The International Association for the Study of Lung Cancer Lung Cancer Staging Project: Proposals for the Revision of the Clinical and Pathologic Staging of Small Cell Lung Cancer in the Forthcoming Eighth Edition of the TNM Classification for Lung Cancer

INTRODUCTION

Small cell lung cancer (SCLC) is commonly classified as either limited or extensive, but the Union for International Cancer Control TNM Classification of Malignant Tumours seventh edition (2009) recommended tumor, node, and metastasis (TNM) staging based on analysis of the International Association for the Study of Lung Cancer (IASLC) database.

METHODS

Survival analyses were performed for clinically and pathologically staged patients presenting with SCLC from 1999 through 2010. Prognosis was compared in relation to the TNM seventh edition staging to serve as validation and analyzed in relation to proposed changes to the T descriptors found in the eighth edition.

RESULTS

There were 5002 patients: 4848 patients with clinical and 582 with pathological stages. Among these, 428 had both. Survival differences were confirmed for T and N categories and maintained in relation to proposed revisions to T descriptors for seventh edition TNM categories and proposed changes in the eighth edition. There were also survival differences, notably at 12 months, in patients with brain-only single-site metastasis (SSM) compared to SSM at other sites, and SSM without a pleural effusion showed a better prognosis than other patients in the M1b category.

CONCLUSION

We confirm the prognostic value of clinical and pathological TNM staging in patients with SCLC, and recommend continued usage for SCLC in relation to proposed changes to T, N, and M descriptors for NSCLC in the eighth edition. However, for M descriptors, it remains uncertain whether survival differences in patients with SSM in the brain simply reflect better treatment options rather than better survival based on anatomic extent of disease.

[Traumatic rupture of the diaphragm]

OBJECTIVE

Traumatic rupture of the diaphragm (TRD) is a rare occurrence, with variable morbidity and mortality. The aim of this study was to analyze cases of TRD in a tertiary hospital and assess prognostic factors associated with mortality.

PATIENTS AND METHODS

A retrospective study was performed of patients diagnosed with TRD in Hospital Universitario La Fe, Valencia, Spain, between 1969 and 2006. The following variables were analyzed: sex, age, cause, diagnosis, associated lesions, surgical procedure, side and size of the lesion, visceral herniation, and postoperative morbidity and mortality.

RESULTS

The study group comprised 132 patients (105 men, 79.5%) with a mean (SD) age of 39.64 (17.04) years. Traffic accidents were the most common cause of TRD. Rupture involved the left hemidiaphragm in 96 cases (72.7%), and 113 patients (85.6%) had associated lesions, most often affecting the abdomen. Thoracotomy was performed in 83 cases (62.9%) and laparotomy in 41 (31.1%). Visceral herniation was reported in 90 patients (68.3%), most often involving the stomach. The rates of perioperative morbidity and mortality were 62.8% and 20.5%, respectively. Diagnostic delay and the presence of morbidity and serious associated lesions all had a statistically significant impact on mortality (P< .05). In the case of serious associated lesions, the odds ratio was 2.898 (95% confidence interval, 1.018-8.250) and for perioperative morbidity it was 1.488 (95% confidence interval, 1.231-1.798).

CONCLUSIONS

TRD is an infrequent occurrence in young men, is generally caused by traffic accidents, and is more common on the left side. Associated lesions are present in most cases and represent the main prognostic factor affecting morbidity and mortality. TRD can be considered a relative surgical emergency when not accompanied by other lesions that in themselves constitute surgical emergencies.

[Thyroid carcinoma with tracheal invasion: a series of five cases]

We report five cases of thyroid carcinoma with tracheal invasion. In two patients infiltration was found during thyroid exeresis. Diagnosis was based on respiratory signs such as hemoptysis and stridor in the other three patients. The pathologic diagnosis was papillary carcinoma for four patients and follicular carcinoma for one, the only man in the series. Treatment by thyroidectomy, tracheal resection and end-to-end anastomosis with node removal was followed by long-term survival. A search for tracheal involvement during thyroidectomy and clinical suspicion were the keys to a good prognosis for these patients.

[Postoperative survival in stage II non-small-cell bronchogenic carcinoma]

OBJECTIVE

This study aimed to validate in our population changes in the stage II criteria for non-small cell bronchogenic carcinoma.

PATIENTS AND METHODS

We retrospectively reviewed and followed the course of disease in 336 patients who underwent complete resection in our hospital between January 1969 and December 1995 with stage II disease, classified as T1N1M0 (41), T2N1M0 (144) and T3N0M0 (151).

RESULTS

The expected five-year survival in our population was 43.19 +/- 2.90%. Estimated mean survival was 3 +/- 0.71 years (95% confidence interval: 1.60-4.40). Mean survival was 8.82 +/- 0.67 years (95% confidence interval 7.51-10.13). Five-year survival was 53.32 +/- 8.55% for tumors classified as T1N1M0, 38.57 +/- 4.40% for T2N1M0, and 44.46 +/- 4.30% for T3N0M0. We observed significant differences in survival depending on histological type, tumor size, and IIA or IIB staging, degree of tumor invasion (T), number of nodes involved (N1) and location. T3N0M0 tumors displayed great variation in expected survival rates in relation to structures involved (27.53% to 59.98%). Multivariate analysis confirmed degree of tumor invasion, size and histological type to be the main prognostic factors.

CONCLUSIONS

We conclude that the new staging system gives a more realistic prognosis for patients in our practice. The stage IIA and IIB division is appropriate and gives significantly different prognoses. However, the T3N0M0 category is heterogeneous and is not significantly different from T1-2N1M0, such that stage II overall continues to be an indivisible, homogeneous group of patients. Other prognostic variables, such as histological type, affect survival in our patients.

[Prognosis of T3N0M0 small-cell non-anaplastic bronchogenic carcinoma]

We analyzed the survival after surgery for non-small cell lung cancer (NSCLC) classified as T3N0. Between January 1969 and 1995, 151 patients underwent surgery for NSCLC in our hospital. Survival analysis was performed using the Kaplan-Meier statistical method and the curves were compared using Mantel-Cox, Breslow and Tarone-Ware tests. The estimated five-year survival in the studied population was 44.46 +/- 4.30%. Four groups were defined based on degree of tumoral invasion of mediastinal structures, parietal pleura, chest wall or superior sulcus. Significant differences in five-year survival were observed between groups. Patients in the mediastinal group (59.98 +/- 8.71%) had the best prognosis, followed by patients with parietal pleura involvement (52.79 +/- 6.69%). Survival in the chest wall group was 27.53 +/- 7.22%. No patients with superior sulcus tumors survived over five years (median survival 1.50 +/- 1.16 years; 95% confidence interval 0.00 to 3.77 years). Prognosis is clearly determined by degree of tumoral invasion in T3N0 patients. In spite of the evident conceptual improvements achieved with the revised International Staging System, the system still fails to fully define prognosis in such cases.