Non-Small Cell Lung Cancer Professional Information

STAGE INFORMATION

Stage has a critical role in the selection of therapy. The stage of disease is based on a combination of clinical (physical examination, radiologic, and laboratory studies) and pathologic (biopsy of lymph nodes, bronchoscopy, mediastinoscopy, or anterior mediastinotomy.[1] The distinction between clinical stage and pathologic stage should be considered when evaluating reports of survival outcome. Surgical staging of the mediastinum is considered standard if accurate evaluation of the nodal status is needed to determine therapy. The Radiology Diagnostic Oncology Group reported that the sensitivity and specificity of computed tomographic (CT) scanning is only 52% and 69%, respectively.[2] Magnetic resonance imaging does not appear to improve the accuracy of staging.[2] Early evaluation of the role of positron emission tomography (PET) suggests that the combination of CT and PET may have greater sensitivity and specificity than CT alone.[3] A report evaluating the staging of 1,400 patients undergoing tumor resection found that clinical staging by radiologic studies accurately assessed the T stage in 78% of patients and the N stage in only 47% of patients. Errors in clinical staging were equally divided between overstaging and understaging.[4]

The Revised International Staging System for Lung Cancer

The American Joint Committee on Cancer (AJCC) has designated staging by TNM classification.[6]

TNM definitions

TX: Primary tumor cannot be assessed, or tumor proven by the presence of malignant cells in sputum or bronchial washings but not visualized by imaging or bronchoscopy
T0: No evidence of primary tumor
Tis: Carcinoma in situ
T1: A tumor that is 3 cm or less in greatest dimension, surrounded by lung or visceral pleura, and without bronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e., not in the main bronchus)*
T2: A tumor with any of the following features of size or extent: More than 3 cm in greatest dimension Involves the main bronchus, 2 cm or more distal to the carina Invades the visceral pleura Associated with atelectasis or obstructive pneumonitis that extends to the hilar region but does not involve the entire lung
T3: A tumor of any size that directly invades any of the following: chest wall (including superior sulcus tumors), diaphragm, mediastinal pleura, parietal pericardium; or tumor in the main bronchus less than 2 cm distal to the carina but without involvement of the carina; or associated atelectasis or obstructive pneumonitis of the entire lung
T4: A tumor of any size that invades any of the following: mediastinum, heart, great vessels, trachea, esophagus, vertebral body, carina; or separate tumor nodules in the same lobe; or tumor with a malignant pleural effusion **

**Note: Most pleural effusions associated with lung cancer are due to tumor. However, there are a few patients in whom multiple cytopathologic examinations of pleural fluid are negative for tumor. In these cases, fluid is non-bloody and is not an exudate. When these elements and clinical judgement dictate that the effusion is not related to the tumor, the effusion should be excluded as a staging element and the patient should be staged as T1, T2, or T3.

Regional lymph nodes (N)

NX: Regional lymph nodes cannot be assessed
N0: No regional lymph node metastasis
N1: Metastasis to ipsilateral peribronchial and/or ipsilateral hilar lymph nodes, and intrapulmonary nodes including involvement by direct extension of the primary tumor
N2: Metastasis to ipsilateral mediastinal and/or subcarinal lymph node(s)
N3: Metastasis to contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph node(s)

MX: Distant metastasis cannot be assessed
M0: No distant metastasis
M1: Distant metastasis present

BRA = brain EYE = eye HEP = hepatic
LYM = lymph nodes MAR = bone marrow OSS = osseous
OTH = other OVR = ovary PER = peritoneal
PLE = pleura PUL = pulmonary SKI = skin

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AJCC stage groupings

Occult carcinoma

TX, N0, M0

Stage 0

Tis, N0, M0

Stage IA

T1, N0, M0

Stage IB

T2, N0, M0

Stage IIA

T1, N1, M0

Stage IIB

T2, N1, M0 T3, N0, M0

Stage IIIA

T1, N2, M0 T2, N2, M0 T3, N1, M0 T3, N2, M0

Stage IIIB

Any T, N3, M0
T4, Any N, M0

Stage IV

Any T, Any N, M1

References:

1. Ginsberg RJ: Invasive and noninvasive techniques of staging in potentially operable lung cancer. Seminars in Surgical Oncology 6(5): 244-247, 1990.
2. Webb WR, Gatsonis C, Zerhouni EA, et al.: CT and MR imaging in staging non-small cell bronchogenic carcinoma: report of the Radiologic Diagnostic Oncology Group. Radiology 178(3): 705-713, 1991.
3. Vansteenkiste JF, Stroobants SG, De Leyn PR, et al.: Lymph node staging in non-small-cell lung cancer with FDG-PET scan: a prospective study on 690 lymph node stations from 68 patients. Journal of Clinical Oncology 16(6): 2142-2149, 1998.
4. Bulzebruck H, Bopp R, Drings P, et al.: New aspects in the staging of lung cancer: prospective validation of the International Union Against Cancer TNM classification. Cancer 70(5): 1102-1110, 1992.
5. Mountain CF: Revisions in the International System for Staging Lung Cancer. Chest 111(6): 1710-1717, 1997.
6. Lung. In: American Joint Committee on Cancer: AJCC Cancer Staging Manual. Philadelphia, Pa: Lippincott-Raven Publishers, 5th ed., 1997, pp 127-137.

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