Lung Staging

Which primary lung tumors are staged using the AJCC TNM system?

Non-small cell lung carcinoma (NSCLC)

• Squamous cell carcinoma — Central

• Adenocarcinoma — Peripheral

Small cell carcinoma → Central, mets early

Pulmonary carcinoid tumors → Central endobronchial mass

Which lung cancer is usually central?

Squamous cell carcinoma

Small cell carcinoma

Which lung cancer is usually peripheral?

Adenocarcinoma

Which lung cancer usually presents as a central endobronchial mass?

Carcinoid tumor

Which lung cancer frequently metastasizes early and is therefore often not treated surgically?

Small cell carcinoma

Which pulmonary procedures are commonly received for lung cancer staging?

Wedge resection

Segmentectomy

Lobectomy

Bilobectomy

Pneumonectomy

What gross findings should always be documented for lung cancer staging?

Specimen type

Tumor location

Tumor focality

Greatest tumor dimension

Visceral pleural invasion

Lymph node status

Margin status

Which tumor measurement is used for AJCC T staging?

Greatest single dimension of the invasive tumor

Which pleural finding directly affects T stage?

Visceral pleural invasion

What is pT1mi?

Minimally invasive lepidic pattern ≤ 5 mm

• Lepidic predominant

What is pTis?

Carcinoma in situ

What is pT1?

Tumor ≤3 cm

• Surrounded by lung or visceral pleura, without invasion proximal to the lobar bronchu

What are the T1 subdivisions?

T1a: ≤1 cm

T1b: >1–2 cm

T1c: >2–3 cm

What is pT2?

Tumor >3–5 cm

OR a tumor with any of the following:

• Visceral pleural invasion

• Main bronchus involvement (not involving the carina)

• Atelectasis or obstructive pneumonitis extending to the hilum

What are the T2 subdivisions?

T2a: >3–4 cm OR visceral pleura/central invasion

T2b: >4–5 cm

What is pT3?

>5-7 cm

OR invading:

• Chest wall

  • Thoracic T1, T2 nerve roots

  • Stellate ganglion

• Phrenic nerve, azygos vein

• Parietal pleura

• Pericardium

OR separate tumor nodule(s) in the same lobe

What are pT4?

>7 cm

OR invading:

• Diaphragm

• Mediastinum

• Heart

• Vagus nerve

• Great vessels

• SVC

• Trachea

• Recurrent laryngeal nerve

• Esophagus

• Vertebral body

• Carina

• Subclavian vessels, plexus brachialis, cervical nerve roots

OR separate tumor nodule(s) in a different ipsilateral lobe

Which bronchial landmark automatically makes a tumor T4 if invaded?

Carina

A 0.8 cm adenocarcinoma confined to the lung. T stage?

T1a

A 1.8 cm adenocarcinoma. T stage?

T1b

A 2.8 cm peripheral adenocarcinoma. T stage?

T1c

A 3.6 cm squamous cell carcinoma, but without invasion. T stage?

T2a

A 4.7 cm adenocarcinoma. T stage?

T2b

A 2.2 cm tumor with visceral pleural invasion. T stage?

T2 (visceral pleural invasion upstages the tumor regardless of size)

A 6.2 cm tumor confined to the lung. T stage?

T3

A 3 cm tumor invading the chest wall. T stage?

T3

A 3 cm tumor invading the phrenic nerve. T stage?

T3

A 3 cm tumor with another tumor nodule in the same lobe. T stage?

T3

An 8.5 cm tumor confined to the lung. T stage?

T4

A 2 cm tumor invading the carina. T stage?

T4

A 4 cm tumor invading the heart. T stage?

T4

A 2 cm tumor invading the esophagus. T stage?

T4

A tumor with a second nodule in a different ipsilateral lobe. T stage?

T4

What is pN0?

No regional lymph node metastasis.

What is pN1?

Mets in ipsilateral:

• Peribronchial

• Hilar

• Intrapulmonary

What is pN2?

Mets in ipsilateral:

• Mediastinal

• Subcarinal

What is pN3?

Mets in:

• Contralateral mediastinal

• Hilar

• Ipsilateral

• Contralateral scalene

• Supraclavicular nodes

What is pM1?

Distant mets

What is pM1a?

Any of the following:

• Contralateral lung nodule

• Pleural/Pericardial dissemination

  • Pleural nodules

  • Pericardial nodules

  • Malignant pleural effusion

  • Malignant pericardial effusion

Metastasis identified in ipsilateral hilar lymph nodes. N stage?

N1

Metastasis in intrapulmonary nodes. N stage?

N1

Metastasis in ipsilateral mediastinal nodes. N stage?

N2

Metastasis in subcarinal nodes. N stage?

N2

Metastasis in contralateral mediastinal nodes. N stage?

N3

Metastasis in supraclavicular nodes. N stage?

N3

What is M0?

No distant metastasis

What is M1b?

One single extrathoracic lesion (metastasis outside the thorax)

What are the M1c subcategories?

M1c1 — Multiple lesions, 1 organ system

M1c2 — Multiple lesions, >1 organ systems

Separate tumor nodule in the opposite lung. M stage?

M1a

Malignant pleural effusion. M stage?

M1a

Pericardial tumor nodules. M stage?

M1a

Single adrenal metastasis. M stage?

M1b

Liver and bone metastases. M stage?

M1c

T1a N0 M0 — Stage?

Stage IA1

T1b N0 M0 — Stage?

Stage IA2

T1c N0 M0 — Stage?

Stage IA3

T1a-c N1 M0 — Stage?

Stage IIA

T1a-c N2a M0 — Stage?

Stage IIB

T1a-c N3 M0 — Stage?

Stage IIIB

T2a N0 M0 — Stage?

Stage IB

T2a N1 M0 — Stage?

Stage IIB

T2a N2a M0 — Stage?

Stage IIIA

T2a N3 M0 — Stage?

Stage IIIB

T2b N0 M0 — Stage?

Stage IIA

T2b N1 M0 — Stage?

Stage IIB

T2b N2a M0 — Stage?

Stage IIIA

T2b N2b M0 — Stage?

Stage IIIB

T2b N3 M0 — Stage?

Stage IIIB

T3 N0 M0 — Stage?

Stage IIB

T3 N1 M0 — Stage?

Stage IIIA

T3 N2a M0 — Stage?

Stage IIIA

T3 N2b M0 — Stage?

Stage IIIB

T3 N3 M0 — Stage?

Stage IIIC

T4 N0 M0 — Stage?

Stage IIIA

T4 N1 M0 — Stage?

Stage IIIA

T4 N2a-b M0 — Stage?

Stage IIIB

T4 N3 M0 — Stage?

Stage IIIC

Any T N0 M0 — Stage?

Stage III disease (specific subgroup depends on T category)

Any T Any N M1a — Stage?

Stage IVA

Any T Any N M1b — Stage?

Stage IVA

Any T Any N M1c1 — Stage?

Stage IVB

Any T Any N M1c2 — Stage?

Stage IVB

Which pulmonary resection provides the most complete pathologic staging?

Pneumonectomy

Which pulmonary procedure is most commonly performed for a small peripheral pulmonary nodule?

Wedge resection

T1a-c N2b M0 — Stage?

Stage IIIA

T2a N2b M0 — Stage?

Stage IIIB