1. Proposed Changes to the 7th Edition
TNM and LUNG CANCER
Proposed Changes to the 7th Edition
Thank you for inviting me to speak to you today. I plan to review some basic anatomy of the lungs and their lymph nodes. I will review with you the current staging for non-small cell lung cancer. Then we will discuss some of the proposed changes to the TNM classification.

2. TNM and LUNG CANCER LUNG ANATOMY
Normal adult lungs removed from the body and prepared with a special device to inflate the lungs. Note the healthy pink color with only a small amount of anthrocosis.

3. TNM and LUNG CANCER LUNG ANATOMY
Drawing of the lungs to highlight the lobes and nodes. Each lobe has a specific lymph drainage pattern. Note that LLL can drain to Right paratracheal nodes ( R2 and R4 )

4. TNM and LUNG CANCER
Hard to see the details but note that lymph drainage covers a wide area of the upper body.

5. TNM and LUNG CANCER
This drawing may be easier to see. This is a representation of the nodal stations. Upper Zone or superior mediastinal nodes ( 2R 2L 3a-prevascular 3p-retrotracheal 4R 4L ). Subcarinal Zone (station 7). Lower Zone (station 8 paraesophageal and 9 pulmonary ligament). These represent the N2 nodes. Hilar/Interlobar Zone ( 10 and 11 ) and The Peripheral Zone ( ) comprise the N1 nodes

6. TNM and LUNG CANCER
This is a better view of the Upper Zone prevascular and retrotracheal nodal stations. You also can see the AP Zone nodal stations.

7. TNM and LUNG CANCER
Stage Ia tumor is less than 3 cm, completely surrounded by normal lung tissue, and no nodal involvement. Stage Ib is the same but a larger tumor, >3 -5 cm.

8. TNM and LUNG CANCER
Stage IIa . Stage IIb can be a tumor >5-7cm with N1 nodes. Stage IIb can also be >7 with no nodes or invade local structures or have two tumors in same lobe.

9. TNM and LUNG CANCER
Stage IIIa is a tumor with spread to N2 nodes.

10. TNM and LUNG CANCER
Stage IIIb is a tumor with spread to distant nodes N3

11. TNM and LUNG CANCER
Stage IV is a cancer that has distant spread to other organs

12. TNM and LUNG CANCER
Prognostic importance of staging. Impact on surgical resection. Stage I and II have a reasonable chance of cure and surgery is an important part of the overall treatment. IIIb and IV have little chance of cure and surgical resection should not be part of treatment. IIIa is a gray zone and in certain select cases resection is utilized. TNM classification and staging has significant ramifications in treatment planning.

13. TNM and LUNG CANCER First significant changes since 2009
Based on data from 77,000 lung cancer patients
Taxonomic refinement
Not intended to alter clinical practice
Treatment of lung cancer seems to be changing daily. Revisions were necessary to keep up and reflect these changes. Data collected from 1999 thru Minimum of 6 years follow up. Clinical judgement is the final decision maker.

14. TNM and LUNG CANCER 2015 WHO Classification
Captures a decade of remarkable advances in all specialties
Driven by rapid expansion of immunohistochemical and molecular tools
Reclassify tumors and improve subtyping
Utilized the recently updated WHO classification of lung tumors. Took into consideration advances in surgery, medical oncology, radiation oncology, and especially the advances in pathology over the last decade. In particular the advances in testing for common genetic mutations and the development of targeted chemotherapy for these mutations was a driving force in making these revisions.

15. TNM and LUNG CANCER
Gives more weight to tumor size as a prognostic factor
Reclassifies some primary tumor descriptors
Validates current nodal descriptors
Modifies definition of some types of metastases
Overview of the revisions based on the review of those 77,000 cases of lung cancer.

16. TNM and LUNG CANCER EXPECTATIONS
Improve prediction of survival and recurrence
Survival benefit with platinum-based chemotherapy
Allow radiologic/pathologic correlations
Emphasizes solid tumor size vs whole tumor size
These revisions are expected to help clinicians to more precisely stage tumors and therefore develop a more precise, individualized treatment plan.

17. TNM and LUNG CANCER Tumor 7th edition 8th edition 1-2 cm T1a T1b
>2 but <3 cm T1b T1c
>4 but <5 cm T2a T2b
>5 but <7 cm T2b T3
>7 cm T T4
Invade Diaphragm T T4
<2cm from carina T T2
Lets look at some of the changes. Tumors < 1 cm will be T1a. Tumors 3-4 cm will be T2a.

18. TNM and LUNG CANCER No Change in Nodal Descriptors
N0 No Nodal Metastasis
N1 Local Nodal Metastasis
N2 Regional Nodal Metastasis
N3 Distant Nodal Metastasis
There were no changes in the nodal classification.

19. TNM and LUNG CANCER Metastases 7th Edition 8th Edition
Within Chest M1a M1a
Single/Single Organ M1b M1b
Multiple/ Single-Multiple M1b M1c
Pleural/pericardial effusions, contralateral/bilateral lung and pleural nodules, or combinations would remain M1a. This is essentially metastases within the thorax. They found that patients with single mets in a single organ did significantly better than those patients with multiple mets in multiple organs.

20. TNM and LUNG CANCER SUMMARY Refinement of previous classification
Based on 77,000 patients from 1999 to 2010
Takes into consideration new advances in pathology
Gives more weight to tumor size
Hope to improve prediction of survival and recurrence
Expected to be enacted in January of 2017
1) Refine 7th edition enacted in 2009; 2) at least 6 year follow up; 3) testing for common genetic mutations and the reclassification of adenocarcinoma and squamous cell ; 4) ; 5) especially if there will be a survival benefit with platinum based chemotherapy

21. TNM and LUNG CANCER
Thank you. Will try to answer questions.