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TNM Staging: LungTONYA BRANDENBURG, MHA, CTR
KENTUCKY CANCER REGISTRY
Overview
Lung Anatomy Clinical Staging vs Pathological Staging Changes in T,N,M Staging from AJCC 6th
edition to 7th edition Elements of Staging: TX-T4, NX-N3, and
M0-M1b Stage Groups and Prognostic Factors Helpful Hints Lung Examples
Lung
Anatomic subsites of the lung.
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Bronchioles: The passageways by which air passes through the nose or mouth to the lungs. They are branches of the bronchi.
Alveolus ("little cavity") is an anatomical structure that has the form of a hollow cavity.[
The pulmonary alveoli are the terminal ends ofthe respiratory tree. The alveolar sacs or alveolar ducts are both sites of gas exchange with the blood as well.
Source of definitions: Wikipedia.com
Pancoast Tumor - A superior sulcus tumor that arises in the apex of the lung and spreads into chest wall (coded to upper lobe, C34.1)
Hilum – The root of the lung is located at the hilum of each lung, just above the middle of the mediastinal surface and behind the cardiac impression of the lung. (coded to main bronchus, C34.0)
Apex – The apex is at the top of the lung. It extends into the root of the neck, reaching between 2.5 centimeters and 4 centimeters above the level of the sternal end of the first rib. (coded to upper lobe, 34.1)
Mesothelioma - A malignancy that arises in the pleura (coded and staged to pleura, C38.4)
Topography Review
Mediastinum - The mediastinum is the central compartment of the thoracic cavity. The mediastinum contains the heart and its vessels, the esophagus, trachea, phrenic and cardiac nerves, the thoracic duct, thymus and lymph nodes of the central chest.
Pleura – The pleural cavity is the thin fluid-filled space between the two pulmonary pleurae (visceral and parietal) of each lung. A pleura is a serous membrane which folds back onto itself to form a two-layered membranous pleural sac.
Great Vessels – The great vessels include the aorta, superior vena cava, inferior vena cava, main pulmonary artery, intrapericardial segments of the trunk of the right and left pulmonary artery, intrapericardial segements of the superior and inferior right and left pulmonary veins
Common Terms
Clinical Staging
Clinical staging based on evidence acquired before treatment
Includes physical exam, imaging procedures (CT, PET) lab tests, and staging procedures such as scopes, thoracentesis and exploratory thoracotomy.
Within 4 months or before treatment, whichever is shorter
Pathological Staging
Pathological staging based on clinical staging info, definitive surgical resection operative findings, and path report of resected specimen
Or within 4 months of dx, whichever is longer There can be no systemic treatment or radiation
prior to resection If a patient has systemic treatment before
definitive surgery, you must stage using the y descriptor
Surgical resection must meet criteria for the chapter in order to stage the case pathologically
When to use blanks and X’s
Blanks should be used if:
There is no info in the chart to assign an AJCC value
If the patient isn’t eligible for pathological staging
If AJCC criteria for this stage classification is not met
X should be used if: Criteria for this stage classification is met
T cannot be assessed
N cannot be assessed
Cannot use X in the M category; MX is not a valid value
Does patient meet criteria for that stage classification?
Yes – patient meets classification criteria
If physician could not assess T and/or N for the patient, and definitive information for T and N not in chart
– Use TX and/or NX (Use of X is rare)
If there is no information about diagnostic workup or resection pathology in chart
– Use blank• Indicates registrar could not find information in
chart
– Do not use X
No – patient does NOT meet classification criteria
– Do NOT use X• Indicates patient eligible for staging
• Implies physician did not assess or have info on patient’s T and/or N
– Must use blanks• Indicates patient did not meet
classification criteria
Changes in T,N,M Staging for Lung from 6th edition to 7th edition
Classification recommended for: Non-small cell carcinomas, Small cell lung
carcinomas, and Carcinoid tumors T:
New tumor sizes and sub-classifications Multiple tumors in same lobe now T3 Multiple tumors in same lung different lobe now T4
N: New international lymph node map
M: Malignant pleural effusion now M1a
Elements of Staging:TX, T0, and Tis
TX: Tumor not seen on bronchoscopy or films, but diagnosed by sputum cytology (occult carcinoma)
T0: No evidence of primary tumor (use when you have metastasis that is consistent with lung primary, but no evidence of a primary tumor can be found)
Tis- Carcinoma in situ (rare in lung) – This is increasing because bronchio – alveolar carcinoma is now called adenocarcinoma in situ
Elements of Staging: T1
T1- Tumor 3 cm or less, surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus (not in the main bronchus) T1a = Tumor 2 cm or less in greatest dimension T1b = Tumor more than 2 cm but less than 3 cm
in greatest dimension
T1 is defined as a tumor 3 cm or less in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e., not in the main bronchus). T1a is defined as a tumor 2 cm or less in greatest dimension (upper left). T1a is also defined as a superficial spreading tumor of any size with its invasive component limited to the bronchial wall, which may extend proximally to the main bronchus (lower left). T1b is defined as a tumor more than 2 cm but 3 cm or less in greatest dimension (right).
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., Byrd
, D.R
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Elements of Staging: T2 T2- Tumor more than 3 cm but less than 7 cm
or tumor with any of the following features: Involves main bronchus, 2 cm or more distal to the carina
Invades visceral pleura (PL1 or PL 2) Associated with atelectasis or obstructive pneumonitis that
extends to the hilar region, but does not involve the entire lung
T2a = more than 3 cm but 5 cm or less in greatest dimension
T2b = Tumor more than 5 cm but 7 cm or less in greatest dimension
T2 is defined as a tumor more than 3 cm but 7 cm or less or tumor with any of the following features (T2 tumors with these features are classified T2a if 5 cm or less); involves main bronchus, 2 cm or more distal to the carina (middle left and middle right); invades visceral pleura (PL1 or PL2) (upper right); associated with atelectasis or obstructive pneumonitis that extends to the hilar region but does not involve the entire lung (bottom left). T2a is defined as tumor more than 3 cm but 5 cm or less in greatest dimension (upper left). T2b is defined as tumor more than 5 cm but 7 cm or less in greatest dimension (bottom right).
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, C.C
., Byrd
, D.R
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Elements of Staging: T3
T3- Tumor more than 7 cm that has any of the following: Parietal pleura (PL3) Chest wall (including superior sulcus
“pancoast” tumors, but see T4 as well) Diaphragm, Phrenic nerve, Mediastinal pleura,
or Parietal pericardium Tumor in main bronchus less than 2 cm distal
to the carina without carina involvement Associated atelectasis or obstructive
pneumonitis of the entire lung Separate tumor nodules in the same lobe
T3 is defined as a tumor more than 7 cm (upper middle left) or one that directly invades any of the following: parietal pleural (PL3), chest wall (including superior sulcus tumors) (upper left), diaphragm (lower left), phrenic nerve, mediastinal pleura, parietal pericardium; or tumor in the main bronchus (less than 2 cm distal to the carina but without involvement of the carina) (lower middle left); or associated atelectasis or obstructive pneumonitis of the entire lung (right) or separate tumor nodule(s) in the same lobe.
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, C.C
., Byrd
, D.R
., et al., E
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T3 includes separate tumor nodule(s) in the same lobe. T4 includes separate tumor nodule(s) in a different ipsilateral lobe.
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., Byrd
, D.R
., et al., E
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Elements of Staging: T4
Mediastinum Heart Great vessels Trachea Recurrent laryngeal
nerve Esophagus
Vertebral body
(including extension from a Pancoast Tumor)
Carina Separate tumor
nodules in a different ipsilateral lobe
T4 is tumor of any size that invades any of the following:
T4 is defined as tumor of any size that invades any of the following: mediastinum, heart, great vessels (upper right), trachea (upper left), recurrent laryngeal nerve, esophagus (lower right), vertebral body (lower left), carina (middle left and right), separate tumor nodule(s) in a different ipsilateral lobe.
Com
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, C.C
., Byrd
, D.R
., et al., E
dito
rs. AJC
C C
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rSta
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N1 Nodes: Numbers 8 through 11 and includinginterlobar (not shown)N2 Nodes: Numbers 1 through 7N3 Nodes (not shown): Supraclavicular, scalene, any node contralateral to primary tumor
AP Window Nodes are N2 Nodes
Elements of Staging: NX, N0, and N1
NX: Regional lymph nodes cannot be assessed
N0: No regional lymph node metastasis N1: Metastasis in ipsilateral peribronchial
and or ipsilateral hilar lymph nodes and intrapulmonary nodes, including involvement by direct extension
Com
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, C.C
., Byrd
, D.R
., et al., E
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rs. AJC
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Elements of Staging: N2 and N3
N2: Metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s)
N3: Metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph nodes
Don’t forget: N3 is DISTANT disease in SEER Summary Staging
Com
pton
, C.C
., Byrd
, D.R
., et al., E
dito
rs. AJC
C C
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rSta
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s, 2
nd E
dition
. New
Yo
rk: Sp
ring
er, 20
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Com
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, C.C
., Byrd
, D.R
., et al., E
dito
rs. AJC
C C
ance
rSta
gin
g Atla
s, 2
nd E
dition
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Elements of Staging: MX, M0, and M1
MX: No longer exists in TNM Staging
M0: No distant metastasis (Remember: not possible for
pathologic staging)
M1: Distant Metastasis M1a includes:
Separate tumor nodule(s) in a contralateral lobe Tumor with pleural nodules Malignant pleural or pericardial effusion
M1b- Metastasis in distant organs or lymph nodes
Com
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, C.C
., Byrd
, D.R
., et al., E
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rs. AJC
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Stage Groups
Prognostic Factor: Plueral/Elastic Layer Invasion
A tumor that falls short of completely traversing the elastic layer of the visceral pleura is defined as PL0. A tumor that extends through the elastic layer is defined as PL1 and one that extends to the surface of the visceral pleural as PL2. Extension of the tumor to the parietal pleura is defined as PL3.
Com
pton
, C.C
., Byrd
, D.R
., et al., E
dito
rs. AJC
C C
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s, 2
nd E
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TNM Staging Scheme DOES NOT match the SEER Summary Staging Scheme for lung cancer!
Pages 260 through 262 have a listing of the different lymph node stations in Japan Lung Cancer Society Map, MD-ATS Map, and IASLC Map (now the recommended means of describing regional node involvement for lung cancer)
Additional notes for TNM staging can be found on page 266 under “Additional Notes Regarding TNM Descriptors”
Helpful Hints
Lung Case 1 Answers
Topography: C34.3
Histology: 8041/3 This case is one primary per rule M12
Clinical Staging
cT 2a
cN 2
cM 1a
Clinical Stage Group
IV
Pathological Staging
pT Blank
pN Blank
pM Blank
Pathologic Stage Group
Blank
SEER Summary Stage: 7- Distant
Lung Case 2 Answers
Topography: C34.3
Histology: 8140/3 This case is one primary per rule M2
Clinical Staging
cT 1a
cN 0
cM 0
Clinical Stage Group
IA
Pathological Staging
pT 2a
pN 0
pM cM0
Pathologic Stage Group IB
SEER Summary Stage: 1 – Local disease
