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Blasberg JD, Sotolongo A, Detterbeck F, Blasberg JD. Surgical Management of Disseminated Pulmonary Mucormycosis in the Immunocompromised. Surg Case Rep 2020. [DOI: 10.31487/j.scr.2020.04.09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Pulmonary mucormycosis is a rare and aggressive fungal infection that is known to
predominantly affect immunocompromised hosts. Early surgical resection with prolonged antimycotic
therapy is an established therapy for localized disease; however, the role of surgery in multifocal pulmonary
disease is less clear.
Case: We report successful treatment of medically refractory disseminated pulmonary mucormycosis with
a salvage lobectomy and intrapleural antibiosis in a 58-year-old immunocompromised female.
Conclusion: Surgery resection of necrotic foci in disseminated pulmonary mucormycosis is a viable
surgical treatment option even if extensive resection is required. This treatment option should be considered
early, given the high incidence of medically refractory disease.
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Ruffini E, Fang W, Guerrera F, Huang J, Okumura M, Kim DK, Girard N, Billè A, Boubia S, Cangir AK, Detterbeck F, Falkson C, Filosso PL, Giaccone G, Kondo K, Infante M, Lucchi M, Marino M, Marom EM, Nicholson AG, Rimner A, Rami-Porta R, Asamura H. The International Association for the Study of Lung Cancer Thymic Tumors Staging Project: The Impact of the Eighth Edition of the Union for International Cancer Control and American Joint Committee on Cancer TNM Stage Classification of Thymic Tumors. J Thorac Oncol 2020; 15:436-447. [DOI: 10.1016/j.jtho.2019.11.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 10/27/2019] [Accepted: 11/17/2019] [Indexed: 10/25/2022]
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Roden AC, Fang W, Shen Y, Carter BW, White DB, Jenkins SM, Spears GM, Molina JR, Klang E, Segni MD, Ackman JB, Sanchez EZ, Girard N, Shumeri E, Revel MP, Chassagnon G, Rubinowitz A, Dicks D, Detterbeck F, Ko JP, Falkson CB, Sigurdson S, Segreto S, Del Vecchio S, Palmieri G, Ottaviano M, Marino M, Korst R, Marom EM. Distribution of Mediastinal Lesions Across Multi-Institutional, International, Radiology Databases. J Thorac Oncol 2019; 15:568-579. [PMID: 31870881 DOI: 10.1016/j.jtho.2019.12.108] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 11/27/2019] [Accepted: 12/03/2019] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Mediastinal lesions are uncommon; studies on their distribution are, in general, small and from a single institution. Furthermore, these studies are usually based on pathology or surgical databases and, therefore, miss many lesions that did not undergo biopsy or resection. Our aim was to identify the distribution of lesions in the mediastinum in a large international, multi-institutional cohort. METHODS At each participating institution, a standardized retrospective radiology database search was performed for interpretations of computed tomography, positron emission tomography-computed tomography, and magnetic resonance imaging scans including any of the following terms: "mediastinal nodule," "mediastinal lesion," "mediastinal mass," or "mediastinal abnormality" (2011-2014). Standardized data were collected. Statistical analysis was performed. RESULTS Among 3308 cases, thymomas (27.8%), benign mediastinal cysts (20.0%), and lymphomas (16.1%) were most common. The distribution of lesions varied among mediastinal compartments; thymomas (38.3%), benign cysts (16.8%), and neurogenic tumors (53.9%) were the most common lesions in the prevascular, visceral, and paravertebral mediastinum, respectively (p < 0.001). Mediastinal compartment was associated with age; patients with paravertebral lesions were the youngest (p < 0.0001). Mediastinal lesions differed by continent or country, with benign cysts being the most common mediastinal lesions in the People's Republic of China, thymomas in Europe, and lymphomas in North America and Israel (p < 0.001). Benign cysts, thymic carcinomas, and metastases were more often seen in larger hospitals, whereas lymphomas and thymic hyperplasia occurred more often in smaller hospitals (p < 0.01). CONCLUSIONS Our study confirmed that the spectrum and frequency of mediastinal lesions depend on mediastinal compartment and age. This information provides helpful demographic data and is important when considering the differential diagnosis of a mediastinal lesion.
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Godfrey MS, Bramley KT, Detterbeck F. Medical and Surgical Management of Empyema. Semin Respir Crit Care Med 2019; 40:361-374. [PMID: 31525811 DOI: 10.1055/s-0039-1694699] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Infection of the pleural space is an ancient and common clinical problem, the incidence which is on the rise. Advances in therapy now present clinicians of varying disciplines with an array of therapeutic options ranging from thoracentesis and chest tube drainage (with or without intrapleural fibrinolytic therapies) to video-assisted thoracic surgery (VATS) or thoracotomy. A framework is provided to guide decision making, which involves weighing multiple factors (clinical history and presentation, imaging characteristics, comorbidities); multidisciplinary collaboration and active management are needed as the clinical course over a few days determines subsequent refinement. The initial choice of antibiotics depends on whether the empyema is community-acquired or nosocomial, and clinicians must recognize that culture results often do not reflect the full disease process. Antibiotics alone are rarely successful and can be justified only in specific circumstances. Early drainage with or without intrapleural fibrinolytics is usually required. This is successful in most patients; however, when surgical decortication is needed, clear benefit and low physiologic impact are more likely with early intervention, expeditious escalation of interventions, and care at a center experienced with VATS.
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Ye Q, Wu J, Lu Y, Naganawa M, Gallezot JD, Ma T, Liu Y, Tanoue L, Detterbeck F, Blasberg J, Chen MK, Casey M, Carson RE, Liu C. Improved discrimination between benign and malignant LDCT screening-detected lung nodules with dynamic over static 18F-FDG PET as a function of injected dose. Phys Med Biol 2018; 63:175015. [PMID: 30095083 PMCID: PMC6158045 DOI: 10.1088/1361-6560/aad97f] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Lung cancer mortality rate can be significantly reduced by up to 20% through routine low-dose computed tomography (LDCT) screening, which, however, has high sensitivity but low specificity, resulting in a high rate of false-positive nodules. Combining PET with CT may provide more accurate diagnosis for indeterminate screening-detected nodules. In this work, we investigated low-dose dynamic 18F-FDG PET in discrimination between benign and malignant nodules using a virtual clinical trial based on patient study with ground truth. Six patients with initial LDCT screening-detected lung nodules received 90 min single-bed PET scans following a 10 mCi FDG injection. Low-dose static and dynamic images were generated from under-sampled list-mode data at various count levels (100%, 50%, 10%, 5%, and 1%). A virtual clinical trial was performed by adding nodule population variability, measurement noise, and static PET acquisition start time variability to the time activity curves (TACs) of the patient data. We used receiver operating characteristic (ROC) analysis to estimate the classification capability of standardized uptake value (SUV) and net uptake constant K i from their simulated benign and malignant distributions. Various scan durations and start times (t *) were investigated in dynamic Patlak analysis to optimize simplified acquisition protocols with a population-based input function (PBIF). The area under curve (AUC) of ROC analysis was higher with increased scan duration and earlier t *. Highly similar results were obtained using PBIF to those using image-derived input function (IDIF). The AUC value for K i using optimized t * and scan duration with 10% dose was higher than that for SUV with 100% dose. Our results suggest that dynamic PET with as little as 1 mCi FDG could provide discrimination between benign and malignant lung nodules with higher than 90% sensitivity and specificity for patients similar to the pilot and simulated population in this study, with LDCT screening-detected indeterminate lung nodules.
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Tsukazan MTR, Terra RM, Detterbeck F, Santoro IL, Hochhegger B, Meirelles GDSP, Fortunato G, Prado GF. Management of lung nodules in Brazil-assessment of realities, beliefs and attitudes: a study by the Brazilian Society of Thoracic Surgery (SBCT), the Brazilian Thoracic Society (SBPT) and the Brazilian College of Radiology (CBR). J Thorac Dis 2018; 10:2849-2856. [PMID: 29997949 DOI: 10.21037/jtd.2018.05.23] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Pulmonary nodules are common; some are inconsequential while others are malignant. Management of solitary pulmonary nodule (SPN) in Brazil appears to be highly variable, potentially leading to suboptimal outcomes. Assessment of the variability and the association with the degree of availability of resources can provide a foundation for development of clinical guidelines for management of SPN specific for the Brazilian setting. Methods A web-based survey was developed by thoracic surgeons, pulmonologists and radiologists to evaluate SPN perception and management. This survey was sent to their respective national societies members and answers collected between August and December 2016. That included multiple choice questions regarding age, specialty, SPN management, accessibility to exams and interventional procedures characterizing public (SUS) and supplementary private working settings. Results A total of 461 questionnaires were answered. More than half of participants live in cities with over one million people. Specialties were reasonable equilibrated with 43.5% radiologists, 33.5% thoracic surgeons, 20.3% pulmonologists and 2.6% others. Most of the respondents work in both public and private sector (72.7%). Private has a similar reality compared to well-developed nations regarding exams accessibility and interventions. SUS setting has a significant variability access according to the participants. CT is only easily available in 31.9% of cases, PET-CT is easily available in 24.4%, bronchoscopy is easily available for 42.8%, transthoracic needle biopsy is only easily available in 13.9% and video-assisted thoracoscopic surgery (VATS) biopsy is not available in 19.5%. When there is a probability of malignancy of 50% or higher, 46.5% of participants would be comfortable recommending surgical biopsy. When the probability is higher than 10%, only 36.9% would be comfortable following up radiologically. Conclusions Brazil has a very different setting for public and private patients regarding exams accessibility and management options. That might explain why participants have a higher tendency to choose interventional diagnosis and explains why current guidelines may not be applicable to developing countries reality.
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Fang W, Yao X, Antonicelli A, Gu Z, Detterbeck F, Vallières E, Aye RW, Farivar AS, Huang J, Shang Y, Louie BE. Comparison of surgical approach and extent of resection for Masaoka-Koga Stage I and II thymic tumours in Europe, North America and Asia: an International Thymic Malignancy Interest Group retrospective database analysis. Eur J Cardiothorac Surg 2018; 52:26-32. [PMID: 28329118 DOI: 10.1093/ejcts/ezx042] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 01/03/2017] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Surgeons at different institutions worldwide choose different types of operations for thymic tumours. It is not known whether these differences affect the outcomes of the patients. METHODS A total of 1430 patients with Masaoka-Koga pathological Stage I-II thymic tumours without myasthenia gravis or pre-treatment were identified from the International Thymic Malignancy Interest Group retrospective database. Outcomes of patients from 3 major continents (Europe, North America and Asia) were compared. RESULTS Patients from the 3 continents were comparable in gender and performance status. More European patients had more paraneoplastic syndromes; North American patients had the smallest tumour sizes and less adjuvant therapy; and Asian patients were younger and had more Stage I disease but higher grade tumours. Partial thymectomy was performed more often in Asian patients (31.7%) than in European (2.4%) and North American (5.4%; P < 0.001) patients. The median approach (sternotomy/clamshell) was the major approach in Europe (75.3%) and North America (76.6%). In contrast, the median approach was applied significantly less frequently in Asia (45.6%, P < 0.001); unilateral open (thoracotomy/hemi-clamshell, 23.3%) and minimally invasive approaches (video-assisted thoracoscopic surgery/robot, 31.1%) were used more often with similar rates of complete resection. The 10-year overall survival rate was 82% for Europe, 78% for North America and 90% for Asia ( P = 0.005), respectively. The 10-year cumulative recurrence rates were similar among the geographic groups (European 0.08, North American 0.07, and Asian 0.06, P = 0.61). Age was the only independent predictive factor for overall survival ( P < 0.001, HR = 1.089, 95% CI 1.056-1.123) in multivariable analysis. Types B3 and thymic carcinoma ( P = 0.003, HR = 3.932, 95% CI 1.615-9.576) were independent risk factors for increased recurrence. CONCLUSIONS This study shows that the selection of the surgical approach and the extent of resection for Stage I and II thymic tumours differ by geographic region. However, these differences seem to have little impact on outcomes.
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Padda SK, Yao X, Antonicelli A, Riess JW, Shang Y, Shrager JB, Korst R, Detterbeck F, Huang J, Burt BM, Wakelee HA, Badve SS. Paraneoplastic Syndromes and Thymic Malignancies: An Examination of the International Thymic Malignancy Interest Group Retrospective Database. J Thorac Oncol 2018; 13:436-446. [PMID: 29191778 PMCID: PMC5983900 DOI: 10.1016/j.jtho.2017.11.118] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 11/08/2017] [Accepted: 11/12/2017] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Thymic epithelial tumors (TETs) are associated with paraneoplastic/autoimmune (PN/AI) syndromes. Myasthenia gravis is the most common PN/AI syndrome associated with TETs. METHODS The International Thymic Malignancy Interest Group retrospective database was examined to determine (1) baseline and treatment characteristics associated with PN/AI syndromes and (2) the prognostic role of PN/AI syndromes for patients with TETs. The competing risks model was used to estimate cumulative incidence of recurrence (CIR) and the Kaplan-Meier method was used to calculate overall survival (OS). A Cox proportional hazards model was used for multivariate analysis. RESULTS A total of 6670 patients with known PN/AI syndrome status from 1951 to 2012 were identified. PN/AI syndromes were associated with younger age, female sex, thymoma histologic type, earlier stage, and an increased rate of total thymectomy and complete resection status. There was a statistically significant lower CIR in the group with a PN/AI syndrome than in the group without a PN/AI syndrome (10-year CIR 17.3% versus 21.2%, respectively [p = 0.0003]). The OS was improved in the group with a PN/AI syndrome compared to the group without a PN/AI syndrome (median OS 21.6 years versus 17.0 years, respectively [hazard ratio = 0.63, 95% confidence interval: 0.54-0.74, p < 0.0001]). However, in the multivariate model for recurrence-free survival and OS, PN/AI syndrome was not an independent prognostic factor. DISCUSSION Previously, there have been mixed data regarding the prognostic role of PN/AI syndromes for patients with TETs. Here, using the largest data set in the world for TETs, PN/AI syndromes were associated with favorable features (i.e., earlier stage and complete resection status) but were not an independent prognostic factor for patients with TETs.
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Tsukazan MR, Terra R, Santoro I, Fortunato G, Meirelles G, Detterbeck F. P2.13-022 Lung Nodule Survey: One Pathology, Perspectives from Thoracic Surgeon, Pulmonologist and Radiology Point of View. J Thorac Oncol 2017. [DOI: 10.1016/j.jtho.2017.09.1369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Korst RJ, Fernando S, Catlin AC, Rutledge JR, Girard N, Huang J, Detterbeck F. Positron Emission Tomography in Thymic Tumors: Analysis Using a Prospective Research Database. Ann Thorac Surg 2017; 104:1815-1820. [PMID: 29033016 DOI: 10.1016/j.athoracsur.2017.06.053] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 06/08/2017] [Accepted: 06/21/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Positron emission tomography may have a role in the pretreatment workup of patients with thymic malignancies. This study was undertaken to determine the utility of the maximum standardized uptake value (SUVmax) in predicting histologic type and tumor stage in a large cohort of thymic epithelial tumors. METHODS The large, multiinstitutional, prospective database of The International Thymic Malignancy Interest Group (ITMIG) was queried for the use of positron emission tomography in the pretreatment workup of patients with thymic tumors. Data analyzed included demographics, SUVmax, histologic tumor type, and tumor stage. The distribution of SUVmax according to histologic type and Masaoka-Koga pathologic stage was determined, and the ability of SUVmax to predict these two variables was calculated using analysis of receiver operating characteristic curves. RESULTS Since 2012, data from 926 patients with thymic malignancies were entered into the ITMIG prospective database, of which 154 had a reported value for SUVmax. The area under the receiver operating characteristic curve for SUVmax in predicting histologic type and pathologic stage was 0.79 (95% confidence interval, 0.70 to 0.88; p < 0.001) and 0.81 (95% confidence interval, 0.73 to 0.88; p < 0.001), respectively. In addition, there was a significant relationship between SUVmax and histologic type (p < 0.001) as well as Masaoka-Koga pathologic stage (p < 0.001). CONCLUSIONS Positron emission tomography has utility in predicting clinicopathologic features of thymic malignancies. These results may have clinical application in the pretreatment workup of patients with these rare tumors.
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Rothberg BG, Das R, Jackson L, Lazowski H, Bai Y, O'Neill D, Roberts S, Rothberg J, Herbst R, Kim A, Boffa D, Rimm D, Detterbeck F, Tanoue L. P1.05-017 The Prognostic Impact of EGFR, KRAS and TP53 Somatic Mutations in Curatively Resected Early-Stage Lung Adenocarcinomas. J Thorac Oncol 2017. [DOI: 10.1016/j.jtho.2016.11.801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Detterbeck F, Molins L. Video-assisted thoracic surgery and open chest surgery in lung cancer treatment: present and future. J Vis Surg 2016; 2:173. [PMID: 29078558 DOI: 10.21037/jovs.2016.11.03] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 10/01/2016] [Indexed: 11/06/2022]
Abstract
Surgical resection remains the most effective treatment of early stage lung cancer. The surgical approach has evolved, and now consists primarily of video-assisted thoracic surgery (VATS) and more limited incisions even with open techniques. Both approaches have their place. Many factors contribute to deciding whether one or the other is better for a particular tumor, patient and in a particular setting and region. Video assisted surgery, where appropriate, is associated with fewer complications and a shorter hospital stay, and similar long term survival. But modern open surgery is also associated with good results. This article reviews the data and discusses considerations to weigh in finding the right balance between the video-assisted and the open approaches.
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Nicholson AG, Detterbeck F, Marx A, Roden AC, Marchevsky AM, Mukai K, Chen G, Marino M, den Bakker MA, Yang WI, Judge M, Hirschowitz L. Dataset for reporting of thymic epithelial tumours: recommendations from the International Collaboration on Cancer Reporting (ICCR). Histopathology 2016; 70:522-538. [PMID: 27735079 DOI: 10.1111/his.13099] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 10/10/2016] [Indexed: 12/18/2022]
Abstract
AIMS The International Collaboration on Cancer Reporting (ICCR) is a not-for-profit organization formed by the Royal Colleges of Pathologists of Australasia and the United Kingdom, the College of American Pathologists, the Canadian Association of Pathologists-Association Canadienne des Pathologists in association with the Canadian Partnership Against Cancer, and the European Society of Pathology. Its goal is to produce standardized, internationally agreed, evidence-based datasets for use throughout the world. METHODS AND RESULTS This article describes the development of a cancer dataset by the multidisciplinary ICCR expert panel for the reporting of thymic epithelial tumours. The dataset includes 'required' (mandatory) and 'recommended' (non-mandatory) elements, which are validated by a review of current evidence and supported by explanatory text. Seven required elements and 12 recommended elements were agreed by the international dataset authoring committee to represent the essential information for the reporting of thymic epithelial tumours. CONCLUSIONS The use of an internationally agreed, structured pathology dataset for reporting thymic tumours provides all of the necessary information for optimal patient management, facilitates consistent and accurate data collection, and provides valuable data for research and international benchmarking. The dataset also provides a valuable resource for those countries and institutions that are not in a position to develop their own datasets.
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Shepherd A, Riely G, Detterbeck F, Simone CB, Ahmad U, Huang J, Korst R, Rajan A, Rimner A. Thymic Carcinoma Management Patterns among International Thymic Malignancy Interest Group (ITMIG) Physicians with Consensus from the Thymic Carcinoma Working Group. J Thorac Oncol 2016; 12:745-751. [PMID: 27876674 DOI: 10.1016/j.jtho.2016.11.2219] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 11/03/2016] [Accepted: 11/08/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Thymic carcinomas are rare epithelial malignancies with limited data to guide management. METHODS To identify areas of agreement and variability in current clinical practice, a 16-question electronic survey was given to members of the International Thymic Malignancy Interest Group (ITMIG). Areas of controversy were discussed with the Thymic Carcinoma Working Group and consensus was achieved, as described. RESULTS A total of 100 ITMIG members responded. There was general agreement regarding the role for multimodality therapy with definitive surgical resection in physically fit patients with advanced but resectable disease. Areas of controversy included the need for histologic confirmation before surgery, the role of adjuvant therapy, the optimal first-line chemotherapy regimen, and the recommended treatment course for marginally resectable disease with invasion into the great vessels, pericardium, and lungs. CONCLUSIONS The results of the questionnaire provide a description of the management of thymic carcinoma by 100 ITMIG members with a specific interest or expertise in thymic malignancies. Although there was agreement in some areas, clinical practice appears to vary significantly. There is a great need for collaborative research to identify optimal evaluation and treatment strategies. Given the need for multimodality therapy in many cases, a multidisciplinary discussion of the management of patients with thymic carcinoma is critical.
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Filosso PL, Yao X, Ruffini E, Ahmad U, Antonicelli A, Huang J, Guerrera F, Venuta F, van Raemdonck D, Travis W, Lucchi M, Rimner A, Thomas P, Weder W, Rocco G, Detterbeck F, Korst R. Comparison of outcomes between neuroendocrine thymic tumours and other subtypes of thymic carcinomas: a joint analysis of the European Society of Thoracic Surgeons and the International Thymic Malignancy Interest Group. Eur J Cardiothorac Surg 2016; 50:766-771. [PMID: 27032473 PMCID: PMC6279171 DOI: 10.1093/ejcts/ezw107] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 01/12/2016] [Accepted: 02/11/2016] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVES The latest World Health Organization (WHO) histological classification divides thymic epithelial tumours in thymomas and thymic carcinomas (TCs), the latter also including the neuroendocrine thymic tumours (NETTs). NETTs and other TC histotypes have been described to have a significantly lower survival than thymomas, but these two groups of tumours have rarely been compared directly. Using the European Society of Thoracic Surgeons and the International Thymic Malignancy Interest Group datasets, we wanted to study this issue. METHODS This is a retrospective multicentre cohort study of patients operated for TC. Outcome measures were overall survival (OS) and recurrence-free survival (RFS). OS was analysed using the Kaplan-Meier method and RFS was assessed using competing risk analysis. The association with clinical and prognostic factors for OS and RFS was evaluated with log-rank test and Gray's test, respectively. RESULTS A total of 1247 tumours (1042 TCs) were collected between 1984 and 2012. A R0 resection was performed in 363 TCs and in 52 NETTs. The median follow-up was 4.4 years for TCs and 4.1 years for NETTs. Owing to the missing values for survival information, a total of 728 TC patients and 132 NETTs were included in the OS analysis. Among them, 262 TC and 39 NETT patients died. The median OS was 6.6 years for TC and 7.5 years for NETTs. The overall 5-year survival rates were 60% for TC and 68% for NETTs; 10-year survival rates were 40% for TCs and 39% for NETTs (P = 0.19). Five-year RFS was 0.35 and 0.34 for TCs and NETTs (P = 0.36). On multivariate analysis, histology did not influence either OS (P = 0.79) or RFS (P = 0.59). CONCLUSIONS This represents the largest clinical series of TCs and NETTs collected. Despite the biological aggressiveness of these rare neoplasms, the 5-year survival rate after resection is over 60% and TCs and NETT showed a similar rate of survival and recurrences after surgery.
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Nowak AK, Chansky K, Rice DC, Pass HI, Kindler HL, Shemanski L, Billé A, Rintoul RC, Batirel HF, Thomas CF, Friedberg J, Cedres S, de Perrot M, Rusch VW, Rami-Porta R, Asamura H, Ball D, Beer D, Beyruti R, Bolejack V, Chansky K, Crowley J, Detterbeck F, Eberhardt WEE, Edwards J, Galateau-Sallé F, Giroux D, Gleeson F, Groome P, Huang J, Kennedy C, Kim J, Kim YT, Kingsbury L, Kondo H, Krasnik M, Kubota K, Lerut A, Lyons G, Marino M, Marom EM, van Meerbeeck J, Mitchell A, Nakano T, Nicholson AG, Nowak A, Peake M, Rice T, Rosenzweig K, Ruffini E, Rusch V, Saijo N, Van Schil P, Sculier JP, Shemanski L, Stratton K, Suzuki K, Tachimori Y, Thomas CF, Travis W, Tsao MS, Turrisi A, Vansteenkiste J, Watanabe H, Wu YL, Baas P, Erasmus J, Hasegawa S, Inai K, Kernstine K, Kindler H, Krug L, Nackaerts K, Pass H, Rice D, Falkson C, Filosso PL, Giaccone G, Kondo K, Lucchi M, Okumura M, Blackstone E, Asamura H, Batirel H, Bille A, Pastorino U, Call S, Cangir A, Cedres S, Friedberg J, Galateau-Salle F, Hasagawa S, Kernstine K, Kindler H, McCaughan B, Nakano T, Nowak A, Ozturk CA, Pass H, de Perrot M, Rea F, Rice D, Rintoul R, Ruffini E, Rusch V, Spaggiari L, Galetta D, Syrigos K, Thomas C, van Meerbeeck J, Nafteux P, Vansteenkiste J, Weder W, Optiz I, Yoshimura M. The IASLC Mesothelioma Staging Project: Proposals for Revisions of the T Descriptors in the Forthcoming Eighth Edition of the TNM Classification for Pleural Mesothelioma. J Thorac Oncol 2016; 11:2089-2099. [PMID: 27687963 DOI: 10.1016/j.jtho.2016.08.147] [Citation(s) in RCA: 112] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 08/18/2016] [Accepted: 08/20/2016] [Indexed: 12/23/2022]
Abstract
INTRODUCTION The current T component for malignant pleural mesothelioma (MPM) has been predominantly informed by surgical data sets and consensus. The International Association for the Study of Lung Cancer undertook revision of the seventh edition of the staging system for MPM with the goal of developing recommendations for the eighth edition. METHODS Data elements including detailed T descriptors were developed by consensus. Tumor thickness at three pleural levels was also recorded. An electronic data capture system was established to facilitate data submission. RESULTS A total of 3519 cases were submitted to the database. Of those eligible for T-component analysis, 509 cases had only clinical staging, 836 cases had only surgical staging, and 642 cases had both available. Survival was examined for T categories according to the current seventh edition staging system. There was clear separation between all clinically staged categories except T1a versus T1b (hazard ratio = 0.99, p = 0.95) and T3 versus T4 (hazard ratio = 1.22, p = 0.09), although the numbers of T4 cases were small. Pathological staging failed to demonstrate a survival difference between adjacent categories with the exception of T3 versus T4. Performance improved with collapse of T1a and T1b into a single T1 category; no current descriptors were shifted or eliminated. Tumor thickness and nodular or rindlike morphology were significantly associated with survival. CONCLUSIONS A recommendation to collapse both clinical and pathological T1a and T1b into a T1 classification will be made for the eighth edition staging system. Simple measurement of pleural thickness has prognostic significance and should be examined further with a view to incorporation into future staging.
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Fang W, Yao X, Antonicelli A, Louie B, Gu Z, Vallieres E, Huang J, Korst R, Detterbeck F. B-002COMPARISON OF SURGICAL APPROACH AND EXTENT OF RESECTION FOR STAGE I AND II THYMIC TUMOURS IN EUROPE, NORTH AMERICA AND ASIA: AN ITMIG RETROSPECTIVE DATABASE GEOGRAPHIC ANALYSIS. Interact Cardiovasc Thorac Surg 2016. [DOI: 10.1093/icvts/ivw260.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Rimner A, Yao X, Huang J, Antonicelli A, Ahmad U, Korst RJ, Detterbeck F, Gomez DR. Postoperative Radiation Therapy Is Associated with Longer Overall Survival in Completely Resected Stage II and III Thymoma-An Analysis of the International Thymic Malignancies Interest Group Retrospective Database. J Thorac Oncol 2016; 11:1785-92. [PMID: 27346413 DOI: 10.1016/j.jtho.2016.06.011] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 06/11/2016] [Accepted: 06/13/2016] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The aim of this study was to determine whether postoperative radiation therapy (PORT) is associated with an overall survival (OS) benefit in patients with completely resected Masaoka or Masaoka-Koga stage II and III thymoma. METHODS All patients with completely resected (R0) stage II or III thymoma were identified in a large database of the International Thymic Malignancy Interest Group. Clinical, pathologic, treatment, and follow-up information were extracted. OS was the primary end point. A univariate analysis using the log-rank test was performed, and a multivariate Cox model was created to identify factors associated with OS. RESULTS Of 1263 patients meeting the selection criteria, 870 (69%) had stage II thymoma. The WHO histologic subtype was A/AB in 360 patients (30%) and B1/B2/B3 in 827 (70%). PORT was given to 55% of patients (n = 689), 15% (n = 180) received chemotherapy, and 10% (n = 122) received both. The 5- and 10-year OS rates for patients having undergone an operation plus PORT were 95% and 86%, respectively, compared with 90% and 79% for patients receiving an operation alone (p = 0.002). This OS benefit remained significant when patients with stage II (p = 0.02) and stage III thymoma (p = 0.0005) were analyzed separately. On multivariate analysis, earlier stage, younger age, absence of paraneoplastic syndrome, and PORT were significantly associated with improved OS. CONCLUSIONS We observed an OS benefit with the use of PORT in completely resected stage II and III thymoma. In the absence of a randomized trial, this represents the most comprehensive analysis of individual patient data and strong evidence in favor of PORT in this patient population.
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Detterbeck FC, Nicholson AG, Franklin WA, Marom EM, Travis WD, Girard N, Arenberg DA, Bolejack V, Donington JS, Mazzone PJ, Tanoue LT, Rusch VW, Crowley J, Asamura H, Rami-Porta R, Goldstraw P, Rami-Porta R, Asamura H, Ball D, Beer DG, Beyruti R, Bolejack V, Chansky K, Crowley J, Detterbeck F, Erich Eberhardt WE, Edwards J, Galateau-Sallé F, Giroux D, Gleeson F, Groome P, Huang J, Kennedy C, Kim J, Kim YT, Kingsbury L, Kondo H, Krasnik M, Kubota K, Lerut A, Lyons G, Marino M, Marom EM, van Meerbeeck J, Mitchell A, Nakano T, Nicholson AG, Nowak A, Peake M, Rice T, Rosenzweig K, Ruffini E, Rusch V, Saijo N, Van Schil P, Sculier JP, Shemanski L, Stratton K, Suzuki K, Tachimori Y, Thomas CF, Travis W, Tsao MS, Turrisi A, Vansteenkiste J, Watanabe H, Wu YL, Baas P, Erasmus J, Hasegawa S, Inai K, Kernstine K, Kindler H, Krug L, Nackaerts K, Pass H, Rice D, Falkson C, Filosso PL, Giaccone G, Kondo K, Lucchi M, Okumura M, Blackstone E, Erasmus J, Flieder D, Godoy M, Goo JM, Goodman LR, Jett J, de Leyn P, Marchevsky A, MacMahon H, Naidich D, Okada M, Perlman M, Powell C, van Schil P, Tsao MS, Warth A, Cavaco FA, Barrera EA, Arca JA, Lamelas IP, Obrer AA, Jorge RG, Ball D, Bascom G, Blanco Orozco A, González Castro M, Blum M, Chimondeguy D, Cvijanovic V, Defranchi S, de Olaiz Navarro B, Escobar Campuzano I, Macía Vidueira I, Fernández Araujo E, Andreo García F, Fong K, Francisco Corral G, Cerezo González S, Freixinet Gilart J, García Arangüena L, García Barajas S, Girard P, Goksel T, González Budiño M, González Casaurrán G, Gullón Blanco J, Hernández J, Hernández Rodríguez H, Herrero Collantes J, Iglesias Heras M, Izquierdo Elena J, Jakobsen E, Kostas S, León Atance P, Núñez Ares A, Liao M, Losanovscky M, Lyons G, Magaroles R, De Esteban Júlvez L, Mariñán Gorospe M, McCaughan B, Kennedy C, Melchor Íñiguez R, Miravet Sorribes L, Naranjo Gozalo S, Álvarez de Arriba C, Núñez Delgado M, Padilla Alarcón J, Peñalver Cuesta J, Park J, Pass H, Pavón Fernández M, Rosenberg M, Ruffini E, Rusch V, Sánchez de Cos Escuín J, Saura Vinuesa A, Serra Mitjans M, Strand T, Subotic D, Swisher S, Terra R, Thomas C, Tournoy K, Van Schil P, Velasquez M, Wu Y, Yokoi K. The IASLC Lung Cancer Staging Project: Summary of Proposals for Revisions of the Classification of Lung Cancers with Multiple Pulmonary Sites of Involvement in the Forthcoming Eighth Edition of the TNM Classification. J Thorac Oncol 2016; 11:639-650. [DOI: 10.1016/j.jtho.2016.01.024] [Citation(s) in RCA: 111] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 01/20/2016] [Accepted: 01/21/2016] [Indexed: 12/25/2022]
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Detterbeck FC, Bolejack V, Arenberg DA, Crowley J, Donington JS, Franklin WA, Girard N, Marom EM, Mazzone PJ, Nicholson AG, Rusch VW, Tanoue LT, Travis WD, Asamura H, Rami-Porta R, Goldstraw P, Rami-Porta R, Asamura H, Ball D, Beer DG, Beyruti R, Bolejack V, Chansky K, Crowley J, Detterbeck F, Erich Eberhardt WE, Edwards J, Galateau-Sallé F, Giroux D, Gleeson F, Groome P, Huang J, Kennedy C, Kim J, Kim YT, Kingsbury L, Kondo H, Krasnik M, Kubota K, Lerut A, Lyons G, Marino M, Marom EM, van Meerbeeck J, Mitchell A, Nakano T, Nicholson AG, Nowak A, Peake M, Rice T, Rosenzweig K, Ruffini E, Rusch V, Saijo N, Van Schil P, Sculier JP, Shemanski L, Stratton K, Suzuki K, Tachimori Y, Thomas CF, Travis W, Tsao MS, Turrisi A, Vansteenkiste J, Watanabe H, Wu YL, Baas P, Erasmus J, Hasegawa S, Inai K, Kernstine K, Kindler H, Krug L, Nackaerts K, Pass H, Rice D, Falkson C, Filosso PL, Giaccone G, Kondo K, Lucchi M, Okumura M, Blackstone E, Erasmus J, Flieder D, Godoy M, Goo JM, Goodman LR, Jett J, de Leyn P, Marchevsky A, MacMahon H, Naidich D, Okada M, Perlman M, Powell C, van Schil P, Tsao MS, Warth A, Cavaco FA, Barrera EA, Arca JA, Lamelas IP, Obrer AA, Jorge RG, Ball D, Bascom G, Blanco Orozco A, González Castro M, Blum M, Chimondeguy D, Cvijanovic V, Defranchi S, de Olaiz Navarro B, Escobar Campuzano I, Macía Vidueira I, Fernández Araujo E, Andreo García F, Fong K, Francisco Corral G, Cerezo González S, Freixinet Gilart J, García Arangüena L, García Barajas S, Girard P, Goksel T, González Budiño M, González Casaurrán G, Gullón Blanco J, Hernández Hernández J, Hernández Rodríguez H, Herrero Collantes J, Iglesias Heras M, Izquierdo Elena J, Jakobsen E, Kostas S, León Atance P, Núñez Ares A, Liao M, Losanovscky M, Lyons G, Magaroles R, De Esteban Júlvez L, Mariñán Gorospe M, McCaughan B, Kennedy C, Melchor Íñiguez R, Miravet Sorribes L, Naranjo Gozalo S, Álvarez de Arriba C, Núñez Delgado M, Padilla Alarcón J, Peñalver Cuesta J, Park J, Pass H, Pavón Fernández M, Rosenberg M, Ruffini E, Rusch V, Sánchez de Cos Escuín J, Saura Vinuesa A, Serra Mitjans M, Strand T, Subotic D, Swisher S, Terra R, Thomas C, Tournoy K, Van Schil P, Velasquez M, Wu Y, Yokoi K. The IASLC Lung Cancer Staging Project: Background Data and Proposals for the Classification of Lung Cancer with Separate Tumor Nodules in the Forthcoming Eighth Edition of the TNM Classification for Lung Cancer. J Thorac Oncol 2016; 11:681-692. [DOI: 10.1016/j.jtho.2015.12.114] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 12/01/2015] [Accepted: 12/29/2015] [Indexed: 12/01/2022]
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Travis WD, Asamura H, Bankier AA, Beasley MB, Detterbeck F, Flieder DB, Goo JM, MacMahon H, Naidich D, Nicholson AG, Powell CA, Prokop M, Rami-Porta R, Rusch V, van Schil P, Yatabe Y. The IASLC Lung Cancer Staging Project: Proposals for Coding T Categories for Subsolid Nodules and Assessment of Tumor Size in Part-Solid Tumors in the Forthcoming Eighth Edition of the TNM Classification of Lung Cancer. J Thorac Oncol 2016; 11:1204-1223. [PMID: 27107787 DOI: 10.1016/j.jtho.2016.03.025] [Citation(s) in RCA: 460] [Impact Index Per Article: 57.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 03/21/2016] [Accepted: 03/24/2016] [Indexed: 12/15/2022]
Abstract
This article proposes codes for the primary tumor categories of adenocarcinoma in situ (AIS) and minimally invasive adenocarcinoma (MIA) and a uniform way to measure tumor size in part-solid tumors for the eighth edition of the tumor, node, and metastasis classification of lung cancer. In 2011, new entities of AIS, MIA, and lepidic predominant adenocarcinoma were defined, and they were later incorporated into the 2015 World Health Organization classification of lung cancer. To fit these entities into the T component of the staging system, the Tis category is proposed for AIS, with Tis (AIS) specified if it is to be distinguished from squamous cell carcinoma in situ (SCIS), which is to be designated Tis (SCIS). We also propose that MIA be classified as T1mi. Furthermore, the use of the invasive size for T descriptor size follows a recommendation made in three editions of the Union for International Cancer Control tumor, node, and metastasis supplement since 2003. For tumor size, the greatest dimension should be reported both clinically and pathologically. In nonmucinous lung adenocarcinomas, the computed tomography (CT) findings of ground glass versus solid opacities tend to correspond respectively to lepidic versus invasive patterns seen pathologically. However, this correlation is not absolute; so when CT features suggest nonmucinous AIS, MIA, and lepidic predominant adenocarcinoma, the suspected diagnosis and clinical staging should be regarded as a preliminary assessment that is subject to revision after pathologic evaluation of resected specimens. The ability to predict invasive versus noninvasive size on the basis of solid versus ground glass components is not applicable to mucinous AIS, MIA, or invasive mucinous adenocarcinomas because they generally show solid nodules or consolidation on CT.
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Detterbeck F. Report of ITMIG 2015 Meeting. J Thorac Dis 2016; 7:S177-9. [PMID: 26807268 DOI: 10.3978/j.issn.2072-1439.2015.ab053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Leuzzi G, Rocco G, Ruffini E, Sperduti I, Detterbeck F, Weder W, Venuta F, Van Raemdonck D, Thomas P, Facciolo F. Multimodality therapy for locally advanced thymomas: A propensity score–matched cohort study from the European Society of Thoracic Surgeons Database. J Thorac Cardiovasc Surg 2016; 151:47-57.e1. [DOI: 10.1016/j.jtcvs.2015.08.034] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Revised: 06/17/2015] [Accepted: 08/10/2015] [Indexed: 11/27/2022]
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Nicholson AG, Chansky K, Crowley J, Beyruti R, Kubota K, Turrisi A, Eberhardt WEE, van Meerbeeck J, Rami-Porta R, Asamura H, Ball D, Beer DG, Beyruti R, Bolejack V, Chansky K, Crowley J, Detterbeck F, Erich Eberhardt WE, Edwards J, Galateau-Sallé F, Giroux D, Gleeson F, Groome P, Huang J, Kennedy C, Kim J, Kim YT, Kingsbury L, Kondo H, Krasnik M, Kubota K, Lerut T, Lyons G, Marino M, Marom EM, van Meerbeeck J, Mitchell A, Nakano T, Nicholson AG, Nowak A, Peake M, Rice T, Rosenzweig K, Ruffini E, Rusch V, Saijo N, Van Schil P, Sculier JP, Shemanski L, Stratton K, Suzuki K, Tachimori Y, Thomas CF, Travis W, Tsao MS, Turrisi A, Vansteenkiste J, Watanabe H, Wu YL, Baas P, Erasmus J, Hasegawa S, Inai K, Kernstine K, Kindler H, Krug L, Nackaerts K, Pass H, Rice D, Falkson C, Filosso PL, Giaccone G, Kondo K, Lucchi M, Okumura M, Blackstone E, Cavaco FA, Barrera EA, Arca JA, Lamelas IP, Obrer AA, Jorge RG, Ball D, Bascom G, Blanco Orozco A, González Castro M, Blum M, Chimondeguy D, Cvijanovic V, Defranchi S, de Olaiz Navarro B, Escobar Campuzano I, Vidueira IM, Araujo EF, García FA, Fong K, Corral GF, González SC, Gilart JF, Arangüena LG, Barajas SG, Girard P, Goksel T, González Budiño M, González Casaurrán G, Gullón Blanco J, Hernández Hernández J, Rodríguez HH, Collantes JH, Heras MI, Izquierdo Elena J, Jakobsen E, Kostas S, Atance PL, Ares AN, Liao M, Losanovscky M, Lyons G, Magaroles R, De Esteban Júlvez L, Gorospe MM, McCaughan B, Kennedy C, Melchor Íñiguez R, Miravet Sorribes L, Naranjo Gozalo S, de Arriba CÁ, Núñez Delgado M, Alarcón JP, Peñalver Cuesta J, Park J, Pass H, Pavón Fernández M, Rosenberg M, Rusch V, de Cos Escuín JS, Vinuesa AS, Serra Mitjans M, Strand T, Subotic D, Swisher S, Terra R, Thomas C, Tournoy K, Van Schil P, Velasquez M, Wu Y, Yokoi K. The International Association for the Study of Lung Cancer Lung Cancer Staging Project: Proposals for the Revision of the Clinical and Pathologic Staging of Small Cell Lung Cancer in the Forthcoming Eighth Edition of the TNM Classification for Lung Cancer. J Thorac Oncol 2015; 11:300-11. [PMID: 26723244 DOI: 10.1016/j.jtho.2015.10.008] [Citation(s) in RCA: 244] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 10/01/2015] [Accepted: 10/03/2015] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Small cell lung cancer (SCLC) is commonly classified as either limited or extensive, but the Union for International Cancer Control TNM Classification of Malignant Tumours seventh edition (2009) recommended tumor, node, and metastasis (TNM) staging based on analysis of the International Association for the Study of Lung Cancer (IASLC) database. METHODS Survival analyses were performed for clinically and pathologically staged patients presenting with SCLC from 1999 through 2010. Prognosis was compared in relation to the TNM seventh edition staging to serve as validation and analyzed in relation to proposed changes to the T descriptors found in the eighth edition. RESULTS There were 5002 patients: 4848 patients with clinical and 582 with pathological stages. Among these, 428 had both. Survival differences were confirmed for T and N categories and maintained in relation to proposed revisions to T descriptors for seventh edition TNM categories and proposed changes in the eighth edition. There were also survival differences, notably at 12 months, in patients with brain-only single-site metastasis (SSM) compared to SSM at other sites, and SSM without a pleural effusion showed a better prognosis than other patients in the M1b category. CONCLUSION We confirm the prognostic value of clinical and pathological TNM staging in patients with SCLC, and recommend continued usage for SCLC in relation to proposed changes to T, N, and M descriptors for NSCLC in the eighth edition. However, for M descriptors, it remains uncertain whether survival differences in patients with SSM in the brain simply reflect better treatment options rather than better survival based on anatomic extent of disease.
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