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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
Kari Chansky, Frank C. Detterbeck, Andrew G. Nicholson, Valerie W. Rusch, Eric Vallières, FRCSC, Patti Groome, Catherine Kennedy et al.Journal of Thoracic Oncology, July 2017, Volume 12, Issue 7, Pages 1109-1121
Commentary by Solange Peters
The AJCC/UICC stage classification of lung cancer is relatively unique among stage classifications of cancer sites. It is uniquely and rationally based on a large international database and an extensive analysis with multiple levels of internal validation.
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 of this manuscript is an external validation of the revisions by using the National Cancer Data Base (NCDB) of the American College of Surgeons.
The NCDB database is particularly useful for TNM classification validation because it is strong in an area in which the IASLC database is weak. Indeed, there is a relative underrepresentation of North America and nonsurgically managed patients in the IASLC database.
Cases presenting from 2000 through 2012 were drawn from the NCDB and reclassified according to the eighth edition stage classification. The T, N, and overall TNM classifications were evaluated according to clinical, pathologic, and “best” stage (N = 780,294).
Interesting points reported were a better survival for all stage categories, revealing possibly some better patient’s selection. Some of this difference can be explained by the higher proportion of surgical cases, and perhaps also by the higher proportion of adenocarcinoma cases in this NCDB database. Additionally, more recent years of analysis, and potentially variability in transversal quality of care, from surgery to death, can also explain this improved outcome across stages, with this database focusing on more performant centers than the whole database.
Despite the size and detailed nature of the NCDB database, there are some essential limitations. To me, the NCDB data does not allow to conclude anything about stage IV disease, knowing that if surgery is performed in that setting, this is only for highly selected patients (oligometastatic ?) or incidental stage IV diagnosis. Validation of the M1a/b/c categories could therefore not be performed in this trial.
However, and this is the most important goal of this validation, the eighth edition TNM stage classification system demonstrated consistent ability to discriminate TNM categories using NCDB database, and confirming its adequacy for NSCLC stage grouping.
Indications for invasive mediastinal staging in patients with early non-small cell lung cancer staged with PET-CT
Sarah J. Gao, Anthony W. Kim, Jonathan T. Puchalski et al.Lung Cancer, Volume 109, July 2017, Pages 36–41
Commentary by Nir Peled
Moving towards screening for lung cancer by low dose CT scans for high risk cohort is expected to affect the stage split within the lung cancer epidemic. With a growing percentage of early disease, it is highly important to use the most appropriate tools for accurate staging. This important retrospective study indicates that peripheral non-solid T1N0 lesions do not require invasive mediastinal staging while central, solid T2N0 do. With the improvement of the CT-PET technology, we may even improve these results.
Does Lymph Node Metastasis Have a Negative Prognostic Impact in Patients with NSCLC and M1a Disease?
Chenyang Dai MD, Yijiu Ren MD, Dong Xie MD, PhD, Hui Zheng MD, PhD, Yunlang She MD, Ke Fei MD, Gening Jiang MD, Chang Chen MD, PhD
Journal of Thoracic Oncology, Volume 11, Issue 10, October 2016, Pages 1745 - 1754