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강 창 현 서울대학교병원 흉부외과 서울대학교 의과대학
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Staging Communication Evaluation TreatmentPrognosis Research
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TNM based stage AJCC (1977) UICC (1958) Collaboration since 1982
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AJCC Cancer Staging Manual editions EditionsPublicationEffective dates 11977 1978 - 1983 21983 1984 - 1988 31988 1989 - 1992 41992 1993 - 1997 51997 1998 - 2002 62002 2003 - 2009 72009 2010 -
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References T-descriptorsJTO 2007 N-descriptorsJTO 2007 M-descriptorsJTO 2007 Stage groupingJTO 2007 ValidationJTO 2007
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References SCLC (clinical staging) JTO 2007 SCLC (pathological staging) JTO 2009 Carcinoid tumorsJTO 2008 Additional prognostic factorJTO 2008 IASLC nodal mapJTO 2009
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AJCC 7 th edition Based on staging project by IASLCBased on staging project by IASLC International multi-institute dataInternational multi-institute data Internal and external validationInternal and external validation
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IASLC staging project 1996 IASLC workshop 1998 New staging committees 2001 Draft of data element 2005 Final submission of data
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IASLC database Time Frame 1990 ~ 2000 Source of data 45 sources from 20 countries
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Numbers of cases Total cases submitted100,869 Excluded from current analysis19,374 Included in analysis81,495 SCLC13,032 NSCLC68,463
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Treatment modalities Surgery 42% RT 8% Chemotherapy 15% Surgery + Chemo 4% Surgery + RT 5% Chemo + RT 12% Tri- modality3 %
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Distribution by continent
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Validation InternalExternal By Data source Geographical regions By SEER data 1998-2000 Literature review
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Numbers analyzed T descriptors18,198 N descriptors28,371 –pN1 & pN22,876 M descriptors6,596 SCLC (clinical)8,088 SCLC (Pathologic)349 Carcinoid tumor513
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T-descriptors Cutpoints of tumor size Malignant pleural effusion Separate nodules Other T2 descriptors Other T3 descriptors Other T4 descriptors
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New cutpoints in size 6 th Edition7 th Edition T1≤ 3cmT1a≤ 2cm T1b≤ 3cm T2> 3cmT2a≤ 5cm T2b≤ 7cm T3> 7cm
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T1 learning set (n=2,284)T2 learning set (n=2607)
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Separate nodules & Malignant effusion 6 th Edition 7 th Edition Separate nodules in Same lobeT4T3 in different lobe (same lung) M1T4 in contralateral lungM1M1a Malignant pleural effusionT4M1a
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N-descriptors Verification of N1, N2, & N3 Location of involved LNs Number of involved LN stations Skip metastasis Anatomical “zones”
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Negative results Peripheral specific LNs Single specific LN zones Presence of skip metastasis did not had prognostic significance (except LUL with AP zone single metastasis)
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Positive results? N1a single N1 zone N1b Multiple N1 zone N2a Single N2 zone N2b Multiple N2 zone
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Overall disease burden, rather than anatomical location may have the most important influence on outcome
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Suggestions Six Nodal zones Subdivision to 3 prognostic groups 1)N1a 2)N1b & N2a 3)N2b No change of current N-descriptors
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Discrepancy in nodal maps Naruke map Naruke map (Japan Lung Cancer Society map) MD-ATS map MD-ATS map (Mountain-Dresler modification of American Thoracic Society map) vs. #1#1 & #2 #2, #3, #4R, #4L#4R, #4L #7, #10#7
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M-descriptors Separate nodules –Same lobe –Same lung –Contralateral lung Malignant pleural effusion Distant metastasis –Site of interest (brain) –Single vs. multiple
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Stage grouping T1a / T1b T2aT2bT3T4N0IAIBIIAIIBIIIA N1IIAIIAIIBIIIAIIIA N2IIIAIIIAIIIAIIIAIIIB N3IIIBIIIBIIIBIIIBIIIB M1a / M1b IVIVIVIVIV
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AJCC the 6 th edition
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AJCC the 7 th edition
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Small cell lung cancer
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Carcinoid tumor
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Potential prognostic factors Tumor characteristics Patients characteristics Laboratory parameters Tumor biology
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Potential prognostic factors
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Changes in the 7 th edition Recommended for the classification of both NSCLC and SCLC and for carcinoid tumors T classification T1a (≤2cm) and T1b (>2-3cm) T2a (>3-5cm) and T2b (>5-7cm) T2 (>7cm) → T3 Multiple tumor nodules in the same lobe → T3 Multiple tumor nodules in the same lung → T4
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Changes in the 7 th edition No changes in N classification But new international nodal map was proposed M classification Malignant pleural or pericardial effusion → M1a Separate tumor nodules in contralateral lung → M1a M1b designates distant metastasis MX designation has been eliminated
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Limitations Lack of detailed data in each descriptors Too small numbers in specific category Different lymph node maps Biased distribution in treatment modality Effect of treatment had not been considered
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New IASLC Prospective project Prospective data acquisition International multi-institute study Complete set of data Including non-anatomical prognostic factors
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Timetable 2009-2010Data collection 2011-2012Follow-up 2013Data analysis Jan 2014 Submission of recommendations to UICC and AJCC Jan – July 2014 Publication in JTO 2016 Publication of 8 th edition of TNM classification by the UICC and AJCC
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Future
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