIBIIIB T4 (same lobe nodules)T4 (same lobe nodules) IIB (ex IIIB)IIB (ex IIIB) IIIA (exIIIA (ex IIIB)IIIB) IIIA (ex IIIB)IIIA (ex IIIB) IIIBIIIB T4 (extension)T4 (extension) T4T4 IIIA (ex IIIB)IIIA (ex IIIB) IIIA (exIIIA (ex IIIB)IIIB) IIIBIIIB IIIBIIIB M1 (ipsilateral lung)M1 (ipsilateral lung) IIIA (ex IV)IIIA (ex IV) IIIA (ex IV)IIIA (ex IV) IIIB (ex IV)IIIB (ex IV) IIIB (ex IV)IIIB (ex IV) T4 (pleural effusion)T4 (pleural effusion) M1aM1a IV (ex IIIB)IV (ex IIIB) IV (ex IIIB)IV (ex IIIB) IV (ex IIIB)IV (ex IIIB) IV (ex IIIB)IV (ex IIIB) M1 (controlateral lung)M1 (controlateral lung) IVIV IVIV IVIV IVIV M1 (distant)M1 (distant) M1bM1b IVIV IVIV IVIV IVIV In yellow changing in classificationIn yellow changing in classification Same lobe nodules are being already considered for surgery
  30. 30. TNM7 - Therapeutic implications? T and M descriptorsT and M descriptors N0N0 N1N1 N2N2 N3N3 66thth editionedition 77thth editionedition StadioStadio StadioStadio StadioStadio StadioStadio T1 (< 2 cm)T1 (< 2 cm) T1aT1a IAIA IIAIIA IIIAIIIA IIIBIIIB T1 (> 2-3 cm)T1 (> 2-3 cm) T1bT1b IAIA IIAIIA IIIAIIIA IIIBIIIB T2 (< 5 cm)T2 (< 5 cm) T2aT2a IBIB IIA (ex IIB)IIA (ex IIB) IIIAIIIA IIIBIIIB T2 (> 5 < 7 cm)T2 (> 5 < 7 cm) T2bT2b IIA (ex IB)IIA (ex IB) IIBIIB IIIAIIIA IIIBIIIB T2 (> 7 cm)T2 (> 7 cm) T3T3 IIB (ex IB)IIB (ex IB) IIIA (ex IIB)IIIA (ex IIB) IIIAIIIA IIIBIIIB T3 invasionT3 invasion IIBIIB IIIAIIIA IIIAIIIA IIIBIIIB T4 (same lobe nodules)T4 (same lobe nodules) IIB (ex IIIB)IIB (ex IIIB) IIIA (exIIIA (ex IIIB)IIIB) IIIA (ex IIIB)IIIA (ex IIIB) IIIBIIIB T4 (extension)T4 (extension) T4T4 IIIA (ex IIIB)IIIA (ex IIIB) IIIA (exIIIA (ex IIIB)IIIB) IIIBIIIB IIIBIIIB M1 (ipsilateral lung)M1 (ipsilateral lung) IIIA (ex IV)IIIA (ex IV) IIIA (ex IV)IIIA (ex IV) IIIB (ex IV)IIIB (ex IV) IIIB (ex IV)IIIB (ex IV) T4 (pleural effusion)T4 (pleural effusion) M1aM1a IV (ex IIIB)IV (ex IIIB) IV (ex IIIB)IV (ex IIIB) IV (ex IIIB)IV (ex IIIB) IV (ex IIIB)IV (ex IIIB) M1 (controlateral lung)M1 (controlateral lung) IVIV IVIV IVIV IVIV M1 (distant)M1 (distant) M1bM1b IVIV IVIV IVIV IVIV In yellow changing in classificationIn yellow changing in classification T4N0-1 was being already considered for surgery
  31. 31. TNM7 - Therapeutic implications? T and M descriptorsT and M descriptors N0N0 N1N1 N2N2 N3N3 66thth editionedition 77thth editionedition StadioStadio StadioStadio StadioStadio StadioStadio T1 (< 2 cm)T1 (< 2 cm) T1aT1a IAIA IIAIIA IIIAIIIA IIIBIIIB T1 (> 2-3 cm)T1 (> 2-3 cm) T1bT1b IAIA IIAIIA IIIAIIIA IIIBIIIB T2 (< 5 cm)T2 (< 5 cm) T2aT2a IBIB IIA (ex IIB)IIA (ex IIB) IIIAIIIA IIIBIIIB T2 (> 5 < 7 cm)T2 (> 5 < 7 cm) T2bT2b IIA (ex IB)IIA (ex IB) IIBIIB IIIAIIIA IIIBIIIB T2 (> 7 cm)T2 (> 7 cm) T3T3 IIB (ex IB)IIB (ex IB) IIIA (ex IIB)IIIA (ex IIB) IIIAIIIA IIIBIIIB T3 invasionT3 invasion IIBIIB IIIAIIIA IIIAIIIA IIIBIIIB T4 (same lobe nodules)T4 (same lobe nodules) IIB (ex IIIB)IIB (ex IIIB) IIIA (exIIIA (ex IIIB)IIIB) IIIA (ex IIIB)IIIA (ex IIIB) IIIBIIIB T4 (extension)T4 (extension) T4T4 IIIA (ex IIIB)IIIA (ex IIIB) IIIA (exIIIA (ex IIIB)IIIB) IIIBIIIB IIIBIIIB M1 (ipsilateral lung)M1 (ipsilateral lung) IIIA (ex IV)IIIA (ex IV) IIIA (ex IV)IIIA (ex IV) IIIB (ex IV)IIIB (ex IV) IIIB (ex IV)IIIB (ex IV) T4 (pleural effusion)T4 (pleural effusion) M1aM1a IV (ex IIIB)IV (ex IIIB) IV (ex IIIB)IV (ex IIIB) IV (ex IIIB)IV (ex IIIB) IV (ex IIIB)IV (ex IIIB) M1 (controlateral lung)M1 (controlateral lung) IVIV IVIV IVIV IVIV M1 (distant)M1 (distant) M1bM1b IVIV IVIV IVIV IVIV In yellow changing in classificationIn yellow changing in classification The ipsilateral/other lobe disease was already being considered for surgery if less than N2
  32. 32. TNM7 - Therapeutic implications? T and M descriptorsT and M descriptors N0N0 N1N1 N2N2 N3N3 66thth editionedition 77thth editionedition StadioStadio StadioStadio StadioStadio StadioStadio T1 (< 2 cm)T1 (< 2 cm) T1aT1a IAIA IIAIIA IIIAIIIA IIIBIIIB T1 (> 2-3 cm)T1 (> 2-3 cm) T1bT1b IAIA IIAIIA IIIAIIIA IIIBIIIB T2 (< 5 cm)T2 (< 5 cm) T2aT2a IBIB IIA (ex IIB)IIA (ex IIB) IIIAIIIA IIIBIIIB T2 (> 5 < 7 cm)T2 (> 5 < 7 cm) T2bT2b IIA (ex IB)IIA (ex IB) IIBIIB IIIAIIIA IIIBIIIB T2 (> 7 cm)T2 (> 7 cm) T3T3 IIB (ex IB)IIB (ex IB) IIIA (ex IIB)IIIA (ex IIB) IIIAIIIA IIIBIIIB T3 invasionT3 invasion IIBIIB IIIAIIIA IIIAIIIA IIIBIIIB T4 (same lobe nodules)T4 (same lobe nodules) IIB (ex IIIB)IIB (ex IIIB) IIIA (exIIIA (ex IIIB)IIIB) IIIA (ex IIIB)IIIA (ex IIIB) IIIBIIIB T4 (extension)T4 (extension) T4T4 IIIA (ex IIIB)IIIA (ex IIIB) IIIA (exIIIA (ex IIIB)IIIB) IIIBIIIB IIIBIIIB M1 (ipsilateral lung)M1 (ipsilateral lung) IIIA (ex IV)IIIA (ex IV) IIIA (ex IV)IIIA (ex IV) IIIB (ex IV)IIIB (ex IV) IIIB (ex IV)IIIB (ex IV) T4 (pleural effusion)T4 (pleural effusion) M1aM1a IV (ex IIIB)IV (ex IIIB) IV (ex IIIB)IV (ex IIIB) IV (ex IIIB)IV (ex IIIB) IV (ex IIIB)IV (ex IIIB) M1 (controlateral lung)M1 (controlateral lung) IVIV IVIV IVIV IVIV M1 (distant)M1 (distant) M1bM1b IVIV IVIV IVIV IVIV In yellow changing in classificationIn yellow changing in classification As always been treated has stage IV
  33. 33. TNM7 & Adjuvant therapy Complete resection and N0 IB (new): T2a (3-5 cm) = 5-y Survival 58% IIA (new): T2b (5-7 cm) = 5-y Survival 49% IIB (new): T3 (> 7 cm) = 5-y Survival 35% IIB (new): T3 (invasion) = 5-y Survival 41% IIB (new): T3 (same lobe) = 5-y Survival 45% *Strauss GM et al JCO 2008 **Winton et al NEJM 2005 [should we evaluate post- or pre-operative chemotherapy in selected patients?] CALGB9633 (4 cm)* = 5-y Survival 62% JBR.10 (N1 disease)** = 5-y Survival 68%
  34. 34. 0 500 1000 1500 2000 2500 3000 3500 4000 Europe Australia N. America Asia Limited Extensive TNM Only IASLC Lung Cancer Database: SCLC Small Cell Lung Cancer: Stage Distribution by Continent, 13,290 Cases (58%)(58%) (6%)(6%) (34%)(34%) (2%)(2%) Percent of total smallPercent of total small cell cases contributedcell cases contributed
  35. 35. Shepherd F et al J Thorac Oncol 2007; 2:1067–1077 TNM7: Small Cell Lung Cancer TNM6 TNM7 Survival by clinical sixth edition of TNM, and IASLC proposed TNM stage
  36. 36. TNM7: To date application in clinical practice • Effective January 2010, the 7th editions of the American Joint Commission (AJCC) on Cancer and the International Union Against Cancer (UICC) Staging Manuals were published* • Since January 2010, 3 clinical trials concerning NSCLC therapy have been activated in our Division: • All trials were activated in the second half of 2009 • 1 Trial addressed to locally-advanced NSCLC (stage IIIA-IIIB) • 2 Trials addressed to advanced NSCLC (stage IIIB-IV) • No trials use TNM7 *Rusch VW et al J Thorac Cardiovasc Surg 2010
  37. 37. TNM7: Final Comments • The IASLC Lung Cancer Staging System is the largest, validated, internationally recognized system to date (over 100.000 patients registered in 46 databases) • Challenges are mainly seen with T size stratification, multiple nodule recharacterization, and pleural effusion impact • These changes may define new strategies for surgical approaches as well as the use of adjuvant or neoadjuvant therapies • This classification is also reccomended for small cell lung cancer • Prospective database collection for the forthcoming 8th Edition to correct TNM7 biases • Trials will be needed to clarify appropriate treatment strategies
  38. 38. Thank you www.esanum.it/cool

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