Naming and Staging Lung Cancers

JNCI: Journal of the National Cancer Institute, Mar 2016

Delude, Cathryn

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Naming and Staging Lung Cancers

JNCI J Natl Cancer Inst ( news Naming and Staging Lung Cancers By Cathryn Delude - In any clinical trial or study of cancer, edition, with its eighth TNM edition2 pathology classification from relying on researchers must compare how tumors slated for publication in 2017. grow and respond to therapy, which requires everyone calling the same thing by the same name. That truism applies to both the pathological subtype of the tumor, small-cell or non–small-cell lung cancer, for example, and the clinical stage, from early to metastatic disease. Both the pathologic classification and clinical staging influence treatment decisions, albeit in different ways. Pathologic classification tells what subtype the cancer is, which often indicates which therapy is most appropriate. Staging tells where the cancer is in the body and whether it has spread beyond the pri mary tumor to lymph nodes or metastases, which helps determine whether to treat a patient with local therapy (surgery and/or radiation), systemic therapy, or both. The fast pace of clinical research “If different clinicians classify the same cancer subtype differently, or two different subtypes as the same type, then any data about how these tumors behave or respond to therapies will not be reliable.” Progress in Pathological Classification Frank Detterbeck, M.D. in lung cancer has complicated both “WHO took the lead many decades ago in efforts, particularly for the most comclassifying lung cancer pathologies,” said Illei said. “A promising area that is not mon category, non–small-cell carcinoPeter Illei, M.D., a lung cancer patholo addressed is immunotherapy because mas. For this large, heterogeneous group gist at the Johns Hopkins Kimmel Cancer the data are still coming in.” of adenocarcinomas, identifying genetic Center in Baltimore. It published the first One major change is the reclassificaabnormalities in specific subtypes has issue pathologic classification in 1967, tion of tumors previously classified as led to targeted therapies that improved with updates every decade or so. The large-cell carcinoma, “a term that was survival of patients with even advanced previous 2004 edition began including historically a wastebasket for poorly difdisease. some genetic and immunohistochemferentiated tumors,” Travis said. With the The two most widely used systems are istry findings, but the next decade of availability of easily applied antibodies the World Health Organization’s (WHO) research revealed many more clinically for immunohistochemical markers of pathologic classification of lung tumors significant molecular distinctions among adenocarcinomas (such as TTF-1) and and the International Association for the lung cancer subtypes. In 2011, IASLC, the squamous cell carcinomas (such as p40 Study of Lung Cancer’s (IASLC) tumor– premier organization for treating and or P63), most of these tumors now have node–metastasis (TNM) staging system. diagnosing lung cancer, and other collabmore definitive designations, so cliniThose systems are trying to keep abreast orators revised the system for pathologic cians have a better idea how to treat the of recent research findings. In September classification of lung adenocarcinomas patient. 2015, WHO published its first update1 after reviewing evidence-based medi Another change addresses the issue since 2004, and IASLC announced reccine and genetic studies. “That 2011 revi that most lung cancer patients are elderly ommendations for revisions to its 2011 sion fundamentally changed the role of and first present with advanced disease histology to also analyzing molecular biology and immunohistochemistry,” said William Travis, MD, a pathologist at the Memorial Sloan–Kettering Cancer Center in New York and editor of the 1999, 2004, and 2015 editions of the WHO classification. The 2015 WHO classification now includes more genetic testing for driver mutations, such as EGFR ALK, that and are targeted by U.S. Food and Drug Administration– approved therapies. “WHO also did a good job by including additional genetic targets that have targeted therapy in clinical trials,” 1 of 8 that cannot be surgically removed. Those said Patrick Forde, M.D., an oncologist at Detterbeck said. “If different clinicians cancers are diagnosed in small biopsies Johns Hopkins Kimmel Cancer Center. classify the same cancer subtype differ or cytology specimens that may not rep“Some have a very small primary tumor ently, or two different subtypes as the resent the entire tumor. In recognition of but lots of nodes; others have larger pri same type, then any data about how this problem, the classification includes mary tumors but no nodes. Some have these tumors behave or respond to ther a separate terminology for these small better prognosis than others.” apies will not be reliable.” tissue samples and offers guidelines Recent TNM revisions reflect attempts A similar issue affects whether for using special stains and for triagto better group sta (...truncated)


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Delude, Cathryn. Naming and Staging Lung Cancers, JNCI: Journal of the National Cancer Institute, 2016, Volume 108, Issue 3, DOI: 10.1093/jnci/djw052