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University of Rome “Sapienza” Department of Thoracic Surgery

University of Rome “Sapienza” Department of Thoracic Surgery. WHAT SHOULD CHANGE IN LUNG CANCER STAGING. AIMS of TNM. Use the same language worldwhile Pool patients with similar disease Differentiate prognosis and treatment Avoid overlapping prognosis Compare data worldwide. HISTORY.

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University of Rome “Sapienza” Department of Thoracic Surgery

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  1. University of Rome “Sapienza”Department of Thoracic Surgery WHAT SHOULD CHANGE IN LUNG CANCER STAGING

  2. AIMS of TNM • Use the same language worldwhile • Pool patients with similar disease • Differentiate prognosis and treatment • Avoid overlapping prognosis • Compare data worldwide

  3. HISTORY • 1946 Union Internationale Contre Cancer (UICC) TNM System • 1959 American Joint Commette for Cancer (AJCC) Staging • 1966 UICC TNM and Staging • 1974 UICC e AJCC • 1986 International Staging System UICC e AJCC (IV Internat. Congr. Lung Ca.) Mountain • 1997 Revision of the International Staging System of Lung Cancer. Mountain CF. Chest 1997; 111:1710-17 • 2009 The hypothetical next…

  4. WHERE WE ARE

  5. WHERE WE ARE • 0 Carcinoma in situ • IA T1N0M0 • IB T2N0M0 • IIA T1N1M0 • IIB T2N1M0, T3N0M0 • IIIA T3N1M0, any N2 • IIIB Any T4, any N3 • IV Any T and any N M1

  6. WHERE WE ARE

  7. WHERE WE ARE

  8. HYPOTHESIS • In small-size tumors the diameter is a prognostic factor? • Different prognosis in the same T factor with different sites of invasion? • How much important is the nodal status? • Are other subgroups important in the N status ?

  9. OPEN QUESTIONS • T1 Size • T2 larger 5 cm T3 ? • T3 – T4: Site of invasion • T4 satellite – T4 invasion • N1: single – multiple; micro – macro

  10. T1: SIZE OF THE TUMORLiterature Watch

  11. STAGE IB – IIA J. Thorac. Cardiovasc. Surg. Aug 2006;132: 316-9

  12. STAGE IB – IIA • Year 1994 only – 6644 Patients • Multicenter retrospective review • T1a≤ 2 cm • T1b > 2.1 – 3 cm Now Then • IA T1N0M0 T1aN0M0 • IB T2N0M0 T1bN0M0 • IIA T1N1M0 T2N0M0 + T1N1M0

  13. STAGE IB – IIA CLINICAL PATHOLOGIC J. Thorac. Cardiovasc. Surg. Aug 2006;132: 316-9

  14. STAGE IB – IIA CLINICAL PATHOLOGIC • Stages IB and IIA merged as new IIA • Cut-off T1a vs T1b ≤ 2 cm J. Thorac. Cardiovasc. Surg. Aug 2006;132: 316-9

  15. T2 LARGER THAN 5 CM … T3? J. Thorac. Cardiovasc. Surg. 2001;122:907-12

  16. T2 LARGER THAN 5 CM … T3? • 545 Patients (T > 3 cm) • Same nodal status • 3 Groups (3.1 – 5 cm, 5.1 – 7 cm, > 7 cm) • T2a ≤ 5 cm vs T2b > 5 cm

  17. T2 LARGER THAN 5 CM … T3? J. Thorac. Cardiovasc. Surg. 2001;122:907-12

  18. T2 LARGER THAN 5 CM … T3? J. Thorac. Cardiovasc. Surg. 2001;122:907-12 WHEN THE TUMOR IS LARGER THAN 5 CM THE PROGNOSIS IS THE SAME

  19. T2 LARGER THAN 5 CM … T3? J. Thorac. Cardiovasc. Surg. 2001;122:907-12

  20. T2 LARGER THAN 5 CM … T3? • T2b poorer survival than T2a • T2b upgraded to T3 • Nodal status has addictive effect

  21. STAGE III J. Thorac. Cardiovasc. Surg. 2002;124:503-10 • Overall 429 Patients • 73 IIIA and 79 IIIB

  22. STAGE III J. Thorac. Cardiovasc. Surg. 2002;124:503-10 IN THIS SERIES no difference in survival between IIIA and IIIB

  23. STAGE III J. Thorac. Cardiovasc. Surg. 2002;124:503-10 IN THIS SERIES no difference in survival between T3 and T4

  24. STAGE III Overall 429 Patients 73 IIIA and 79 IIIB • T3 bronchial vs T3 extrapulmonary • T4 tracheal, T4 satellite, T4 extrapulmonary, T4 malignant exudate • Complete surgical resection for T3 • R0 resections for T4

  25. STAGE III T3 T4 J. Thorac. Cardiovasc. Surg. 2002;124:503-10

  26. STAGE III T3 BRONCHIAL T2 T4 SATELLITE & TRACHEAL T3

  27. RECLASSIFICATION J. Thorac. Cardiovasc. Surg. 2002;124:503-10

  28. STAGE III • T3 bronchial downstaged to T2 • T4 tracheal and satellite downstaged to T3 • Better survival for R0 T3 and T4 • Surgical curativity should be taken into account in the reevaluation of staging

  29. T4 SATELLITE vs INVASION Ann. Thorac. Surg.2006;82:1808-14

  30. T4 SATELLITE vs INVASION • Overall 337 Patients • T4N0M0 Satellite (n=26) • T4N0M0 Invasion (n=25) • T4 pleural effusion excluded

  31. T4 SATELLITE vs INVASION N0 Ann. Thorac. Surg.2006;82:1808-14

  32. T4 SATELLITE vs INVASION Ann. Thorac. Surg.2006;82:1808-14 PET UPTAKE!!!!!

  33. T4 SATELLITE vs INVASION • Separation of heterogeneous types of T4 • T4N0M0 Satellite should be downstaged • MaxSUV should be taken into account as best predictor

  34. N1 INVOLVEMENT Lung Cancer 2004;43:151-7

  35. N1 INVOLVEMENT Lung Cancer 2004;43:151-7

  36. N1 SINGLE vs MULTIPLE Lung Cancer 2004;43:151-7

  37. N1 MICRO vs MACRO Lung Cancer 2004;43:151-7

  38. N1 INVOLVEMENT • Micro and single-node N1 downstaged respect macro and multiple-node N1 • Different therapeutic approaches for subgroups

  39. FUTURE

  40. FUTURE

  41. FUTURE

  42. WHERE ARE WE GOING? • It is necessary new staging (2009?) • T factor is a good target • MaxSUV could be a better survival predictor than TNM • Genomic studies ?????? • Long-term survival is affected not only by staging but first of all by treatment…

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