The New International Staging SystemLung Cancer

Valerie W. Rusch, MDChief, Thoracic Surgery

Memorial Sloan-Kettering Cancer CenterChair, Lung and Esophagus Task Force,American Joint Commission on Cancer

Member, IASLC Staging Committee

HISTORY OF STAGINGTNM Concept

• Describes extent of tumor:– local (T = tumor)– regional (N = nodes) – distant (M = metastasis)

• Developed by Pierre Denoix 1943-52• Accepted by UICC in 1953 as basis for

classification of anatomical extent of cancer

• Incorporated in 1st edition of staging manual, 1968

HISTORY OF STAGING:UICC and AJCC

• From 1950-1980s, variations among staging systems

• 1987: Reconciliation of AJCC and UICC staging system

• Currently, AJCC and UICC agree jointly on revisions and publish simultaneously

• AJCC / UICC staging systems used worldwide and govern all US state and national tumor registries

• Chief, Thoracic Surgery, M.D. Anderson Hospital and Tumor Institute, (Houston, TX) 1951-1986

Clifton F. Mountain, 1924-2007

LUNG CANCER STAGING

• In 1973, AJC proposed TNM staging system for lung cancer

• Based on 2155 cases in Mountain’s database at MDACC

• Expanded database used by Mountain to propose revisions through 1997 (5th

editions)• No data to recommend changes for 6th

editions of staging manuals

LUNG CANCER STAGINGIASLC* Staging Committee & Database

• Following 1997 staging system revision, IASLC decided to sponsor development of international database

• 1999-2000, IASLC database organized by Peter Goldstraw (thoracic surgeon, Brompton, UK) and John Crowley (CRAB, Seattle, USA)

• IASLC Staging Committee is international and multidisciplinary

* = International Association for the Study of Lung Cancer

LUNG CANCER STAGINGIASLC Database

• 100,869 cases treated between 1990-2000

• 81,015 cases suitable for analysis (67,725 NSCLC, 13,290 SCLC, 513 carcinoid tumors)

• Evidence-based changes in T and M descriptors, maintenance of N descriptors

Goldstraw et al. JTO 2007;2:706-714;multiple articles (Rami-Porta, Rusch, Postmus, Groome, Shepherd, Sculier, Travis) in JTO 2007-2009

NUMBERS OF CASES ANALYZED, by type of data source

Registry 16,660Series treated surgically 19,172Clinical trial 24,239Series treated by all modalities (incl surgery)

7866

Consortium 5912Institutional registry 5492Surgical registry 2154TOTAL 81,495

Goldstraw et al. JTO 2006;1:281-286.

Goldstraw et al. JTO 2006;1:281-286.

Goldstraw et al. JTO 2006;1:281-286

Rami-Porta et al. J Thorac Oncol 2007;2:593-602.

Rusch VW et al. J Thorac Oncol, 2007;2:603-612.

Survival by cN and pN for Surgically Managed Patients

Rusch VW et al. J Thorac Oncol, 2007;2:603-612.

Survival by N Status and Number of Involved N Zones

Goldstraw et al. J Thorac Oncol 2007;2:706-714.

Goldstraw et al.J Thorac Oncol2007;2:706-714

Overall survival, expressed as a median survival time (MST) and 5-year survival, by clinical stage using the sixth edition of TNM (A) and proposed IASLC recommendations (B).

Goldstraw et al.J Thorac Oncol 2007;2:706-714.

Overall survival, expressedas a median survival time(MST) and 5-year survival,by pathologic stage usingsixth edition of TNM (A)and proposed IASLC recommendations (B)

LUNG CANCER STAGING SYSTEM7th Edition: 2009

• New staging system applies to:

–Non-small cell lung cancer–Small cell lung cancer (replacing

“limited /extensive” staging classification)

–Carcinoid tumors

Naruke vs. Mountain/Dresler MapsComparison of Nomenclature

Japanese Mountain / Dresler (ATS)

Level 1 Levels 1 and 2

Levels 2, 3, 4R, 4L Levels 4R and 4L

Levels 7 and 10 (subcarinal)

Level 7

Rusch VW et al. J Thorac Oncol, 2007;2:603-612.

New IASLCLymph Node

Map

Rusch & Asamura:JTO 2009; 4(5):568-577

Developing / Revising Staging Systems• Evidence for proposed revisions requires:

– international & multidisciplinary participation

– statisticians capable of managing and analyzing huge datasets

• Prospective data collection key to future revisions for all thoracic malignancies

• IASLC staging committee will now also address mesothelioma, esophageal Ca and possibly thymoma

Japan LungCancer Society,Tokyo: Kanehara& Co, 2000.

Naruke Lymph

Node Map

MountainDresler

Lymph NodeMap

Chest, 1997;111:1718-1723.