Foreword: Hello everyone! Today, I would like to share with you an overview and doubts about the 9th edition of TNM staging updates for lung cancer published in the journal Chest. Since the release of the ninth edition of the staging, the most familiar is the division of N2 into N2a and N2b, as well as the summary of some evidence for the R staging. But in terms of the details of specific clinical applications, looking back at history, what exactly did the ninth version of TNM staging solve? Didn't solve anything? What are the possible solutions in the short term? What are the possible problems that are far away? Let's take a look at the Yale team's perspective.
The Proposed 9th Edition TNM Classification of Lung Cancer
Frank C. Detterbeck, MD, Gavitt A. Woodard, MD, Anna S. Bader, MD, MS, Assistant Professor, Sanja Dacic, MD PhD, Professor of Pathology, Michael J. Grant, MD, Assistant Professor, Henry S. Park, MD, MPH, Associiate Professor, Lynn T. Tanoue, MD, Professor of Medicine
A universal nomenclature of the anatomic extent of lung cancer has been critical for individual patient care as well as research advances. As progress occurs, new details emerge that need to be included in a refined system that aligns with contemporary clinical management issues. The 9th edition TNM classification of lung cancer, which is scheduled to take effect in January of 2025, addresses this need. It is based on a large international database, multidisciplinary input and extensive statistical analyses. Key features of the 9th edition include validation of the significant changes in the T component introduced in the 8th edition, subdivision of N2 after exploration of fundamentally different ways of categorizing the N component, and further subdivision of the M component. This has led to reordering of the TNM combinations included in stage groups, primarily involving stage groups IIA, IIB, IIIA and IIIB. This paper summarizes the analyses and revisions for the TNM classification of lung cancer to familiarize the broader medical community and facilitate implementation of the 9th edition system.
The common nomenclature of the anatomical scope of lung cancer is essential for the individualized diagnosis and study of patients. As research progresses, new details emerge that need to be included in a concise system that aligns with contemporary clinical management issues. The 9th edition of the TNM classification for lung cancer, which is scheduled to come into force in January 2025, meets this need. The staging is based on a large international database, multidisciplinary inputs, and extensive statistical analysis. Key features of the 9th edition include validation of the significant changes in the T component introduced in the 8th edition, subdivision of N2 after exploring fundamentally different methods of classification of the N component, and further subdivision of the M component. This has led to a reordering of the Stage group to include different TNM combinations, mainly involving the Stage groups IIA, IIB, IIIA, and IIIB. This article summarizes the analysis and revision of the TNM classification of lung cancer to make the medical community more familiar with and facilitate the implementation of the 9th edition system.
Take Home Points
Study question: How is the 9th edition TNM classification of lung cancer different from the 8th edition system?
Results: N2 is subdivided into single- and multi-station N2, M1c is subdivided into single- and multi-organ system M1c, resulting in a re-arrangement of T and N categories included in the stage groups IIA, IIB, IIIA and IIIB.
Interpretation: A consistent nomenclature about anatomic extent of disease is fundamental to clear communication about clinical trial results and applicability to individual patients.
Summary of key messages
Research question: How does the 9th edition TNM staging for lung cancer differ from the 8th edition system?
Results: N2 was divided into single-station and multi-station N2, and M1c was divided into single-organ system M1c and multi-organ system M1c, resulting in a rearrangement of the T and N categories included in the stage IIA, IIB, IIIA, and IIIB groups.
Explanation: A consistent nomenclature regarding the anatomical scope of a disease is essential to clearly communicate clinical trial results and their applicability to individual patients.
Study notes
1、首先开篇介绍TNM分期并不是一个预后模型，只作为一种肿瘤侵犯范围的解剖性语义词典（预后除了受到TNM分期影响，还有患者、临床背景、治疗相关的因素）。 颇为有趣的是作者说了字典也可能会“错”！临床诊疗请不要教条主义（Finally, treatment is not determined by the nomenclature of stage; this merely enables communication.）。
2. Details
(1) When it is recommended to record the staging of the record, record the evaluation method (E1/2/3/4) to facilitate communication.
(2) For the T, N, and M components, the staging committee clarified what was explored when analyzing the data and why some analyses could not be done (e.g., why the number of lymph nodes/stations/blocks was not used as one of the parameters for inclusion in the N staging)? It even talked about what could be done in the future and what was not promising at all. It also reflects the scientific taste of the Yale team in the process of annotating the ninth edition of TNM.
(3) The disadvantages of the needle are not hidden. It would be interesting to clarify the staging to show which groups of people compared, such as the prognosis of Higer T/lower N and Lower T/higher N (although there is currently no significant difference in OS between the two groups). It also clarifies the staging principle of tumor invasion of regional lymph nodes and local ribs/liver (not divided into M1).
④针对肺内多灶病变患者，在四大分类之外，特殊提及了lung cancer with air lucency (LCAL)的研究必要性。
(5) It is interesting to note that the R classification can also be used like this, R0 (thorax) or R0 (adrenal). It means to pave the way for the in-depth definition of oligometastasis and clinical intervention, which is quite implied by the examiner - plus some questions. It is also mentioned that exfoliative cytology, which is almost non-administered with pleural fluid lavage fluid in other regions except Japan, also leads to a limited range of applications for this parameter.
⑥Minimal disease Manifestations模块甚至还尝试把乳腺癌中判宏转移和微转移的原则提出到肺癌中进行潜在应用。
3. How non-anatomical parameters should be included in staging has been a controversial topic. Structured staging may and should not be sticking to it, and in the future it may be necessary to construct a diagnosis and treatment evidence map based on more complex clinical states (recognition of diagnosis and treatment patterns before and after, rather than diagnosis and treatment status recognition). But when you think about it, the NCCN guidelines are actually problematic in terms of strict staging, and many potential clinical scenarios are overlooked.
We are also looking forward to the clinical evidence around the 9th stage output.
Chart summary
1. The analysis scope of each version of the TNM classification data for lung cancer
The number of cases, contributing centers, and countries on which different versions of the lung cancer TNM classification system are based
2. Background of TNM classification
The type of assessment used to determine the tumour stage of the patient
CT computed tomography, EBUS-TBNA (intrabronchial ultrasound-transbronchial needle aspiration), MRI (magnetic resonance imaging), ;P ET (positron emission tomography).
3、T/N/M描述符的定义
4. Lymph node diagram of lung cancer
5. Comparison of the 8th and 9th edition stage groups
6. The overall survival rate of the ninth edition stage group
7. Internal Validation – Compare training and validation datasets
8. Extensibility evaluation
9. Staging in the 9th edition of the TNM classification of lung cancer
10. Specific TNM categories included in the 9th Edition Phase Group
11. 5-year overall survival rate by stage group and TNM version (%)
12. 5-year overall survival rate (%), by stage group and region, 9th edition data
13. 5-year overall survival rate (%) or PS, 9th edition data by stage group and time period
14. Disease patterns in patients with multiple lung cancer
15. Examples of four disease patterns manifested in multiple lung sites of lung cancer
16. Criteria for distinguishing the second primary tumor from related tumors
17. Criteria for classifying lesions as separate tumor nodules
18. Criteria for classifying tumors as multifocal GG/L adenocarcinoma
19. Criteria for classifying tumors as pneumonic adenocarcinoma
20. Residual tumor after surgical resection
21. Classification of residual tumors
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