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J Thorac Oncol. 2016 May;11(5):639-650. doi: 10.1016/j.jtho.2016.01.024. Epub 2016 Mar 3.

The IASLC Lung Cancer Staging Project: Summary of Proposals for Revisions of the Classification of Lung Cancers with Multiple Pulmonary Sites of Involvement in the Forthcoming Eighth Edition of the TNM Classification.

Collaborators (158)

Goldstraw P, Rami-Porta R, Asamura H, Ball D, Beer DG, Beyruti R, Bolejack V, Chansky K, Crowley J, Detterbeck F, Erich Eberhardt WE, Edwards J, Galateau-Sallé F, Giroux D, Gleeson F, Groome P, Huang J, Kennedy C, Kim J, Kim YT, Kingsbury L, Kondo H, Krasnik M, Kubota K, Lerut A, Lyons G, Marino M, Marom EM, van Meerbeeck J, Mitchell A, Nakano T, Nicholson AG, Nowak A, Peake M, Rice T, Rosenzweig K, Ruffini E, Rusch V, Saijo N, Van Schil P, Sculier JP, Shemanski L, Stratton K, Suzuki K, Tachimori Y, Thomas CF Jr, Travis W, Tsao MS, Turrisi A, Vansteenkiste J, Watanabe H, Wu YL, Baas P, Erasmus J, Hasegawa S, Inai K, Kernstine K, Kindler H, Krug L, Nackaerts K, Pass H, Rice D, Falkson C, Filosso PL, Giaccone G, Kondo K, Lucchi M, Okumura M, Blackstone E, Erasmus J, Flieder D, Godoy M, Goo JM, Goodman LR, Jett J, de Leyn P, Marchevsky A, MacMahon H, Naidich D, Okada M, Perlman M, Powell C, van Schil P, Tsao MS, Warth A, Cavaco FA, Barrera EA, Arca JA, Lamelas IP, Obrer AA, Jorge RG, Ball D, Bascom GK, Blanco Orozco AI, González Castro MA, Blum MG, Chimondeguy D, Cvijanovic V, Defranchi S, de Olaiz Navarro B, Escobar Campuzano I, Macía Vidueira I, Fernández Araujo E, Andreo García F, Fong KM, Francisco Corral G, Cerezo González S, Freixinet Gilart J, García Arangüena L, García Barajas S, Girard P, Goksel T, González Budiño MT, González Casaurrán G, Gullón Blanco JA, Hernández J, Hernández Rodríguez H, Herrero Collantes J, Iglesias Heras M, Izquierdo Elena JM, Jakobsen E, Kostas S, León Atance P, Núñez Ares A, Liao M, Losanovscky M, Lyons G, Magaroles R, De Esteban Júlvez L, Mariñán Gorospe M, McCaughan B, Kennedy C, Melchor Íñiguez R, Miravet Sorribes L, Naranjo Gozalo S, Álvarez de Arriba C, Núñez Delgado M, Padilla Alarcón J, Peñalver Cuesta JC, Park JS, Pass H, Pavón Fernández MJ, Rosenberg M, Ruffini E, Rusch V, Sánchez de Cos Escuín J, Saura Vinuesa A, Serra Mitjans M, Strand TE, Subotic D, Swisher S, Terra R, Thomas C, Tournoy K, Van Schil P, Velasquez M, Wu YL, Yokoi K.

Author information

Department of Surgery, Yale University, New Haven, Connecticut. Electronic address:
Department of Histopathology, Royal Brompton and Harefield National Health Service Foundation Trust and Imperial College, London, United Kingdom.
Department of Pathology, University of Colorado, Denver, Colorado.
Department of Diagnostic Imaging, Tel-Aviv University, Ramat Gan, Israel.
Department of Pathology, Sloan-Kettering Cancer Center, New York, New York.
Respiratory Medicine Service, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France.
Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan.
Cancer Research And Biostatistics, Seattle, Washington.
Department of Thoracic Surgery, New York University, New York, New York.
Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio.
Department of Internal Medicine, Yale University, New Haven, Connecticut.
Thoracic Surgery Service, Sloan-Kettering Cancer Center, New York, New York.
Division of Thoracic Surgery, Keio University, School of Medicine, Tokyo, Japan.
Thoracic Surgery Service, Hospital Universitari Mutua Terrassa; Centros de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES) Lung Cancer Group, Terrassa, Barcelona, Spain.



Patients with lung cancer who harbor multiple pulmonary sites of disease have been challenging to classify; a subcommittee of the International Association for the Study of Lung Cancer Staging and Prognostic Factors Committee was charged with developing proposals for the eighth edition of the tumor, node, and metastasis (TNM) classification to address this issue.


A systematic literature review and analysis of the International Association for the Study of Lung Cancer database was performed to develop proposals for revision in an iterative process involving multispecialty international input and review.


Details of the evidence base are summarized in other articles. Four patterns of disease are recognized; the clinical presentation, pathologic correlates, and biologic behavior of these suggest specific applications of the TNM classification rules. First, it is proposed that second primary lung cancers be designated with a T, N, and M category for each tumor. Second, tumors with a separate tumor nodule of the same histologic type (either suspected or proved) should be classified according to the location of the separate nodule relative to the index tumor-T3 for a same-lobe, T4 for a same-side (different lobe), and M1a for an other-side location-with a single N and M category. Third, multiple tumors with prominent ground glass (imaging) or lepidic (histologic) features should be designated by the T category of the highest T lesion, the number or m in parentheses (#/m) to indicate the multiplicity, and a collective N and M category for all. Finally, it is proposed that diffuse pneumonic-type lung cancers be designated by size (or T3) if in one lobe, T4 if involving multiple same-side lobes, and M1a if involving both lungs with a single N and M category for all areas of involvement.


We propose to tailor TNM classification of multiple pulmonary sites of lung cancer to reflect the unique aspects of four different patterns of presentation. We hope that this will lead to more consistent classification and clarity in communication and facilitate further research in the nature and optimal treatment of these entities.


Lung cancer; Lung cancer staging; Multiple tumors; Non–small cell lung cancer; TNM classification

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