University of Rome “Sapienza” Department of Thoracic Surgery

University of Rome “Sapienza”University of Rome “Sapienza”Department of Thoracic SurgeryDepartment of Thoracic Surgery

WHAT SHOULD WHAT SHOULD CHANGE IN LUNG CHANGE IN LUNG CANCER STAGINGCANCER STAGING

AIMS of TNMAIMS of TNM

• Use the same language worldwhileUse the same language worldwhile• Pool patients with similar diseasePool patients with similar disease• Differentiate prognosis and treatmentDifferentiate prognosis and treatment• Avoid overlapping prognosisAvoid overlapping prognosis• Compare data worldwideCompare data worldwide

HISTORYHISTORY

• 19461946 Union Internationale Contre Cancer (UICC) TNM System Union Internationale Contre Cancer (UICC) TNM System

• 1959 1959 American Joint Commette for Cancer (AJCC) StagingAmerican Joint Commette for Cancer (AJCC) Staging

• 1966 1966 UICC TNM and StagingUICC TNM and Staging

• 19741974 UICC e AJCC UICC e AJCC

• 19861986 International Staging System UICC e AJCC (IV Internat. International Staging System UICC e AJCC (IV Internat.

Congr. Lung Ca.) MountainCongr. Lung Ca.) Mountain

• 1997 1997 Revision of the International Staging System of Lung Revision of the International Staging System of Lung

Cancer. Mountain CF. Chest 1997; 111:1710-17Cancer. Mountain CF. Chest 1997; 111:1710-17

• 20092009 The hypothetical next… The hypothetical next…

WHERE WE AREWHERE WE ARE


• 00 Carcinoma in situCarcinoma in situ• IAIA T1N0M0T1N0M0• IBIB T2N0M0T2N0M0• IIAIIA T1N1M0T1N1M0• IIBIIB T2N1M0, T3N0M0T2N1M0, T3N0M0• IIIAIIIA T3N1M0, any N2T3N1M0, any N2• IIIBIIIB Any T4, any N3Any T4, any N3• IVIV Any T and any N M1Any T and any N M1

WHERE WE ARE WHERE WE ARE


HYPOTHESISHYPOTHESIS

• In small-size tumors the diameter is a In small-size tumors the diameter is a prognostic factor? prognostic factor?

• Different prognosis in the same T Different prognosis in the same T factor with different sites of invasion?factor with different sites of invasion?

• How much important is the nodal How much important is the nodal status?status?

• Are other subgroups important in the Are other subgroups important in the N status ?N status ?

OPEN QUESTIONSOPEN QUESTIONS

• T1 Size T1 Size

• T2 larger 5 cm T3 ?T2 larger 5 cm T3 ?

• T3 – T4: Site of invasion T3 – T4: Site of invasion

• T4 satellite – T4 invasionT4 satellite – T4 invasion

• N1: single – multiple; micro – macroN1: single – multiple; micro – macro

T1: SIZE OF THE TUMORT1: SIZE OF THE TUMORLiterature Watch Literature Watch

STAGE IB – IIA STAGE IB – IIA

J. Thorac. Cardiovasc. Surg. Aug 2006;132: 316-9 J. Thorac. Cardiovasc. Surg. Aug 2006;132: 316-9


• Year 1994 only – 6644 Patients Year 1994 only – 6644 Patients • Multicenter retrospective reviewMulticenter retrospective review• T1aT1a ≤ 2 cm ≤ 2 cm • T1b T1b > 2.1 – 3 cm> 2.1 – 3 cm

Now Now Then Then• IA IA T1N0M0T1N0M0 T1aN0M0T1aN0M0• IB IB T2N0M0T2N0M0 T1bN0M0T1bN0M0• IIA IIA T1N1M0T1N1M0 T2N0M0T2N0M0 + T1N1M0 + T1N1M0


J. Thorac. Cardiovasc. Surg. Aug 2006;132: 316-9 J. Thorac. Cardiovasc. Surg. Aug 2006;132: 316-9

CLINICALCLINICAL PATHOLOGICPATHOLOGIC


• Stages IB and IIA merged as new IIAStages IB and IIA merged as new IIA

• Cut-off T1a vs T1b Cut-off T1a vs T1b ≤ 2 cm≤ 2 cmJ. Thorac. Cardiovasc. Surg. Aug 2006;132: 316-9 J. Thorac. Cardiovasc. Surg. Aug 2006;132: 316-9

CLINICALCLINICAL PATHOLOGICPATHOLOGIC

T2 LARGER THAN 5 CM … T3?T2 LARGER THAN 5 CM … T3?

J. Thorac. Cardiovasc. Surg. 2001;122:907-12J. Thorac. Cardiovasc. Surg. 2001;122:907-12


• 545 Patients (T > 3 cm)545 Patients (T > 3 cm)

• Same nodal statusSame nodal status

• 3 Groups (3.1 – 5 cm, 5.1 – 7 cm, > 7 cm)3 Groups (3.1 – 5 cm, 5.1 – 7 cm, > 7 cm)

• T2a T2a ≤ 5 cm vs T2b > 5 cm ≤ 5 cm vs T2b > 5 cm





WHEN THE TUMOR IS LARGER THAN 5 CM THE PROGNOSIS IS THE SAMEWHEN THE TUMOR IS LARGER THAN 5 CM THE PROGNOSIS IS THE SAME




• T2b poorer survival than T2aT2b poorer survival than T2a

• T2b T2b upgradedupgraded to T3 to T3

• Nodal status has addictive effectNodal status has addictive effect

STAGE IIISTAGE III


• Overall 429 PatientsOverall 429 Patients• 73 IIIA and 79 IIIB73 IIIA and 79 IIIB

STAGE IIISTAGE III


IN THIS SERIESIN THIS SERIES no difference in survival between IIIA and IIIB no difference in survival between IIIA and IIIB

STAGE IIISTAGE III


IN THIS SERIESIN THIS SERIES no difference in survival between T3 and T4 no difference in survival between T3 and T4

STAGE IIISTAGE III

Overall 429 PatientsOverall 429 Patients73 IIIA and 79 IIIB73 IIIA and 79 IIIB

• T3 bronchial vs T3 extrapulmonaryT3 bronchial vs T3 extrapulmonary• T4 tracheal, T4 satellite, T4 T4 tracheal, T4 satellite, T4

extrapulmonary, T4 malignant exudateextrapulmonary, T4 malignant exudate• Complete surgical resection for T3Complete surgical resection for T3• R0 resections for T4R0 resections for T4

STAGE IIISTAGE III


T3T3 T4T4

STAGE IIISTAGE III

T3 BRONCHIAL T3 BRONCHIAL

T2T2

T4 SATELLITE & TRACHEAL T4 SATELLITE & TRACHEAL

T3T3

RECLASSIFICATIONRECLASSIFICATION


STAGE III STAGE III

• T3 bronchial downstaged to T2T3 bronchial downstaged to T2

• T4 tracheal and satellite downstaged to T3T4 tracheal and satellite downstaged to T3

• Better survival for R0 T3 and T4Better survival for R0 T3 and T4

• Surgical curativity should be taken into Surgical curativity should be taken into account in the reevaluation of staging account in the reevaluation of staging

T4 SATELLITE vs INVASIONT4 SATELLITE vs INVASION

Ann. Thorac. Surg.2006;82:1808-14Ann. Thorac. Surg.2006;82:1808-14


• Overall 337 PatientsOverall 337 Patients

• T4N0M0 Satellite (n=26)T4N0M0 Satellite (n=26)

• T4N0M0 Invasion (n=25)T4N0M0 Invasion (n=25)

• T4 pleural effusion excludedT4 pleural effusion excluded



N0N0



PET UPTAKE!!!!!PET UPTAKE!!!!!


• Separation of heterogeneous types of T4Separation of heterogeneous types of T4• T4N0M0 Satellite should be downstagedT4N0M0 Satellite should be downstaged• MaxSUV should be taken into account as best MaxSUV should be taken into account as best

predictor predictor

N1 INVOLVEMENTN1 INVOLVEMENT

Lung Cancer 2004;43:151-7Lung Cancer 2004;43:151-7



N1 SINGLE vs MULTIPLEN1 SINGLE vs MULTIPLE


N1 MICRO vs MACRON1 MICRO vs MACRO



• Micro and single-node N1 downstaged Micro and single-node N1 downstaged respect macro and multiple-node N1respect macro and multiple-node N1

• Different therapeutic approaches for Different therapeutic approaches for subgroups subgroups

FUTUREFUTURE

FUTUREFUTURE

FUTUREFUTURE

WHERE ARE WE GOING?WHERE ARE WE GOING?

• It is necessary new staging (2009?)It is necessary new staging (2009?)

• T factor is a good targetT factor is a good target

• MaxSUV could be a better survival MaxSUV could be a better survival predictor than TNM predictor than TNM

• Genomic studies ??????Genomic studies ??????

• Long-term survival is affected not only by Long-term survival is affected not only by staging but first of all by treatment…staging but first of all by treatment…

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University of Rome “Sapienza” Department of Thoracic Surgery