Chest
Special FeatureSpecial FeatureThe New Lung Cancer Staging System
Section snippets
Fundamentals of the UICC/AJCC Staging System
The NSCLC stage classification is based on the TNM system, which is used for most cancers. The T descriptor defines the extent of the primary tumor, the N descriptor the extent of involvement of regional lymph nodes, and the M descriptor the extent of spread to distant sites. The staging system is based solely on the anatomic extent of disease. Other factors, such as clinical symptoms or molecular biological characterization of the tumor, have not been included. Increasing T status reflects
Development and Methodology of the IASLC Staging System
A proposal to develop an international effort to inform a future revision of the TNM staging classification for lung cancer originated in 1996 at a workshop sponsored by IASLC. An international committee was established and work began in 1999. An unrestricted grant from Eli Lilly and Company enabled the establishment of a database (Eli Lilly and Company played no role in the data collection, analysis, or recommendation development process). The database was developed in cooperation with Cancer
T Descriptor
The IASLC International Staging Committee analyzed the effect of tumor size in detail, in part because there were many patients in whom reliable information was available. The size threshold of 3 cm was confirmed as a significant cutpoint and retained as a definition of a T1 vs a T2 tumor. In addition, significant cutpoints were identified at 2, 5, and 7 cm. Tumors > 7 cm had survival that tracked with other definitions of T3 (ie, invasion or central location) and are therefore placed within
N Descriptor
Analysis of the prognostic influence of the N descriptor resoundingly supported the traditional categorization of N0, N1, N2, and N3, as shown for clinically and pathologically staged patients in Figure 3.3 Therefore, no changes were made in the N descriptor as defined in the 6th edition of the staging manual. Further analyses were done to explore whether particular node stations within an N category had any particular impact. No such relationship could be identified.3 Specifically, there was
M Descriptor
The committee on the M descriptor considered patients traditionally classified as M0 or M1 (distant metastases), but it also considered patients with a malignant pleural effusion or with additional tumor nodules in the lung.4 After analysis and discussion, patients with an additional tumor nodule in the primary tumor lobe or a different ipsilateral lobe were redefined along with other aspects of the T descriptor (see “T Descriptor” section). The remaining cohorts categorized by the M descriptor
Stage Grouping
The IASLC International Staging Committee has defined stage groupings. Despite the recognition of many new subdivisions of the T and M descriptor, the stage grouping has not added any new subdivisions. However the definition of the stage groups has become more complex due to the additional T and M descriptor subgroups. Two different representations of the stage grouping scheme are shown in Table 4 and Figure 6. Survival curves for the stage groupings based on clinical and pathologic staging are
Discussion
The development of the new NSCLC staging system represents an astounding amount of work. This extends from the careful detailed analysis as summarized in this article, back through the establishment of a database (with the necessary definitions, quality controls, and data cleansing), to the individuals and institutions that collected data in the first place with sufficient detail and rigor. An effort of this magnitude as a basis for a staging system is quite unique among types of cancer. The
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