Lung cancer staging

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kim-Son H. Nguyen M.D., Cafer Zorkun, M.D., Ph.D. [2]. Rim Halaby, M.D. [3], Michael Maddaleni, B.S.

Overview

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

Staging

The following is 2017 TNM classification of lung cancer.

T: Primary Tumor

T	Description
TX	Primary tumor cannot be assessed. OR Tumor is demonstrated by the presence of malignant cells in bronchial washings or sputum, but is not visualized by imaging or bronchoscopy.
T0	There is no evidence of primary tumor.
Tis	Carcinoma in situ
T1	The tumor has the following characteristics: 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
	T4	N3	M0
Stage IVA	Any T	Any N	M1a
	Any T	Any N	M1b
Stage IVB	Any T	Any N	M1c

Procedures

There are currently multiple different procedures available to stage lung cancer.

• They can be broken down into two overarching categories, invasive and minimally invasive.
  • The invasive procedures are:
    • EUS-NA (esophageal endoscopic ultrasound with needle aspiration)
    • TBNA (transbronchial needle aspiration)
    • EBUS-NA (endobronchial ultrasound with needle aspiration)
    • TTNA (transthoracic needle aspiration)
    • VATS staging (video assisted thoracic surgery) aka thoracoscopy
    • Extended cervical mediastinoscopy
    • Chamberlain procedure
  • The minimally invasive procedures are:
    • EBUS-FNA (endobronchial ultrasound guided fine needle aspiration)
    • EUS-FNA (esophageal endoscopic ultrasound guided fine needle aspiration)

References

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