The IASLC Lung Cancer Staging Project: proposals for revision of the M descriptors in the forthcoming (seventh) edition of the TNM classification of lung cancer

Performance status and smoking status are independent favorable prognostic factors for survival in non-small cell lung cancer: a comprehensive analysis of 26,957 patients with NSCLC

BACKGROUND

Performance status (PS) is an important factor in determining survival outcome in non-small cell lung cancer (NSCLC) but is generally confounded by stage, age, gender, and smoking status. We investigated the prognostic significance of PS taking into account these important factors.

METHODS

Retrospective analysis of registry database of the National Hospital Study Group for Lung Cancer (NHSGLC) between 1990 and 2005. Univariate analysis was performed using Kaplan-Meier method. Multivariate analysis was performed using Cox proportional hazards model to identify independent prognostic factors.

RESULTS

A total of 26,957 patients with NSCLC were analyzed of which 12,613 patients (46.8%) had World Health Organization (WHO) PS = 0, 8,137 patients were never smokers (30.2%), and most of them were females (72.7%). The majority of PS = 0 patients presented with stage I disease (56.9%). Patients with PS = 0 constituted the group with the highest proportion of never smokers (36.7%). There was a significant difference in the median overall survival (OS) between patients with PS = 0 and PS = 1 (51.5 months versus 15.4 months, respectively; p < 0.0001) and among patients with various PS within individual American Joint Committee on Cancer stage (all p values <0.0001). Never smokers had significantly improved median OS than ever smokers (30.0 months versus 19.0 months, respectively; p < 0.0001). Multivariate analysis demonstrated good PS, never smoker (versus ever smoker; hazard ratio = 0.935, 95% confidence interval: 0.884-0.990; p = 0.0205), early stage, female gender, squamous cell carcinoma histology, and treatment were all as independent favorable prognostic factors.

CONCLUSIONS

PS and smoking status are independent prognostic factors for OS in NSCLC.

CD24, a novel cancer biomarker, predicting disease-free survival of non-small cell lung carcinomas: a retrospective study of prognostic factor analysis from the viewpoint of forthcoming (seventh) new TNM classification

INTRODUCTION

Metastasis-associated protein CD24 has been identified as a new prognostic factor and stem cell marker in the human neoplasm. However, the importance of the CD24 in non-small cell lung carcinomas (NSCLCs) has not been elucidated well.

METHODS

We evaluated CD24 expression in 267 consecutive cases of NSCLC by immunohistochemistry using a tissue microarray technique and correlated with clinicopathologic parameters including forthcoming (seventh) new tumor node metastasis classification.

RESULTS

CD24-high expression was demonstrated in 87 of 267 (33%) and was associated with adenocarcinoma (ADC) histology than in squamous cell carcinoma histology (64 of 165 [39%] vs. 20 of 88 [23%]; p = 0.023). Patients with CD24-high tumors tended to have a higher risk of disease progression (p < 0.001) and cancer-related death (p = 0.002). Multivariate analysis proved CD24-high expression as independent prognostic factors of disease progression and cancer-related death (p = 0.002, hazard ratio = 1.78, 95% confidence interval = 1.23-2.58 and p = 0.017, hazard ratio = 1.93, 95% confidence interval =1.13-3.31). CD24-high expression had a tendency to correlate with new pathologic stage (p-stage) (p = 0.089) rather than old p-stage (p = 0.253). Performance status and new p-stage, regardless of the tumor histology, were identified as consistent independent prognostic factors of disease progression and cancer-related death. However, age was related to a significantly shorter cancer-specific survival in ADC only.

CONCLUSIONS

CD24 expression in NSCLC is associated with ADC histology and disease progression and cancer-related death, indicative of aggressive tumor behavior. Performance status and new p-stage, to a lesser extent, age correlated with progression-free survival and cancer-specific survival, regardless of tumor histology.

[Anatomy, biology and concepts, pertaining to lung cancer stage classification]

尽管用于此修订本的大样本量患者数据库已极大地拓宽了我们的知识面，但最新提出的肺癌分期系统仍以解剖学特征为基础。可以预见，由于所鉴定出的患者亚群数目不断增加，肺癌分期系统变得愈加复杂。表述这些亚组的临床特征有可能为我们提供肿瘤亚组特殊的生物学行为特性的线索。本文探索了可用于以解剖学为基础的新分期系统的肿瘤生物学相关观念。

'Evidence-based medicine: the time has come to set standards for staging'. Is a radical overhaul really needed?

This Invited Response addresses concerns and opinions expressed in an Invited Commentary, 'Evidence-based medicine: the time has come to set standards for staging', by Quirke et al., published in this issue of The Journal of Pathology.

Vascular invasion is a strong prognostic factor after complete resection of node-negative non-small cell lung cancer

BACKGROUND

The seventh edition of TNM classification for non-small cell lung cancer (NSCLC) has been approved. Vascular invasion has been reported as being a strong risk factor; therefore, we reviewed the impact of vascular invasion on new TNM classification.

METHODS

We reviewed patients with completely resected NSCLC without lymph node metastasis treated at our institute between January 1993 and December 2003. Vascular invasion was examined using Victoria blue-van Gieson stains performed in maximum cut sections of tumor. Correlation between vascular invasion and other clinicopathologic factors, such as age, sex, histology, serum carcinoembryonic antigen (CEA) levels, smoking habitation, and T descriptors, were assessed. In addition, we evaluated the impact of vascular invasion on survival.

RESULTS

A total of 826 patients were analyzed. Median age was 65 years (range, 32-86). Thirty-two percent of patients were > 70 years, 44% were women, 78% had adenocarcinoma, 41% were never smokers, 39% smoked > 30 pack-years, and 31% had elevated serum CEA levels. Vascular invasion was detected in 279 patients (33.8%) and more was observed in patients who were male, did not have adenocarcinoma, were smokers, and had elevated CEA levels. Positive vascular invasion was significantly correlated with worse prognosis compared with negative (5-year survival, 90.5% vs 71.0%, P < .001). This trend was observed in each subgroup of T1a (92.9% vs 72.5%, P < .001), T1b (89.7% vs 77.2%, P = .015), and T2a (86.3% vs 65.6%, P < .001).

CONCLUSIONS

Vascular invasion was a strong prognostic factor in the revised TNM classification. Further investigation is warranted to generalize these findings.

[Surgical aspects of the new TNM system for lung cancer]

Recent results of basic research in lung cancer and development of new antitumoral drugs provided the bases for the revision of TNM system of lung cancer. In addition, the VI-th Edition of TNM classification was based on a relatively small database anyway. Multicentric analysis and biostatistical evaluation were carried out by the initiation of IASCL. 100869 patients were collected and 81015 cases were included in the analysis finally (NSCLC: 67725, SCLC: 13290). The aim of the study was to modify T, N as well as M factors of the classification. The recommendations were based on a large international database and survival analysis of that. It is expected that this change will influence treatment algorithms of lung cancer and it will improve survival of patients therefore.

A radiologic review of the new TNM classification for lung cancer

OBJECTIVE

In 2009, a new TNM staging system was published by the International Union Against Cancer and the American Joint Committee on Cancer. The new edition will encompass non-small cell lung cancer, small cell lung cancer, and bronchopulmonary carcinoids. This article will review many important changes that have been made in the revised staging system.

CONCLUSION

It is important that radiologists learn the new system and understand the reasons for the changes to provide more accurate clinical staging.

Third-line chemotherapy in advanced non-small cell lung cancer: identifying the candidates for routine practice

BACKGROUND

The interest of first- and second-line treatments in non-small cell lung cancer (NSCLC) has been demonstrated by successive randomized trials. Improvements in lung cancer care have routinely allowed a significant proportion of patients to be considered for third-line treatment.

METHODS

A retrospective analysis was performed, including all consecutive patients with advanced NSCLC, who received at least three lines of systemic antineoplastic treatment at our institution.

RESULTS

From a population of 613 patients treated with first-line treatment, a total of 173 patients received third-line treatment (cytotoxic chemotherapy in 131 patients; epidermal growth factor (EGFR) tyrosine kinase inhibitors in 42 patients). Only 13 patients (8%) received less than 75% of the theoretical dose intensity; 22 patients (13%) presented with severe toxicities. Symptom relief and performance status (PS) improvement were observed in 121 (92% of the 131 patients with symptoms) and 90 patients (52%), respectively. Using multivariate analysis, survival after third-line treatment was significantly increased in patients younger than 70 years-old (hazard ratio [HR] = 0.73, 95% confidence interval [CI]: 0.53-0.99, p = 0.047), who smoked less than 10 pack-years (HR = 0.82, 95% CI: 0.57-0.93, p = 0.036), with no cancer-related symptoms (HR = 0.75, 95% CI: 0.61-0.92, p = 0.007), a weight loss inferior to 5 kg since the beginning of second-line (HR = 0.63, 95% CI: 0.52-0.75, p = 0.013), a PS 0 to 1 (HR = 0.81, 95% CI: 0.76-0.86, p = 0.008), and no extrathoracic tumor spread at initiation of third-line treatment (HR = 0.67, 95% CI: 0.47-0.94, p = 0.042). Disease control after both first- and second-line treatments was the strongest predictor of prolonged survival after third-line treatment (HR = 0.47, 95% CI: 0.33-0.67, p = 0.001).

CONCLUSIONS

Patients with advanced NSCLC may benefit from third-line treatment. The best candidates can be identified using standard prognostic factors, such as PS, and disease control after first- and second-line treatments.

Lung Carcinoma Staging Problems

The tumor-node-metastasis (TNM) system is the most commonly used staging system for cancers, including lung cancer. The TNM descriptors and the stage groupings reflect differences in patient prognosis and choices for specific therapies. Generally, the higher the T, N, or M, and the higher the stage grouping, the worse the prognosis is for patients in that category. TNM stage is traditionally the most important factor predicting survival of lung cancer patients.

Analysis of second primary lung cancers in the SEER database

BACKGROUND

We sought to examine the outcomes of second primary lung cancers in the large population-based Surveillance Epidemiology and End Results (SEER) database. We also sought to study the outcomes of synchronous second non-small-cell lung cancers (NSCLCs), classified as stage IVA (M1A) according to the seventh edition of the TNM staging for lung cancer.

METHODS

Data of patients with at least two primary lung cancers were obtained. All available variables potentially associated with the incidence of a second primary lung cancer were examined. The overall survival of patients with synchronous NSCLC was compared with those with metachronous and stage IV NSCLC.

RESULTS

A small proportion (1.5%) of patients with lung cancer developed a second primary. A second primary is associated with younger age, female gender, earlier stage, and white race. The median survival of patients with metachronous NSCLCs (n = 3352) was worse than those with synchronous NSCLCs (n = 1858) (median survival 22 mo versus 29 mo, respectively; P < 0.01). After adjusting for age, race, gender, stage, and histology of both primaries, this difference in survival between patients with synchronous and metachronous second primary lung cancers was not statistically significant, but was better than those with stage IV NSCLC (n = 127,654; median survival 4 mo).

CONCLUSIONS

The incidence of second primary lung cancer is lower than that previously reported. Factors associated with good prognosis predict a second primary. Synchronous NSCLCs have an outcome better than a stage IV (M1a) designation. These patients should receive appropriate stage-specific multi-modality therapy suitable for the independent stage of each cancer without considering them unresectable.

An update on lung cancer staging

The staging committee of the International Association for the Study of Lung Cancer has recently published, in collaboration with the International Union Against Cancer and the American Joint Committee on Cancer, the recommendations for the upcoming 7th edition of the tumor, node, metastasis classification and staging manual. This article reviews the changes in criteria for the tumor, node, metastasis components and discusses the issues that will be faced by pathologists when examining lung cancer specimens, including recommendations for tumor measurement, differentiation of multiple primary tumors versus metastases, and visceral pleural invasion.

Multidisciplinary Evaluation of Patients With Suspected Lung Cancer

Lung cancer diagnosis and treatment has evolved to require the input and expertise of multiple diverse medical and surgical specialties. The approach to lung cancer patients requires the adherence to a few principles that include thorough use of staging modalities to assure the proper treatment for each patient, and an understanding of the limitations and advantages of each of these modalities. Evidence is continuing to emerge that supports the notion that diagnostic workup and treatment of lung cancer patients is best done within the context of a multidisciplinary team devoted to this purpose.

Updated lung cancer staging system

The tumor, node and metastasis classification of malignant tumors is periodically revised. Its seventh edition includes the updated classification for lung cancer, based on the analyses of the International Association for the Study of Lung Cancer international database. It is the largest validation ever carried out to date: 100,869 patients registered in 46 databases from 20 countries. The analysis of this database allowed a detailed study of the impact of tumor size on prognosis, the reclassification of additional tumor nodules, the reclassification of pleural dissemination and the separation of two groups of metastatic disease. These changes led to modifications in stage grouping that better differentiate tumors with different prognosis. This updated classification is also recommended for small-cell lung cancer, and for broncho–pulmonary carcinoids. A new international nodal map with stations and zones, and a histological definition of visceral pleura invasion, have also been proposed.

The IASLC Lung Cancer Staging Project: proposals regarding the relevance of TNM in the pathologic staging of small cell lung cancer in the forthcoming (seventh) edition of the TNM classification for lung cancer

INTRODUCTION

For more than 50 years, small cell lung cancer (SCLC) has been staged mainly as either limited or extensive stage disease. Small published series of resected SCLC have suggested that the tumor, node, metastases (TNM) pathologic staging correlates with the survival of resected patients. Recent analysis of the 8088 cases of SCLC in the International Association for the Study of Lung Cancer (IASLC) database demonstrated the usefulness of clinical TNM staging in this malignancy. The IASLC data bank contains an unprecedented number of resected SCLC cases with pathologic staging information. This analysis was undertaken to examine the impact of the TNM system on the pathologic staging of SCLC and to assess the new IASLC proposals in this subtype of lung cancer.

METHODS

Using the IASLC database, survival analyses were performed for resected patients with SCLC. Prognostic groups were compared, and the new IASLC TNM proposals were applied to this population and to the Surveillance, Epidemiology, and End Results (SEER) database.

RESULTS

The IASLC database contained 349 cases of resected SCLC where pathologic TNM staging was available. Survival after resection correlated with both T and N category with nodal status having a stronger influence on survival. Stage groupings using the 6th edition of TNM clearly identify patient subgroups with different prognoses. The IASLC proposals for the 7th edition of TNM classification also apply to this population and to the SEER database.

CONCLUSION

This analysis further strengthens our previous recommendation to use TNM staging for all SCLC cases.

Medical thoracoscopy

PURPOSE OF REVIEW

The technique and clinical applications of medical thoracoscopy have substantially evolved in the last few decades. The recent development of a semirigid thoracoscope, which is handled similarly to a bronchoscope, has made this procedure more attractive to pulmonologists. We will review the latest data on clinical applications, recently developed techniques, and safety of medical thoracoscopy, focusing mainly on its role in thoracic malignancies.

RECENT FINDINGS

Recent data confirm the high diagnostic yield of medical thoracoscopy - both with rigid and semirigid instruments - in detecting pleural metastases and determining the origin of pleural effusions. The degree of pleural adhesions found during thoracoscopy has been proposed by some authors as a prognostic factor for survival in patients with malignant pleural effusion. A large prospective multicenter study has established the safety of talc poudrage with large-particle talc, showing no cases of acute respiratory distress syndrome.

SUMMARY

Medical thoracoscopy is an excellent tool to establish diagnosis in patients with exudative pleural effusion of unclear origin. It is highly valuable in clarifying the origin of pleural effusions in patients with lung cancer, as the presence of a malignant pleural effusion is associated with poor survival and precludes the possibility of treatment with curative intention. Pleurodesis with talc poudrage is efficacious and well tolerated, especially with the use of large-particle talc.

Update in neoplastic lung diseases and mesothelioma

CONTEXT

Lung cancer is a common disease frequently seen by the surgical pathologist. Although secondary to improvements in screening and radiologic techniques and aggressive resection of small pulmonary nodules, the diagnosis of preneoplastic lesions is increasing in frequency and importance. Consequently, a greater understanding of their role in the development of lung carcinoma is needed for optimal patient care. Two lesions often encountered as small pulmonary nodules are bronchioloalveolar carcinoma and adenocarcinoma, which can be challenging to distinguish. Recently, updates to the TNM classification of non-small cell lung carcinoma have been reported that directly impact prognosis and treatment algorithms. Identification of new molecular targets in pleural mesothelioma and in preneoplastic lesions may lead to improved therapeutic strategies.

OBJECTIVE

To present recent advances in our understanding of neoplastic lung diseases and mesothelioma and to describe how these advances relate to the current practice of pulmonary pathology.

DATA SOURCES

Published literature from PubMed (National Library of Medicine) and primary material from the authors' institution.

CONCLUSIONS

It is important for the surgical pathologist to understand current diagnostic classifications of non-small cell lung cancer and to be aware of the range of preneoplastic lesions, as well as the features useful for distinguishing bronchioloalveolar carcinoma from adenocarcinoma in small pulmonary nodules. Although pleural mesothelioma has distinct features, it can also overlap histologically with adenocarcinoma, and immunohistochemistry can greatly aid in accurate diagnosis. New therapies targeting molecular markers in both non-small cell lung cancer and mesothelioma rely on accurate histopathologic diagnosis of these entities.

The new lung cancer staging system

The International Association for the Study of Lung Cancer (IASLC) has conducted an extensive initiative to inform the revision of the lung cancer staging system. This involved development of an international database along with extensive analysis of a large population of patients and their prognoses. This article reviews the recommendations of the IASLC International Staging Committee for the definitions for the TNM descriptors and the stage grouping in the new non-small cell lung cancer staging system.

Application of the revised lung cancer staging system (IASLC Staging Project) to a cancer center population

OBJECTIVE

The International Association for the Study of Lung Cancer (IASLC) proposed a revision to the Union Internationale Contre le Cancer (UICC-6) staging system for non-small cell lung cancer. The goal of our study was to compare these systems in patients undergoing surgery for non-small cell lung cancer to determine whether one system is superior in staging operable disease.

METHODS

Pathologic stages in 1154 patients undergoing complete resection over a 9-year period were analyzed. Patients were assigned a stage based on both IASLC and UICC-6 systems. We tested for statistically meaningful differences between the two staging systems using the Wilcoxon signed rank test and the permutation test.

RESULTS

The IASLC system is more effective than the UICC-6 system at ordering and differentiating patients (P = .009). Application of the IASLC system resulted in 202 (17.5%) patients being reassigned to a different stage (P = .012), with the most common shifts occurring from IB to IIA and IIIB to IIIA. The 5-year and median survivals of the IASLC IIIA patients including those shifted from the UICC-6 IIIB were 37% and 35 months, respectively. Reclassifying UICC-6 IIIB to IASLC IIIA did not reduce survival for the newly characterized IIIA cohort.

CONCLUSION

Our data confirm that the proposed IASLC staging system is more effective at differentiating stage than the UICC-6 system. Reclassifying patients from UICC-6 IIIB to IASLC IIIA will shift some patients from a stage previously considered unresectable to a stage frequently offered surgical resection. Further study and validation of the IASLC system are warranted.

The IASLC Lung Cancer Staging Project: data elements for the prospective project

The International Association for the Study of Lung Cancer Retrospective Staging Project culminated in a series of recommendations to the International Union Against Cancer and to the American Joint Committee on Cancer regarding the seventh edition of the tumor, node, metastasis (TNM) classification for lung cancer. The International Staging Committee of the International Association for the Study of Lung Cancer now issues this call for participation in the Prospective Project designed to assess the validity of each component of T, N, and M, and other factors relevant to lung cancer staging and prognosis. In the Retrospective Project, the original data acquisition was typically motivated by interests other than staging. In contrast, the Prospective Project offers online data entry. Alternatively, participants may transfer existing data, provided core objectives are addressed. Cancer Research and Biostatistics will coordinate data management and analysis. The study population is newly diagnosed lung cancer patients. Data elements include patient characteristics, baseline laboratory values, first-line treatment, TNM plus supporting evidence, and survival. Pretreatment TNM will be collected for all cases; postsurgical TNM, if resection is attempted. T descriptors include size and degree of tumor extension, with further description of extent of visceral pleural invasion, venous invasion, carcinomatous lymphangitis, and pleural lavage cytology. M descriptors characterize the newly proposed M1a category and sites of distant metastases. Nodal station involvement is described by means of a newly proposed nodal map, facilitating international participation, and allowing further investigation of nodal zones. Successful collection and analysis of these data can be expected to yield unprecedented improvements in the utility and validity of lung cancer staging.

New TNM classification for non-small-cell lung cancer

The International Association for the Study of Lung Cancer (IASLC) staging committee has recently completed a decade of work devoted to updating the stage classification system for lung cancer. The IASLC has proposed revisions based on the evaluation of outcomes in an extensive worldwide database. This review outlines the changes in the tumor, node, metastasis (TNM) descriptors and stage groupings anticipated in the official new stage classification system for non-small-cell lung cancer with the forthcoming publication of the 7th Edition of the stage classification.

The applicability of the proposed IASLC staging revisions to small cell lung cancer (SCLC) with comparison to the current UICC 6th TNM Edition

BACKGROUND

We examined the impact of the proposed Internal Association for the Study of Lung Cancer (IASLC) tumor, node, metastasis (TNM) and stage grouping revisions on staging and survival outcome of small cell lung cancer (SCLC).

METHODS

A total of 10,660 SCLC patients from the California Cancer Registry between 1991 to 2005 with complete TNM staging were identified and reclassified according to the IASLC proposed TNM revisions and new stage groupings. Surveillance Epidemiology and End Results extent of disease codes were used to identify various T4 and M descriptors. Cox proportional hazards regression was used to identify prognostic factors.

RESULTS

Survival was correlated with the current UICC6 and IASLC proposed T descriptors. Patients without mediastinal lymph node involvement (N 0-1) had superior survival compared to patients with mediastinal lymph node involvement (N 2-3). The IASLC proposed stage grouping results in better separation of survival curves among early stage SCLC than the current Union Internationale Centre le Cancer (UICC) 6 stage groupings by both univariate and multivariate analyses. Pleural effusion (IASLC M1a) in SCLC had survival similar to other IASLC M1a categories (pericardial effusion, contralateral intrapulmonary metastasis) by pairwise hazard ratio comparisons.

CONCLUSIONS

The IASLC proposed TNM staging changes result in better separation of stage-specific SCLC survival curves than the current UICC6 staging system. The new IASLC M1a descriptors (pleural effusion, pericardial effusion, and contralateral/bilateral intrapulmonary metastasis) adequately prognosticate SCLC patients as having metastatic disease.

Risk of intracranial hemorrhage and cerebrovascular accidents in non-small cell lung cancer brain metastasis patients

BACKGROUND

Brain metastases confer significant morbidity and a poorer survival in non-small cell lung cancer (NSCLC). Vascular endothelial growth factor-targeted antiangiogenic therapies (AAT) have demonstrated benefit for patients with metastatic NSCLC and are expected to directly inhibit the pathophysiology and morbidity of brain metastases, yet patients with brain metastases have been excluded from most clinical trials of AAT for fear of intracranial hemorrhage (ICH). The underlying risk of ICH from NSCLC brain metastases is low, but needs to be quantitated to plan clinical trials of AAT for NSCLC brain metastases.

METHODS

Data from MD Anderson Cancer Center Tumor Registry and electronic medical records from January 1998 to March 2006 was interrogated. Two thousand one hundred forty-three patients with metastatic NSCLC registering from January 1998 to September 2005 were followed till March 2006. Seven hundred seventy-six patients with and 1,367 patients without brain metastases were followed till death, date of ICH, or last date of study, whichever occurred first.

RESULTS

The incidence of ICH seemed to be higher in those with brain metastasis compared with those without brain metastases, in whom they occurred as result of cerebrovascular accidents. However, the rates of symptomatic ICH were not significantly different. All ICH patients with brain metastasis had received radiation therapy for them and had been free of anticoagulation. Most of the brain metastasis-associated ICH's were asymptomatic, detected during increased radiologic surveillance. The rates of symptomatic ICH, or other cerebrovascular accidents in general were similar and not significantly different between the two groups.

CONCLUSIONS

In metastatic NSCLC patients, the incidence of spontaneous ICH appeared to be higher in those with brain metastases compared with those without, but was very low in both groups without a statistically significant difference. These data suggest a minimal risk of clinically significant ICH for NSCLC brain metastasis patients and proposes having more well designed prospective trail to see the role of AAT in this patient population.

[The IASLC lung cancer staging project. Comparing the current 6(th) TNM edition with the proposed 7(th) edition]

The future 7th edition of TNM classification for lung cancer will be published in 2009 and comprises the IASLC recommendations for TNM parameters. The general staging of lung cancer includes the new parameters: reclassification of tumours larger than 7 cm from T2 to T3; extra tumoral nodules will change their category to T3, T4 and M1 when in the same, ipsilateral or contralateral lobe, respectively; pleural effusion will be M1a. With these alterations, cases staged as IB - T2b N0 M0 will be IIA, cases staged IIB - T2a N1 M0 will be IIA and cases IIIB- T4 N0- -1 M0 will be IIIA. The 7(th) TNM edition recommendations were applied to 203 broncho -pulmonary carcinomas, concerning epidermoid carcinomas (83) and adenocarcinomas (120) registered in the archive of the Serviço de Anatomia Patológica of the Hospitais da Universidade de Coimbra - Portugal, previously submitted to surgical resection and lymph node excision. The following alterations will be kept as the application of the future 7(th) TNM edition: 20 cases in stage IB will move to stage IIA (17) and stage IIB (3); 18 cases will change from stage IIB to stage IIA (17) and 1 case to stage IIIA; 2 cases from stage IIIB will move to stage IV; 6 cases in stage IV will move to stage IIIA (5) and 1 case to stage IIIB. In this translational adaptation from 6th to 7th TNM staging, 51 out of the 203 analysed cases change their staging, corresponding to 25.1%.

Reclassification of neuroendocrine tumors improves the separation of carcinoids and the prediction of survival

INTRODUCTION

The classification of neuroendocrine lung tumors has changed over the last decades. Reliable diagnoses are crucial for the quality of clinical databases. The purpose of this study is to determine to which extent the use of different diagnostic criteria of neuroendocrine lung tumors has influenced the classification of these tumors. The prognostic information of tumor, node, metastasis descriptors was also evaluated.

METHODS

We retrieved 110 tumors from the period 1989 to 2007. All tumors were reclassified according to the World Health Organization classification of 2004. Tumor, node, metastasis descriptors were evaluated.

RESULTS

By reclassification, the diagnoses on 48 tumors (44%) were changed. More diagnoses were changed in the older part of the material. A significantly different survival was shown for all patients in relation to tumor size (p < 0.0001). An endobronchial component was seen in 54%, 31%, and 11% of typical carcinoid, atypical carcinoid, and large cell neuroendocrine carcinoma, respectively with no impact on survival (p = 0.90). For all included patients the survival was significantly worse for patients having metastasis to N1 nodes as compared with N0 (p = 0.03). However, the number of removed lymph nodes were insufficient for definitive determination of the prognostic impact of node metastases. Regarding the revised diagnoses, a significant difference in survival between typical carcinoid, atypical carcinoid, large cell neuroendocrine carcinoma and small cell carcinoma was noted (p < 0.005).

CONCLUSION

Tumors must be rediagnosed before entering a central database. Tumor and node seem to be useful predictors of survival.

Proceedings of the IASLC International Workshop on Advances in Pulmonary Neuroendocrine Tumors 2007

The International Association for the Study of Lung Cancer, (IASLC) International Congress on Advances in Pulmonary Neuroendocrine Tumors was a two-day meeting held at the Royal Brompton Hospital in London, United Kingdom on the thirteenth and forteenth of December 2007. The meeting was led by 14 member international faculty-in the disciplines of pathology, surgery, medicine, oncology, endocrinology, nuclear medicine, diagnostic imaging, and biostatistics. The aims were twofold, as an educational meeting, and to develop the IASLC International Pulmonary Neuroendocrine Tumors Registry. The meeting highlighted the difference in presentation of the tumors, management options for early and advanced stage disease including the use of novel agents and approaches. The need, process, and approach to an International Registry of Pulmonary Neuroendocrine Tumors were emphasized. International collaboration to develop a retrospective registry, prospective data collection, virtual tissue bank, and collaborative clinical trials were universally agreed as the best way to advance our understanding and treatment of these rare tumors.

Neoadjuvant therapy for resectable non-small cell lung cancer with mediastinal lymph node involvement

The optimal treatment for stage IIIA (N2) NSCLC remains controversial. Numerous studies with induction chemotherapy or chemoradiotherapy show that both approaches in the neoadjuvant setting are feasible. Outcomes following induction therapy have been associated with mediastinal nodal response, with residual mediastinal involvement a negative predictor of survival. Appropriate selection of patients to undergo resection following induction therapy is critical. Lobectomy may be safely performed following induction therapy while pneumonectomy may carry a high and possibly unacceptable rate of perioperative mortality. Combined modality therapy has increased the overall survival of patients with stage III NSCLC. Future trials looking at different induction regimens with or without radiotherapy and with or without surgery may help identify the ideal treatment for this heterogeneous disease stage. The SAKK-16/00 study is an ongoing phase III European trial randomizing patients with stage IIIA NSCLC to receive neoadjuvant chemotherapy with three cycles of docetaxel and cisplatin followed by radiation and then surgical resection, or to chemotherapy with the same regimen followed by surgery alone. Other ongoing trials include investigations of novel chemotherapeutic combinations, such as cisplatin with pemetrexed, in the phase II setting. The RTOG 0229 phase II study is evaluating neoadjuvant paclitaxel and carboplatin concurrently with radiation therapy, followed by surgery and consolidation chemotherapy with paclitaxel and carboplatin for stage III NSCLC. The combination of neoadjuvant docetaxel, carboplatin, and radiation therapy followed by surgical resection for stage III NSCLC is also currently being investigated in a phase II trial. The future of treatment for stage III NSCLC may lie in the outcome of trials investigating molecularly targeted agents, such as EGFR inhibitors, anti-angiogenic agents, or multitargeted agents. Optimal incorporation into the multimodality approach required of locally advanced N2 NSCLC will require careful investigation. The results from these trials are eagerly awaited.