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ARTICLE IN PRESS

doi:10.1510/icvts.2011.267021

Editorial
New Ideas
Interactive CardioVascular and Thoracic Surgery xxx (xxx) xxx–xxx
www.icvts.org
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2 Institutional report - Thoracic oncologic 3

Progress Report
4 Effects of reclassification from the TNM-6 into the TNM-7 staging

Work in
system in bronchoplastic resection for non-small cell lung cancer夞

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5
6

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7 Thomas Klikovits , Adelheid End *, Gunther Riedl , Michaela Stiebler , Gerhard Dekan , Walter Klepetko
a a, a a b a

Protocol
8
9 a
Division of Thoracic Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
10 b
Clinical Institute of Pathology, Medical University of Vienna, Vienna, Austria
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12 Received 20 January 2011; received in revised form 5 April 2011; accepted 7 April 2011

Institutional
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27

Report
28 Abstract
29
30 In 2007, the International Association for the Study of Lung Cancer proposed changes to the sixth edition of the lung cancer stage
31 classification system, which were adopted by the Union Internationale Contre le Cancer in 2009 (TNM-7). Using historic patient data, the

Article
ESCVS
32 effects of reclassification from the TNM-6 to the TNM-7 system were researched within a single institution. We retrospectively reclassified
33 the pathological records of 145 patients who underwent bronchoplastic resection for non-small cell lung cancer between 1991 and 2004,
34
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by applying the new TNM-7 classification for lung cancer. A comparison between the previous and the new system was conducted. Out of

Proposal for Bail-


out Procedure
35 145 patients, 49 (33.8%) were reclassified into a new stage, 42 (85.7% of reclassified cases) being allocated to a lower and seven (14.3%)
36 being assigned to a higher stage. Most of the patients switched from stage IIB to IIA (ns31, 63.3%). The application of the new TNM-7
37 staging system resulted in a more accurate stratification of five-year survival curves. The newly revised TNM classification for lung cancer
38 appears to be superior in defining different prognostic groups for this cohort and should lead to an improvement in stage specific tumor
therapy.
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40 䊚 2011 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.

Negative
Results
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42 Keywords: Non-small cell lung carcinoma; Tumor staging; Thoracic surgery
43
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Follow-up
44 65

Paper
46 1. Introduction 2. Materials and methods

47 The TNM staging system is a well-established method for 2.1. Patients 66

State-of-the-art
48 the classification of various tumors into different stages,
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Between 1 January 1991, and 1 September 2004, 145 67


49 for estimating prognosis and enable a decision on appropri-
bronchoplastic procedures were performed in patients with 68
50 ate treatment options. The TNM Classification of Malignant
NSCLCs at the Department of Cardiothoracic Surgery, Med- 69
Tumours is being revised and published by the International
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51
ical University of Vienna, Austria. Out of these, a cohort of 70
52 Union Against Cancer and the American Joint Committee
63 patients with bronchoplastic resections for NSCLC 71

Best Evidence
53 on Cancer on a regular basis to provide best scientific and
between 1991 and 1997 were part of a two-center study 72
54 clinical evidence w1x. The latest (seventh) edition of the published in 2000 w8x. The patients comprised 117 males 73
Topic

55 lung cancer staging classification was published in late 2009 (80.7%) and 28 females (19.3%) with a mean age of 61 74
and is based on the recommendations of the International
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56
(range 41–82 years) at the time of surgical intervention. 75
57 Association for the Study of Lung Cancer (IASLC) w2–7x. They underwent bronchoplastic resection for squamous cell 76
Nomenclature

58 The aim of this study was to retrospectively assess the carcinoma (ns98, 67.6%), adenocarcinoma (ns38; 26.2%), 77
59 effects of reclassification from the past (TNM-6) to the large cell carcinoma (ns4; 2.8%), or other types of NSCLC 78
60 new TNM-7 system on stage groupings and survival charac- (ns5, 3.4%). Bronchoplastic procedures consisted of 90 79
61 teristics in a well-defined subset of patients undergoing sleeve lobectomies, 27 sleeve bilobectomies, 21 sleeve 80
62 bronchoplastic resection for non-small cell lung cancer pneumonectomies, four right upper sleeve lobectomies 81
Historical

63 (NSCLC) at a single institution, in order to gain experience with carinal resection, and three sleeve resections of the
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82
64 with the new system and to identify its workload. carina. 83
340 Data for retrospective analysis were extracted from the 84
341 夞 The data in this paper were partly presented at the 50th Annual Meeting medical records, including sex, age, histology, size and 85
Communication

342 of the Austrian Society of Surgery, Vienna, June 18, 2009, the Annual location of tumor, staging, neoyadjuvant therapy, date of 86
343 Congress of the European Respiratory Society, Barcelona, September 19, last follow-up, and death from any cause. Overall median 87
Brief

344 2010, and the Joint Meeting of the German, Austrian and Swiss Societies of
345 Thoracic Surgery, Vienna, October 7, 2010.
follow-up time for all patients was 37 months (range 0.03– 88
346 *Corresponding author. Tel.: q43-1-40400-5620; fax: q43-1-40400-6490. 182.5 months). Median follow-up for patients alive (ns44) 89
347 E-mail address: adelheid.end@meduniwien.ac.at (A. End). was 92 months (range 25.9–182.5 months). 90
Case Report

䊚 2011 Published by European Association for Cardio-Thoracic Surgery

icvts 267021 Mp 1 Friday Apr 22 2011 06:54 AM 10


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91 109
2.1.1. Adjuvantyneoadjuvant therapy T4, and those in a contralateral lobe as M1a w4x. Tumors
92 Adjuvant chemotherapy was performed in 21 patients combined with pleural effusion, pleural dissemination, or 110
93 (14.9%). A total of 26 patients (17.9%) underwent adjuvant pericardial effusion are also defined as M1a w7x. In addition, 111
94 radiotherapy, and nine patients (6.2%) were administered patients with other distant metastases are subclassified as 112
95 adjuvant chemoradiotherapy. There were 23 patients M1b. Concerning the existing N classification, no changes 113
96 (15.9%) undergoing neoadjuvant therapy, including 19 were accomplished in the new edition w5x. For changes in 114
97 patients receiving neoadjuvant chemotherapy, two neo- stage grouping, the IASLC recommended the reclassification 115
98 adjuvant radiotherapy, and two chemoradiotherapy. of patients with T2aN1 and T2bN0 as stage IIA disease, and 116
patients with T4N0 and T4N1 as stage IIIA disease w3x. 117

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99 2.2. The new staging system

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2.2.1. Analyses 118
100 A comparison between the previous (TNM-6) and the new Approval for this retrospective study was obtained from 119
101 (TNM-7) staging system concerning T, N, and M descriptors the Ethics Committee (Institutional Review Board) of the 120
102 is given in Table 1. The IASLC proposed a subclassification Medical University of Vienna and the Vienna General Hos- 121
103 of former T1 tumors into T1a (F2 cm) and T1b ()2 cm pital, Austria. No individual patient consent was required, 122
and F3 cm) and of T2 tumors into T2a ()3 cm and F5 cm) and no personally identifiable information was included in

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104 123
105 and T2b ()5 cm and F7 cm). Tumors larger than 7 cm in this paper. 124
106 the greatest dimension were reclassified as T3. Additional Survival analyses were performed using the Kaplan–Meier 125
107 tumor nodules in the same lobe are now defined as T3, method; differences in survival between consecutive stages 126
108 separate tumor nodules in a different ipsilateral lobe as were evaluated using a log-rank test. Statistical calcula- 127

3
4 Table 1. Comparison of the past and new T, N, and M descriptors w2, 3x
ed
Past TNM staging 1997 (TNM-6) New TNM staging 2009 (TNM-7)
5
10 Primary tumor (T) Primary tumor (T)
11 TX Tumor cannot be assessed, or tumor proven by TX Tumor cannot be assessed, or tumor proven by the
12 the presence of malignant cells in sputum or presence of malignant cells in sputum or bronchial
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13 bronchial washings but not visualized by washings but not visualized by imaging or bronchoscopy
14 imaging or bronchoscopy
15 T0 No evidence of primary tumor T0 No evidence of primary tumor
16 Tis Carcinoma in situ Tis Carcinoma in situ
17 T1 Tumor F3 cm, more distal than lobar bronchus T1 Tumor F3 cm, more distal than lobar bronchus
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18 T1a Tumor F2 cm
19 T1b Tumor )2 cm and F3 cm
20 T2 Tumor )3 cm or T2 Tumor )3 cm and F7 cm or
21 – Invades main bronchus )2 cm distal to carina – Invades main bronchus )2 cm distal to carina
22 – Invades visceral pleura – Invades visceral pleura
23 – Atelectasis or obstructive pneumonia extending – Atelectasis or obstructive pneumonia extending to hilar region
24 to hilar region but not involving entire lung but not involving entire lung
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25 T2a Tumor )3 cm and F5 cm


26 T2b Tumor )5 cm and F7 cm
27 T3 Tumor of any size that invades any of following: T3 Tumor )7 cm or invading any of following:
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28 Chest wall, diaphragm, mediastinal pleura, Chest wall, diaphragm, phrenic nerve, mediastinal pleura,
29 parietal pericardium, or parietal pericardium, or
30 – Invades main bronchus -2 cm distal to the carina – Invades main bronchus -2 cm distal to the carina
31 – Atelectasis or obstructive pneumonia of entire lung – Atelectasis or obstructive pneumonia of entire lung
32 – Separate tumor nodule(s) in same lobe
33 T4 Tumor of any size that invades any of following: T4 Tumor of any size that invades any of following:
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34 Mediastinum, heart, great vessels, trachea, Mediastinum, heart, great vessels, trachea, recurrent
35 esophagus, vertebral body, carina, or laryngeal nerve, esophagus, vertebral body, carina, or
36 – Tumor with malignant pleural or pericardial effusion – Separate tumor nodule(s) in different ipsilateral lobe
37 – Satellite tumor nodule(s) in same ipsilateral lobe
38 Regional lymph nodes (N) Regional lymph nodes (N)
39 NX Regional lymph nodes cannot be assessed NX Regional lymph nodes cannot be assessed
40 N0 No regional lymph node metastasis N0 No regional lymph node metastasis
41 N1 Ipsilateral peribronchial andyor hilar N1 Ipsilateral peribronchial andyor hilar
42 N2 Ipsilateral mediastinal andyor subcarinal N2 Ipsilateral mediastinal andyor subcarinal
43 N3 Contralateral mediastinal andyor hilar N3 Contralateral mediastinal andyor hilar Ipsiycontralateral
44 Ipsiycontralateral supraclavicular supraclavicular
45 Distant metastasis (M) Distant metastasis (M)
46 MX Distant metastasis cannot be assessed MX removed
47 M0 No distant metastasis M0 No distant metastasis
48 M1 Presence of distant metastasis andyor separate M1 Presence of distant metastasis
49 tumor nodule(s) in different ipsilateral lobe
50 M1a Separate tumor nodule(s) in contralateral lobe tumor
51 with malignant pleural (or pericardial) effusion
52 M1b Distant metastasis
53
54 Bold cells indicate changes according to the new staging system.
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T. Klikovits et al. / Interactive CardioVascular and Thoracic Surgery xx (2011) xxx–xxx 3

Editorial
128 153
tions were made with statistical packages SPSS (V. 16.0) IIB. Three patients with previous stage IB disease (T2N0M0)
129 and ‘R’ (V. 2.9.0). were reclassified into new stage T2bN0M0 disease and 154
therefore also switched to stage IIA. In addition, three 155

New Ideas
130 3. Results patients with tumors larger than 7 cm were moved from 156
stage IB (T2N0M0) to new stage IIB (T3N0M0). 157
131 3.1. Distribution in stage subgroups Furthermore, two patients with T4N0M0 and six patients 158
with T4N1M0 disease were allocated from stage IIIB to new

Progress Report
159
132 Distribution according to the TNM-6 classification was stage IIIA. Two patients with additional tumor nodules in a 160

Work in
133 determined as follows: stage IA, ns9 (6.2%); stage IB, different ipsilateral lobe were classified as having T1N1M1 161

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134 ns20 (13.8%); stage IIA, ns12 (8.3%); stage IIB, ns41 and T4N3M1 disease, respectively, and therefore as being 162
(28.3%); stage IIIA, ns35 (24.1%); stage IIIB, ns22 (15.2%);

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135 stage IV disease in the previous system; when applying the 163
136 stage IV, ns6 (4.1%). After reclassification according to new (TNM-7) staging system, they were reclassified as 164

Protocol
137 the new TNM-7 staging system, the distribution was: stage having T4N1M0 and T4N3M0 disease, and were therefore 165
138 IA, ns9 ("0); stage IB, ns14 (–6); stage IIA, ns46 (q34); moved to stages IIIA and IIIB, respectively. 166
139 stage IIB, ns12 (–29); stage IIIA, ns46 (q11); stage IIIB,
140 ns14 (–8); and stage IV, ns4 (–2) (Fig. 1). Overall, 49

Institutional
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3.2. Survival 167

Report
141 patients (33.8%) were redefined into a new stage: 42
142 patients were shifted to a lower and seven were shifted to
With regard to the TNM-6 staging system, five-year surviv- 168
143 a higher stage (i.e. 85.7% and 14.3% of reclassified cases,
al rates were as follows: IA, 87.5%; IB, 50.0%; IIA, 75.0%; 169
144 respectively), compared to the previous staging system.
IIB, 28.2%; IIIA, 25.4%; IIIB, 27.3%; IV, 16.7%. Five-year 170

Article
The numbers of patients in all stage subgroups using the

ESCVS
145
survivals in the TNM-7 staging system were: IA, 87.5%; IB, 171
146 previous (TNM-6) and the new (TNM-7) staging system are
42.9%; IIA, 45.0%; IIB, 31.2%; IIIA, 28.1%; IIIB, 21.4%; IV, 0%
147 listed in Table 2.
ed (Fig. 2). In the previous staging system (TNM-6), survival
172
173

Proposal for Bail-


148 Due to the reclassification of T2aN1 and T2bN0 disease,

out Procedure
was significantly different between stages IA and IB 174
149 the number of patients in stage IIA increased from 12
(Ps0.023) and stages IIA and IIB (Ps0.020); the survival 175
150 (8.3%) in the previous system to 46 (31.7%) in the new
in stage IIA was better than in stage IB. 176
151 staging system (by 283.3%). A total of 31 (67.4%) of these
When applied to the newly revised staging system (TNM- 177
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152 46 patients in new stage IIA were reclassified from stage
7), survival between stages IA and IB differed significantly 178
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Table 2. Total number of patients in all stages and TNM subgroups using the
previous (TNM-6) and the new (TNM-7) staging system (ns145) 67
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68

Follow-up
Previous staging 1997 (TNM-6) New staging 2009 (TNM-7) 69

Paper
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Stage n % of 145 Stage n % of 145
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I 29 20 I 23 15.9 78

State-of-the-art
T1N0 (IA) 9 T1aN0 (IA) 6 79
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T2N0 (IB) 20 T1bN0 (IA) 3 80


T2aN0 (IB) 14 81
II 53 36.6 II 58 40 82
T1N1 (IIA) 12 T1aN1 (IIA) 3 83
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T2N1 (IIB) 38 T1bN1 (IIA) 9 84


T3N0 (IIB) 3 T2aN1 (IIA) 31 85

Best Evidence
T2bN0 (IIA) 3 86
Topic
T2bN1 (IIB) 6 87
T3N0 (IIB) 6 88
IIIA 35 24.1 IIIA 46 31.7 89
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T1N2 3 T1aN2 1 90
T2N2 24 T1bN2 2 91
Nomenclature

T3N1 4 T2aN2 18 92
T3N2 4 T2bN2 3 93
T3N1 5 94
T3N2 8 95
T4N0 2 96
T4N1 7 97
Historical

IIIB 22 15.2 IIIB 14 9.7 98


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T4N0 2 T4N2 10 99
T4N1 6 T4N3 4 100
T4N2 11 101
T4N3 3 102
IV 6 4.1 IV 4 2.7 103
Communication

T1N1 M1 1 T2aN2 M1b 2 104


Brief

T2N0 M1 1 T2bN0 M1b 1 105


58 Fig. 1. Comparison of distribution in stage subgroups in the TNM-6 and TNM- T2N2 M1 2 T4N3 M1b 1 106
108
59 7 staging systems. The number of patients in stage IIA increased from 12 T4N3 M1 2 107
109
60 (8.3%) in the previous system to 46 (31.7%) in the new system (q283.3%). Total 145 100% 145 100%
61 In addition, the number of patients in stage IIB decreased remarkably. 110
Case Report
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(Ps0.013), and survival rates of patients in stage IB were According to the TNM-7 guidelines, there was a significant
180 almost identical to those of patients having IIA disease. difference in survival between T1b and T2a (Ps0.032). 194
181 Survival differences between stages IIA and IIB did not The five-year survival rate in T3 patients tended to be 195
182 differ significantly when using the new TNM-7 system. superior to that in T4 patients, although it was statistically 196
183 In the TNM-6 system, the results for five-year survival by not significant (Ps0.489) (Fig. 3). 197
184 T classification were: T1, 75.1%; T2, 32.5%; T3, 18.2%; T4,
185 25.0%. Applying the TNM-7 system, five-year survival rates 4. Discussion 198
186 were: T1a, 88.9%; T1b, 64.3%; T2a, 30.3%; T2b, 30.8%; T3,
187 31.6%; T4, 29.2%. According to the TNM-6 system, there The TNM staging system is an excellent and well-accepted 199

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188 was a significant difference in survival between T1 and T2 method for the classification of malignant tumors into 200

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189 (P-0.0001). Patients classified as T2 tended to have a different stages, for estimating prognosis, planning treat- 201
190 better prognosis than patients with T3, but differences ment options, and exchanging information between sur- 202
191 were not significant (Ps0.088). Survival rates of patients geons, oncologists, and institutions w1x. In this study, we 203
192 with T4 were better than those of patients with T3 disease. evaluated the effects of reclassification according to the 204
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115 Fig. 2. Survival curves for the previous (a) and the new (b) classification based on pathological stage. With regard to the TNM-6 staging system, there were
116 significant differences between stages IA and IB (Ps0.023) and between stages IIA and IIB (Ps0.020). In the TNM-7 staging system, differences were significant
117 between stages IA and IB (Ps0.013) only. n, number of patients.
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State-of-the-art
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122 Fig. 3. Survival curves by T classifications for the past (a) and the new (b) staging system. There was a significant difference in survival between T1 and T2

Best Evidence
123
124 (P -0.0001) in the TNM-6 system and between the new (TNM-7) T1b and T2a (Ps0.032) classifications. n, number of patients.
Topic

205 222
new TNM-7 staging system in a well-defined subset of NSCLC (Ps0.023), and between stages IIA and IIB (Ps0.02).
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206 patients, i.e. 145 patients undergoing bronchoplastic resec- Survival for stage IIA was better than for IB. Furthermore, 223
Nomenclature

207 tion at our institution. five-year survival rates for stages IIB, IIIA, and IIIB were 224
208 The subclassification of T1 and T2 represents one of the 28.2%, 25.4%, and 27.3%, respectively. With regard to the 225
209 most important changes to the TNM-7 system, emphasizing new TNM-7 system, survival differed significantly between 226
210 the prognostic impact of exact tumor size. Some authors stages IA and IB (Ps0.013) only, and survival for stage IB 227
211 have previously shown that there are clear differences in was now similar to that for stage IIA. We think that the 228
survival according to exact tumor size w4, 9–11x. Due to small differences in survival between stages IB, IIA, and IIB
Historical

212 229
Pages

213 improvements in screening and multislice computed tomog- in the new system are caused by the small number of 230
214 raphy imaging, smaller tumors can be found earlier, and patients in these subcategories. Moreover, the new system 231
215 surgical treatment becomes more successful w12x. appears to be superior in separating stages IIB, IIIA, and 232
216 In our series, we found significant differences only IIIB in this cohort. 233
Communication

217 between T1b and T2a tumors (Ps0.032), which may be a Many authors report relatively small numbers of patients 234
Brief

218 result of the relatively small numbers of patients with T1a with stage IIA disease using the previous (sixth) edition of 235
219 (ns10), T1b (ns14), and T2b (ns13) lesions. the TNM staging system w2, 8, 11x. According to the changes 236
220 In the analysis of survival by stage, we found significant in the new (seventh) edition, this should be corrected by 237
221 differences between previous (TNM-6) stages IA and IB the reclassification of T2bN0 and T2aN1 tumors w3x. After 238
Case Report
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239 282
conducting a reclassification from the past to the new University of Vienna, Austria) for statistical data analyses
240 system, the number of patients with stage IIA disease and manuscript revision. 283
241 increased from 12 to 46 (by 283%) in this series.
242 Some of these changes to the descriptors and stage References 284

243 groupings may influence therapy strategies for some w1x Sobin L, Wittekind C. International Union Against Cancer (UICC): TMM 285
244 patients that are assigned to a lower or a higher stage due classification of malignant tumours. 6th edition. New York: John Wiley, 286
245 to a restaging according to the revised TNM classification. 2002. 287
w2x Mountain CF. Revisions in the International System for Staging Lung 288
246 However, the revision to the lung cancer staging system
Cancer. Chest 1997;111:1710–1717. 289
247 was not addressed to evaluate treatment w13x. Thus, pro-

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w3x Goldstraw P, Crowley J, Chansky K, Giroux DJ, Groome PA, Rami-Porta 290
248 spective trials are needed before the actual benefit of R, Postmus PE, Rusch V, Sobin L. The IASLC Lung Cancer Staging Project: 291

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249 adjuvant chemotherapy in very early stages (IA and IB) or proposals for the revision of the TNM stage groupings in the forthcoming 292
250 surgical intervention in advanced stages (IIB and IIIA) can (seventh) edition of the TNM classification of malignant tumours. J 293
Thorac Oncol 2007;2:706–714. 294
251 be assumed for patients being newly classified according w4x Rami-Porta R, Ball D, Crowley J, Giroux DJ, Jett J, Travis WD, Tsuboi 295
252 to the new TNM-7 system. M, Vallieres E, Goldstraw P. The IASLC Lung Cancer Staging Project: 296
253 As the new TNM classification is strictly based on statis- proposals for the revision of the T descriptors in the forthcoming 297
tical analyses of the largest database of lung cancer (seventh) edition of the TNM classification for lung cancer. J Thorac 298

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254
Oncol 2007;2:593–602. 299
255 patients worldwide, it has become more complex than w5x Rusch VW, Crowley J, Giroux DJ, Goldstraw P, Im JG, Tsuboi M, Tsuchiya 300
256 previous editions. Some authors have previously reported R, Vansteenkiste J. The IASLC Lung Cancer Staging Project: proposals 301
257 on their experience with the new staging system and for the revision of the N descriptors in the forthcoming seventh edition 302
258 reclassification of retrospective datasets. Fukui et al., for of the TNM classification for lung cancer. J Thorac Oncol 2007;2:603– 303
612. 304
259 instance, underline that the new system is superior in
w6x Groome PA, Bolejack V, Crowley JJ, Kennedy C, Krasnik M, Sobin LH, 305
260 separating stages IB and IIA and provides an even distribu-
261 tion among stage groups, although it is considered to be
ed Goldstraw P. The IASLC Lung Cancer Staging Project: validation of the
proposals for revision of the T, N, and M descriptors and consequent
306
307
262 slightly complicated w11x. In our experience, the new stag- stage groupings in the forthcoming (seventh) edition of the TNM 308
263 ing system appears to be more complex and even more classification of malignant tumours. J Thorac Oncol 2007;2:694–705. 309
w7x Postmus PE, Brambilla E, Chansky K, Crowley J, Goldstraw P, Patz EF 310
264 time-consuming than the previous version. However, a Jr, Yokomise H. The IASLC Lung Cancer Staging Project: proposals for 311
265 balance must be found between a system that is easily revision of the M descriptors in the forthcoming (seventh) edition of 312
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266 applied and one that provides detailed information on the TNM classification of lung cancer. J Thorac Oncol 2007;2:686–693. 313
267 distinguishing different prognostic groups. w8x End A, Hollaus P, Pentsch A, Brannath W, Janakiev D, Mueller MR, 314
Pridun N, Wolner E. Bronchoplastic procedures in malignant and non- 315
268 To sum up, the new TNM-7 classification for lung cancer
malignant disease: multivariable analysis of 144 cases. J Thorac Cardio- 316
269 will shift some patients (approximately 33% in this series)
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vasc Surg 2000;120:119–127. 317


270 to a higher or lower stage, which may lead to the consid- w9x Ye C, Masterman JR, Huberman MS, Gangadharan SP, McDonald DC, 318
271 eration of new stage-specific therapy options in some of Kent MS, DeCamp MM. Subdivision of the T1 size descriptor for stage I 319
272 these cases. non-small cell lung cancer has prognostic value: a single institution 320
experience. Chest 2009;136:710–715. 321
273 This is a selected population of patients undergoing bron- w10x Birim O, Kappetein AP, Takkenberg JJ, van Klaveren RJ, Bogers AJ. 322
274 choplastic procedures for NSCLC, which might not reflect Survival after pathological stage IA non-small cell lung cancer: tumor 323
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275 the majority of lung cancer patients. However, our findings size matters. Ann Thorac Surg 2005;79:1137–1141. 324
w11x Fukui T, Mori S, Hatooka S, Shinoda M, Mitsudomi T. Prognostic evalua- 325
276 support the changes in the new (seventh) edition of the
tion based on a new TNM staging system proposed by the International 326
277 TNM classification, emphasizing the more accurate distri- Association for the Study of Lung Cancer for resected non-small cell 327
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278 bution in different prognostic groups. lung cancers. J Thorac Cardiovasc Surg 2008;136:1343–1348. 328
w12x Henschke CI, Yankelevitz DF, Libby DM, Pasmantier MW, Smith JP, 329
Miettinen OS. Survival of patients with stage I lung cancer detected on 330
279 Acknowledgments CT screening. N Engl J Med 2006;355:1763–1771. 331
w13x Boffa DJ, Detterbeck FC, Smith EJ, Rami-Porta R, Crowley J, Zelterman 332
D, Tanoue L, Kim AW, Goldstraw P. Should the 7th edition of the lung 333
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280 We thank Werner Brannath (Core Unit for Medical Statis- cancer stage classification system change treatment algorithms in non- 334
281 tics and Informatics, Section of Medical Statistics, Medical small cell lung cancer? J Thorac Oncol 2010;5:1779–1783. 335
336