Predicting the Prognosis of Lung Cancer: The Evolution of Tumor, Node and Metastasis in the Molecular Age—Challenges and Opportunities

Ramón Rami-Porta; Hisao Asamura; Peter Goldstraw


Transl Lung Cancer Res. 2015;4(4):415-423. 

In This Article

Origin and Evolution of the TNM Classification for Lung Cancer

The TNM classification was developed by Pierre Denoit in a series of articles published from 1943 to 1952. It was soon adopted by the UICC that published brochures covering several anatomical sites, the lung being included in 1966. Two years later, the UICC published the first edition of the TNM Classification of Malignant Tumors and agreements were reached with the AJCC, created in 1959 as the American Joint Committee for Cancer Staging and End Results Reporting, to consult each other to avoid publication of differing classifications. Since then, the UICC and the AJCC have been responsible for updating and revising the TNM classifications of malignant tumors with the participation of national TNM committees of several countries and taking into account the published reports on the topic. The second to sixth editions of the UICC manual on the TNM Classification of Malignant Tumors and the first to sixth editions of the AJCC Staging Manual included classifications for lung cancer that had been informed by a progressively enlarging database initially collected by Mountain, Carr and Anderson, and subsequently managed by Mountain. Their database originally contained a little over 2,000 patients, but it had grown to more than 5,000 by the time the fifth edition of the TNM classification for lung cancer was published in 1997. The sixth edition was published in 2002 with no modifications.[9]

While the fifth edition of the classification was being printed, the International Workshop on Intrathoracic Staging took place in London, United Kingdom, in October 1996, sponsored by the International Association for the Study of Lung Cancer (IASLC).[10] At that meeting, in the presence of Dr. Mountain, the limitations of the database that had been used to revise the TNM classification for lung cancer were openly discussed. In essence, it was considered that, while the database consisted of a relatively large number of patients, all of them originated from the United States of America, and, therefore, the staging system could not really be called 'international', as it was called at that time; and, although all tumors had clinical and pathological classifications, the majority had been treated surgically. So, the database was thought not to be representative of the international community, as there were no patients from other countries; or of the current clinical practice, as there were no patients treated with other therapies. Therefore, an agreement was reached to issue a worldwide call to build a really international database of lung cancer patients treated by all therapeutic modalities. This required the constitution of an International Staging Committee that was approved and given a small amount of funding, to pump-prime, by the IASLC Board in 1998. Subsequently substantial financial support was secured by an unrestricted grant from Eli-Lilly. Cancer Research And Biostatistics (CRAB), a not-for-profit biosciences statistical center in Seattle, was appointed to collect, manage and analyze the new database. The proprietors and managers of known databases were subsequently summoned to attend a series of preparatory meetings to identify potential contributors to the IASLC international database for the purpose of revising the TNM classification of lung cancer.