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The Case of a Good Satellite: Outcomes of Resected Ipsilateral Same-Lobe Satellite Pulmonary Nodules FREE TO VIEW

Julian R. Molina, MD, PhD
Author and Funding Information

Correspondence to: Julian R. Molina, MD, PhD, Department of Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905; e-mail: molina.julian@mayo.edu

Dr. Molina is affiliated with Division of Medical Oncology, Mayo Clinic College of Medicine.


The author has reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;136(3):660-662. doi:10.1378/chest.09-0897
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In January 2009, the seventh edition of the TNM classification for lung cancer proposed by the International Association for the Study of Lung Cancer (IASLC), and undertaken by the American Joint Committee on Cancer Staging System and the International Union against Cancer went into effect (Table 1).15 This new staging system replaced the sixth edition of the TNM classification introduced in 2002, which was based on Dr. Clifton Mountain's limited database of 5,319 cases.5

Table Graphic Jump Location
Table 1 IASLC Staging Classification

The seventh edition of the TNM classification was the culmination of a major effort by the IASLC based on data submitted from multiple registries, clinical trial groups, cancer centers, and series from Europe, North America, Asia, and Australia that included patients with all stages and histologic types of lung cancer.15 The new TNM classification system proposed, among other changes, a redefinition of satellite nodules within the same lobe from T4 (in the sixth edition of the TNM classification) to T3 and for malignant pleural effusion from T4 to M1a (Table 2). In addition, ipsilateral nodules in different lobes were reclassified from M1 (in the sixth edition of the TNM classification) to T4, and contralateral nodules with no extrathoracic disease were classified as M1a (Table 2).15

Table Graphic Jump Location
Table 2 Staging Groups in the IASLC Staging Classification

The goal of any staging system is to group patients with homogeneous prognoses in cohorts.6 This not only facilitates treatment, as this can be determined by the appropriate stage, but also the development and interpretation of clinical trials. However, staging systems based only on prognosis tend to miss potentially good or bad outcomes determined by other factors such as genetic background, biology of the tumor, performance status, initial treatment modality, histology and even access to good medical care.6 Accurate staging is critical for the appropriate management of patients with non-small cell lung cancer. Downstaging leads to unnecessary surgeries, and upstaging has the potential of depriving patients of therapies that may favorably impact their outcomes.

In this issue of CHEST, William et al7 (see page 701) present an analysis of the Surveillance, Epidemiology, and End Results (or SEER) data for cases of stage IIIB and stage IV non-small cell lung cancer. The survival curves for patients with T4 satellite and M1 ipsilateral tumors indicated that in the presence of N0-1 disease, survival was comparable to that for stage IB/IIA (for T4 satellite N0), IIB (for T4 satellite N1), and IIB-IIA (for M1 ipsilateral N0-1) disease in the TNM sixth edition. The most important piece of information from the article by William et al7 is that T4 satellite tumors, especially those with no lymph node involvement (N0), behave similarly to T2b tumors and not to T3 tumors, as proposed under the new IASLC staging classification.

Should the seventh edition of the TNM classification for lung cancer be modified to downstage ipsilateral same-lobe pulmonary nodules? The answer is “no” at this time. Data from 100,869 patients submitted to the IASLC international database were the basis for the revision in the TNM sixth edition.1 However, only data from 18,198 patients fulfilled the criteria for T component analysis.1 Furthermore, the number of ipsilateral pulmonary nodules classified as T3 (n = 1,224) and T4 (n = 363) were low compared to the main totals.1 The task force involved in the revision of the T descriptors noticed that patients with T4 ipsilateral pulmonary nodules have survival times similar to those of patients with T3 nodules (p = 0.2838), and better survival times than those of patients with other T4 tumors, such as those that invade the mediastinum. The task force also noticed improved survival for patients with those tumors previously called M1 with ipsilateral separate-lobe pulmonary nodules. Survival times for these patients were similar to those with T4 tumors (p = 0.41).1

The diagnosis of ipsilateral pulmonary nodules, especially those located in the same lobe, is primarily made at the time of surgery. However, currently available imaging techniques such as high-resolution CT scans and PET/CT scans have the power to detect most cases of satellite pulmonary nodules before surgery. Patients with T4 satellite and M1 ipsilateral tumors should be presented to tumor boards to discuss a potential surgical treatment. There is a clear benefit for those with N0 disease and even some potential benefit for some T4 ipsilateral nodes with N1 disease.

References

Rami-Porta R, Ball D, Crowley J, et al. The IASLC lung cancer staging project: proposals for revision of the T descriptors in the forthcoming (seventh) edition of the TNM classification of lung cancer. J Thorac Oncol. 2007;2:593-602. [PubMed] [CrossRef]
 
Rusch VW, Crowley J, Giroux DJ, et al. The IASLC lung cancer staging project: proposals for the revision of the N descriptors in the forthcoming seventh edition of the TNM classification for lung cancer. J Thorac Oncol. 2007;2:603-612. [PubMed]
 
Postmus P, Brambilla E, Chansky K, et al. The IASLC lung cancer staging project: proposals for revision of the M descriptors in the forthcoming (seventh) edition of the TNM classification of lung cancer. J Thorac Oncol. 2007;2:686-693. [PubMed]
 
Groome PA, Bolejack V, Crowley J, et al. The IASLC lung cancer staging project: validation of the proposals for revision of the T, N, and M descriptors and consequent stage groupings in the forthcoming (seventh) edition of the TNM classification of malignant tumors. J Thorac Oncol. 2007;2:694-705. [PubMed]
 
Goldstraw P, Crowley J, Chansky K, et al. The IASLC lung cancer staging project: proposals for the revision of the TNM stage groupings in the forthcoming (seventh) edition of the TNM Classification of malignant tumors. J Thorac Oncol. 2007;2:706-714. [PubMed]
 
Detterbeck F, Tanoue L, Boffa DJ. Anatomy, biology and concepts, pertaining to lung cancer stage classification. J Thorac Oncol. 2009;4:437-443. [PubMed]
 
William WN Jr, Lin HY, Lee J, et al. Revisiting stage IIIB and IV non-small cell lung cancer: analysis of the Surveillance, Epidemiology and End Results Data. Chest. 2009;136:701-709. [PubMed]
 

Figures

Tables

Table Graphic Jump Location
Table 1 IASLC Staging Classification
Table Graphic Jump Location
Table 2 Staging Groups in the IASLC Staging Classification

References

Rami-Porta R, Ball D, Crowley J, et al. The IASLC lung cancer staging project: proposals for revision of the T descriptors in the forthcoming (seventh) edition of the TNM classification of lung cancer. J Thorac Oncol. 2007;2:593-602. [PubMed] [CrossRef]
 
Rusch VW, Crowley J, Giroux DJ, et al. The IASLC lung cancer staging project: proposals for the revision of the N descriptors in the forthcoming seventh edition of the TNM classification for lung cancer. J Thorac Oncol. 2007;2:603-612. [PubMed]
 
Postmus P, Brambilla E, Chansky K, et al. The IASLC lung cancer staging project: proposals for revision of the M descriptors in the forthcoming (seventh) edition of the TNM classification of lung cancer. J Thorac Oncol. 2007;2:686-693. [PubMed]
 
Groome PA, Bolejack V, Crowley J, et al. The IASLC lung cancer staging project: validation of the proposals for revision of the T, N, and M descriptors and consequent stage groupings in the forthcoming (seventh) edition of the TNM classification of malignant tumors. J Thorac Oncol. 2007;2:694-705. [PubMed]
 
Goldstraw P, Crowley J, Chansky K, et al. The IASLC lung cancer staging project: proposals for the revision of the TNM stage groupings in the forthcoming (seventh) edition of the TNM Classification of malignant tumors. J Thorac Oncol. 2007;2:706-714. [PubMed]
 
Detterbeck F, Tanoue L, Boffa DJ. Anatomy, biology and concepts, pertaining to lung cancer stage classification. J Thorac Oncol. 2009;4:437-443. [PubMed]
 
William WN Jr, Lin HY, Lee J, et al. Revisiting stage IIIB and IV non-small cell lung cancer: analysis of the Surveillance, Epidemiology and End Results Data. Chest. 2009;136:701-709. [PubMed]
 
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