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Osarogiagbon RU, Van Schil P, Giroux DJ, Lim E, Putora PM, Lievens Y, Cardillo G, Kim HK, Rocco G, Bille A, Prosch H, Vásquez FS, Nishimura KK, Detterbeck F, Rami-Porta R, Rusch VW, Asamura H, Huang J. The International Association for the Study of Lung Cancer Lung Cancer Staging Project: Overview of Challenges and Opportunities in Revising the Nodal Classification of Lung Cancer. J Thorac Oncol 2023; 18:410-418. [PMID: 36572339 PMCID: PMC10065917 DOI: 10.1016/j.jtho.2022.12.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 12/12/2022] [Accepted: 12/16/2022] [Indexed: 12/25/2022]
Abstract
The status of lymph node involvement is a major component of the TNM staging system. The N categories for lung cancer have remained unchanged since the fourth edition of the TNM staging system, partly because of differences in nodal mapping nomenclature, partly because of insufficient details to verify possible alternative approaches for staging. In preparation for the rigorous analysis of the International Association for the Study of Lung Cancer database necessary for the ninth edition TNM staging system, members of the N-Descriptors Subcommittee of the International Association for the Study of Lung Cancer Staging and Prognostic Factors Committee reviewed the evidence for alternative approaches to categorizing the extent of lymph node involvement with lung cancer, which is currently based solely on the anatomical location of lymph node metastasis. We reviewed the literature focusing on NSCLC to stimulate dialogue and mutual understanding among subcommittee members engaged in developing the ninth edition TNM staging system for lung cancer, which has been proposed for adoption by the American Joint Committee on Cancer and Union for International Cancer Control in 2024. The discussion of the range of possible revision options for the N categories, including the pros and cons of counting lymph nodes, lymph node stations, or lymph node zones, also provides transparency to the process, explaining why certain options may be discarded, others deferred for future consideration. Finally, we provide a preliminary discussion of the future directions that the N-Descriptors Subcommittee might consider for the 10th edition and beyond.
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Affiliation(s)
| | - Paul Van Schil
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Antwerp University, Antwerp, Belgium
| | | | - Eric Lim
- Imperial College London, London, United Kingdom; The Academic Division of Thoracic Surgery, Royal Brompton Hospital, London, United Kingdom
| | - Paul Martin Putora
- Department of Radiation Oncology, Kantonsspital St. Gallen, St. Gallen, Switzerland; Department of Radiation Oncology, University of Bern, Bern, Switzerland
| | - Yolande Lievens
- Radiation Oncology Department, Ghent University Hospital, Ghent, Belgium
| | - Giuseppe Cardillo
- Azienda Ospedaliera San Camillo-Forlanini, Rome, Italy; UniCamillus-Saint Camillus International University of Health Sciences, Rome, Italy
| | - Hong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Gaetano Rocco
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrea Bille
- Department of Thoracic Surgery, Guy's Hospital, London, United Kingdom; King's College University, London, United Kingdom
| | - Helmut Prosch
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Francisco Suárez Vásquez
- Thoracic Surgeon, Surgery Department, Clínica Santa María, Santiago, Chile; Universidad de Los Andes, Santiago, Chile
| | | | | | - Ramon Rami-Porta
- Department of Thoracic Surgery, Hospital Universitari Mútua Terrassa, University of Barcelona, Terrassa, Barcelona, Spain; Network of Centres for Biomedical Research in Respiratory Diseases (CIBERES) Lung Cancer Group, Terrassa, Barcelona, Spain
| | - Valerie W Rusch
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hisao Asamura
- Division of Thoracic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - James Huang
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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Rami-Porta R. The Evolving Concept of Complete Resection in Lung Cancer Surgery. Cancers (Basel) 2021; 13:2583. [PMID: 34070418 DOI: 10.3390/cancers13112583] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 05/22/2021] [Accepted: 05/23/2021] [Indexed: 12/25/2022] Open
Abstract
Simple Summary In the surgical treatment of lung cancer, the complete removal of the portion of the lung where the cancer is and of the involved adjacent structures is of paramount importance to achieve long-term survival. The International Association for the Study of Lung Cancer (IASLC) proposed a definition of complete resection that included a well-defined type of removal of the regional lymph nodes as a fundamental step. The lymph nodes may contain cancer cells and, if left behind, cancer will soon progress. The IASLC also defined incomplete resection when there is any evidence of persistent cancer after the operation. It also defined an intermediate condition, uncertain resection, when no evidence of residual disease can be proved, but all the conditions of complete resection are not fulfilled. Four validations of the definitions have proved their prognostic value and, therefore, the definitions should be followed when a surgical resection of lung cancer is planned. Abstract Different definitions of complete resection were formulated to complement the residual tumor (R) descriptor proposed by the American Joint Committee on Cancer in 1977. The definitions went beyond resection margins to include the status of the visceral pleura, the most distant nodes and the nodal capsule and the performance of a complete mediastinal lymphadenectomy. In 2005, the International Association for the Study of Lung Cancer (IASLC) proposed definitions for complete, incomplete and uncertain resections for international implementation. Central to the IASLC definition of complete resection is an adequate nodal evaluation either by systematic nodal dissection or lobe-specific systematic nodal dissection, as well as the integrity of the highest mediastinal node, the nodal capsule and the resection margins. When there is evidence of cancer remaining after treatment, the resection is incomplete, and when all margins are free of tumor, but the conditions for complete resection are not fulfilled, the resection is defined as uncertain. The prognostic relevance of the definitions has been validated by four studies. The definitions can be improved in the future by considering the cells spread through air spaces, the residual tumor cells, DNA or RNA in the blood, and the determination of the adequate margins and lymphadenectomy in sublobar resections.
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González-Rivas D, Rami-Porta R. Reply from the authors: The quantification of nodal disease has prognostic relevance. J Thorac Cardiovasc Surg 2019; 159:e146-e147. [PMID: 31610966 DOI: 10.1016/j.jtcvs.2019.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 09/11/2019] [Accepted: 09/11/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Diego González-Rivas
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China; Department of Thoracic Surgery and Minimally Invasive Thoracic Surgery Unit, Coruña Hospital, Coruña, Spain
| | - Ramón Rami-Porta
- Department of Thoracic Surgery, Hospital Universitari Mútua Terrassa, University of Barcelona, Terrassa, Spain; Network of Centers for Biomedical Research in Respiratory Diseases Lung Cancer Group, Terrassa, Spain
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Butnor KJ, Asamura H, Travis WD. Node Doubt: Rigorous Surgical Nodal Procurement Combined With Thorough Pathologic Evaluation Improves Non-Small Cell Lung Carcinoma Staging Accuracy. Ann Thorac Surg 2017; 102:353-6. [PMID: 27449422 DOI: 10.1016/j.athoracsur.2016.05.075] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 05/17/2016] [Accepted: 05/20/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Kelly J Butnor
- Department of Pathology and Laboratory Medicine, University of Vermont Medical Center, Burlington, Vermont
| | - Hisao Asamura
- Division of Thoracic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - William D Travis
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York.
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Osarogiagbon RU, Sareen S, Eke R, Yu X, McHugh LM, Kernstine KH, Putnam JB, Robbins ET. Audit of lymphadenectomy in lung cancer resections using a specimen collection kit and checklist. Ann Thorac Surg 2014; 99:421-7. [PMID: 25530090 DOI: 10.1016/j.athoracsur.2014.09.049] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 09/11/2014] [Accepted: 09/19/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Audits of operative summaries and pathology reports reveal wide discordance in identifying the extent of lymphadenectomy performed (the communication gap). We tested the ability of a prelabeled lymph node specimen collection kit and checklist to narrow the communication gap between operating surgeons, pathologists, and auditors of surgeons' operation notes. METHODS We conducted a prospective single cohort study of lung cancer resections performed with a lymph node collection kit from November 2010 to January 2013. We used the kappa statistic to compare surgeon claims on a checklist of lymph node stations harvested intraoperatively with pathology reports and an independent audit of surgeons' operative summaries. Lymph node collection procedures were classified into four groups based on the anatomic origin of resected lymph nodes: mediastinal lymph node dissection, systematic sampling, random sampling, and no sampling. RESULTS From the pathology reports, 73% of 160 resections had a mediastinal lymph node dissection or systematic sampling procedure, 27% had random sampling. The concordance with surgeon claims was 80% (kappa statistic 0.69, 95% confidence interval: 0.60 to 0.79). Concordance between independent audits of the operation notes and either the pathology report (kappa 0.14, 95% confidence interval: 0.04 to 0.23) or surgeon claims (kappa 0.09, 95% confidence interval: 0.03 to 0.22) was poor. CONCLUSIONS A prelabeled specimen collection kit and checklist significantly narrowed the communication gap between surgeons and pathologists in identifying the extent of lymphadenectomy. Audit of surgeons' operation notes did not accurately reflect the procedure performed, bringing its value for quality improvement work into question.
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Affiliation(s)
- Raymond U Osarogiagbon
- Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee; School of Public Health, University of Memphis, Memphis, Tennessee.
| | - Srishti Sareen
- Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee
| | - Ransome Eke
- School of Public Health, University of Memphis, Memphis, Tennessee
| | - Xinhua Yu
- School of Public Health, University of Memphis, Memphis, Tennessee
| | - Laura M McHugh
- Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee
| | - Kemp H Kernstine
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern, Dallas, Texas
| | - Joe B Putnam
- Department of Cardiovascular and Thoracic Surgery, Vanderbilt University, Nashville, Tennessee
| | - Edward T Robbins
- Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee
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Osarogiagbon RU, Eke R, Sareen S, Leary C, Coleman L, Faris N, Yu X, Spencer D. The impact of a novel lung gross dissection protocol on intrapulmonary lymph node retrieval from lung cancer resection specimens. Ann Diagn Pathol 2014; 18:220-6. [PMID: 24866232 DOI: 10.1016/j.anndiagpath.2014.03.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 02/26/2014] [Accepted: 03/28/2014] [Indexed: 11/25/2022]
Abstract
Although thorough pathologic nodal staging provides the greatest prognostic information in patients with potentially curable non-small cell lung cancer, N1 nodal metastasis is frequently missed. We tested the impact of corrective intervention with a novel pathology gross dissection protocol on intrapulmonary lymph node retrieval. This study is a retrospective review of consecutive lobectomy, or greater, lung resection specimens over a period of 15 months before and 15 months after training pathologist's assistants on the novel dissection protocol. One hundred forty one specimens were examined before and 121 specimens after introduction of the novel dissection protocol. The median number of intrapulmonary lymph nodes retrieved increased from 2 to 5 (P<.0001), and the 75th to 100th percentile range of detected intrapulmonary lymph node metastasis increased from 0 to 5 to 0 to 17 (P=.0003). In multivariate analysis, the extent of resection, examination period (preintervention or postintervention), and pathologic N1 (vs N0) status were most strongly associated with a higher number of intrapulmonary lymph nodes examined. A novel pathology dissection protocol is a feasible and effective means of improving the retrieval of intrapulmonary lymph nodes for examination. Further studies to enhance dissemination and implementation of this novel pathology dissection protocol are warranted.
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Affiliation(s)
- Raymond U Osarogiagbon
- Thoracic Oncology Research Group, Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, TN; Division of Epidemiology and Biostatistics, School of Public Health, University of Memphis, Memphis, TN.
| | - Ransome Eke
- Division of Epidemiology and Biostatistics, School of Public Health, University of Memphis, Memphis, TN
| | - Srishti Sareen
- Thoracic Oncology Research Group, Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, TN
| | - Cynthia Leary
- Trumbull Laboratories, LLC/Pathology Group of the Mid-South, Memphis, TN
| | - LaShundra Coleman
- Thoracic Oncology Research Group, Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, TN
| | - Nicholas Faris
- Thoracic Oncology Research Group, Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, TN
| | - Xinhua Yu
- Division of Epidemiology and Biostatistics, School of Public Health, University of Memphis, Memphis, TN
| | - David Spencer
- Trumbull Laboratories, LLC/Pathology Group of the Mid-South, Memphis, TN
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Osarogiagbon RU, Darling GE. Towards optimal pathologic staging of resectable non-small cell lung cancer. Transl Lung Cancer Res 2013; 2:364-71. [PMID: 25806255 PMCID: PMC4367727 DOI: 10.3978/j.issn.2218-6751.2013.10.04] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Accepted: 10/10/2013] [Indexed: 12/21/2022]
Abstract
Pathologic nodal staging is the most accurate means of determining prognosis of patients with resectable non-small cell lung cancer (NSCLC), but confusion prevails about the optimal pre-operative and surgical lymph node examination procedures for candidates of curative-intent resection. The landmark American College of Surgeons Oncology Group Z0030 trial revealed no difference in the survival of patients with clinical T1 or T2, N0 or N1 (hilar node-negative), M0 NSCLC who either had a fastidious, pre-defined systematic hilar and mediastinal lymph node sampling procedure, or who received a complete mediastinal lymph node dissection. We place the results of this major trial into a contemporary clinical practice context, and discuss problems associated with apparent misunderstanding of the lessons from this trial, especially in light of evidence of prevailing sub-optimal nodal examination practices. We also discuss evolving knowledge about the origin of the quality gap in pathologic nodal staging and the emerging literature on corrective interventions.
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Affiliation(s)
- Raymond U. Osarogiagbon
- Thoracic Oncology Research Group, Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, TN, USA
| | - Gail E. Darling
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
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Buzogany I, Vaczi L, Domjan Z, Bagheri F, Kiss A, Alex D, Molnar TF. Newly developed histological tray for the application of identifying exact lymph node dissections in uro-logical surgical oncology. Health (London) 2013. [DOI: 10.4236/health.2013.510219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Molnar TF. On lymph node trays in lung cancer surgery. J Thorac Oncol 2013; 8:e8. [PMID: 23242447 DOI: 10.1097/JTO.0b013e318279159a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Osarogiagbon RU. On lymph node trays in lung cancer surgery. J Thorac Oncol 2013; 8:e8. [PMID: 23242448 DOI: 10.1097/JTO.0b013e31827915b1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Molnár FT, Horváth OP, Farkas L, Gerlinger I, Pajor L, Kelemen D, Kalmár Nagy K, Tizedes G, Pavlovics G, Bódis J, Gocze P, Szekeres G. [From the surgical field to the microscope. A new tool to identify the lymph node specimens in oncologic surgery]. Magy Seb 2011; 64:6-11. [PMID: 21330257 DOI: 10.1556/maseb.64.2011.1.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Oncologic surgery and pTNM staging require systemic removal of the locoregional lymphnodes. While the optimal extent and therapeutical and/or prognostic value of the lymphadenectomy/sampling are debated organ by organ and (sub)speciality by (sub)speciality, relevance of the lymphnode sytem-tumor concept itself is beyond doubt. Loss of information and existence of traps on the "surgical field-microscope" pathway is an international phenomenon, calling for solution. An integrated sterile and disposable lymphnode tray system is presented here for applications in the different fields of cancer surgery of the upper GI tract, retroperitoneum (gynecology, urology) and ear-nose-throat surgery.
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Affiliation(s)
- F Tamás Molnár
- Pécsi Tudományegyetem Klinikai Központ Sebészeti Klinika 7634 Pécs Ifjúság u. 13.
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Abstract
A retrospective study was carried out on 74 patients with advanced non-small-cell lung cancer (52 in stage IIIA, 22 in stage IIIB) who received platinum-based induction chemotherapy in doublets and triplets, followed by tumor resection. Thirty-day postoperative mortality was 5.4% (4 patients); 5 patients in stage IIIB and 17 in stage IIIA did not respond, but the other 47 (63.5%) were downstaged to < IIIA (26 were downstaged to stage I, 20 to stage II, and 1 had complete remission). There was no change in T factor in 22 (30%) patients, nor in N factor in 21 (28%). The actuarial 5-year survival rate for patients in postoperative stages IIIA and IIIB was 0.496; survival was significantly longer in patients who responded to therapy. Parallel improvement in both T and N status predicted worse survival than a multistage regression in any single factor. N status was found to be a stronger survival indicator than T status. Cell type did not influence the response rate or outcome. Induction chemotherapy significantly improved survival in patients who responded, despite a poor prognosis.
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Affiliation(s)
- Tamás F Molnár
- Department of Pneumonology, University of Pécs, Hungary.
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