Lung cancer classification

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

Overview

Primary lung cancer can be classified into two main categories: small cell lung cancer (~15%) and non small cell lung cancer (~85%). Non small cell lung cancer includes several subtypes grouped together because their prognosis and management are similar. The 2004 WHO histological classification of tumors of the lung categorized lung tumors into malignant epithelial tumors, benign epithelial tumors, lymphoproliferative tumors, miscellaneous tumors, and metastatic tumors.

Classification

• Primary lung cancer can be classified into two main categories: small cell lung cancer (~15%) and non small cell lung cancer (~85%).
• There are three main sub-types of non small cell lung cancer , which are grouped together because their prognosis and management are similar:
  • Squamous cell carcinoma (25% of lung cancers)
  • Adenocarcinoma (40% of lung cancers) and large cell lung carcinoma (10% of lung cancers)
  • Large cell carcinoma (10% of lung cancers)
• A subtype of adenocarcinoma, the bronchioloalveolar carcinoma, is more common in female never-smokers, and may have different responses to treatment.

WHO Histological Classification of Tumors of the Lung

Malignant Epithelial Tumors

• Squamous cell carcinoma

• Papillary
• Clear cell
• Small cell
• Basaloid

• Small cell carcinoma

• Combined small cell carcinoma

• Adenocarcinoma

• Adenocarcinoma, mixed subtype
• Acinar adenocarcinoma
• Papillary adenocarcinoma
• Bronchioloalveolar carcinoma

• Nonmucinous
• Mucinous
• Mixed nonmucinous and mucinous or indeterminate

• Solid adenocarcinoma with mucin production

• Fetal adenocarcinoma
• Mucinous (“colloid”) carcinoma
• Mucinous cystadenocarcinoma
• Signet ring adenocarcinoma
• Clear cell adenocarcinoma

• Large cell carcinoma

• Large cell neuroendocrine carcinoma

• Combined large cell neuroendocrine carcinoma

• Basaloid carcinoma
• Lymphoepithelioma-like carcinoma
• Clear cell carcinoma
• Large cell carcinoma with rhabdoid phenotype

• Adenosquamous carcinoma

• Sarcomatoid carcinoma

• Pleomorphic carcinoma
• Spindle cell carcinoma
• Giant cell carcinoma
• Carcinosarcoma
• Pulmonary blastoma

• Carcinoid tumor

• Typical carcinoid
• Atypical carcinoid

• Salivary gland tumors

• Mucoepidermoid carcinoma
• Adenoid cystic carcinoma
• Epithelial-myoepithelial carcinoma

• Preinvasive lesions

• Squamous carcinoma in situ
• Atypical adenomatous hyperplasia
• Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia

• Mesenchymal tumors

• Epithelioid haemangioendothelioma
• Angiosarcoma
• Pleuropulmonary blastoma
• Chondroma
• Congenial peribronchial myofibroblastic tumor
• Diffuse pulmonary lymphangiomatosis
• Inflammatory myofibroblastic tumor
• Lymphangioleiomyomatosis
• Synovial sarcoma

• Monophasic
• Biphasic

• Pulmonary artery sarcoma
• Pulmonary vein sarcoma

Benign Epithelial Tumors

• Papillomas

• Squamous cell papilloma

• Exophytic
• Inverted

• Glandular papilloma
• Mixed squamous cell and glandular papilloma

• Adenomas

• Alveolar adenoma
• Papillary adenoma
• Adenomas of the salivary gland type

• Mucous gland adenoma
• Pleomorphic adenoma
• Others

• Mucinous cystadenoma

Lymphoproliferative Tumors

• Marginal zone B-cell lymphoma of the MALT type
• Diffuse large B-cell lymphoma
• Lymphomatoid granulomatosis
• Langerhans cell histiocytosis

Miscellaneous Tumors

• Harmatoma
• Sclerosing hemangioma
• Clear cell tumor
• Germ cell tumors

• Teratoma, mature
• Immature
• Other germ cell tumors

• Intrapulmonary thymoma

• Melanoma

TNM Classification of Lung Cancer

T: Primary Tumor

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

N:Regional Lymph Nodes

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

M: Distant Metastasis

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

Classification of Lung Cancer by Staging

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

References

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