7ed stage lung cancer

DOI 10.1378/chest.10-1099 2011;139;183-189Chest

Omar Lababede, Moulay Meziane and Thomas Rice Quick Reference Chart and Diagrams

:Manual and Stage Grouping of Lung Cancer Seventh Edition of the Cancer Staging

http://chestjournal.chestpubs.org/content/139/1/183.full.html

services can be found online on the World Wide Web at: The online version of this article, along with updated information and

ISSN:0012-3692)http://chestjournal.chestpubs.org/site/misc/reprints.xhtml(

written permission of the copyright holder.this article or PDF may be reproduced or distributed without the priorDundee Road, Northbrook, IL 60062. All rights reserved. No part of Copyright2011by the American College of Chest Physicians, 3300Physicians. It has been published monthly since 1935.

is the official journal of the American College of ChestChest

© 2011 American College of Chest Physicians by guest on March 8, 2012chestjournal.chestpubs.orgDownloaded from


http://chestjournal.chestpubs.org/site/misc/reprints.xhtml

http://chestjournal.chestpubs.org/

CHEST Special Features

www.chestpubs.org CHEST / 139 / 1 / JANUARY, 2011 183

Lung cancer is the leading cause of cancer mortal-ity in both men and women in the United States. 1

Staging plays a critical role in guiding treatment selection and determining prognosis of cancer. Additionally, the evaluation of the response to treat-ment and the clinical research of cancer are facili-tated by a universal system. TNM staging provides a consistent, reproducible description of cancers based on the extent of anatomic involvement. This is achieved by defi ning the characteristics of the primary tumor (T), regional lymph node involvement (N), and metas-tases (M). The seventh edition of TNM staging for lung tumors has been released recently. The revisions in the new edition were recommended by the Inter-national Association for the Study of Lung Cancer staging project and were accepted by both the Inter-national 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 be

diffi cult 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 pri-mary 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 group-ings are color coded and can be found at the intersec-tions of appropriately matched horizontal and vertical columns. Stages with unique characteristics such as stages 0 and IV are defi ned in separate boxes. The basic design of the chart is based on our previously published reference chart of the fi 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 refl ected in our chart and diagrams. These changes include the following:

TNM system application to small cell lung car-• cinoma and carcinoid tumor of the lung (the previous system was applicable to non-small cell lung carcinoma only) Redefi nition of the primary tumor classifi cation • based on size:

T1 is subdivided into T1a and T1b T2 is subdivided into T2a and T2b Cancer larger than 7 cm is reclassifi ed as T3.

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 classifi cation of lymph node stations and zones is illustrated as well. CHEST 2011; 139(1):183–189

Abbreviations: M 5 metastases; N 5 regional lymph node involvement; T 5 primary tumor

Seventh Edition of the Cancer Staging Manual and Stage Grouping of Lung Cancer Quick Reference Chart and Diagrams

Omar Lababede , MD ; Moulay Meziane , MD ; and Thomas Rice , MD , FCCP

Manuscript received April 27, 2010; revision accepted June 14, 2010. Affi liations: 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: [email protected] © 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


http://www.chestpubs.org/site/misc/reprints.xhtml


www.chestpubs.org


184 Special Features

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. Malig-nant pleural and pericardial effusions were clas-sifi ed previously as T4 N0 Mx. Changes to stage groupings, including •

T4N0M0 and T4N1M0 tumors are reassigned from stage IIIB to stage IIIA.

The newly defi ned T2b tumors with no lymph node or distant metastases (T2bN0M0) are grouped under IIA instead of IB.

The newly defi ned T2a tumors with N1 lymph node but without distant metastases (T2aN1M0) are grouped under IIA rather than IIB.

Satellite nodule(s) in the same lobe as the pri-• mary tumor will now classify the tumor as T3 (previously T4), whereas their presence in a dif-ferent lobe of the same lung is reclassifi ed as T4 (previously M1).

Table 1— Seventh Edition of TNM Staging of Lung Tumors: Defi nition of T, N, and M 2-6

Descriptor Defi nition

Primary tumor (T ) Tx Tumor that cannot be assessed or is not detected radiologically or bronchoscopically but is proven histopathologically

(malignant cells in bronchopulmonary secretions) T0 No evidence of primary tumor Tis Carcinoma in situ T1 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 pleuraSubdivisions: T1a (size � 2 cm) and T1b (2 cm , size � 3 cm)

T2 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 pleuraSubdivisions: T2a (3 cm , size � 5 cm) and T2b (5 cm , size � 7 cm)

T3 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

T4 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

Lymph nodes (N) Nx Regional lymph nodes cannot be assessed N0 Absence of regional lymph node involvement N1 Presence of metastasis to ipsilateral peribronchial and/or ipsilateral hilar lymph nodes (including direct extension to

intrapulmonary nodes) N2 Presence of metastasis to ipsilateral mediastinal and/or subcarinal lymph nodes N3 Presence of metastasis to any of the following lymph node groups: contralateral mediastinal, contralateral hilar,

ipsilateral or contralateral scalene, or supraclavicular nodesDistant 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 superfi cial spreading tumor of any size with its invasive component limited to the bronchial wall is classifi ed as T1a even in the case of extension to main bronchus.

Table 2— Seventh Edition of TNM Staging of Lung Tumors: Stage Grouping 2-6

Occult carcinoma (TxN0M0)Stage 0 (TisN0M0)Stage IA (T1a/bN0M0)Stage IB (T2aN0M0)Stage IIA (T1a/bN1M0, T2aN1M0,T2bN0M0)Stage IIB (T2bN1M0, T3N0M0)Stage IIIA (T(1-3)N2M0, T3N1M0, T4N(0-1)M0)Stage IIIB (T4N2M0, T(1-4)N3M0)Stage IV (Any T, any N, M1)




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) classifi cations have not changed, a unifi ed map of lymph node sta-tions was adopted by the International Association for the Study of Lung Cancer. 2,3,8 The new map rec-

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.


www.chestpubs.org



Figure 2. Reference diagrams for 2009 TNM staging system of lung cancer. The T classifi cation can be defi ned by evaluating the size fi rst (upper left), then upgrading the classifi cation (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 classifi cation. The lower diagram can be used to defi ne the N and M classifi cation and to determine the corresponding stage. Note that N1, N2, N3, and the separate tumor nodule of M1a were depicted in the lower illustration based on a right-sided tumor (T). For left lung tumors, a mirror image of these descriptors should be used. Additionally, the endobronchial exten-sion and local invasion (A and B of the criteria of extent) were shown in the upper illustration based on a left-sided tumor to simplify the drawing. See Figure 1 legend for expansion of abbreviations.




Table 3— IASLC Lymph Node Defi nition 2,3,8

Nodal Zone Nodal Station Nodes Description

Defi nition

Upper Border Lower Border Other

Supraclavicular 1 (R and L) Low cervical, supraclavicular

and sternal notch

Lower margin of cricoid cartilage

Clavicles and upper border of the manubrium

Midline of the trachea defi nes

R and LUpper mediastinal

2R Right upper paratracheal

Apex of right lung and pleural cavity and upper

border of the manubrium

Intersection of caudal margin of the innominate

vein and trachea

Left lateral margin of the trachea

defi nes R and L2L Left upper

paratrachealApex of left lung and pleural cavity and upper border of

the manubrium

Upper limits of the aortic arch

3a Prevascular Apex of chest Level of carina a 3p Retrotracheal Apex of chest Level of carina ...4R Right lower

paratrachealIntersection of caudal margin of the innominate vein and

trachea

Lower border of the azygos vein

Left lateral margin of the trachea

defi nes R and L4L Left lower

paratrachealUpper limits of the aortic arch Upper rim of the left main

pulmonary arteryAortopulmonary 5 Subaortic

(aortopulmonary window)

Lower border of the aortic arch Upper rim of the left main pulmonary artery

Lateral to ligamentum

arteriosum6 Paraaortic (ascending

aorta or phrenic)Line tangential to the upper limits of the aortic arch

Lower border of the aortic arch

...

Subcarinal 7 Subcarinal The carina Upper border of lower lobe bronchus on the left and

lower border of the bronchus intermedius on the right

...

Lower mediastinal

8 (R and L) Paraesophageal Upper border of lower lobe bronchus on the left and

lower border of the bronchus intermedius on the right

Diaphragm The midline defi nes R and L

9 (R and L) Pulmonary ligaments The inferior pulmonary vein Diaphragm Within the pulmonary

ligamentHilar/interlobar 10 (R and L) Hilar Lower rim of the azygos on the

right and upper rim of the left main pulmonary artery on the left

Interlobar regions b

11 (R and L) Interlobar Between the origin of the lobar bronchi c Peripheral 12 (R and L) Lobar Adjacent to the lobar bronchi

13 (R and L) Segmental Adjacent to the segmental bronchi14 (R and L) Subsegmental Adjacent to the subsegmental bronchi

IASLC 5 International Association for the Study of Lung Cancer; L 5 left; R 5 right. a The posterior sternum forms the anterior border of the prevascular nodes, whereas the posterior border is limited by the anterior border of the superior vena cava on the right side and the left carotid artery on the left side. b Includes nodes adjacent to the main stem bronchi and hilar vessels, including the proximal aspects of the pulmonary arteries and veins. c Can be subdivided on the right into 11s (between the right upper lobe and bronchus intermedius) and 11i (between the middle and lower lobe bronchi).


www.chestpubs.org



Figure 3. The International Association for the Study of Lung Cancer lymph node map depicted on views of the chest. A, right lateral view. B, left lateral view. The lymph node stations are color coded and grouped into zones. The colored arrows defi ne the anatomic limits of certain color-matching stations. AA 5 aortic arch; AAo 5 ascending aorta; Ao 5 aorta; AzV 5 azygos vein; BI 5 bronchus intermedius; C 5 carina; E 5 esophagus; IPV 5 inferior pulmonary vein; IV 5 innominate vein; L 5 left; LLLB 5 left lower lobe bronchus; LPA 5 left main pulmonary artery; PA 5 main pulmonary artery; PUL. LIG. 5 pulmo-nary ligament; R 5 right; RLLB 5 right lower lobe bronchus; SVC 5 superior vena cava; T 5 trachea. 2,3,8




Acknowledgments Financial/nonfi nancial disclosures: The authors have reported to CHEST that no potential confl icts of interest exist with any companies/organizations whose products or services may be dis-cussed in this article.

References 1 . Jemal A , Siegel R , Ward E , Hao Y , Xu J , Thun MJ . Cancer

statistics, 2009 . CA Cancer J Clin . 2009 ; 59 ( 4 ): 225 - 249 . 2 . Goldstraw P, ed. International Association for the Study of

Lung Cancer Staging Manual in Thoracic Oncology . 1st ed. Orange Park, FL: Editorial Rx Press; 2009 .

3 . Edge SB , Byrd DR , Compton CC , Fritz AG , Greene FL , Trotti A III, eds. AJCC Cancer Staging Manual . 7th ed. New York, NY: Springer; 2009 .

4 . Goldstraw P . The 7th rdition of TNM in lung cancer: what now? J Thorac Oncol . 2009 ; 4 ( 6 ): 671 - 673 .

5 . Detterbeck FC , Boffa DJ , Tanoue LT . The new lung cancer staging system . Chest . 2009 ; 136 ( 1 ): 260 - 271 .

6 . Goldstraw P , Crowley J , Chansky K , et al ; International Association for the Study of Lung Cancer International Staging Committee ; Participating Institutions . The IASLC Lung Cancer Staging Project: proposals for the revision of the TNM stage groupings in the forthcoming (seventh) edition of the TNM Classifi cation of malignant tumours . J Thorac Oncol . 2007 ; 2 ( 8 ): 706 - 714 .

7 . Lababede O , Meziane MA , Rice TW . TNM staging of lung cancer: a quick reference chart . Chest . 1999 ; 115 ( 1 ): 233 - 235 .

8 . Rusch VW , Asamura H , Watanabe H , Giroux DJ , Rami-Porta R , Goldstraw P ; Members of IASLC Staging Committee . The IASLC lung cancer staging project: a proposal for a new international lymph node map in the forthcoming seventh edition of the TNM classifi cation for lung cancer . J Thorac Oncol . 2009 ; 4 ( 5 ): 568 - 577 .

Figure 3. Continued.


www.chestpubs.org


DOI 10.1378/chest.10-1099 2011;139; 183-189Chest

Omar Lababede, Moulay Meziane and Thomas RiceLung Cancer : Quick Reference Chart and Diagrams

Seventh Edition of the Cancer Staging Manual and Stage Grouping of

March 8, 2012This information is current as of

http://chestjournal.chestpubs.org/content/139/1/183.full.htmlUpdated Information and services can be found at:

Updated Information & Services

http://chestjournal.chestpubs.org/content/139/1/183.full.html#ref-list-1This article cites 6 articles, 2 of which can be accessed free at:

References

http://www.chestpubs.org/site/misc/reprints.xhtmlfound online at: Information about reproducing this article in parts (figures, tables) or in its entirety can bePermissions & Licensing

http://www.chestpubs.org/site/misc/reprints.xhtmlInformation about ordering reprints can be found online:

Reprints

"Services" link to the right of the online article.Receive free e-mail alerts when new articles cite this article. To sign up, select the

Citation Alerts

PowerPoint slide format. See any online figure for directions. articles can be downloaded for teaching purposes inCHESTFigures that appear in Images in PowerPoint format



http://chestjournal.chestpubs.org/content/139/1/183.full.html#ref-list-1




7ed stage lung cancer

Documents