国际肺癌研究协会第八版国际肺癌TNM分期修订稿解读

肺癌导致的死亡人数位于各类恶性肿瘤之首,它是对人类健康和生命威胁最大的恶性肿瘤之一。肺癌的TNM分期系统描述了肺癌的生长和扩散等信息,对于指导其临床治疗起了非常重要的作用。目前临床上广泛采用的是国际抗癌联盟（Union for International Cancer Control, UICC）和美国癌症联合会（American Joint Committee on Cancer, AJCC）于2009年发布的第七版肺癌TNM分期。随着肺癌综合治疗的发展以及临床实践模式的改变,肺癌的疗效及其预后也有了明显的改变,旧的分期标准可能难以满足目前的临床需求。因此,国际肺癌研究协会（international association for the study of lung cancer, IASLC）于2014年就开始进行最新一轮的肺癌TNM分期标准修订研究计划。本次分期研究克服了以往分析数据均为回顾性数据的缺陷,采用囊括了回顾性和前瞻性数据的新数据库。该数据库主要是由1999—2010年间新确诊的94 708名肺癌患者数据组成。通过对该数据库分析研究,国际肺癌研究协会对TNM分期进行了相应的修改,并最终在2015年发表了第八版国际肺癌TNM分期的修订稿。本文就该修订稿的细节进行解读。     

最新肺癌国际TNM分期标准

目前普遍应用的肺癌国际ＴＮＭ分期标准，是由美国胸腔学会（ＡＴＳ）于１９８３年制定的，经过修订后于１９８６年被美国癌症联合会（ＡＪＣＣ）和国际抗癌联盟（ＵＩＣＣ）所采用［１～３］。此标准应用１０余年来，为全世界肿瘤研究人员和临床医师的实际工作提供了极大...     

食管癌国际TNM分期第7版解读与评价

国际抗癌联盟(UICC)制定的恶性肿瘤TNM分期系统是目前世界上最广泛运用的肿瘤分期标准,对判断恶性肿瘤患者的病期与预后、选择合适的治疗方案及国内、国际间肿瘤防治结果与经验交流起到了积极作用.1987年,美国癌症联合会(AJCC)开始与UICC联合制订统一的恶性肿瘤TNM分期标准(即第4版)向全球推广.     

肺癌临床TNM分期与手术病理TNM分期的比较分析

背景与目的　肺癌临床TNM分期准确与否直接关系到患者的处理决策是否恰当。本研究旨 在探讨肺癌临床与手术病理TNM分期的一致性并分析其原因。方法　随机抽取我院2000年以来接受手术 治疗的肺癌患者150例,根据1997年新修订的国际肺癌分期标准分别进行临床和手术病理TNM分期,对两 种分期结果采用Kappa统计量进行一致性分析,同时比较T分期各亚组临床与手术病理分期的符合率。结 果　临床与手术病理T分期的一致性较为满意(Kappa值=0.729),但将病例分层分析后发现,临床T3、临床 T4组与手术病理结果的符合率明显低于临床T1和临床T2组(P<0.01)。临床与手术病理N分期的一致性 不够理想(Kappa值=0.108),两种TNM分期的一致程度也随之降低(Kappa值=0.287)。结论　目前基于 CT的肺癌临床T分期能较为真实地反映肿瘤的部位、大小,但是当原发灶靠近胸壁或者纵隔时,其边界不易 确定,部分临床T4病例仍可获得完全性切除。临床与手术病理N分期的一致程度不够理想,寻找更可靠的 术前诊断淋巴结转移的技术是提高肺癌临床TNM分期准确性的关键。     

肺癌第9版TNM分期解读

流行病学数据显示, 肺癌发病率位居恶性肿瘤第2位, 死亡率位居恶性肿瘤第1位, 2020年约180万例患者死于肺癌。对于晚期肺癌患者, 驱动基因的发现及相应靶向药物的应用不仅改善了患者生活质量, 同时提高了患者的生存时间。免疫检查点抑制剂的应用则革新了驱动基因突变阴性患者的治疗策略。TNM分期是包括肺癌在内的实体瘤应用最为广泛的分期系统, 统一的分期方法不仅为国际间的学术交流提供了共同的学术语言, 同时也为疾病的预后判断及后续治疗决策制定提供了重要的工具。随着对肺癌预后因素的深入认识及研究数据的不断积累和成熟, 肺癌TNM分期不断更新。2023年9月在新加坡举行的世界肺癌大会上, 第9版TNM分期向全球公布并预计在2024年1月正式采用。本文就肺癌TNM分期的历史沿革、数据来源、第9版分期的主要变化及局限性进行讨论。     

小细胞肺癌与TNM分期

小细胞肺癌的临床侵袭性强,易于转移,因而长期以来认为手术疗效较差,治疗方法主要是放化疗,因此分期手段也以美国退伍军人肺癌协会的局限期和广泛期为主。随着肺癌分期手段的进步,分期的准确性进一步提高。大量回顾性的资料表明,早期小细胞肺癌的手术疗效不亚于非小细胞肺癌。而对拟手术的小细胞肺癌的分期也应采用现代更精确的TNM分期。     

肺癌临床TNM与病理TNM分期一致性的探讨

２５例肺癌病人被前瞻性地随机分成研究组（７５例）和对照组（１５０例），进行临床ＴＮＭ（简称ＣＴＮＭ）与病理ＴＮＭ（简称ＰＴＮＭ）分期一致性的研究。研究组采用系统的纵隔淋巴结清扫术，平均每例清除淋巴结１１．５个，对照组仅切除可疑转移的纵隔淋巴结，平均每例清除淋巴结３．４个。两组病人均依据临床体检、胸部影像诊断和支纤镜检查结果进行ＣＴＮＭ分期，术后进行ＰＴＮＭ分期，采用Ｋａｐｐ值判断ＣＴＮＭ与ＰＴＮＭ的分期一致性。结果发现，两组病例的分期一致性均未能达到公认的Ｋａｐｐａ值最低标准的０．４，研究组的分期一致性（Ｋａｐｐａ＝０．０９７）比对照组（Ｋａｐｐａ＝０．３７１）更差。影响分期一致性的主要因素为ＣＴＮＭ对Ｎ组分的估计不足，分期不一致的主要表现为ＰＴＮＭ较ＣＴＮＭ的期数增高，研究组中有４３％的病例表现为期数增高，对照组则为３３％（Ｐ＜０．０５）。结果表明，目前借以进行ＣＴＮＭ分期的手段存在严重不足，需加以充实完善，仅切除可疑转移的纵隔淋巴结之术式不能满足ＰＴＮＭ真正分期的需要，要对肺癌病例准确地进行ＰＴＮＭ分期，准确地评价肺癌的疗效，只有系统地进行纵隔淋巴结清扫术才能做到。     

关于2009第7版食管癌国际TNM分期的思考

2009年UICC公布了第7版食管癌TNM分期标准,与2002年第6版相比,新版分期除T、N、M各参数均有变化外,还新增加了癌细胞的组织学分型和癌细胞的分化程度。这些变化都为食管癌研究提供了空间,同时也提出了其所面临的许多问题。     

Validation of the Eighth Edition TNM Lung Cancer Staging System

IntroductionWe performed a validation study at our institution, the International Union Against Cancer (Union for International Cancer Control latest version of TNM Classification of Malignant Tumors Eighth Edition).MethodsData were collected from the Queensland Oncology Online registry of NSCLC or SCLC cases between 2000 and 2015 and validated against the Queensland Integrated Lung Cancer Outcomes Project registry using case identification number, first name, last name, and date of birth. Where data were available, cases were classified according to the Union for International Cancer Control TNM seventh edition stage groupings and then compared with the eighth edition groupings. Kaplan-Meier curves were plotted, and the log-rank test of survival differences was performed with SPSS version 25 (IBM Corp, Armonk, NY).ResultsOf the 3636 cases, 3352 and 1031 had complete clinical and pathologic staging, respectively. Median survival time was found to reduce with increasing clinical stage: seventh edition (IA: 88, IB: 44, IIA: 31, IIB: 18, IIIA: 15, IIIB: 8, and IV: 5 mo) versus eighth edition TNM stage (IA1: not reached, IA2: 88, IA3: 53, IB: 56, IIA: 36, IIB: 22, IIIA: 14, IIIB: 9, IIIC: 8, IVA: 6, and IVB: 3 mo). A similar overall pattern was reflected in the pathologic stage: seventh edition (IA: 124, IB: 110, IIA: 48, IIB: 42, IIIA: 26, IIIB: 31, and IV: 27 mo) versus eighth edition (IA1: not reached, IA2: 122, IA3: 125, IB: 144, IIA: 98, IIB: 57, IIIA: 31, IIIB: 24, and IVA: 7 mo). The log-rank test for survival curves was significant at p < 0.001.ConclusionsOur external validation study confirms the prognostic accuracy of the eighth edition TNM lung cancer classification. Our analyses also indicated that IIIB, IIIC, and IVA stage groups had similar survival outcomes and suggest further research for refinement.     

Validation of the Stage Groupings in the Eighth Edition of the TNM Classification for Lung Cancer

IntroductionThe aim of this study was to validate stage groupings in the eighth edition of the TNM classification in an independent Chinese cohort.MethodsWe retrospectively analyzed a total of 3599 patients with pathological stage IA to IIIA (seventh edition of the TNM) NSCLC who underwent surgical treatment in two surgical centers in the People's Republic of China between 2005 and 2012. All patients were reclassified according to the eighth edition of the TNM classification. Survival was compared between adjacent stage groupings by using a log-rank test and a Cox regression model. R² was calculated to evaluate the discrimination of the two TNM stage classifications.ResultsThe median follow-up time was 48.7 months. According to the eighth edition of the TNM classification, the overall survival (OS) of adjacent stage groupings showed significant differences except for IA3 vs. IB. The eighth edition of the TNM classification yielded a slightly higher R² than the seventh edition (0.172 vs. 0.162).ConclusionsThis study provided an external validation of the stage groupings in the eighth edition of the TNM classification for lung cancer among surgically treated Chinese patients with NSCLC.     

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

IntroductionRevisions 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.MethodsCases 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.ResultsThe 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.ConclusionsThe 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.