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Non Small Cell Lung Cancer New Pathological Staging System

Highlights in the Management of lung cancer Domus Sessoriana, Rome. Non Small Cell Lung Cancer New Pathological Staging System. Oscar Nappi Anatomia Patologica AORN A. Cardarelli - Napoli. May 15 – 16, 2009.

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Non Small Cell Lung Cancer New Pathological Staging System

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  1. Highlights in the Management of lung cancer Domus Sessoriana, Rome Non Small Cell Lung CancerNew Pathological Staging System Oscar Nappi Anatomia Patologica AORN A. Cardarelli - Napoli May 15 – 16, 2009

  2. Nella nuova classificazione TNM dei tumori polmonari,la presenza di noduli separati nello stesso lobo si indica con la sigla • M1 • M0+ • T4 • T2c • T3 Cross-tablabel 0 / 30

  3. Nella nuova classificazione TNM dei tumori polmonari la sigla T1a configura • Tumore inferiore o uguale a 3 cm • Tumore inferiore o uguale a 2 cm • Tumore compreso tra due e tre cm • Tumore superiore a 3 cm • Tumore compreso tra 1 e 3 cm Cross-tablabel 0 / 5

  4. Nella nuova classificazione TNM dei tumori polmonari, un tumore che presenta anche noduli pleurici omolaterali o versamento pleurico “maligno” si indica con la sigla • M1b • M1 • T4 • M1a • T4a Cross-tablabel 0 / 5

  5. TNM • Clinical cTNM or TNM • Pathologic pTNM • Retreatment rTNM • Autopsy aTNM

  6. National commites UICC Italy Dr Antonino Carbone (chair) Dr Emilio Bajetta Dr Franca Fossati Bellani Dr Generoso Bevilacqua Dr Emilio Bombardieri Dr Paolo Crosignani Dr Francesco Facciolo Dr Vincenzo Mazzaferro Dr Renato Musumeci Dr Giovanni Muto Dr Oscar Nappi Dr Donato Nitti Dr Roberto Orecchia Dr Ugo Pastorino Dr Marco Piemonte Dr Aldo Scarpa Dr Rosella Silvestrini Dr Giuseppe Spriano Dr Mauro Trovo Dr Mauro Truini

  7. Proposed Revisions for the 7th Edition AJCC Cancer Staging Manual CONFIDENTIAL: NOT FOR DISTRIBUTION 1 of 19

  8. International Association for the Study of Lung Cancer IASLC

  9. Proposed changes for lung cancer staging 7th edition of TNM • T component Tumour size Multiple tumours Pleural invasion • N component No changes in N component • M component Minimal but significant change

  10. Proposed changes for lung cancer staging 7th edition of TNM T component Tumour size Multiple tumours Pleural invasion

  11. T1 TNM

  12. T1 ( 6th ed ) Tumour < 3 cm in greatest dimension , surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus ( i.e. not in the main bronchus )

  13. 6th Edition Tumour < 3 cm 7th Edition T1aTumour < 2 cm T1bTumour > 2 but < 3 cm T1

  14. T2 6th edition Tumor with any of the following features of size or extent : • more than 3 cm in greatest dimension• involves main bronchus, 2 cm or more distal to the carina • invades the visceral pleura • associated with atelectasis or obstructive pneumonitis that extends to the hilar region but does not involve the entire lung

  15. T2 7th edition • Tumor >3 cm but < 7 cm T2a - Tumor >3 cm but < 5 cm T2b - Tumor >5 cm but < 7 cm • Tumor with any of the following features: * Involves main bronchus, 2 cm distal to carina * Invades visceral pleura * Associated with atelectasis or obstructive pneumonitis that extends to the hilar region but does not involve the entire lung

  16. 6th Edition Tumor > 3 cm 7th Edition T2aTumor > 3 cm but <5 cm Tumour between 3 and 7cm T2bTumor > 5 cm but <7cm T2

  17. T3 6th edition • Tumor of any size that directly invades any of the following:chest wall (including superior sulcus tumors),diaphragm,mediastinal pleura,parietal pericardium • Tumor of any size in the main bronchus less than 2 cm distal to the carina but without involvement of the carina • Tumor of any size associated atelectasis or obstructive pneumonitis of the entire lung

  18. T3 7th edition • Tumour >7 cm • Direct invasion of any of the following: chest wall, diaphragm, phrenic nerve, mediastinal pleura, parietal pericardium, • Tumour in the main bronchus <2 cm from carina (without involvement of carina) • Atelectasis or obstructive pneumonitis of the entire lung • Separate tumor nodules in the same lobe

  19. Tumor of any size that invades any of the following • mediastinum • heart • great vessels • trachea • esophagus • vertebral body * carina Tumor of any size that invades any of the following mediastinum heart great vessels trachea esophagus, vertebral body carina Recurrent laryngeal nerve 6th edT4 7th ed

  20. * Tumor of any size with satellite tumor nodule(s) within the primary tumor lobe * Tumor of any size with a malignant pleural effusion * Separate tumor nodules in a different ipsilateral lobe 6th edT4 7th ed

  21. Tumour sizeSummary • Size cut off 3 cm ( T1 ) 6th ed • New size cut off 2 cm ( T1a ) 7th ed 5 cm ( T2a ) 7 cm ( T2b )

  22. Hsu PK, Huang HC, Hsich CC et al Effect of formalin fixation on tumor size determination in stage I non-small cell lung cancer Ann Thorac Surg 84 : 1825 – 1829, 2007 After formalin fixation 20% of tumours > 3 cm shrank by an average of 1cm ! Downstaged ! Size should be recorded from the unfixed specimen

  23. Multiple tumours • It is important the communication between Surgeon and Pathologist ! • Some tumours are more difficult to find for the Pathologist than the Radiologist ( i.e. Broncho-Alveolar Carcinoma )

  24. Small cell carcinoma Shepherd FA, Crowley J, Van HP et al The International Association for the Study of lung cancer staging project : proposal regarding the clinical staging of small cell lung cancer in the fothcoming ( seventh ) edition of the tumor, node, metastasis classification for lung cancer J Thoracic Oncol 2 : 1067 – 1077, 2007

  25. Carcinoid tumours The IASLC Staging Committee has reccomended that in the 7th edition that the TNM be applied to pulmonary carcinoid tumours

  26. Main changes in stage groupings • T2b N0M0 from IB to IIA • T2a N1M0 from IIB to IIA • T4 N0 ( N1) M0 from IIIB to IIIA

  27. 5 years survival • IA 50% • IB 47% • IIA 36% • IIB 26% • IIIA 19% • IIIB 7% • IV 2%

  28. SCLC NSCLC

  29. Squamous cell carc. Adenocarcinoma Large cell carcinoma Adenosquamous carc. Sarcomatoid carc. NSCLC

  30. Renewed interest in lung cancer histotype The advent of effective targeted therapies ! • Anti EGFR ( Erlotinib, Gefinitib ) • Anti VEGF ( Bevacizumab ) • New chemotherapic agents

  31. Pathologists and Lung cancer • 2/3 of lung cancer are unresectable/advanced • Diagnosis of lung cancer is achieved on cytology ( even effusion ) or small biopsies • Goal : To optimize the tumour tissue 1. Diagnosis 2. Possible biological markers ( EGFR,k-ras,ERCC1 etc… )

  32. Diagnostic IHC in confirming and subtyping primary lung cancer • TTF 1 • P 63

  33. Diagnostic IHC in confirming and subtyping primary lung cancer Napsin A

  34. Pathologist’s Role At present • Any effort has to be made in order to typizing Squamous Cell Carcinoma and Adenocarcinoma. • A diagnosis of NSCLC - NOS should be avoided

  35. IHC in distinguish SCC and AC in poorly differentiated tumours

  36. Large Cell CarcinomaWHO 2004 • poorly differentiated NSCLC that lacks cytologic and architectural features of SCLC and glandular or squamous differentiation • 5 variants: • LCNEC Large Cell Neuroendocrine Carcinoma • Basaloid • Lymphoepithelioma-like • Clear cell • Large cell with rhabdoid phenotype

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