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}}{{Trusha}},{{MMF}}
+{{CMG}}; {{AE}}{{Trusha}}, {{MMF}}
 == Overview ==
-Chest X-Ray is the initial study performed when non-small cell lung cancer is suspected. Lung CT scan is the diagnostic study of choice for the diagnosis of 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 [[Non-small cell lung cancer biopsy|lung biopsy]] helps to differentiate between the various subtypes of lung cancer.
+[[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 ==
-=== 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="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 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>
-*[[Chest X-ray|Chest X-Ray]] is the initial study performed when non-small cell lung cancer is suspected.
+*[[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 [[Computed tomography|contrast-enhanced computed tomography (CT)]].
+*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:<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>
+*On [[Computed tomography|CT]], characteristic findings of non-small cell lung cancer include:
-**Centrally located tumors, invading the [[Mediastinum|mediastinal structures]]
+**Centrally located [[Lung cancer|tumors]], invading the [[Mediastinum|mediastinal structures]]
-**Peripherally located tumors, invading the [[Pleural cavity|pleura]] and [[Thoracic wall|chest wall]]
+**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 histology)
+**Tumor density: Uniformly solid; central necrosis; cavitation ([[Squamous cell carcinoma of the lung|squamous histology]])
-**Area of consolidation in the pulmonary field
+**Area of consolidation in the [[Chest X-ray|pulmonary field]]
-**Ground-glass opacity (GGO)
+**[[Chest x ray|Ground-glass opacity (GGO)]]
-**Air bronchogram
+**[[Chest x ray#Air Bronchogram Sign|Air bronchogram]]
-**Pleural or pericardial perfusion
+**[[Pleural effusion|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.
+*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.
+* [[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 type of cancer. [[Non small cell lung cancer other diagnostic studies|Click here]] to view the biopsy findings of the subtypes.
+*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===
-The algorithm below summarizes the initial imaging approach for patients with suspected non-small cell lung cancer.<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="who">WHO: Lung cancer/Tumours of the Lung. https://www.iarc.fr/en/publications/pdfs-online/pat-gen/bb10/bb10-chap1.pdf Accessed on March 1, 2016</ref>
+The algorithm below summarizes the initial imaging approach for patients with suspected non-small cell lung cancer.
   {{familytree/start |summary= Imaging Evaluation Algorithm Non-Small Cell Lung Cancer}}
-{{familytree | | | | | | A02 | | | | | | A02=<div style="width: 10em; padding:0.2em;">'''Imaging approach'''<br> ❑ Suspected lung cancer</div>}}
+{{familytree | | | | | | A02 | | | | | | A02=<div style="width: 10em; padding:0.2em;">'''Imaging approach'''<br> ❑ Suspected [[lung cancer]]</div>}}
 {{familytree | | | | | | |!| | | | | | | | }}
-{{familytree | | | | | | Z01 | | | | | | | Z01=Chest X Ray normal?}}
+{{familytree | | | | | | Z01 | | | | | | | Z01=[[Chest X Ray]] normal?}}
 {{familytree | | | |,|-|-|^|-|-|.| | | | | }}
 {{familytree | | | B01 | | | | B02 | | | B01=No|B02=Yes}}
 {{familytree | | | |!| | | | | |!| | | | | }}
-{{familytree | | | C01 | | | | C02 | | | | C01=<div style="width: 17em; padding:1em;text-align:left">'''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 | | | 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>''' Type of adenopathy'''<br> ❑ Hiliar <br> ❑ Mediastinal <br></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> ❑ Bronchoscopy<br> ❑ Mediastinoscopy <br> ❑ PET/CT </div>}}
+{{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 biopsy|Biopsy]]''' </div>}}
+{{familytree | | | | | | F01 | | | | | | | F01=<div style="width: 15em; padding:1em;">'''[[Non small cell lung cancer other diagnostic studies|Biopsy]]''' </div>}}
 {{familytree/end}}
+===Diagnostic modality for staging===
+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>
+*'''Endoscopic ultrasound:'''
+**First-line diagnostic modality for mediastinal staging.
+**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]].
+== Staging ==
+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>
+===T: Primary Tumor===
+{|
+|-
+| 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" |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]].
+|-
+| 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.
+* 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
+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.
+|-
+| 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]].
+|}
+===N:Regional Lymph Nodes===
+{| style="cellpadding=0; cellspacing= 0; width: 600px;"
+|-
+| 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" |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.
-===Diagnostic modality for staging===
+N2a2 - One lymph node infested with a lymph node of an N1-defined lymph node station
-Staging of cancer and extent of metastasis can be diagnosed by various methods.
-* '''Endobronchial ultrasound–guided transbronchial needle aspiration:''' First-line diagnostic modality for mediastinal staging.
-* The sensitivity of endobronchial ultrasound–guided transbronchial needle aspiration 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>
+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).]]
+|}
-*On ultrasound (endobronchial ultrasound), characteristic findings of non-small cell lung cancer include:
+===M: Distant Metastasis===
-**Enlarged lymph nodes
+{| style="cellpadding=0; cellspacing= 0; width: 600px;"
-**Local invasion of adjacent [[bronchial]] structures and [[mediastinum]]
+|-
+| 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
-* Indications for the endobronchial ultrasound:
+M1b - Simple metastases in an organ
-**Evaluation of lymph nodes and other structures in the [[mediastinum]]
-**Mediastinal invasion staging
-**Determination of management strategy
-**Real-time evaluation of structures
-==Staging==
+M1c - Multiple metastases in one organ or one or more metastases in more than one organ
-*Staging system classifications for non-small cell lung cancer include:<ref name="canadian">Stages of non–small cell lung cancer. Canadian Cancer Society. http://www.cancer.ca/en/cancer-information/cancer-type/lung/staging/?region=ab</ref><ref name="harrison">Horn, Leora, et al. "Neoplasms of the Lung." Harrison's Principles of Internal Medicine, 19e. Eds. Dennis Kasper, et al. New York, NY: McGraw-Hill, 2015. n. pag. AccessMedicine. Web. 1 Mar. 2016. <http://accessmedicine.mhmedical.com.ezp-prod1.hul.harvard.edu/content.aspx?bookid=1130&Sectionid=69857702>.</ref>
+|}
-:*American Joint Committee on Cancer (AJCC) staging system
-:*International Union Against Cancer (UICC) staging system
-===American Joint Committee on Cancer (AJCC) Staging===
+==Classification of Lung Cancer by Staging==
-*The table below summarizes the TNM staging system for the diagnosis of non-small cell lung cancer.<ref name="canadian">Stages of non–small cell lung cancer. Canadian Cancer Society. http://www.cancer.ca/en/cancer-information/cancer-type/lung/staging/?region=ab</ref>
+{| style="cellpadding=0; cellspacing= 0; width: 600px;"
-{| style="border: 0px; font-size: 90%; margin: 3px; width: 600px" align="center"
+|-
-| valign="top" |
+| 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="background: #4479BA; width: 100px;" | {{fontcolor|#FFF|TNM}}
+| 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="background: #4479BA; width: 400px;" | {{fontcolor|#FFF|Description}}
+|-
+| 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
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" |TX
+| 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="padding: 5px 5px; background: #F5F5F5;" |The primary [[tumour]] cannot be assessed, or there are [[malignant]] [[cell (biology)|cells]] in the [[sputum]] or [[bronchoalveolar lavage]] but not seen on imaging or [[bronchoscopy]]
+| 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="padding: 5px 5px; background: #DCDCDC;" |T0
+| 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="padding: 5px 5px; background: #F5F5F5;" |No evidence of primary tumor
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" |Tis
+| 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="padding: 5px 5px; background: #F5F5F5;" |[[Carcinoma in situ]]
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" |T1
+| 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="padding: 5px 5px; background: #F5F5F5;" |Tumour less than 3 cm in its greatest dimension, surrounded by [[lung]] or visceral [[pleura]] and without bronchoscopic invasion into the main [[bronchus]].
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" |T2
+| 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="padding: 5px 5px; background: #F5F5F5;" |A tumour with any of: More than 3 cm in greatest dimension; Extending into the main bronchus, but more than 2 cm distal to the [[Carina (anatomy)|carina]]; Obstructive [[pneumonitis]], but not involving the entire lung
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" |T3
+| 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="padding: 5px 5px; background: #F5F5F5;" |A tumour with any of: Invasion of the chest wall, [[Thoracic diaphragm|diaphragm]], [[mediastinum|mediastinal]] pleura, or parietal [[pericardium]]; Extending into the main bronchus, within 2 cm of the carina, but not involving the carina; Obstructive pneumonitis of the entire lung
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" |T4
+| 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="padding: 5px 5px; background: #F5F5F5;" |A tumour with any of: Invasion of the mediastinum, [[heart]], great vessels, [[Vertebrate trachea|trachea]], [[oesophagus]], [[vertebra]], or carina; Separate tumour nodules in the same lobe; Malignant [[pleural effusion]]
 |-
-| colspan="3" style="padding: 0 5px; background: #4479BA" |{{fontcolor|#FFF| Regional Lymph Nodes}}
+| 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="padding: 5px 5px; background: #DCDCDC;" |NX
+| 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="padding: 5px 5px; background: #F5F5F5;" |[[Lymph node]]s cannot be assessed
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" |N0
+| 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="padding: 5px 5px; background: #F5F5F5;" |No lymph nodes involved
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" |N1
+| 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="padding: 5px 5px; background: #F5F5F5;" |[[Metastasis]] to [[ipsilateral]] peribronchial or ipsilateral hilar lymph nodes
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" |N2
+| 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="padding: 5px 5px; background: #F5F5F5;" |Metastasis to ipsilateral mediastinal or subcarinal lymph nodes
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" |N3
+| 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
-| style="padding: 5px 5px; background: #F5F5F5;" |Metastasis to any of: Ipsilateral supraclavicular lymph nodes; Ipsilateral scalene lymph nodes; [[Contralateral]] lymph nodes.
-|- |-
-| colspan="3" style="padding: 0 5px; background: #4479BA" |{{fontcolor|#FFF| Distant Metastasis}}
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" |MX
+| 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="padding: 5px 5px; background: #F5F5F5;" |Distant metastasis cannot be assessed
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" |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="padding: 5px 5px; background: #F5F5F5;" |No distant metastasis
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" |M1
+| 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="padding: 5px 5px; background: #F5F5F5;" |Distant metastasis is present
-|}
-===International Union Against Cancer (UICC) Staging System===
-*The table below summarizes the TNM staging system for the diagnosis of non-small cell lung cancer.<ref name="canadian">Stages of non–small cell lung cancer. Canadian Cancer Society. http://www.cancer.ca/en/cancer-information/cancer-type/lung/staging/?region=ab</ref>
-{| style="border: 0px; font-size: 90%; margin: 3px; width: 600px" align="center"
-| valign="top" |
-|+
-! style="background: #4479BA; width: 100px;" | {{fontcolor|#FFF|Stage}}
-! style="background: #4479BA; width: 100px;" | {{fontcolor|#FFF| T}}
-! style="background: #4479BA; width: 100px;" | {{fontcolor|#FFF| N}}
-! style="background: #4479BA; width: 100px;" | {{fontcolor|#FFF| M}}
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" |Occult carcinoma
+| 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="padding: 5px 5px; background: #F5F5F5;" |TX
-| style="padding: 5px 5px; background: #F5F5F5;" |N0
-| style="padding: 5px 5px; background: #F5F5F5;" |M0
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" |Stage 0
+| 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="padding: 5px 5px; background: #F5F5F5;" |Tis
-| style="padding: 5px 5px; background: #F5F5F5;" |N0
-| style="padding: 5px 5px; background: #F5F5F5;" |M0
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" |Stage IA
+| 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="padding: 5px 5px; background: #F5F5F5;" |T1
-| style="padding: 5px 5px; background: #F5F5F5;" |N0
-| style="padding: 5px 5px; background: #F5F5F5;" |M0
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" |Stage IB
+| 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="padding: 5px 5px; background: #F5F5F5;" |T2
-| style="padding: 5px 5px; background: #F5F5F5;" |N0
-| style="padding: 5px 5px; background: #F5F5F5;" |M0
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" |Stage IIA
+| 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="padding: 5px 5px; background: #F5F5F5;" |T1
-| style="padding: 5px 5px; background: #F5F5F5;" |N1
-| style="padding: 5px 5px; background: #F5F5F5;" |M0
 |-
-| rowspan="2" style="padding: 5px 5px; background: #DCDCDC;" |Stage IIB
+| 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="padding: 5px 5px; background: #F5F5F5;" |T2
-| style="padding: 5px 5px; background: #F5F5F5;" |N1
-| style="padding: 5px 5px; background: #F5F5F5;" |M0
 |-
-| style="padding: 5px 5px; background: #F5F5F5;" |T3
+| 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="padding: 5px 5px; background: #F5F5F5;" |N0
-| style="padding: 5px 5px; background: #F5F5F5;" |M0
 |-
-| rowspan="4" style="padding: 5px 5px; background: #DCDCDC;" |Stage IIIA
+| 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="padding: 5px 5px; background: #F5F5F5;" |T1
-| style="padding: 5px 5px; background: #F5F5F5;" |N2
-| style="padding: 5px 5px; background: #F5F5F5;" |M0
 |-
-| style="padding: 5px 5px; background: #F5F5F5;" |T2
+| 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
-| style="padding: 5px 5px; background: #F5F5F5;" |N2
-| style="padding: 5px 5px; background: #F5F5F5;" |M0
 |-
-| style="padding: 5px 5px; background: #F5F5F5;" |T3
+| 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="padding: 5px 5px; background: #F5F5F5;" |N1
-| style="padding: 5px 5px; background: #F5F5F5;" |M0
 |-
-| style="padding: 5px 5px; background: #F5F5F5;" |T3
+| 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
-| style="padding: 5px 5px; background: #F5F5F5;" |N2
-| style="padding: 5px 5px; background: #F5F5F5;" |M0
 |-
-| rowspan="2" style="padding: 5px 5px; background: #DCDCDC;" |Stage IIIB
+| 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="padding: 5px 5px; background: #F5F5F5;" |Any T
-| style="padding: 5px 5px; background: #F5F5F5;" |N3
-| style="padding: 5px 5px; background: #F5F5F5;" |M0
 |-
-| style="padding: 5px 5px; background: #F5F5F5;" |T4
+| 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="padding: 5px 5px; background: #F5F5F5;" |Any N
-| style="padding: 5px 5px; background: #F5F5F5;" |M0
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" |Stage IV
+| 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
-| style="padding: 5px 5px; background: #F5F5F5;" |Any T
-| style="padding: 5px 5px; background: #F5F5F5;" |Any N
-| style="padding: 5px 5px; background: #F5F5F5;" |M1
 |}
@@ Line 214: / Line 238: @@
 {{WH}}
 {{WS}}
+<references />