Lung Cancer Staging: The Revised TNM Classification
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1 Norwegian Society of Thoracic Imaging Oslo, October 2011 Lung Cancer Staging: The Revised TNM Classification Sujal R Desai King s College Hospital, London
2 Lung Cancer The Scale of the Problem Leading cause of cancer-related death in West. UK: ~40000 new diagnoses/deaths. US: ~ new cases and deaths <15% (overall) vs 70% 5ys (Stage I disease) >70% stage IIIB or greater at presentation Smoking rates declining: >90 x10 6 US population with smoking history/ 50% current smokers (2007) National Lung Screening Trial Research Team. The national lung screening trial: overview and study design Radiology 2011;258:
3 Lung Cancer The Scale of the Problem Ahmedin J et al. Annual report to the nation on the status of cancer, , featuring trends in lung cancer, tobacco use, and tobacco control J Natl Cancer Inst 2008;100:
4 Lung Cancer The Scale of the Problem 5-year cumulative relative survival Holmberg L et al. National comparisons of lung cancer survival in England, Norway and Sweden : differences occur early in follow-up Thorax 2011;65:
5 Lung Cancer Major Paradigm Shifts... IASLC/ATS/ERS reclassification of adenocarcinoma Lung cancer screening - NLST aborted; 20% reduction in lung-cancer specific mortality Revision to the TNM classification (version 7)
6 Issues with TNM-6 (& earlier) TNM-6 based on earlier versions and unchanged Small numbers (~5300); predominant surgically treated Single centre data; limited internal, no external validation No account of developing technologies (MDCT) Goldstraw P et al. The IASCLC lung cancer staging project: proposals for the revision of the TNM group stagings in the forthcoming (seventh) editon of the TNM classification of malignant tumours J Thorac Oncol 2007;2:
7 The Revised (TNM-7) Criteria 46 centres 19 countries 100,869 81,015 67,725 NSCLC 13,290 SCLC Goldstraw P et al. The IASCLC lung cancer staging project: proposals for the revision of the TNM group stagings in the forthcoming (seventh) editon of the TNM classification of malignant tumours J Thorac Oncol 2007;2:
8 The Revised (TNM-7) Criteria Groome PA et al. The IASCLC lung cancer staging project: validation of the proposals for revision of the T, N, and M descriptors and consequent stage groupings in the forthcoming (seventh) edition of TNM classification of malignant tumours J Thorac Oncol 2007;2:
9 Aims To summarise differences between the revised (TNM-7) descriptors and earlier versions To present the radiological (CT) features of lung cancer relevant to the revised staging system To discuss the limitations and (continuing) uncertainties in the radiological staging of lung cancer
10 Key Changes to TNM-6 Subdivision of T1 stage: T1 <3cms T1a 2cm T1b >2, 3cm Groome PA et al. The IASCLC lung cancer staging project: validation of the proposals for revision of the T, N, and M descriptors and consequent stage groupings in the forthcoming (seventh) edition of TNM classification of malignant tumours J Thorac Oncol 2007;2:
11 Key Changes to TNM-6 Subdivision of T2 stage: T2 >3cms T2a >3, 5cms T2b >5, 7 Groome PA et al. The IASCLC lung cancer staging project: validation of the proposals for revision of the T, N, and M descriptors and consequent stage groupings in the forthcoming (seventh) edition of TNM classification of malignant tumours J Thorac Oncol 2007;2:
12 T1 and T2 Tumours 1.6cm T1a T2b
13 T1 and T2 Tumours difficulties T1 or T2?
14 T1 and T2 Tumours difficulties
15 Key Changes to TNM-6 Tumour of any size but with invasion of chest wall,diaphragm, mediastinal pleura, parietal pleura, parietal pericardium, or tumour in main bronchus <2cm from carina but not involving carina; or atelectasis / obstructive pneumonitis of entire lung T3 Goldstraw P et al. The IASCLC lung cancer staging project: proposals for the revision of the TNM group stagings in the forthcoming (seventh) editon of the TNM classification of malignant tumours J Thorac Oncol 2007;2:
16 Unequivocal T3 Tumours *
17 Unequivocal T3 Tumours
18 Contentious T3 Tumours
19 Contentious T3 Tumours < 3cm mediastinal contact Preserved fat planes <90º circumferential contact Presence of at least one of these features predicts resectability (97%) * 1 Glazer HS Indeterminate mediastinal invasion by bronchogenic carcinoma: CT evaluation Radiology 1989;173:37
20 Key Changes to TNM-6 Tumour of any size but with invasion of: heart, great vessels, trachea, oesophagus, vertebral body, carina; tumour with malignant pleural / pericardial effusion; or with satellite tumour nodule(s) in ipsilateral primary-tumour lobe T4 Groome PA et al. The IASCLC lung cancer staging project: validation of the proposals for revision of the T, N, and M descriptors and consequent stage groupings in the forthcoming (seventh) edition of TNM classification of malignant tumours J Thorac Oncol 2007;2:
21 Unequivocal T4 Tumours
22 Unequivocal T4 Tumours IMAGE FROM: Nair A et al. Revisions to the TNM staging of non-small cell lung cancer: rationale, clinicoradiologic implications, and persistent limitations Radiographics 2011;31:
23 Key Changes to TNM-6 Groome PA et al. The IASCLC lung cancer staging project: validation of the proposals for revision of the T, N, and M descriptors and consequent stage groupings in the forthcoming (seventh) edition of TNM classification of malignant tumours J Thorac Oncol 2007;2:
24 Key Changes to TNM-6 Tumour in primary lobe TNM-6 T4 TNM-7 T3 M1 T4 OTHER LUNG (M1 M1a) Groome PA et al. The IASCLC lung cancer staging project: validation of the proposals for revision of the T, N, and M descriptors and consequent stage groupings in the forthcoming (seventh) edition of TNM classification of malignant tumours J Thorac Oncol 2007;2:
25 Key Changes to TNM-6 T4 T3 Groome PA et al. The IASCLC lung cancer staging project: validation of the proposals for revision of the T, N, and M descriptors and consequent stage groupings in the forthcoming (seventh) edition of TNM classification of malignant tumours J Thorac Oncol 2007;2:
26 Key Changes to TNM-6 FROM: Nair A et al. Revisions to the TNM staging of non-small cell lung cancer: rationale, clinicoradiologic implications, and persistent limitations Radiographics 2011;31:
27 Nodal Staging Goldstraw P et al. The IASCLC lung cancer staging project: proposals for the revision of the TNM group stagings in the forthcoming (seventh) editon of the TNM classification of malignant tumours J Thorac Oncol 2007;2:
28 Nodal Staging N1 N2
29 Nodal Staging Issues The reliance on size criteria (1cm CT cut-off) Variable dimensions of normal nodes ( cm) Small nodes (<1cm) may harbour metastases Large nodes may be reactive
30 Nodal Staging Issues: Value of PET 102 patients NSCLC Standard Staging -versus- Staging + PET Mediastinal LN and distant metastases PET CT Sensitivity Specificity PET Different staging (cpd standard) in 62/102 patients; Downstaging in 20 / Upstaging in 42 Pieterman RM et al. Pre-operative staging of non-small-cell lung cancer with positron-emission tomography N Engl J Med 2000;343:254
31 Nodal Staging Issues: Value of PET, PET/CT
32 Nodal Staging Issues: Value of PET, PET/CT 50 patients NSCLC Nodal staging PET/CT vs PET PET/CT vs CT PET/CT > PET PET/CT = CT Lardinois D et al. Staging of non-small-cell lung cancer with intergrated positron-emission tomography and computed tomography N Engl J Med 2003;348:
33 Nodal Staging: PET/CT vs CT vs invasive staging Tournoy KG et al. Integrated FDG-PET/CT does not make invasive staging of the intrathoracic lymph nodes in non-small cell lung cancer redundant: a prospective study Thorax 2007;62:
34 Nodal Staging: PET/CT vs CT vs invasive staging Tournoy KG et al. Integrated FDG-PET/CT does not make invasive staging of the intrathoracic lymph nodes in non-small cell lung cancer redundant: a prospective study Thorax 2007;62:
35 Nodal Staging: PET/CT vs CT vs invasive staging SENSITIVITY SPECIFICITY Tournoy KG et al. Integrated FDG-PET/CT does not make invasive staging of the intrathoracic lymph nodes in non-small cell lung cancer redundant: a prospective study Thorax 2007;62:
36 Nodal Staging: PET/CT vs CT vs invasive staging Negative Predictive Values: Small LN without FDG uptake 91% Large LN without FDG uptake 90% Positive Predictive Values: Small LN with FDG uptake 50% Large LN with FDG uptake 79% Tournoy KG et al. Integrated FDG-PET/CT does not make invasive staging of the intrathoracic lymph nodes in non-small cell lung cancer redundant: a prospective study Thorax 2007;62:
37 Nodal Staging: PET/CT vs CT vs invasive staging Tournoy KG et al. Integrated FDG-PET/CT does not make invasive staging of the intrathoracic lymph nodes in non-small cell lung cancer redundant: a prospective study Thorax 2007;62:
38 Nodal Staging Issues N3 or M1? IMAGE FROM: Nair A et al. Revisions to the TNM staging of non-small cell lung cancer: rationale, clinicoradiologic implications, and persistent limitations Radiographics 2011;31:
39 Metastatic Disease Goldstraw P et al. The IASCLC lung cancer staging project: proposals for the revision of the TNM group stagings in the forthcoming (seventh) editon of the TNM classification of malignant tumours J Thorac Oncol 2007;2:
40 Metastatic Disease Liver 33-39% Adrenals 20-33% Brain 16-26% Bone 15-21%
41 Summary Lung cancer staging is an important component of management New revisions to the existing TNM-6 descriptors are an improvement: based on larger numbers, multiple centre and validated Limitations and uncertainties exist in the radiological staging of disease
42 An Invitation in 2012
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