Cancer esophageal mesothelioma staging

The Lung Cancer Study Group, just prior to its demise, initiated efforts to develop clinical trials comparing primary resection for esophageal cancer with multimodality therapy. In initiating these proposals, a new staging system and map were developed that conformed to the staging system available for pulmonary malignancies. This staging system and map are currently being used by the ongoing intergroup trial in North America (INT-113).

The Lung Cancer Study Group (LCSG) was initially charged with the task of assessing the value of adjuvant therapy following surgical resection in the management of early-stage, surgically treatable lung cancer. Following successful completion of five phase 3 randomized trials of adjuvant therapy for resected lung cancer, the group embarked on phase 2 trials of neoadjuvant treatment. As well, we decided to investigate surgical treatment of other forms of thoracic malignancy, initially addressing questions concerning the management of malignant pleural effusions and malignant mesothelioma. Prior to its disbandment in 1989, a small working cadre of LCSG surgeons (R.J. Finaly, V. Rusch, R.I. Inculet, and R.J. Ginsberg) initiated discussions relative to the surgical treatment of esophageal cancer.

Initially, because of our imperative to perform accurate preoperative and intraoperative staging as reflected in all previous LCSG trials, we attempted to standardize surgical staging of esophageal cancer. By this time, the new TNM staging for this disease had been introduced and therefore a staging map, consistent with the LCSG lung map already used for staging lung cancer,(1) was developed. This allowed LCSG and other thoracic surgeons, already conversant with this lung map, to identify more accurately the various lymph node sites involved in esophageal cancer both preoperatively by CT correlation and intraoperatively and eliminated the potential confusion resulting from a myriad of proposed esophageal staging maps, all with their own numbering system.(2)(3)(4) This LCSG esophageal map, consistent with the numbering of the lung cancer staging map, extended the numbering below the diaphragm to include the gastric and duodenal lymphatic drainage regions (Fig 1). Both LCSG maps and instructional handbooks have been made available to interested parties, including surgeons, other oncologists, radiologists, pathologists, and data managers.(5)

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Following this initial step, a proposal was made to investigate the use of induction chemotherapy followed by surgery vs surgery alone for resectable esophageal cancer. Despite the demise of the LCSG, this proposal continued to be developed within the cooperative group system, ultimately leading to the first nationwide phase 3 trial of induction therapy and surgery for carcinoma of the esophagus. This intergroup trial (INT 113) has now been actively accruing patients from all national cooperative groups for 3 1/2 years. As of May 1994, over 300 patients have been entered and randomized, with an accrual rate of more than 10 patients per month. This trial compares surgical resection alone with perioperative (induction and postoperative) chemotherapy with cisplatin and fluorouracil combined with surgical resection. It is anticipated that the trial will complete accrual by mid-1995. Ultimately, the best arm of this trial will be compared with the best arm of a currently active nonsurgical trial in assessing the optimum management of early-stage esophageal carcinoma.

Despite the demise of the LCSG, its initial efforts in standardizing the preoperative and surgical staging of esophageal carcinoma have now been translated into a very successful phase 3 randomized trial assessing the efficacy of perioperative chemotherapy in the management of surgically resected esophageal carcinoma.

REFERENCES

(1)Hermanek P, Sobin LH, eds. TNM classification of malignant tumors. 4th ed. Berlin: Springer-VErlag, UICC International Union Against Cancer: TNH classification of malignant tumours. Berlin: Springer-Verlag, 1987; 1-12, 40-2

(2)Beahrs OH, Myers MH, eds. Manual for staging of cancer. 2nd ed. Philadelphia: JP Lippincott, 1983; 61-6

(3)Japanese Society of Esophageal Diseases. Guidelines for the clinical and pathologic studies on carcinoma of the esophagus: I. Clinical classification; II. Pathologic classification. Jpn J Surg 1976; 6:69-89

(4)Japanese Committee for Registration of Esophageal Carcinoma. A proposal for a new TNM classification of esophageal carcinoma. Jpn J Clin Oncol 1985; 14:625-36

(5)Casson AJ, Inclulet R, Zankowicz N, et al. Lymph node mapping for resectable lung esophageal cancer--a guide for thoracic surgeons. Princeton, NJ: Bristol-Myers Squibb, 1993