ChestHealth

In July 2009 a new lung cancer staging system was revealed: The 7^th edition of the Tumor/LymphNode/Metastasis (TNM) classification. The 7^th edition TNM classification is a result of the International Staging Committee (ISC) created by the International Association for the Study of Lung Cancer (IASLC), resulting in the IASLC Lung Cancer Retrospective Staging Project.¹

            The ISC compiled clinical data on over 100,000 patients diagnosed with NSCLC and SCLC between 1990 and 2000, making the patient population examined 20 times the size of the 1997 analysis.  All components of the staging system were considered for upgrading, with the majority of changes occurring in the T and M components.¹

            The 6^th staging edition divided tumors into two size groups: T1 < 3cm in diameter, and T2 ≥ 3cm in diameter.  However, most thoracic surgeons and medical oncologists can anecdotally attest that the biologic behavior of node negative tumors that are 6-7cm, behave differently then 3cm node negative tumors, despite both being in the same broad T2 grouping.  The ISC confirmed this assumption.  Results suggested that new size groupings should be created of 2, 3, 5 and 7cm.  5 year survival rates for the pathologic groupings with negative nodes and no metastasis were 77% for T1 ≤ 2cm, 71% for T1 > 2cm and ≤ 3cm, 58% for T2 > 3cm and ≤ 5cm, 49% > 5cm and ≤ 7cm and 35% for T2 > 7cm.  Subsequently, the ISC recommended subclassifying T1 into T1a (≤ 2cm) and T1b (>2cm and ≤3cm) and subclassifying T2 into T2a (> 3cm but ≤ 5cm or tumor with any other T2 descriptors, but ≤ 5cm) and T2b (> 5cm but ≤ 7cm), and reclassify T2 tumors > 7cm to T3.²

                        No formal changes were recommended for nodal staging.  Malignant pleural effusion was reclassified to M1a.  The ISC found that extrathoracic metastasis had poorer prognosis than intrathoracic metastasis.  M1 was therefore sub-classified to M1a for additional tumors in the contralateral lung, malignant pleural and pericardial effusions, and nodular pleural dissemination, and M1b for extrathoracic metastasis.^3,4

            The new stage groupings are as follows:  T2b tumors ((> 5cm but ≤ 7cm) that are N0M0 are upstaged from IB to IIA; T2a tumors (≤ 5cm) that are N1M0 are down staged from IIB to IIA, and T4 tumors that are N0/1 are down staged to IIIA.  Restaging the patient population in the study based on the proposed 7^th TNM edition, found a pathologic 5 year survival rate 73% for IA, 58% for IB, 46% for IIA, 36% for IIB, 24% for IIIA, 9% for IIIB and 13% for IV.⁵

            The 7^th edition TNM staging system for NSCLC is an exciting accomplishment, and will help the clinician to better understand the outcomes of lung cancer and offers an exciting advance to our specialty. 

1. Rami-Porta R, Crowley JJ, Goldstraw P.  The revised TNM staging system for lung cancer.  Ann Thorac Cardiovasc Surg. 2009 Feb;15(1):4-9.

2. Rami-Porta R, Ball D, Crowley J, et al.  The IASLC Lung Cancer Staging Project: proposals for the revision of the T descriptors in the forthcoming (seventh) edition of the TNM classification for lung cancer. J Thorac Oncol. 2007 Jul;2(7):593-602.

3. 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 Jul;2(7):603-12.

3. Postmus PE, 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 Aug;2(8):686-93.

4.  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 tumours.  J Thorac Oncol. 2007 Aug;2(8):706-14. Erratum in: J Thorac Oncol. 2007 Oct;2(10):985.

5. Rusch VW, Asamura H, Watanabe H, et al.  The IASLC lung cancer staging project: a proposal for a new international lymph node map in the forthcoming seventh edition of the TNM classification for lung cancer.  J Thorac Oncol. 2009 May;4(5):568-77.

The UC Davis Lung Cancer Chat Room is an interactive meeting of learning and support for patients, families, friends and caregivers affected by lung cancer.

This support group is proudly sponsored by the UC Davis Comprehensive Cancer Center.

The UC Davis Lung Cancer Chat Room provides a time for education, sharing and an opportunity to connect face-to-face with people who can relate the realities of lung cancer. Special guest speakers are invited to give presentations on topics of interest to patients. Educational and support materials are provided.

3rd Thursday of each month
10:30am-12:00pm
UC Davis Comprehensive Cancer Center
4501 X St. Sacramento, CA
Room #1103

For more information about this group, please contact Jena Cooreman, LCSW at 916-734-5198

2013 Calendar of Group Speakers
DateSpeaker/Topic

February 21st

David Copenhaver, MD, MPH
Director of Cancer Pain, Division of Pain Medicine
Pain Management

March 21st

David Tom Cooke, MD, FCCP, FACS
Section Head of General Thoracic Surgery
Lung Cancer Surgery: When is it Necessary?

April 18th

Kathleen Newman, RD, CSO
Senior Clinical Dietician
Nutrition and Cancer Treatment

May 16th

Elizabeth A. David, MD
Minimally Invasive Lung Cancer Surgery: What Are We Doing Now, What’s on the Horizon?

June 20th

Valerie Kuderer, RN
Thoracic Surgery Nurse Coordinator
Recovery After Lung Cancer Surgery

July 18th

Karen Kelly, MD
Associate Director of Clinical Research
We Might Have a Clinical Trial for That

August 15th

Megan Daly, MD
Advances in Radiation Oncology

September 19th

Marlene von Friederichs-Fitzwater, PhD, MPH
WeCARE! Cancer Peer Navigation Program

October 17th

TBD

November 14th

Tina Li, MD
Personalizing Lung Cancer Therapy: How Tumor Molecular Testing Can Help Your Cancer Care

Gastroesophageal reflux disease (GERD) or acid reflux from the stomach into the esophagus is a known risk factor for Barrett’s metaplasia and subsequently an esophageal cancer known as adenocarcinoma. According to the National Cancer Institute (Cancer.gov) in 2012 there were 17,460 new cases of esophageal cancer in the United States and 15,070 deaths from the disease. Surgery, with or without chemotherapy and radiation may be curative for esophageal cancer, especially for those patients with early stage disease.

Unlike breast and colorectal cancer, screening criteria for esophageal cancer is debatable. Many primary care providers don’t know 1) who is at risk for esophageal cancer, and 2) who needs to be screened.

The ACP helps clarify some of these questions with their Best Practice Advice for screening upper endoscopy criteria for those patients with GERD.

The key points from their guidelines are as follows:

• Everyone with Barrett’s metaplasia should be in an endoscopic surveillance program at least every three years, if there is dysplasia, then surveillance should be more frequent
• Everyone should get a screening endoscopy if they have heartburn [GERD] + additional symptoms (including dysphagia, anemia, vomiting, etc…)
• Everyone should get screening endoscopy if they have GERD symptoms that do not respond to 4-8 weeks of proton-pump inhibitor therapy
• Men over 50 with chronic GERD and additional risk factors (including elevated body mass index, smoking, etc…) should get screening endoscopy

From our perspective, although being male is an independent risk factor for adenocarcinoma of the esophagus (male to female ratio of incidence is 3:1), we would still recommend counseling a woman on screening endoscopy if she fit the above demographics.

For more information on the ACP Best Practice Advice see the below URL:

http://annals.org/article.aspx?articleid=1467417

“What is Thoracic Surgery?” is a good question. Often times the term Thoracic Surgery is used interchangeably with Cardiothoracic Surgery, Adult Cardiac Surgery, Cardiovascular Surgery, Congenital Cardiothoracic Surgery, and General Thoracic Surgery. But for the layperson, Thoracic Surgery should be synonymous with General Thoracic Surgery.

A General Thoracic Surgeon takes care of patients with surgical diseases of the chest, generally excluding the heart and great vessels. About 80% of Thoracic Surgery involves surgery for some sort of cancer. This includes such tumors as lung cancer (which kills more people in the United States than colon, prostate and breast cancer combined), esophageal cancer, tumors of the chest wall (rib cage, sternum, etc…) and tumors of the mediastinum, or the space around the heart.

But a lot of Thoracic Surgery involves curing or helping people with disease processes that are not cancer related. This includes such procedures like thymectomy for Myasthenia Gravis, sympathectomy for hyperhidrosis or “sweaty palms”, first rib resection for thoracic outlet syndrome, myotomy for Achalasia, esophagectomy and reconstruction for end stage benign esophageal disease, plication of the diaphragm for diaphragm paralysis, resection of esophageal diverticulum, removal of cysts of the chest, lung transplantation, and providing tissue or biopsies of the lung and chest tissue to diagnose problems such as interstitial lung disease.

Much of Thoracic Surgery is now done minimally invasively by using small incisions, a thin camera and high definition monitors.  This is called Video-Assisted Thorascopic Surgery or (VATS).

A Thoracic Surgeon should always be either already board certified or in the process of being board certified by the American Board of Thoracic Surgery (ABTS). In addition to ABTS certification, many thoracic surgeons are also board certified by the American Board of Surgery (ABS). There is data that demonstrates that patients who have complex thoracic surgical disease, such as lung and esophageal cancer, have better outcomes when operated on by Thoracic Surgeons as opposed to non-Thoracic Surgeons (Birkmeyer JD et al., NEJM, 2003; Schipper PH et al., Ann Thorac Surg 2009). Also, research shows that patients may not do well after esophagectomy (removal of the esophagus) because of failure of their hospital to “rescue” them from complications (Ghaferi AA et al., Ann Surg, 2009). This fact underscores the importance that some operations should be performed by Thoracic Surgeons at high volume academic medical centers.

So what is Thoracic Surgery? Now you know!

Welcome to UCD ChestHealth, the official blog of UC Davis Thoracic Surgery.  This exciting new outlet, the first of its kind for a UC Davis Health System clinical service, will allow patients, physicians, students, residents, allied health professionals and anyone else who is interested or curious to learn about what we do and the important and not so publicized disease processes that affect thousands of individuals each day such as Lung Cancer, Esophageal Cancer, Emphysema/COPD and Hyperhidrosis.

Most of all, this blog will help answer that age old question “What is Thoracic Surgery?”  My mother asks me that question all of the time!  So feel free to comment, enjoy, and please suggest content.  You can contact or follow us on twitter: @UCD_ChestHealth or email us thoracic.surgery@ucdmc.ucdavis.edu.