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Quick Test posted on 2.7.12:
| Lung Cancer Staging
| In a patient with either a histologically-confirmed lung cancer or a pulmonary lesion suspected to be a lung cancer, assessment encompasses three areas: the primary tumor, presence of metastatic disease, and functional status (the patient's ability to tolerate a pulmonary resection). A discrete approach to these three areas allows the surgeon to systematically evaluate a patient, permits clinical stage assignment, and enables assessment of the patient's functional suitability for pulmonary resection. Assessment of the primary tumor begins with the history and directed questions regarding the presence or absence of pulmonary, nonpulmonary, thoracic, and paraneoplastic symptoms. Patients often have already undergone a chest x-ray or CT scan before their initial visit with the surgeon; the location of the tumor can then help direct the history. Obtaining a chest CT scan is the next stage in evaluating a new patient. A routine chest CT scan should include intravenous contrast material to enable delineation of mediastinal lymph nodes relative to normal mediastinal structures. Chest CT allows assessment of the primary tumor and its relationship to surrounding and contiguous structures. It also indicates whether invasion of contiguous structures has occurred. The determination of invasion often is made by the patient's history and the location of the primary tumor. For example, a tumor abutting the chest wall with underlying rib destruction is clear evidence of local invasion. It is common to see the primary tumor abutting the chest wall without evidence of rib destruction. In this circumstance, the history is an accurate guide to the presence or absence of parietal pleural, rib, or intercostal nerve involvement. Similar observations apply to tumors abutting the recurrent laryngeal nerve, phrenic nerve, diaphragm, vertebral bodies, and chest apex. Thoracotomy should not be denied because of presumptive evidence of invasion of the chest wall, vertebral body, or mediastinal structures; proof of invasion may require thoracoscopy or even thoracotomy. Distant metastases are found in about 40% of patients with newly diagnosed lung cancer. The presence of lymph node or systemic metastases may imply inoperability. A patient's risk of harboring metastatic disease must be carefully considered by the surgeon. As with the primary tumor, assessment for the presence of metastatic disease should begin with the history and physical examination, focusing on the presence or absence of new bone pain, neurologic symptoms, and new skin lesions. In addition, constitutional symptoms (e.g., anorexia, malaise, and unintentional weight loss of greater than 5% of body weight) suggest either a large tumor burden or the presence of metastases. Physical examination should focus on the patient's overall appearance, noting any evidence of weight loss with muscle wasting. The appearance of cervical and supraclavicular lymph nodes as well as that of the oropharynx should also be examined for tobacco-associated tumors. PET scanning has supplanted multiorgan scanning in the search for distant metastases to the liver, adrenal glands, and bones. Currently, chest CT and PET are routine in the evaluation of patients with lung cancer. Brain MRI should be performed when the suspicion or risk of brain metastases is increased. Several reports show that PET scanning appears to detect an additional 10 to 15% of distant metastases not detected by routine chest or abdominal CT and bone scans. The finding of PET FDG uptake at a distant site must be proven not to be a metastasis. This is often accomplished with MRI and/or biopsies.
| | Table 18-9. TNM Stage Groupings. | | Primary tumor | | TX | Primary tumor cannot be assessed, or cytologic evidence 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 | Tumor 3 cm or less in greatest diameter, completely surrounded by lung or visceral pleura, and without bronchoscopic evidence of involvement of more proximal than a lobar bronchus | | T2 | Tumor more than 3 cm in greatest diameter, invading the visceral pleura, involving the main stem bronchus but greater than 2 cm distal to the carina, or tumor associated with atelectasis or obstructive pneumonitis extending to the hilum but not involving the entire lung | | T3 | Tumor of any size invading the chest wall, diaphragm, mediastinal pleura, parietal pericardium, tumor involving the main stem bronchus within 2 cm of but not involving the carina, or tumor associated with atelectasis or obstructive pneumonitis of the entire lung | | T4 | Tumor of any size invading the mediastinum, heart, great vessels, trachea, esophagus, vertebral body, or carina, or tumor associated with a malignant pleural effusion | | Regional lymph nodes (N stage) | | NX | Regional lymph nodes cannot be assessed | | N0 | No evidence of regional lymph node metastases | | N1 | Metastases in ipsilateral peribronchial or hilar lymph nodes, including by direct extension | | N2 | Metastases in ipsilateral mediastinal or subcarinal lymph nodes | | N3 | Metastases in contralateral mediastinal or hilar lymph nodes or ipsilateral or contralateral scalene or supraclavicular nodes | | Distant metastases (M stage) | | MX | Presence of distant metastases cannot be assessed | | M0 | No evidence of distant metastases | | M1 | Distant metastases are present | | Stage grouping | | Occult disease | 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 | T1-2, N2, M0, or T3, N0-2, M0 | | Stage IIIB | T4, Any N, M0, or Any T, N3, M0 | | Stage IV | Any T, Any N, M1 |
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