7ed Stage Lung Cancer

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Seventh Edition of the Cancer Staging Manual and Stage Grouping of Lung Cancer : Quick Reference Chart and DiagramsOmar Lababede, Moulay Meziane and Thomas Rice Chest 2011;139;183-189 DOI 10.1378/chest.10-1099 The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/139/1/183.full.html

Chest is the official journal of the American College of Chest Physicians. It has been published monthly since 1935. Copyright2011by the American College of Chest Physicians, 3300 Dundee Road, Northbrook, IL 60062. All rights reserved. No part of this article or PDF may be reproduced or distributed without the prior written permission of the copyright holder. (http://chestjournal.chestpubs.org/site/misc/reprints.xhtml) ISSN:0012-3692

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CHESTQuick Reference Chart and Diagrams

Special Features

Seventh Edition of the Cancer Staging Manual and Stage Grouping of Lung CancerOmar Lababede, MD; Moulay Meziane, MD; and Thomas Rice, MD, FCCP

Lung cancer remains the most common cause of cancer-related death in the United States. TNM staging, which is an important guide to the prognosis and treatment of lung cancer, has been revised recently. In this article, we propose a quick reference chart and diagrams that consolidate TNM staging information in a simple format. The current classication of lymph node stations and zones is illustrated as well. CHEST 2011; 139(1):183189Abbreviations: M 5 metastases; N 5 regional lymph node involvement; T 5 primary tumor

is the leading cause of cancer Lungincancermen and women in the United mortality both States.1

Staging plays a critical role in guiding treatment selection and determining prognosis of cancer. Additionally, the evaluation of the response to treatment and the clinical research of cancer are facilitated by a universal system. TNM staging provides a consistent, reproducible description of cancers based on the extent of anatomic involvement. This is achieved by dening the characteristics of the primary tumor (T), regional lymph node involvement (N), and metastases (M). The seventh edition of TNM staging for lung tumors has been released recently. The revisions in the new edition were recommended by the International Association for the Study of Lung Cancer staging project and were accepted by both the International Union Against Cancer and the American Joint Committee on Cancer.2-6 TNM staging of lung cancer is complex, and many variables must be considered (Tables 1, 2). It can beManuscript received April 27, 2010; revision accepted June 14, 2010. Afliations: From the Imaging Institute (Drs Lababede and Meziane) and the Department of Thoracic and Cardiovascular Surgery (Dr Rice), Cleveland Clinic, Cleveland, OH. Correspondence to: Omar Lababede, MD, Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195; e-mail: lababeo@ccf.org 2011 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/ site/misc/reprints.xhtml). DOI: 10.1378/chest.10-1099

difcult to use and remember. We have designed a chart and two diagrams to present the new staging system in a simple, but nevertheless comprehensive, format. The comparative characteristics of the primary tumor are listed in the vertical columns of the chart (Fig 1). These features include size and extent (endobronchial location, local invasion, and satellite nodule[s]). The horizontal columns describe regional lymph node involvement. The different stage groupings are color coded and can be found at the intersections of appropriately matched horizontal and vertical columns. Stages with unique characteristics such as stages 0 and IV are dened in separate boxes. The basic design of the chart is based on our previously published reference chart of the fth edition of lung cancer staging.7 The diagrams (Fig 2) illustrate the same information in a more concise visual format. The recently adopted revisions of TNM staging are reected in our chart and diagrams. These changes include the following: TNM system application to small cell lung carcinoma and carcinoid tumor of the lung (the previous system was applicable to non-small cell lung carcinoma only) Redenition of the primary tumor classication based on size: T1 is subdivided into T1a and T1b T2 is subdivided into T2a and T2b Cancer larger than 7 cm is reclassied as T3.CHEST / 139 / 1 / JANUARY, 2011

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Table 1Seventh Edition of TNM Staging of Lung Tumors: Denition of T, N, and M2-6Descriptor Primary tumor (T) Tx T0 Tis T1 Denition Tumor that cannot be assessed or is not detected radiologically or bronchoscopically but is proven histopathologically (malignant cells in bronchopulmonary secretions) No evidence of primary tumor Carcinoma in situ Tumor with the following characteristics: Size 3 cm Airway location: in lobar bronchus or more distal airways Local invasion: none, surrounded by lung or visceral pleura Subdivisions: T1a (size 2 cm) and T1b (2 cm , size 3 cm) Tumor with size . 3 cm but 7 cm or tumor with any of the following characteristics: Airway location: involvement of the main bronchus (distance to the carina is 2 cm) or presence of atelectasis or obstructive pneumonitis that extends to hilar region but does not involve the entire lung Local invasion: involvement of visceral pleura Subdivisions: T2a (3 cm , size 5 cm) and T2b (5 cm , size 7 cm) Tumor . 7 cm in size or tumor with any of the following: Airway location: tumor in the main bronchus (within 2 cm of the carina), or tumor with atelectasis or obstructive pneumonitis of the entire lung Local invasion: direct invasion of chest wall (including superior sulcus tumors), diaphragm, phrenic nerve, mediastinal pleura, or parietal pericardium Satellite tumor nodule(s) in the same lobe as the primary tumor Tumor of any size invading any of the following: mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body, or carina; or tumor with satellite tumor nodule(s) in a different lobe, ipsilateral to that of the primary tumor Regional lymph nodes cannot be assessed Absence of regional lymph node involvement Presence of metastasis to ipsilateral peribronchial and/or ipsilateral hilar lymph nodes (including direct extension to intrapulmonary nodes) Presence of metastasis to ipsilateral mediastinal and/or subcarinal lymph nodes Presence of metastasis to any of the following lymph node groups: contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular nodes

T2

T3

T4

Lymph nodes (N) Nx N0 N1 N2 N3

Distant metastasis (M) M0 Absence of distant metastasis M1 Presence of distant metastasis Subdivisions: M1a (satellite tumor nodule(s) in a contralateral lobe to that of the primary tumor or tumors with malignant pleural or pericardial effusion) M1b (distant metastasis) The uncommon supercial spreading tumor of any size with its invasive component limited to the bronchial wall is classied as T1a even in the case of extension to main bronchus.

Satellite nodule(s) in the same lobe as the primary tumor will now classify the tumor as T3 (previously T4), whereas their presence in a different lobe of the same lung is reclassied as T4 (previously M1).Table 2Seventh Edition of TNM Staging of Lung Tumors: Stage Grouping2-6Occult carcinoma Stage 0 Stage IA Stage IB Stage IIA Stage IIB Stage IIIA Stage IIIB Stage IV (TxN0M0) (TisN0M0) (T1a/bN0M0) (T2aN0M0) (T1a/bN1M0, T2aN1M0,T2bN0M0) (T2bN1M0, T3N0M0) (T(1-3)N2M0, T3N1M0, T4N(0-1)M0) (T4N2M0, T(1-4)N3M0) (Any T, any N, M1)

Redefinition of metastases (M): subdivision of M into M1a and M1b. M1a includes both satellite nodule(s) in the contralateral lung and malignant pleural and pericardial effusions. Malignant pleural and pericardial effusions were classied previously as T4 N0 Mx. Changes to stage groupings, including T4N0M0 and T4N1M0 tumors are reassigned from stage IIIB to stage IIIA. The newly dened T2b tumors with no lymph node or distant metastases (T2bN0M0) are grouped under IIA instead of IB. The newly dened T2a tumors with N1 lymph node but without distant metastases (T2aN1M0) are grouped under IIA rather than IIB.Special Features

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Figure 1. Reference chart for 2009 TNM staging system of lung cancer. M 5 metastases; N 5 regional lymph node involvement; T 5 tumor.

Although regional lymph node (N) classications have not changed, a unied map of lymph node stations was adopted by the International Association for the Study of Lung Cancer.2,3,8 The new map recwww.chestpubs.org

onciles discrepancies among previous nodal mapping proposals and introduces the concept of lymph node zones (Table 3). Figures 3A and 3B demonstrate the new lymph nodes stations.CHEST / 139 / 1 / JANUARY, 2011

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Figure 2. Reference diagrams for 2009 TNM staging system of lung cancer. The T classication can be dened by evaluating the size rst (upper left), then upgrading the classication (if necessary) based on the presence of the other criteria of primary tumor invasion/extent (A, B, and C). The criteria of extent should not be used to assign a lower classication. The lower diagram can be used to dene the N and M classication an