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Faces of Lung Cancer

Lung Cancer Staging

What is staging and why is it important?

Understanding the stage, or extent, of lung cancer is important to a doctor in determining what the patient’s treatment options are, and can help patients better understand the reason for those options.

What tests and procedures are used to stage lung cancer?

Imaging tests
In lung cancer, x-rays, CT (computed tomography, also called CAT) scans, MRI (magnetic resonance imaging) scans, and PET (positron emission tomography) scans are used to find out more about the cancer. These tests can show where the cancer is, what the tumor(s) looks like, the size of the tumor(s), whether the cancer has spread and, if so, how far. For more information on imaging and early disease management of lung cancer visit LCA's Early Interventions Resource Center.

Pathology reports
In lung cancer, biopsies typically provide information for pathology reports. Biopsies may include information about the size of the tumor and growth into other tissues and organs, the type of lung cancer, and the grade of the tumor. Using cells that been coughed up from the lungs, sputum cytology may identify the presence of lung cancer and can tell what type it is but cannot show where the tumor is or the extent of the cancer so follow-up tests are needed.

Surgical biopsy
Surgery can give further information about the size of the tumor and what it looks like, as well as the appearance of lymph nodes and nearby organs.

Laboratory tests
Testing blood, urine, etc. can show how other organs, such as the liver, are functioning. This may provided valuable information regarding if lung cancer has spread.

The two types of lung cancer are staged in different ways.

Non-Small Cell Lung Cancer

Non-small cell lung cancer is one of several cancers that are staged using the TNM system. The cancer is staged according to the size of the tumor (T), the extent the cancer has spread to the lymph nodes (N), and the extent the cancer has spread beyond the lymph nodes, or metastasis (M).

About The TNM Staging System

The TNM staging system:

Was created by merging the staging systems of the American Joint Committee on Cancer (AJCC) http://www.cancerstaging.org/ and the International Union Against Cancer (UICC) http://www.uicc.org/ in 1987
Is one of the most commonly used cancer staging systems
Standardizes cancer staging internationally
NSCLC is staged when the 7th edition of the TNM Classification of Malignant Tumors

How Does The TNM Staging System Work?

T is for Tumor
How big is the tumor? Where is it located? Has it spread to nearby tissue?

N is for Lymph Node
Has the cancer spread to the lymph nodes in and around the lungs?

M is for Metastasis
Has the cancer spread to other parts of the body?

T is for Tumor

TX	The primary tumor cannot be assessed OR the presence of a tumor was only proven by the finding of cancer cells in sputum or other non-imaging tests or bronchoscopy
T0	No evidence of a primary tumor
Tis	"In situ" - cancer is only in the area where the tumor started and has not spread to nearby tissues
T1	The tumor is less than 3 cm (just slightly over 1 inch), has not spread to the membranes that surround the lungs (visceral pleura), and does not affect the main branches of the bronchi
T1a	The tumor is less than 2 cm
T1b	The tumor is larger than 2 cm but less than 3 cm
T2	The tumor is larger than 3 cm but less than 7 cm OR involves the main bronchus or visceral pleura. The tumor may partially block the airways but has not caused the entire lung to collapse (atelectasis) or to develop pneumonia
T2a	The tumor is larger than 3 cm but less than or equal to 5 cm
T2b	The tumor is larger than 5 cm but less than or equal to 7 cm
T3	The tumor is more than 7 cm OR touches an area near the lung (such as the chest wall or diaphragm, or sac surrounding the heart- pericardium) OR has grown into the main bronchus but not the area where the windpipe (trachea) divides OR has caused one lung to collapse or pneumonia in an entire lung OR there is a separate tumor(s) in the same lobe
T4	The tumor is of any size AND has spread to the medistinum, heart, trachea, esophagus, backbone or the place where the windpipe (trachea) branches OR there is a separate tumor(s) in a different lobe of the same lung

N is for Lymph Nodes

NX	Regional lymph nodes cannot be assessed
N0	No cancer found in the lymph nodes
N1	Cancer has spread to lymph nodes within the lung or to the area where the bronchus enters the lung, but only on the same side of the lung as the tumor (ipsilateral)
N2	Cancer has spread to lymph nodes near where the windpipe (trachea) branches into the left and right bronchi or near the mediastinum, but only on the same side of the lung as the tumor
N3	Cancer has spread to lymph nodes found on the opposite side of the lung as the tumor (contralateral) or lymph nodes in the neck

M is for Metastases

MX	Cancer spread cannot be assessed
M0	Cancer has not spread
M1	Cancer has spread
M1a	Cancer has spread: Separate tumor(s) in a lobe in the opposite lung from the primary tumor (contralateral) , OR malignant nodules/effusion in the pleura or pericardium
M1b	Cancer has spread to distant part of the body such as brain, kidney, bone

Overall staging

Overall stage	T	N	M
Stage 0	Tis (in situ)	N0	M0
Stage IA	T1a, b	N0	M0
Stage IB	T2a	N0	M0
Stage IIA	T1a, b T2a T2b	N1 N1 N0	M0 M0 M0
Stage IIB	T2b T3	N1 N0	M0 M0
Stage IIIA	T1, T2 T3 T4	N2 N1, N2 N0, N1	M0 M0 M0
Stage IIIB	T4 Any T	N2 N3	M0 M0
Stage IV	Any T	Any N	M 1a, b

Sources:

National Cancer Institute Fact Sheet 5.9, Tumor Grade: Questions and Answers

National Cancer Institute Fact Sheet 5.32, Staging: Questions and Answers

Goldstraw, Peter. "The IASLC Lung Cancer Staging Project: Proposals for the Revision of the TNM Stage Groupings in the Forthcoming (Seventh) Edition of the TNM Classification of Malignant Tumours." Journal of Thoracic Oncology 2(8)(2007): 706-714.