Non small cell lung cancer diagnostic study of choice: Difference between revisions

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Latest revision as of 17:02, 22 February 2019

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Trusha Tank, M.D.[2], Furqan M M. M.B.B.S [3]

Overview

Chest X-Ray is the initial study performed when non-small cell lung cancer is suspected. Contrast-enhanced computed tomography of the chest, neck and abdomen is the best next step in diagnosing non-small cell lung cancer. Endobronchial ultrasound is a first-line diagnostic modality for the mediastinal staging of the non-small cell lung cancer. The lung biopsy is the gold standard for the diagnosis of the non-small cell lung cancer. The lung biopsy is used to confirm the diagnosis of non small cell lung cancer and identify the histopathological subtype to plan for the treatment.

Diagnostic Study of Choice

Diagnostic approach to the non small cell lung cancer

Non small cell cancer of the lung is diagnosed by the following approach:^[1]^[2]

Chest X-Ray is the initial study performed when non-small cell lung cancer is suspected.^[3]
The next step in diagnosing non small cell carcinoma of the lung is contrast-enhanced computed tomography (CT).
On CT, characteristic findings of non-small cell lung cancer include:
- Centrally located tumors, invading the mediastinal structures
- Peripherally located tumors, invading the pleura and chest wall
- Tumor margins: Smooth, lobulated, irregular and spiculated
- Tumor density: Uniformly solid; central necrosis; cavitation (squamous histology)
- Area of consolidation in the pulmonary field
- Ground-glass opacity (GGO)
- Air bronchogram
- Pleural or pericardial effusion
When the imaging study suggests lung cancer, diagnosis must be confirmed by performing a transthoracic, bronchoscopic or an image-guided biopsy depending upon the location of the tumor.

Gold standard

Lung biopsy is the gold standard test for the diagnosis of non-small cell lung cancer.^[4]
The diagnostic result of lung biopsy is confirmatory of non-small cell lung cancer and depends on the histopathological type of cancer. Click here to view the biopsy findings of the subtypes.

Evaluation Algorithm for Suspected Non-Small Cell Lung Cancer

The algorithm below summarizes the initial imaging approach for patients with suspected non-small cell lung cancer.

Imaging approach
❑ Suspected lung cancer

Chest X Ray normal?

No

Yes

Enhanced Computed Tomography (ECT), includes:
❑ Thorax
❑ Upper Abdomen
❑ Low Neck

Manage and observe

Imaging evaluation

Location
❑ Central
❑ Peripheral
❑ Pleural lesion
Size
Lesion characteristics
❑ Margins (irregular/regular)
❑ Shape (spiculated/rounded)
Presence of cavitation
❑ Yes
❑ No
Type of adenopathy
❑ Hiliar
❑ Mediastinal

Diagnosis and Staging Assessment

Other Imaging or Diagnostic Modalities
❑ Sputum cytology
❑ Endobronchial ultrasound
❑ Endoscopic ultrasound
❑ Bronchoscopy
❑ Mediastinoscopy
❑ PET/CT

Biopsy

Diagnostic modality for staging

Staging of cancer and extent of metastasis can be diagnosed by various methods.^[1]^[2]^[5]

Endoscopic ultrasound:
- First-line diagnostic modality for mediastinal staging.
- For more information on ultrasound findings of non small cell lung cancer, click here.
CT scan:
- Contrast-enhanced CT scan is used to diagnose distant metastasis to liver, adrenal gland, brain or other organs.
- For more information on CT scan findings of non small cell lung cancer, click here.
PET/CT scan:
- PET scan is used to detect non small cell lung cancer in the early stage, look for possible metastasis to liver, adrenal gland or other organs.
- PET scan cannot be used to diagnose metastasis to the brain because brain cells are normally illuminated in PET scan due to high glucose uptake.
- For more information on PET scan findings of non small cell lung cancer, click here.
MRI scan:
- MRI scan is most often used to look for possible metastasis to the brain or spinal cord.
- For more information on MRI findings of non small cell lung cancer, click here.

Staging

The following is 2017 TNM classification of lung cancer.^[6]^[7]^[8]

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: T1a: tumor ≤1 cm in the largest diameter. T1b: tumor> 1 cm, but ≤2 cm in the largest diameter. T1c: tumor> 2 cm, but ≤3 cm in the largest diameter. 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: T2a: tumor> 3 cm, but ≤4 cm in the largest diameter. T2b: Tumor> 4 cm, but ≤5 cm in the largest diameter. 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	Tumor > 5 cm, but ≤ 7 cm in 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	Tumor > 7 cm in size. The tumor 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	Metastasis in ipsilateral peribronchial and/or ipsilateral hilum or intrapulmonary lymph nodes N1a - A lymph node invasion. N1b - > 1 lymph node affected.
N2	There is metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s). N2a1 - One lymph node infested without lymph node involvement of an N1-defined lymph node station. N2a2 - One lymph node infested with a lymph node of an N1-defined lymph node station N2b - > 1 lymph node affected
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). M1a - Tumor foci separated from the primary tumor in a contralateral lung lobe; Tumor with pleural metastases or malignant pleural or pericardial effusion M1b - Simple metastases in an organ M1c - Multiple metastases in one organ or one or more metastases in more than one organ

Classification of Lung Cancer by Staging

Stage	T	N	M
Occult carcinoma	TX	N0	M0
Stage 0	Tis	N0	M0
Stage IA1	T1(mi)/T1a	N0	M0
Stage IA2	T1b	N0	M0
Stage IA3	T1c	N0	M0
Stage IB	T2a	N0	M0
Stage IIA	T2b	N0	M0
Stage IIB	T1a	N1	M0
	T1c	N1	M0
	T2a	N1	M0
	T2b	N1	M0
	T3	N0	M0
Stage IIIA	T1a	N2	M0
	T1b	N2	M0
	T1c	N2	M0
	T2a	N2	M0
	T2b	N2	M0
	T1a	N2	M0
	T1b	N2	M0
	T1c	N2	M0
	T2a	N2	M0
	T2b	N2	M0
	T3	N1	M0
	T4	N0	M0
	T4	N1	M0
Stage IIIB	T1a	N3	M0
	T1b	N3	M0
	T1c	N3	M0
	T2a	N3	M0
	T2b	N3	M0
	T1a	N3	M0
	T1b	N3	M0
	T1c	N3	M0
	T2a	N3	M0
	T2b	N3	M0
	T3	N2	M0
	T4	N2	M0
Stage IIIC	T3	N3	M0
Stage IIIC	T4	N3	M0
Stage IVA	Any T	Any N	M1a
Stage IVA	Any T	Any N	M1b
Stage IVB	Any T	Any N	M1c

References

↑ ^1.0 ^1.1 National Collaborating Centre for Cancer (UK) (2011 Apr). "The Diagnosis and Treatment of Lung Cancer (Update)" (No. 121). PMID 22855970. Vancouver style error: initials (help); Check date values in: |date= (help)
↑ ^2.0 ^2.1 Purandare, NilenduC; Rangarajan, Venkatesh (2015). "Imaging of lung cancer: Implications on staging and management". Indian Journal of Radiology and Imaging. 25 (2): 109. doi:10.4103/0971-3026.155831. ISSN 0971-3026.
↑ Lee Y, Lee HJ, Kim YT, Kang CH, Goo JM, Park CM, Paeng JC, Chung DH, Jeon YK (2013). "Imaging characteristics of stage I non-small cell lung cancer on CT and FDG-PET: relationship with epidermal growth factor receptor protein expression status and survival". Korean J Radiol. 14 (2): 375–83. doi:10.3348/kjr.2013.14.2.375. PMC 3590355. PMID 23483676.
↑ Kinsey CM, Arenberg DA (March 2014). "Endobronchial ultrasound-guided transbronchial needle aspiration for non-small cell lung cancer staging". Am. J. Respir. Crit. Care Med. 189 (6): 640–9. doi:10.1164/rccm.201311-2007CI. PMID 24484269.
↑ "Tests for Non-Small Cell Lung Cancer".
↑ Mountain, CF (2003). A Handbook for Staging, Imaging, and Lymph Node Classification. Charles P Young Company. Retrieved 2007-09-01. Unknown parameter |coauthors= ignored (help)
↑ Collins, LG (Jan 2007). "Lung cancer: diagnosis and management". American Family Physician. American Academy of Family Physicians. 75 (1): 56–63. PMID 17225705. Retrieved 2007-08-10. Unknown parameter |coauthors= ignored (help)
↑ Harms, A.; Kriegsmann, M.; Fink, L.; Länger, F.; Warth, A. (2017). "Die neue TNM-Klassifikation für Lungentumoren". Der Pathologe. 38 (1): 11–20. doi:10.1007/s00292-017-0268-y. ISSN 0172-8113.

Template:WH Template:WS

[pmid22855970-1] 1.0 ^1.1 National Collaborating Centre for Cancer (UK) (2011 Apr). "The Diagnosis and Treatment of Lung Cancer (Update)" (No. 121). PMID 22855970. Vancouver style error: initials (help); Check date values in: |date= (help)

[PurandareRangarajan2015-2] 2.0 ^2.1 Purandare, NilenduC; Rangarajan, Venkatesh (2015). "Imaging of lung cancer: Implications on staging and management". Indian Journal of Radiology and Imaging. 25 (2): 109. doi:10.4103/0971-3026.155831. ISSN 0971-3026.

[pmid23483676-3] Lee Y, Lee HJ, Kim YT, Kang CH, Goo JM, Park CM, Paeng JC, Chung DH, Jeon YK (2013). "Imaging characteristics of stage I non-small cell lung cancer on CT and FDG-PET: relationship with epidermal growth factor receptor protein expression status and survival". Korean J Radiol. 14 (2): 375–83. doi:10.3348/kjr.2013.14.2.375. PMC 3590355. PMID 23483676.

[pmid244842692-4] Kinsey CM, Arenberg DA (March 2014). "Endobronchial ultrasound-guided transbronchial needle aspiration for non-small cell lung cancer staging". Am. J. Respir. Crit. Care Med. 189 (6): 640–9. doi:10.1164/rccm.201311-2007CI. PMID 24484269.

[urlTests_for_Non-Small_Cell_Lung_Cancer-5] "Tests for Non-Small Cell Lung Cancer".

[6] Mountain, CF (2003). A Handbook for Staging, Imaging, and Lymph Node Classification. Charles P Young Company. Retrieved 2007-09-01. Unknown parameter |coauthors= ignored (help)

[Collins-7] Collins, LG (Jan 2007). "Lung cancer: diagnosis and management". American Family Physician. American Academy of Family Physicians. 75 (1): 56–63. PMID 17225705. Retrieved 2007-08-10. Unknown parameter |coauthors= ignored (help)

[HarmsKriegsmann2017-8] Harms, A.; Kriegsmann, M.; Fink, L.; Länger, F.; Warth, A. (2017). "Die neue TNM-Klassifikation für Lungentumoren". Der Pathologe. 38 (1): 11–20. doi:10.1007/s00292-017-0268-y. ISSN 0172-8113.

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@@ Line 1: / Line 1: @@
 __NOTOC__
 {{Non small cell lung cancer}}
-{{CMG}}; {{AE}} {{MMF}}
+{{CMG}}; {{AE}}{{Trusha}}, {{MMF}}
 == Overview ==
+[[Chest X-ray|Chest X-Ray]] is the initial study performed when non-small cell lung cancer is suspected. [[Computed tomography|Contrast-enhanced computed tomography]] of the [[chest]], [[neck]] and [[abdomen]] is the best next step in diagnosing non-small cell lung cancer. [[Endoscopic ultrasound|Endobronchial ultrasound]] is a first-line diagnostic modality for the [[mediastinal]] staging of the non-small cell lung cancer. The lung [[biopsy]] is the gold standard for the diagnosis of the non-small cell lung cancer. The [[Non small cell lung cancer other diagnostic studies|lung biopsy]] is used to confirm the diagnosis of non small cell lung cancer and identify the [[Histopathology|histopathological]] subtype to plan for the treatment.
 == Diagnostic Study of Choice ==
+=== Diagnostic approach to the non small cell lung cancer ===
+Non small cell cancer of the lung is diagnosed by the following approach:<ref name="pmid22855970">{{cite journal |vauthors=National Collaborating Centre for Cancer (UK) |title=The Diagnosis and Treatment of Lung Cancer (Update) |journal= |volume= |issue= No. 121 |pages= |date=2011 Apr |pmid=22855970 |doi= |url=https://www.ncbi.nlm.nih.gov/books/NBK99021/}}</ref><ref name="PurandareRangarajan2015">{{cite journal|last1=Purandare|first1=NilenduC|last2=Rangarajan|first2=Venkatesh|title=Imaging of lung cancer: Implications on staging and management|journal=Indian Journal of Radiology and Imaging|volume=25|issue=2|year=2015|pages=109|issn=0971-3026|doi=10.4103/0971-3026.155831}}</ref>
+*[[Non small cell lung cancer chest x ray|Chest X-Ray]] is the initial study performed when non-small cell lung cancer is suspected.<ref name="pmid23483676">{{cite journal |vauthors=Lee Y, Lee HJ, Kim YT, Kang CH, Goo JM, Park CM, Paeng JC, Chung DH, Jeon YK |title=Imaging characteristics of stage I non-small cell lung cancer on CT and FDG-PET: relationship with epidermal growth factor receptor protein expression status and survival |journal=Korean J Radiol |volume=14 |issue=2 |pages=375–83 |date=2013 |pmid=23483676 |pmc=3590355 |doi=10.3348/kjr.2013.14.2.375 |url=}}</ref>
+*The next step in diagnosing non small cell carcinoma of the lung is [[Non small cell lung cancer CT|contrast-enhanced computed tomography (CT)]].
+*On [[Computed tomography|CT]], characteristic findings of non-small cell lung cancer include:
+**Centrally located [[Lung cancer|tumors]], invading the [[Mediastinum|mediastinal structures]]
+**Peripherally located [[Lung cancer|tumors]], invading the [[Pleural cavity|pleura]] and [[Thoracic wall|chest wall]]
+**Tumor margins: Smooth, lobulated, irregular and spiculated
+**Tumor density: Uniformly solid; central necrosis; cavitation ([[Squamous cell carcinoma of the lung|squamous histology]])
+**Area of consolidation in the [[Chest X-ray|pulmonary field]]
+**[[Chest x ray|Ground-glass opacity (GGO)]]
+**[[Chest x ray#Air Bronchogram Sign|Air bronchogram]]
+**[[Pleural effusion|Pleural]] or [[pericardial effusion]]
+*When the imaging study suggests [[lung cancer]], diagnosis must be confirmed by performing a [[Transthoracic needle aspiration|transthoracic]], [[Bronchoscopy|bronchoscopic]] or an image-guided [[biopsy]] depending upon the location of the [[tumor]].
+===Gold standard===
+* [[Non small cell lung cancer other diagnostic studies|Lung biopsy]] is the gold standard test for the diagnosis of non-small cell lung cancer.<ref name="pmid244842692">{{cite journal |vauthors=Kinsey CM, Arenberg DA |title=Endobronchial ultrasound-guided transbronchial needle aspiration for non-small cell lung cancer staging |journal=Am. J. Respir. Crit. Care Med. |volume=189 |issue=6 |pages=640–9 |date=March 2014 |pmid=24484269 |doi=10.1164/rccm.201311-2007CI |url=}}</ref>
+*The diagnostic result of [[Non small cell lung cancer other diagnostic studies|lung biopsy]] is confirmatory of non-small cell lung cancer and depends on the histopathological type of cancer. [[Non small cell lung cancer other diagnostic studies|Click here]] to view the biopsy findings of the subtypes.
+===Evaluation Algorithm for Suspected Non-Small Cell Lung Cancer===
-=== Study of choice: ===
+The algorithm below summarizes the initial imaging approach for patients with suspected non-small cell lung cancer.
-Computed tomography is the diagnostic study of choice for the diagnosis of non-small cell lung cancer. On CT, characteristic findings of non-small cell lung cancer include:<ref name="pmid7208937">{{cite journal |vauthors=Kundel HL |title=Predictive value and threshold detectability of lung tumors |journal=Radiology |volume=139 |issue=1 |pages=25–9 |year=1981 |pmid=7208937 |doi=10.1148/radiology.139.1.7208937 |url=}}</ref>
-*'''[[Adenocarcinoma of the lung|Lung adenocarcinoma]]'''
-:*Lung adenocarcinomas are typically peripherally located
-:*Usually measure <4 cm in diameter, very few show cavitation
-:*Perihilar and mediastinal involvement
-:*Ground glass opacity (slow growth), usually lesions double the size within a year
-*'''[[Bronchoalveolar carcinoma]]'''
+ {{familytree/start |summary= Imaging Evaluation Algorithm Non-Small Cell Lung Cancer}}
-:*Subtype of adenocarcinoma
+{{familytree | | | | | | A02 | | | | | | A02=<div style="width: 10em; padding:0.2em;">'''Imaging approach'''<br> ❑ Suspected [[lung cancer]]</div>}}
-:*Single pulmonary nodule or mass
+{{familytree | | | | | | |!| | | | | | | | }}
-:*Multicentric or diffuse disease
+{{familytree | | | | | | Z01 | | | | | | | Z01=[[Chest X Ray]] normal?}}
-:*Localized area of parenchymal consolidation
+{{familytree | | | |,|-|-|^|-|-|.| | | | | }}
-:*Bubble-like areas of low attenuation within the mass are a characteristic finding
+{{familytree | | | B01 | | | | B02 | | | B01=No|B02=Yes}}
-:*Hilar and mediastinal lymphadenopathy is uncommon
+{{familytree | | | |!| | | | | |!| | | | | }}
-:*Persistent peripheral consolidation with associated nodules
+{{familytree | | | C01 | | | | C02 | | | | C01=<div style="width: 17em; padding:1em;text-align:left">'''[[CT|Enhanced Computed Tomography (ECT)]], includes:''' <br>❑ Thorax <br>❑ Upper Abdomen<br> ❑ Low Neck<br></div>|C02=<div style="width: 15em; padding:1em;">'''Manage and observe'''</div>}}
+{{familytree | | | |!| | | | | | | | | | | |}}
+{{familytree | | | C03 | | | | | | | | | | | |C03=<div style="width: 10em; padding:0.2em;">'''Imaging evaluation'''</div>}}
+{{familytree|boxstyle= border-top: 0px;| | | C04 | | | | | | | | | | | C04=<div style="width: 17em; padding:1em;text-align:left">'''Location'''<br> ❑ Central<br> ❑ Peripheral <br> ❑ Pleural lesion <br>'''Size''' <br>'''Lesion characteristics'''<br>  ❑ Margins (irregular/regular)<br>  ❑ Shape (spiculated/rounded)<br>'''Presence of cavitation'''<br>❑ Yes<br>❑ No<br>''' [[Lymphadenopathy|Type of adenopathy]]'''<br> ❑ Hiliar <br> ❑ Mediastinal <br></div>}}
+{{familytree | | | |!| | | | | | | | | | | |}}
+{{familytree | | | |`|-| D01 | | | | | | | | D01=<div style="width: 15em; padding:1em;">'''[[Non small cell lung cancer staging|'''Diagnosis and Staging Assessment''']]'''</div>}}
+{{familytree | | | | | | |!| | | | | | | | }}
+{{familytree | | | | | | X01 | | | | | | | X01=<div style="width: 17em; padding:1em;text-align:left">'''[[Non small cell lung cancer other diagnostic studies|'''Other Imaging or Diagnostic Modalities''']]'''<br>❑ Sputum cytology <br> ❑ Endobronchial ultrasound <br> ❑ Endoscopic ultrasound <br> ❑ Bronchoscopy <br> ❑ Mediastinoscopy <br> ❑ PET/CT </div>}}
+{{familytree | | | | | | |!| | | | | | | | }}
+{{familytree | | | | | | F01 | | | | | | | F01=<div style="width: 15em; padding:1em;">'''[[Non small cell lung cancer other diagnostic studies|Biopsy]]''' </div>}}
+{{familytree/end}}
-*'''[[Squamous cell carcinoma of the lung|Squamous cell lung carcinoma]]'''
+===Diagnostic modality for staging===
-:*Centrally located within the lung
+Staging of cancer and extent of metastasis can be diagnosed by various methods.<ref name="pmid22855970">{{cite journal |vauthors=National Collaborating Centre for Cancer (UK) |title=The Diagnosis and Treatment of Lung Cancer (Update) |journal= |volume= |issue= No. 121 |pages= |date=2011 Apr |pmid=22855970 |doi= |url=https://www.ncbi.nlm.nih.gov/books/NBK99021/}}</ref><ref name="PurandareRangarajan2015">{{cite journal|last1=Purandare|first1=NilenduC|last2=Rangarajan|first2=Venkatesh|title=Imaging of lung cancer: Implications on staging and management|journal=Indian Journal of Radiology and Imaging|volume=25|issue=2|year=2015|pages=109|issn=0971-3026|doi=10.4103/0971-3026.155831}}</ref><ref name="urlTests for Non-Small Cell Lung Cancer">{{cite web |url=https://www.cancer.org/cancer/non-small-cell-lung-cancer/detection-diagnosis-staging/how-diagnosed.html |title=Tests for Non-Small Cell Lung Cancer |format= |work= |accessdate=}}</ref>
-:*Usually measure larger than 4 cm in diameter
+*'''Endoscopic ultrasound:'''
-:*Frequent cavitation
+**First-line diagnostic modality for mediastinal staging.
-:*Commonly cause segmental or lobar lung collapse due to central location
+**For more information on ultrasound findings of non small cell lung cancer, [[Non small cell lung cancer ultrasound|click here]].
+*'''CT scan:'''
+**Contrast-enhanced CT scan is used to diagnose distant metastasis to liver, adrenal gland, brain or other organs.
+** For more information on CT scan findings of non small cell lung cancer, [[Non small cell lung cancer CT|click here]].
+*'''PET/CT scan:'''
+**PET scan is used to detect non small cell lung cancer in the early stage, look for possible metastasis to liver, adrenal gland or other organs.
+**PET scan cannot be used to diagnose metastasis to the brain because brain cells are normally illuminated in PET scan due to high glucose uptake.
+**For more information on PET scan findings of non small cell lung cancer, [[Non small cell lung cancer other imaging findings#Other Imaging Findings|click here]].
+*'''MRI scan:'''
+**MRI scan is most often used to look for possible metastasis to the brain or spinal cord.
+**For more information on MRI findings of non small cell lung cancer, [[Non small cell lung cancer MRI|click here]].
-*'''[[Large cell carcinoma of the lung|Large cell lung carcinoma]]'''
+== Staging ==
-:*Rapid growth
+The following is 2017 TNM classification of lung cancer.<ref>{{cite book | last =Mountain | first =CF | authorlink = | coauthors =Libshitz HI, Hermes KE | title =A Handbook for Staging, Imaging, and Lymph Node Classification | publisher =Charles P Young Company | date =2003 | url =http://www.ctsnet.org/book/mountain/index.html | accessdate =2007-09-01 }}</ref><ref name="Collins">{{cite journal | last = Collins | first = LG | coauthors = Haines C, Perkel R, Enck RE | title = Lung cancer: diagnosis and management | journal = American Family Physician | volume = 75 | issue = 1 | pages = 56–63 | publisher = American Academy of Family Physicians | date = Jan 2007 | url= http://www.aafp.org/afp/20070101/56.html | pmid =17225705 | accessdate =2007-08-10 }}</ref><ref name="HarmsKriegsmann2017">{{cite journal|last1=Harms|first1=A.|last2=Kriegsmann|first2=M.|last3=Fink|first3=L.|last4=Länger|first4=F.|last5=Warth|first5=A.|title=Die neue TNM-Klassifikation für Lungentumoren|journal=Der Pathologe|volume=38|issue=1|year=2017|pages=11–20|issn=0172-8113|doi=10.1007/s00292-017-0268-y}}</ref>
-:*Early metastasizes to the mediastinum and brain
-:*Large mediastinal nodules/masses
-:*Lymph node involvement (frequently subcarinal)
-:*Nodular pleural thickening
-:*Pleural effusion
-* The CT scan should be performed when the following is required:
+===T: Primary Tumor===
-:*Assessment of the main bronchi
+{|
-:*Evaluation of the entire thorax
+|-
-:*Detection of chest wall invasion
+| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF; width: 10%" align="center" |'''T'''|| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF" align="center" |'''Description'''
-:*Assessment of hilar and mediastinal invasion/adenopathy
+|-
-:*Determination of non-small cell lung cancer staging
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |TX || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |Primary tumor cannot be assessed.<br> OR <br>Tumor is demonstrated by the presence of malignant cells in bronchial washings or [[sputum]], but is not visualized by imaging or [[bronchoscopy]].
-:*Precise determination of size and tumor dimensions
+|-
-:*Detection of [[liver]], [[Bone tumors|bone]], [[Adrenal gland|adrenal]] , and [[brain]] metastasis
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" | T0 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |There is no evidence of primary tumor.
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |Tis || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |Carcinoma in situ
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T1 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |The tumor has the following characteristics:
+* T1a: tumor ≤1 cm in the largest diameter.
-Endobronchial ultrasound is a first-line diagnostic modality for mediastinal staging.The sensitivity of endobronchial ultrasound is 90% and specificity is 97%.<ref name="pmid24484269">{{cite journal |vauthors=Kinsey CM, Arenberg DA |title=Endobronchial ultrasound-guided transbronchial needle aspiration for non-small cell lung cancer staging |journal=Am. J. Respir. Crit. Care Med. |volume=189 |issue=6 |pages=640–9 |year=2014 |pmid=24484269 |doi=10.1164/rccm.201311-2007CI |url=}}</ref><ref name="cancer"> Tests for non-small cell lung cancer. American Cancer Society. http://www.cancer.org/cancer/lungcancer-non-smallcell/detailedguide/non-small-cell-lung-cancer-diagnosis Accessed on February 25, 2016</ref>
+* T1b: tumor> 1 cm, but ≤2 cm in the largest diameter.
+* T1c: tumor> 2 cm, but ≤3 cm in the largest diameter.<br> AND <br>The tumor is surrounded by lung or [[visceral pleura]]<br> AND <br>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.
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T2 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |The tumor has the following characteristics:
+* T2a: tumor> 3 cm, but ≤4 cm in the largest diameter.
+* T2b: Tumor> 4 cm, but ≤5 cm in the largest diameter.<br>The tumor involves the main bronchus, 2 cm or more distal to the [[carina]]. <br> OR <br>The tumor invades the [[visceral pleura]]. <br> OR <br>There is evidence of [[atelectasis]] or obstructive [[pneumonitis]] that extends to the hilar region without the involvement of the entire lung.
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T3 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |Tumor > 5 cm, but ≤ 7 cm in size.
+AND
-*On ultrasound (endobronchial ultrasound), characteristic findings of non-small cell lung cancer include:
+It directly invades any of the following: [[chest wall]] (including superior sulcus tumors), [[diaphragm]], mediastinal pleura, parietal [[pericardium]].<br> OR <br>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]].<br> OR <br>There is evidence of associated [[atelectasis]] or obstructive [[pneumonitis]] of the entire lung.
-:*Enlarged lymph nodes
+|-
-:*Local invasion of adjacent bronchial structures and mediastinum
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T4 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |Tumor > 7 cm in size.
+The tumor invades any of the following: [[mediastinum]], [[heart]], great vessels, [[trachea]], [[esophagus]], [[vertebral body]], [[carina]]<br> OR <br>There is/are separate tumor nodule(s) in the same lobe. <br> OR
+The tumor is associated with malignant [[pleural effusion]].
+|}
-* The endobronchial ultrasound should be performed when the following is required:
+===N:Regional Lymph Nodes===
-:*Evaluation of lymph nodes and other structures in the mediastinum
+{| style="cellpadding=0; cellspacing= 0; width: 600px;"
-:*Mediastinal invasion staging
+|-
-:*Determination of management strategy
+| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF; width: 10%" align="center" |'''T'''|| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF" align="center" |'''Description'''
-:*Real time evaluation of structures
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |NX || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |the regional [[lymph node]]s cannot be assessed.
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N0 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |There is no evidence of regional lymph node metastasis.
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N1 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |[[Metastasis]] in [[Anatomical terms of location|ipsilateral]] peribronchial and/or [[Anatomical terms of location|ipsilateral]] [[Hilar lymphadenopathy|hilum]] or intrapulmonary [[Lymph node|lymph nodes]]
+N1a - A [[lymph node]] invasion.
+N1b - > 1 [[lymph node]] affected.
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N2 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |There is [[metastasis]] in ipsilateral [[Mediastinum|mediastinal]] and/or subcarinal [[Lymph node|lymph node(s).]]
+N2a1 - One lymph node infested without lymph node involvement of an N1-defined lymph node station.
+N2a2 - One lymph node infested with a lymph node of an N1-defined lymph node station
-* Lung biopsy is the gold standard test for the diagnosis of non-small cell lung cancer.
+N2b - > 1 lymph node affected
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N3 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |There is [[metastasis]] in [[Anatomical terms of location|contralateral]] [[Mediastinum|mediastinal]], contralateral [[Hilum|hilar]], [[Anatomical terms of location|ipsilateral]] or [[Anatomical terms of location|contralateral]] scalene, or supraclavicular [[Lymph node|lymph node(s).]]
+|}
-===== Diagnostic results =====
+===M: Distant Metastasis===
-The diagnostic result of lung biopsy is confirmatory of non-small cell lung cancer and depends on the type of cancer.
+{| style="cellpadding=0; cellspacing= 0; width: 600px;"
-Click [[here|Non small cell lung cancer biopsy]] to view the biopsy findings of the subtypes.
+|-
+| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF; width: 10%" align="center" |'''T'''|| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF" align="center" |'''Description'''
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |MX || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |Distant metastasis cannot be assessed.
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |There is no evidence of distant [[metastasis]].
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M1 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |There is evidence of [[distant]] metastasis which includes the presence of separate tumor nodule(s) in a different lobe (ipsilateral or contralateral).
+M1a - Tumor foci separated from the primary tumor in a contralateral lung lobe; Tumor with pleural metastases or malignant pleural or pericardial effusion
-===== Sequence of Diagnostic Studies =====
+M1b - Simple metastases in an organ
-The [name of investigation] should be performed when:
-* The patient presented with symptoms/signs 1, 2, and 3 as the first step of diagnosis.
-* A positive [test] is detected in the patient, to confirm the diagnosis.
-=== Diagnostic Criteria ===
+M1c - Multiple metastases in one organ or one or more metastases in more than one organ
-* Here you should describe the details of the diagnostic criteria.
-*Always mention the name of the criteria/definition you are about to list (e.g. modified Duke criteria for the diagnosis of endocarditis / 3rd universal definition of MI) and cite the primary source of where this criteria/definition is found.
-*Although not necessary, it is recommended that you include the criteria in a table. Make sure you always cite the source of the content and whether the table has been adapted from another source.
-*Be very clear as to the number of criteria (or threshold) that needs to be met out of the total number of criteria.
-*Distinguish criteria based on their nature (e.g. clinical criteria / pathological criteria/ imaging criteria) before discussing them in details.
-*To view an example (endocarditis diagnostic criteria), click [[Endocarditis diagnosis|here]]
-*If relevant, add additional information that might help the reader distinguish various criteria or the evolution of criteria (e.g. original criteria vs. modified criteria).
-*You may also add information about the sensitivity and specificity of the criteria, the pre-test probability, and other figures that may help the reader understand how valuable the criteria are clinically.
-* [Disease name] is mainly diagnosed based on clinical presentation. There are no established criteria for the diagnosis of [disease name].
-* There is no single diagnostic study of choice for [disease name], though [disease name] may be diagnosed based on [name of criteria] established by [...].
-* The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].
+|}
-* The diagnosis of [disease name] is based on the [criteria name] criteria, which includes [criterion 1], [criterion 2], and [criterion 3].
-* [Disease name] may be diagnosed at any time if one or more of the following criteria are met:
+==Classification of Lung Cancer by Staging==
-** Criteria 1
+{| style="cellpadding=0; cellspacing= 0; width: 600px;"
-** Criteria 2
+|-
-** Criteria 3
+| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF" align="center" |'''Stage'''|| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF" align="center" |'''T'''|| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF" align="center" |'''N'''|| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF" align="center" |'''M'''
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |'''Occult carcinoma''' || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |TX|| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N0|| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |'''Stage 0''' || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |Tis || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" | N0 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |'''Stage IA1''' || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T1(mi)/T1a || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N0 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |'''Stage IA2''' || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T1b || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N0 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" | M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" | '''Stage IA3'''|| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T1c || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N0 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" | M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |'''Stage IB''' || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T2a || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N0 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" | M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |'''Stage IIA''' || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T2b || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N0 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| rowspan="5" style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |'''Stage IIB''' || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T1a || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N1 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" | M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T1c || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N1 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T2a || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N1 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T2b || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N1 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T3 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N0 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| rowspan="13" style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |'''Stage IIIA''' || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T1a
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N2 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T1b || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N2 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T1c || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N2 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T2a || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N2 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T2b || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N2 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T1a || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N2 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T1b || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N2 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T1c || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N2 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T2a || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N2 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T2b || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N2 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T3 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N1 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T4 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N0 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T4|| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N1 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| rowspan="12" style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |'''Stage IIIB''' || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T1a|| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N3 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T1b || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N3 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T1c || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N3 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T2a || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N3 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T2b || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N3 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T1a || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N3 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T1b || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N3 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T1c || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N3 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T2a || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N3 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T2b || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N3 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T3 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N2 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T4 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N2 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| rowspan="2"  style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |'''Stage IIIC'''|| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T3 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N3 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |T4 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |N3 || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M0
+|-
+| rowspan="2" style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |'''Stage IVA'''|| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |Any T || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |Any N || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M1a
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |Any T || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |Any N || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M1b
+|-
+| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |'''Stage IVB'''|| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |Any T || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |Any N || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align="left" |M1c
+|}
-IF there are clear, established diagnostic criteria:
-*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].
-*The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].
-*The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].
-IF there are no established diagnostic criteria:
-*There are no established criteria for the diagnosis of [disease name].
 ==References==
@@ Line 103: / Line 238: @@
 {{WH}}
 {{WS}}
+<references />