How to judge whether IASLC lung cancer surgery is completely removed?

Postoperative lung friend exchange group (click)

Lung cancer is the leading cause of cancer-related mortality worldwid.

IASCL Definition

In 2005, the International Association for the Study of Lung Cancer (IASLC Staging Committee) proposed "complete resection (complete rep)", "incomplete resection (incomplete rep)", "indeterminate resection" based on previous definitions and understanding.

1) Complete resection (R0 no residual tumor)

①Negative margins, including bronchi, arteries, veins, peribronchial tissues, and tissues near the tumor;

② Systematic or lobar-specific lymph node dissection is performed, and the lymph nodes should include at least 6 groups, including intrapulmonary (lobar, interlobar or segmental) and/or hilar group 3 [N1], and mediastinal group 3 (N2, must include area 7) ;

③ There was no extranodal invasion in the separately resected mediastinal lymph nodes or the marginal lymph nodes of the resected lobe.

④ The highest lymph node resected was negative under microscop.

2) Incomplete resection (R1 microscopic residual tumor, R2 macroscopic residual tumor)

①Residual tumor at the resection margin;

②Extranodal invasion of the removed mediastinal lymph nodes or the marginal lymph nodes of the resected lung lobe.

③ Lymph node positive but unresectable (R2);

④ Pleural effusion or pericardial effusion positive for cancer cell.

3) Uncertain excision (R(un))

The margins are negative under microscope, but one of the following conditions occurs:

① Lymph node dissection does not meet the above requirements (see complete resection);

② The highest mediastinal lymph node removed was positive;

③ The bronchial incision margin is carcinoma in situ;

④ Pleural lavage cytology positive (R1 cy+.

Prognostic validation of IASCL definitions

In 2017, Gagliasso et a.

In 2020, a study by Osarogiagbon et a.

In 2020, a study published in JTO by Edwards et a.

pN0 group

pN positive group

Due to the unique prognosis of uncertain resection, a new R descriptive category was added to the seventh edition of the TNM classification: R0 (uncertain) indicates no evidence of residual disease, but nodal assessment is below the minimum recommended value [must achieve systematic Lymph node dissection or lobe-specific lymph node dissection (N1≥3 group + N2≥3 group)] or resection of the highest mediastinal lymph node was positiv.

Prospects for R classification modification [5]

Tumor spread through air space (STAS): When sublobar resection (rather than lobectomy) is performed, spread of cells beyond the tumor margin through air space (STAS) is associated with a significantly increased rate of recurrence relate.

Peripheral blood CTC or ctDNA/RNA: There are identifiable circulating tumor cells and tumor cell products in the blood, such as DNA and RN.

Another important issue for future clarification is the margins of sublobar resectio.

references

[1]Rami-Porta R, Wittekind C, Goldstraw P, et a.

[2] Gagliasso M, Migliaretti G, Ardissone .

[3] Osarogiagbon RU, Faris NR, Stevens W, et a.
Beyond Margin Status: Population-Based Validation of the Proposed International Association for the Study of Lung Cancer Residual Tumor Classification Recategorizatio.
J Thorac Onco.
2020 Mar;15(3) :371-38 doi: 11016/.
jth.
201100 

[4] Edwards JG, Chansky K, Van Schil P, et a.
The IASLC Lung Cancer Staging Project: Analysis of Rep Margin Status and Proposals for Residual Tumor Descriptors for Non-Small Cell Lung Cance.
J Thorac Onco.
2020 Mar;15 (3): 344-35 doi: 11016/.
jth.
201101 

[5] Rami-Porta R, Wittekind C, Goldstraw .
Complete Rep in Lung Cancer Surgery: From Definition to Validation and Beyon.
J Thorac Onco.
2020 Dec;15(12):1815-181 doi: 11016/.
jth.
202000 

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