State of the Art MR Imaging for Lung Cancer TNM Stage Evaluation.
Cancers
Since the Radiology Diagnostic Oncology Group (RDOG) report had been published in 1991, magnetic resonance (MR) imaging had limited clinical availability for thoracic malignancy, as well as pulmonary diseases. However, technical advancements in MR systems, such as sequence and reconstruction methods, and adjustments in the clinical protocol for gadolinium contrast media administration have provided fruitful results and validated the utility of MR imaging (MRI) for lung cancer evaluations. These techniques include: (1) contrast-enhanced MR angiography for T-factor evaluation, (2) short-time inversion recovery turbo spin-echo sequences as well as diffusion-weighted imaging (DWI) for N-factor assessment, and (3) whole-body MRI with and without DWI and with positron emission tomography fused with MRI for M-factor or TNM stage evaluation as well as for postoperative recurrence assessment of lung cancer or other thoracic tumors using 1.5 tesla (T) or 3T systems. According to these fruitful results, the Fleischner Society has changed its position to approve of MRI for lung or thoracic diseases. The purpose of this review is to analyze recent advances in lung MRI with a particular focus on lung cancer evaluation, clinical staging, and recurrence assessment evaluation.
10.3390/cancers15030950
Clinical T category for lung cancer staging: A pragmatic approach for real-world practice.
Choi Yeonu,Kim Sun-Hyung,Kim Ki Hwan,Choi Yeonseok,Park Sung Goo,Sohn Insuk,Kim Hye Seung,Um Sang-Won,Lee Ho Yun
Thoracic cancer
BACKGROUND:To determine which components should be measured and which window settings are appropriate for computerized tomography (CT) size measurements of lung adenocarcinoma (ADC) and to explore interobserver agreement and accuracy according to the eighth edition of TNM staging. METHODS:A total of 165 patients with surgically resected lung ADC earlier than stage 3A were included in this study. One radiologist and two pulmonologists independently measured the total and solid sizes of components of tumors on different window settings and assessed solidity. CT measurements were compared with pathologic size measurements. RESULTS:In categorizing solidity, 25% of the cases showed discordant results among observers. Measuring the total size of a lung adenocarcinoma predicted pathologic invasive components to a degree similar to measuring the solid component. Lung windows were more accurate (intraclass correlation [ICC] = 0.65-0.81) than mediastinal windows (ICC = 0.20-0.72) at predicting pathologic invasive components, especially in a part-solid nodule. Interobserver agreements for measurement of solid components were good with little significant difference (lung windows, ICC = 0.89; mediastinal windows, ICC = 0.91). A high level of interobserver agreement was seen between the radiologist and pulmonologists and between residents (from the division of pulmonology and critical care) versus a fellow (from the division of pulmonology and critical care) on different windows. CONCLUSIONS:A considerable percentage (25%) of discrepancies was encountered in categorizing the solidity of lesions, which may decrease the accuracy of measurements. Lung window settings may be superior to mediastinal windows for measuring lung ADCs, with comparable interobserver agreement and moderate accuracy for predicting pathologic invasive components. KEY POINTS:SIGNIFICANT FINDINGS OF THE STUDY: Lung window settings are better for evaluating part-solid lung adenocarcinoma (ADC), with comparable interobserver agreement and moderate accuracy for predicting pathologic invasive components. The considerable percentage (25%) of discrepancies in categorizing solidity of the lesions may also have decreased the accuracy of measurements. WHAT THIS STUDY ADDS:For accurate measurement and categorization of lung ADC, robust quantitative analysis is needed rather than a simple visual assessment.
10.1111/1759-7714.13701
Clinical significance of part-solid lung cancer in the eighth edition TNM staging system.
Okamoto Tatsuro,Miyawaki Michiyo,Toyokawa Gouji,Karashima Takashi,Abe Miyuki,Takumi Yohei,Hashimoto Takafumi,Osoegawa Atsuhi,Tagawa Tetsuzo,Takeuchi Hideya,Shimokawa Mototsugu,Sugio Kenji
Interactive cardiovascular and thoracic surgery
OBJECTIVES:The ground-glass component of part-solid tumour (PST) was eliminated as a clinical T (cT) descriptor in the eighth edition of the tumour, node and metastasis (TNM) staging system. We aimed to validate the new cT descriptor and investigate the prognostic impact of PST in the new staging system. METHODS:Non-small-cell lung cancer (NSCLC) patients (n = 1061) who underwent lung resection and were available for the assessment of thin-section computed tomography images were retrospectively reviewed. Tumours with a solid component (SC) size-to-whole tumour size (STR) ratio of 0, those with 0 < STR < 1 and those with an STR of 1 were defined as pure ground-glass tumours, PSTs and solid tumours (STs), respectively. RESULTS:Tumours with an SC diameter of >30 mm were less frequently observed among PSTs than among STs (4.83% vs 32.6%, P < 0.001). The postoperative 5-year survival of NSCLC patients with ground-glass tumour, PST and ST was 97.6%, 89.0% and 76.3%, respectively. In the survival analysis of patients with an SC diameter ≤30 mm, significant differences were observed among PST and ST (5-year survival, 90.7% vs 74.6%, P < 0.001). The multivariable analysis showed that age <70 years old, female sex, procedures with a lobectomy or more, SC size, pN0 disease and PST were independent predictors of a better survival among all PST and ST patients. CONCLUSIONS:Among patients with cT1 tumours, those with PST showed a significantly better survival than did those with ST. Small-sized PST tumours may not be suitable for the new cT descriptor.
10.1093/icvts/ivab255
Lung Cancer Staging: Imaging and Potential Pitfalls.
Diagnostics (Basel, Switzerland)
Lung cancer is the leading cause of cancer deaths in men and women in the United States. Accurate staging is needed to determine prognosis and devise effective treatment plans. The International Association for the Study of Lung Cancer (IASLC) has made multiple revisions to the tumor, node, metastasis (TNM) staging system used by the Union for International Cancer Control and the American Joint Committee on Cancer to stage lung cancer. The eighth edition of this staging system includes modifications to the T classification with cut points of 1 cm increments in tumor size, grouping of lung cancers associated with partial or complete lung atelectasis or pneumonitis, grouping of tumors with involvement of a main bronchus regardless of distance from the carina, and upstaging of diaphragmatic invasion to T4. The N classification describes the spread to regional lymph nodes and no changes were proposed for TNM-8. In the M classification, metastatic disease is divided into intra- versus extrathoracic metastasis, and single versus multiple metastases. In order to optimize patient outcomes, it is important to understand the nuances of the TNM staging system, the strengths and weaknesses of various imaging modalities used in lung cancer staging, and potential pitfalls in image interpretation.
10.3390/diagnostics13213359
Dilemmas in Lung Cancer Staging.
Vlahos Ioannis
Radiologic clinics of North America
The advent of the 8th edition of the lung cancer staging system reflects a further meticulous evidence-based advance in the stratification of the survival of patients with lung cancer. Although addressing many limitations of earlier staging systems, several limitations in staging remain. This article reviews from a radiological perspective the limitations of the current staging system, highlighting the process of TNM restructuring, the residual issues with regards to the assignment of T, N, M descriptors, and their associated stage groupings and how these dilemmas impact guidance of multidisciplinary teams taking care of patients with lung cancer.
10.1016/j.rcl.2018.01.010
Reconsidering T component of cancer staging for T3/T4 non-small-cell lung cancer with additional nodule.
Therapeutic advances in medical oncology
Background:Non-small-cell lung cancer (NSCLC) with additional nodule(s) located in the same lobe or ipsilateral different lobe were designated as T3 and T4, respectively, which was merely defined by anatomical location of additional nodule(s), regardless of other prognostic factors. Methods:A total of 4711 patients with T1-4, N0-2, M0 NSCLC undergoing complete resection were identified between 2009 and 2014, including 145 patients with additional nodule(s) in the same lobe (T3-Add) and 174 patients with additional tumor nodule(s) in ipsilateral different lobe (T4-Add). Overall survival (OS) was compared using multivariable Cox regression models and propensity score matching analysis (PSM). Results:T3-Add patients [T3-Add T3, hazard ratio (HR), 0.695; 95% confidence interval (CI), 0.528-0.915; = 0.009] and comparable OS with T2b patients through multivariable Cox analysis, and further validated by PSM. T4-Add patients carried a wide spectrum of prognosis, and the largest diameter of single tumor was screened out as the most effective indicator for distinguishing prognosis. T4-Add (⩽3 cm) patients had better OS than T4 patients [T4-Add (⩽3 cm) T4, HR, 0.629; 95% CI, 0.455-0.869; = 0.005] and comparable OS with T3 patients. And T4-Add (>3 cm) patients had comparable OS with T4 patients. Conclusion:NSCLC patients with additional nodule(s) in the same lobe and ipsilateral different lobe (maximum tumor diameter ⩽ 3 cm) should be further validated and considered restaging as T2b and T3 in the forthcoming 9th tumor, node, and metastasis staging system.
10.1177/17588359221130502
Updates on lung adenocarcinoma: invasive size, grading and STAS.
Histopathology
Advancements in the classification of lung adenocarcinoma have resulted in significant changes in pathological reporting. The eighth edition of the tumour-node-metastasis (TNM) staging guidelines calls for the use of invasive size in staging in place of total tumour size. This shift improves prognostic stratification and requires a more nuanced approach to tumour measurements in challenging situations. Similarly, the adoption of new grading criteria based on the predominant and highest-grade pattern proposed by the International Association for the Study of Lung Cancer (IASLC) shows improved prognostication, and therefore clinical utility, relative to previous grading systems. Spread through airspaces (STAS) is a form of tumour invasion involving tumour cells spreading through the airspaces, which has been highly researched in recent years. This review discusses updates in pathological T staging, adenocarcinoma grading and STAS and illustrates the utility and limitations of current concepts in lung adenocarcinoma.
10.1111/his.15077
Imaging of Lung Cancer Staging: TNM 9 Updates.
Seminars in ultrasound, CT, and MR
Imaging plays a key role in clinical staging of lung cancer and guiding therapy. A thorough understanding of the staging system including the nomenclature and updates is necessary to tailor treatment plans and optimize patient care. The 9th edition of the Tumor, Node, Metastasis staging system for lung cancer has no changes for T classification and subdivides N2 and M1c categories. In nodal staging, N2 splits into N2a, ipsilateral mediastinal single station involvement and N2b, ipsilateral mediastinal multiple stations involvement. In the staging of multiple extrathoracic metastases, M1c splits into M1c1, multiple extrathoracic metastases in one organ system and M1c2, multiple extrathoracic metastases in multiple organ systems. Awareness of the proposed changes in TNM-9 staging classification is essential to provide methodical and accurate imaging interpretation.
10.1053/j.sult.2024.07.005
The International Association for the Study of Lung Cancer Thymic Epithelial Tumor Staging Project: Proposal for the T Component for the Forthcoming (Ninth) Edition of the TNM Classification of Malignant Tumors.
Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer
INTRODUCTION:A TNM-based stage classification system of thymic epithelial tumors was adopted for the eighth edition of the stage classification of malignant tumors. The Thymic Domain of the Staging and Prognostics Factor Committee of the International Association for the Study of Lung Cancer developed a new database with the purpose to make proposals for the ninth edition stage classification system. This article outlines the proposed definitions for the T categories for the ninth edition TNM stage classification of thymic malignancies. METHODS:A worldwide collective database of 11,347 patients with thymic epithelial tumors was assembled. Analysis was performed on 9147 patients with available survival data. Overall survival, freedom-from-recurrence, and cumulative incidence of recurrence were used as outcome measures. Analysis was performed separately for thymomas, thymic carcinomas, and neuroendocrine thymic tumors. RESULTS:Proposals for the T categories include the following: T1 category is divided into T1a (≤5 cm) and T1b (>5 cm), irrespective of mediastinal pleura invasion; T2 includes direct invasion of the pericardium, lung, or phrenic nerve; T3 denotes direct invasion of the brachiocephalic vein, superior vena cava, chest wall, or extrapericardial pulmonary arteries and veins; and T4 category remains the same as in the eighth edition classification, involving direct invasion of the aorta and arch vessels, intrapericardial pulmonary arteries and veins, myocardium, trachea, or esophagus. CONCLUSIONS:The proposed T categories for the ninth edition of the TNM classification provide good discrimination in outcome for the T component of the TNM-based stage system of thymic epithelial tumors.
10.1016/j.jtho.2023.08.024
The IASLC Lung Cancer Staging Project: External Validation of the Revision of the TNM Stage Groupings in the Eighth Edition of the TNM Classification of Lung Cancer.
Chansky Kari,Detterbeck Frank C,Nicholson Andrew G,Rusch Valerie W,Vallières Eric,Groome Patti,Kennedy Catherine,Krasnik Mark,Peake Michael,Shemanski Lynn,Bolejack Vanessa,Crowley John J,Asamura Hisao,Rami-Porta Ramón,
Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer
INTRODUCTION:Revisions to the TNM stage classifications for lung cancer, informed by the international database (N = 94,708) of the International Association for the Study of Lung Cancer (IASLC) Staging and Prognostic Factors Committee, need external validation. The objective was to externally validate the revisions by using the National Cancer Data Base (NCDB) of the American College of Surgeons. METHODS:Cases presenting from 2000 through 2012 were drawn from the NCDB and reclassified according to the eighth edition stage classification. Clinically and pathologically staged subsets of NSCLC were analyzed separately. The T, N, and overall TNM classifications were evaluated according to clinical, pathologic, and "best" stage (N = 780,294). Multivariate analyses were carried out to adjust for various confounding factors. A combined analysis of the NSCLC cases from both databases was performed to explore differences in overall survival prognosis between the two databases. RESULTS:The databases differed in terms of key factors related to data source. Survival was greater in the IASLC database for all stage categories. However, the eighth edition TNM stage classification system demonstrated consistent ability to discriminate TNM categories and stage groups for clinical and pathologic stage. CONCLUSIONS:The IASLC revisions made for the eighth edition of lung cancer staging are validated by this analysis of the NCDB database by the ordering, statistical differences, and homogeneity within stage groups and by the consistency within analyses of specific cohorts.
10.1016/j.jtho.2017.04.011
The International Association for the Study of Lung Cancer Staging Project for Lung Cancer: Proposals for the Revision of the N Descriptors in the Forthcoming Ninth Edition of the TNM Classification for Lung Cancer.
Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer
INTRODUCTION:The accurate assessment of nodal (N) status is crucial to the management and prognostication of nonmetastatic NSCLC. We sought to determine whether the current N descriptors should be maintained or revised for the upcoming ninth edition of the international TNM lung cancer staging system. METHODS:Data were assembled by the International Association for the Study of Lung Cancer on patients with NSCLC, detailing both clinical and pathologic N status, with information about anatomical location and individual station-level identification. Survival was calculated by the Kaplan-Meier method and prognostic groups were assessed by a Cox regression analysis. RESULTS:Data for clinical N and pathologic N status were available in 45,032 and 35,009 patients, respectively. The current N0 to N3 descriptors for both clinical N and pathologic N categories reflect prognostically distinct groups. Furthermore, single-station N2 involvement (N2a) exhibited a better prognosis than multistation N2 involvement (N2b) in both clinical and pathologic classifications, and the differences between all neighboring nodal subcategories were highly significant. The prognostic differences between N2a and N2b were robust and consistent across resection status, histologic type, T category, and geographic region. CONCLUSIONS:The current N descriptors should be maintained, with the addition of new subdescriptors to N2 for single-station involvement (N2a) and multiple-station involvement (N2b).
10.1016/j.jtho.2023.10.012
The International Association for the Study of Lung Cancer Lung Cancer Staging Project: Proposals for the Revisions of the T-Descriptors in the Forthcoming Ninth Edition of the TNM Classification for Lung Cancer.
Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer
INTRODUCTION:An international database was created by the International Association for the Study of Lung Cancer to inform on the ninth edition of the TNM classification of lung cancer. The present analyses concern its T component. METHODS:Data on 124,581 patients diagnosed with lung cancer from January 1, 2011 to December 31, 2019 were submitted to the International Association for the Study of Lung Cancer database. Of these, 33,982 met the inclusion criteria for the clinical T analysis, and 30,715 met the inclusion criteria for the pathologic postsurgical analysis. Survival was measured from the date of diagnosis or operation for clinically and pathologically staged tumors, respectively. T descriptors were evaluated in univariate analysis and multivariable Cox regression analysis adjusted for age, sex, pathologic type, and geographic region. RESULTS:Comprehensive survival analysis revealed that the existing eighth edition T component criteria performed adequately in the ninth edition data set. Although pathologic chest wall or parietal pleura involvement (PL 3) yielded a worse survival compared with the other T3 descriptors, with a similar survival as T4 tumors, this difference was not observed for clinical chest wall or PL 3 tumors. Because of these inconsistent findings, no reallocation of chest wall or PL 3 tumors is advised. CONCLUSIONS:The T subcommittee members proposed not to implement any changes and keep the current eighth-edition T descriptors for the ninth edition.
10.1016/j.jtho.2023.12.006
[The ninth edition of TNM staging for lung cancer: precise staging for precise diagnosis and treatment].
Zhonghua wai ke za zhi [Chinese journal of surgery]
The ninth edition of TNM staging for lung cancer has been announced at the 2023 World Lung Cancer Congress and implemented from January 1, 2024. The focus of the ninth TNM staging change is dividing N2 into N2a and N2b, as well as M1c into M1c1 and M1c2. Although the T staging has not changed, it has played an important role in verifying the eighth edition of the T staging. The subdivision of stage N2 has led some patients with ⅢA of the eighth edition to experience ascending or descending stages, which will more accurately help to assess the condition and prognosis of patients with mediastinal lymph node metastasis, as well as the design of related clinical studies. Modifying the M1c staging will help define oligometastasis and explore new treatment models in the future. The ninth edition of the TNM staging system provides a more detailed division of different tumor loads, but there is no clear explanation for the staging of lung cancer after neoadjuvant therapy. Further data analysis is needed, and it is expected to be answered in the tenth edition of TNM staging.
10.3760/cma.j.cn112139-20231210-00262