Lung cancer staging

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Kim-Son H. Nguyen, M.D., M.P.A., Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA, Cafer Zorkun, M.D., Ph.D. [2]; Rim Halaby, M.D. [3]; Assistant Editor(s)-In-Chief: Michael Maddaleni, B.S.

Overview

Lung cancer staging is an assessment of the degree of spread of the cancer from its original source. It is an important factor affecting the prognosis and potential treatment of lung cancer. Non-small cell lung carcinoma is staged from IA ("one A", best prognosis) to IV ("four", worst prognosis). Small cell lung carcinoma is classified as limited stage and extensive stage.

TNM Classification of Lung Cancer

T: Primary Tumor

T	Description
TX	Primary tumor cannot be assessed. OR Tumor is demonstrated by the presence of malignant cells in bronchial washings or sputum, but is not visualized by imaging or bronchoscopy.
T0	There is no evidence of primary tumor.
Tis	Carcinoma in situ
T1	The tumor has the following characteristics: The greatest dimension is <3 cm AND The tumor is surrounded by lung or visceral pleura AND The tumor does not extend to the main bronchus as demonstrated by the absence of bronchoscopic evidence of invasion more proximal than the lobar bronchus.
T2	The tumor has the following characteristics: The greatest dimension is >3cm OR The tumor involves the main bronchus, 2 cm or more distal to the carina. OR The tumor invades the visceral pleura. OR There is evidence of atelectasis or obstructive pneumonitis that extends to the hilar region without the involvement of the entire lung.
T3	The tumor is of any size AND it directly invades any of the following: chest wall (including superior sulcus tumors), diaphragm, mediastinal pleura, parietal pericardium. OR The tumor is localized in the main bronchus at a distance less than 2 cm distal to the carina but without the involvement of the carina. OR There is evidence of associated atelectasis or obstructive pneumonitis of the entire lung.
T4	The tumor is of any size that invades any of the following: mediastinum, heart, great vessels, trachea, esophagus, vertebral body, carina OR There is/are separate tumor nodule(s) in the same lobe. OR The tumor is associated with malignant pleural effusion.

N:Regional Lymph Nodes

T	Description
NX	the regional lymph nodes cannot be assessed.
N0	There is no evidence of regional lymph node metastasis.
N1	There is metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodes, including involvement by direct extension.
N2	There is metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s).
N3	There is metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph node(s).

M: Distant Metastasis

T	Description
MX	Distant metastasis cannot be assessed.
M0	There is no evidence of distant metastasis.
M1	There is evidence of distant metastasis which includes the presence of separate tumor nodule(s) in a different lobe (ipsilateral or contralateral).

Classification of Lung Cancer by Staging

Stage	T	N	M
Occult carcinoma	TX	N0	M0
Stage 0	Tis	N0	M0
Stage IA	T1	N0	M0
Stage IB	T2	N0	M0
Stage IIA	T1	N1	M0
Stage IIB	T2	N1	M0
	T3	N0	M0
Stage IIIA	T1, T2	N2	M0
	T3	N1, N2	M0
Stage IIIB	Any T	N3	M0
	T4	Any N	M0
Stage IV	Any T	Any N	M1

Procedures

There are currently multiple different procedures available to stage lung cancer. They can be broken down into two over-arching categories, invasive and minimally invasive.

The invasive procedures are:

• EUS-NA (esophageal endoscopic ultrasound with needle aspiration)
• TBNA (transbronchial needle aspiration)
• EBUS-NA (endobronchial ultrasound with needle aspiration)
• TTNA (transthoracic needle aspiration)
• VATS staging (video assisted thoracic surgery) aka thoracoscopy
• Extended cervical mediastinoscopy
• Chamberlain procedure

The minimally invasive procedures are:

• EBUS-FNA (endobronchial ultrasound guided fine needle aspiration)
• EUS-FNA (esophogeal endoscopic ultrasound guided fine needle aspiration)

References

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