Bronchology – A Well Branched Tree
Authors: Mihai Olteanu, Costin Teodor, Bogdan Oprea, Raluca Marinas, Mimi Floarea, Emilia Crisan, Tudorel Ciure
Journal: Endoscopy (2013)

Management of stage IIIA disease is more controversial, but many centers treat it with radiation and chemotherapy, with surgery performed under investigational protocols.Direct mediastinal invasion (T4) or metastasis to contralateral mediastinal nodes (N3) is classified as stage IIIB disease.The 5-year survival rate in this case is at best 5%, and patients are generally offered treatment with chemoradiotherapy without surgery.The previous tumor, node, and metastasis (TNM) classification, the sixth edition of the TNM Classification of Malignant Tumors, was published in 2002.The last revision of the staging system for lung cancer has been presented by Dr. Clifton Mountain in 1997 [2], after his proposal had been adopted in 1973 by the AJCC in the same year and by the UICC in 1974, and this revision remained unaltered on the 2002 manual [3].The 1973 original system was based on a database of 2,155 patients from the MD Anderson Cancer Center in Houston, TX.Subsequent revisions of the TNM staging system continued to be based on this database, which grew to include 5,319 cases at the time the lung cancer staging system was revised in 1997 and it was also validated by Dr. Naruke from Japan in 2001.Mountain's revision was based on a relatively small population of patients who underwent surgical treatment in a single geographic area, and no validation was presented to justify the individual descriptors [4].In order to overcome the limitations of the sixth TNM classification, the International Association for the Study of Lung Cancer (IASLC) launched the Lung Cancer Staging Project in 1996, and in 1998 created an International Staging Committee (ISC) of multidisciplinary members to conduct revisions [5].Changes to the sixth edition were proposed by the IASLC based on an international collection and review of 100,869 patients from 46 sources of 20 countries.Data were drawn from lung cancer cases treated by all modalities between 1990 and 2000.After exclusion of ineligible cases, 81,015 patients (67,725 NSCLC and 13,290 SCLC) remained for investigation [6].Proposals for revision were submitted to the AJCC and UICC for consideration in the new edition of the staging manual, the 7th, and both accepted the recommendations.In the last months of 2009, the Seventh Edition of the TNM Classification of Malignant Tumors was published, with a new lung cancer staging system.The new edition took effect on January 1, 2010 [7].The changes recommended by the IASLC for the 7th edition of TNM classification for lung cancer were based on differences in survival [8], and the results of the data analysis were internally and externally validated [9].These changes include new T and M definitions and consequent new stage groupings, a new lymph node map, a novel definition on pleural invasion, as well as recommendations to apply the TNM system to broncho-pulmonary carcinoid tumors and SCLC.The success story of EBUS-TBNA starts in 2003 with a publication in Thorax by Mark Krasnik and Peter Vilmann from Gentofte University Hospital, Denmark [10].This article gave the first description of the principle of EBUS-TBNA.In the same journal, in 2006, the same group, together with a group from the Thoraxklinik in Heidelberg and Harvad Medical School's Beth Israel Deaconess MC, published their study on 502 patients that showed that EBUS-TBNA resulted in 93% diagnostic yield, a sensitivity of 94%, specificity of 100% and accuracy 94%, with PPV at 100% and NPV at 11% [11].In 2006, an international EBUS-TBNA focus group was formed by Felix J.F. Herth (Copenhagen), Kazuhiro Yasufu-