Impact and application of the IASLC staging project. IASLC staging project

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1 Impact and application of the IASLC staging project Paul Van Schil, MD Department of Thoracic and Vascular Surgery Antwerp University, Belgium 13th European Congress: Perspectives in Lung Cancer Amsterdam, March 9, 2012 No conflict of interest, no financial disclosure Acknowledgement: contribution R. Rami-Porta, Chair ISC IASLC IASLC staging project TNM classification: from 6th to 7th edition T descriptor N descriptor M descriptor also SCLC + carcinoid tumours Prospective database: from 7th to 8th edition New adenocarcinoma classification Conclusions

2 7th TNM classification Which statement is true? 1. T1a tumours are 1 cm 2. Data on the nodal stations are mainly prospective 3. Midline of trachea is on its right side 4. LN station 10R can be reached by cervical mediastinoscopy 7th TNM classification Which statement is true? 1. T1a tumours are 1 cm 2. Data on the nodal stations are mainly prospective 3. Midline of trachea is on its right side 4. LN station 10R can be reached by cervical mediastinoscopy

3 IASLC staging project TNM classification: from 6th to 7th edition T descriptor N descriptor M descriptor Prospective database: from 7th to 8th edition New adenocarcinoma classification Conclusions T descriptor new categories T1a 2 cm T1b > 2 and 3 cm T2a > 3 and 5 cm T2b > 5 and 7 cm adjuvant chemotherapy: 4cm adjuvant chemotherapy: 4 cm > 7cm = T3 additional tumour nodules

4 Additional tumour nodules T3 T4 7th edition TNM (IASLC) additional nodules = lobe T3 ipsilateral nodules lobe T4 pleural dissemination T4 M1a Rami-Porta R et al. J Thorac Oncol 2007; 2: Visceral pleura invasion PL0: PL1 y PL2: T2 PL3: T3 In case of doubt about the visceral pleura involvement, the use of elastic stains is recommended Copyright 2008 Aletta Ann Frazier, MD.

5 IASLC staging project TNM classification: from 6th to 7th edition T descriptor N descriptor M descriptor Prospective database: from 7th to 8th edition New adenocarcinoma classification Conclusions New LN map N descriptor: zones Rusch V. J Thorac Oncol 2009; 4: Best of both worlds: East West Surgery - Radiology Van Schil P. J Thorac Oncol 2009; 4:561-2

6 LN stations - zones lower margin cricoid clavicles, manubrium N3! Rusch V. J Thorac Oncol 2009; 4: Oncological midline: at L side of trachea! tumour R +2R = N2 tumour L +2R = N3

7 LN stations - zones 3 pretracheal! 4 tracheobronchial 3a-p: anatomically distinct 4R lower border of azygos vein 4L upper rim of L main PA 10 R+L interlobar region mediastinoscopy: N1 nodes L+R! Rusch V. J Thorac Oncol 2009; 4: oncological midline 7 carina of trachea L border LLL bronchus R border of bronchus intermedius 7 larger region!

8 LN stations - zones Rusch V. J Thorac Oncol 2009; 4:568-77

9 IASLC : Complete Resection Subcommittee Complete resection R0 free resection margins proved microscopically systematic or lobe-specific systematic nodal dissection : 6 nodal stations (3 mediastinal) no extracapsular extension in nodes removed separately or at the margin of the lung specimen highest mediastinal lymph node must be negative Rami-Porta R et al. Complete resection in lung cancer surgery : proposed definition. Lung Cancer 2005; 49:25-33 IASLC staging project TNM classification: from 6th to 7th edition T descriptor N descriptor M descriptor Prospective database: from 7th to 8th edition New adenocarcinoma classification Conclusions

10 M descriptor new categories M1a intrathoracic metastases pleural pericardial spread contralateral malignant nodules M1b extrathoracic metastases IASLC staging project TNM classification: from 6th to 7th edition T descriptor N descriptor M descriptor Prospective database: from 7th to 8th edition New adenocarcinoma classification Conclusions

11 T descriptor From 7th to 8th edition Objectives Prospective data collection tumour extension visceral pleural, venous invasion carcinomatous lymphangitis pleural lavage cytology Ndescriptor po new map, nodal zones M descriptor N1a N1b N2a - N2b M1a M1b site of distant mets extended to mesothelioma, tumours of thymus and oesophagus Giroux D et al. J Thorac Oncol 2009; 4: Cogen A et al. Acta Chir Belg 2011; 111: p staging c staging! N1a single N1 zone N1b multiple N1 zones N2a single N2 zone N2b multiple N2 zones

12 IASLC staging project TNM classification: from 6th to 7th edition T descriptor N descriptor M descriptor Prospective database: from 7th to 8th edition New adenocarcinoma classification Conclusions IASLC/ATS/ERS ADENOCARCINOMA CLASSIFICATION PREINVASIVE LESIONS ATYPICAL ADENOMATOUS HYPERPLASIA ADENOCARCINOMA IN SITU AIS ( 3 cm - formerly BAC pattern) non-mucinous / mucinous / mixed MINIMALLY INVASIVE ADENOCARCINOMA - MIA non-mucinous / mucinous / mixed 3 cm lepidic predominant tumor with 5mm invasion INVASIVE ADENOCARCINOMA VARIANTS Size should be specified. In well sampled tumors AIS is independent of size; extensive sampling is needed to exclude invasion, particularly in larger tumors Travis W et al. J Thorac Oncol 2011; 6: Eur Resp J 2011; 38:239-42

13 Surgical Implications of the new adenoca. classification how to predict prognosis preoperatively? role of frozen section analysis? is limited resection adequate oncological treatment for some early, stage IA adenoca.? GGO? AIS? MIA? incorporation molecular information - biomarkers diagnostic therapeutic algorithms (randomized trials) Van Schil P. et al. Eur Resp J 2012; 39: New adenoca. classification 8th TNM new categories Tis in situ breast cancer adenoca. squamous cell ca. T1mi minimally invasive adenoca. Tf factor: size of finvasivei component multiple lung adenocarcinomas: synchronous 1ary metachronous 1ary intrapulmonary mets Travis W et al. J Thorac Oncol 2011; 6: Eur Resp J 2011; 38:239-42

14 7th TNM classification Which statement is false? 1. 5 additional malignant nodules in same lobe = T3 2. All lymph node stations with 2 digits are considered to be N1 disease (ipsilateral 1ary tumour) 3. Isolated, resectable brain metastasis = M1b disease 4. Adjuvant chemotherapy is indicated for all pt2a tumours 7th TNM classification Which statement is false? 1. 5 additional malignant nodules in same lobe = T3 2. All lymph node stations with 2 digits are considered to be N1 disease (ipsilateral 1ary tumour) 3. Isolated, resectable brain metastasis = M1b disease 4. Adjuvant chemotherapy is indicated for all pt2a tumours

15 IASLC staging project TNM classification: from 6th to 7th edition T descriptor N descriptor M descriptor Prospective database: from 7th to 8th edition New adenocarcinoma classification Conclusions Conclusions TNM lung cancer From 6th to 7th edition edition refinement T and M descriptor new nodal map, nodal zones From 7th to 8th edition prospective data collection new subcategories adenoca. classification: Tis T1mi invasive component many good-quality data needed! We need your active participation!

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