1. IMAGING FINDINGS - The NSCLC stage classification is based on the TNM system: - T: extent of the primary tumor - N: extent of regional lymph node involvement - M: extent of spread to distant sites This classification does not include clinical symptoms or molecular characterization

2. IMAGING FINDINGS T descriptor The differences with previous T staging are: - A 2 cm cutpoint subdivides T1a and T1b - A 5 cm cutpoint subdivides T2a and T2b - The presence of satellite nodules in the same lobe as the primary tumor is now T3 - The presence of an ipsilateral nodule in a different lobe is now T4

3. IMAGING FINDINGS T1 descriptor T1a: ≤ 2 cm Previously: 2cm Fig 1.- A.- MSCT shows a 6 mm non-calcified lung nodule with well-defined borders located in the right lower lobe. B.- The MSCT exam repeated one year later demonstrated 2 mm increase in size, measuring up to 8 mm. It was resected and proved to be a lung adenocarcinoma stage T1a. AB 8 mm

4. IMAGING FINDINGS T1 descriptor T1b: > 2 cm Previously: 2cm 25 mm Fig 2.- A.- MSCT images showing a spiculated pulmonary nodule with peripheral calcification, dense peripheral halo and bronchogram. Cytology was recommended. B.- The MSCT exam performed two years later showed significant growth (25 x 20 mm), suggesting a T1b stage lung cancer. AB

5. IMAGING FINDINGS T1a and T1b: a 2 cm cutpoint T1b: > 2 cm T1a: ≤ 2 cm Previously: 2cm Fig 3.- MSCT features of a 6 x 5.5 mm adenocarcinoma appearing as a subpleural nodule with spiculated margins and pleural tails located in the right upper lobe. Fig 4.- MSCT shows a 25 x 16 mm focal consolidation located in the right lower lobe proved to be lung adenocarcinoma after surgical excision.

6. IMAGING FINDINGS T descriptor The differences with previous T staging are: - A 2 cm cutpoint subdivides T1a and T1b - A 5 cm cutpoint subdivides T2a and T2b - The presence of satellite nodules in the same lobe as the primary tumor is now T3 - The presence of an ipsilateral nodule in a different lobe is now T4

7. IMAGING FINDINGS T2a and T2b: a 5 cm cutpoint T2a: >3 - ≤5 Previously: 5 cm Fig 6.- A 46 mm malignant lesion located in the right lower lobe with spiculated margins and pleural tails. As its larger diameter measures between 5 and 7 cm it is classified as stage T2b. Fig 5.- Pulmonary mass of 35 x 20 mm located in the right upper lobe suggestive of malignancy. As its larger diameter measures between 3 and 5 cm, it is classified as stage T2a.

8. IMAGING FINDINGS T2 descriptor T2b: >5 - ≤7 Previously: 5 cm Fig 7- A.- Axial view. B.- Sagittal view. A 52 mm malignant pulmonary mass located in the middle lobe with well-defined borders and peripheral halo causing the amputation of the middle lobe bronchus. AB

9. IMAGING FINDINGS T2a and T2b: a 5 cm cutpoint T2b: >5 - ≤7T2a: >3 - ≤5 Previously: 5 cm Fig 9.- A 53 mm malignant lesion located in the right upper lobe with spiculated margins and pleural tails. As its larger diameter mesures between 5 and 7 cm it is classified as stage T2b. Fig 8.- Pulmonary mass of 35 x 20 mm located in the right upper lobe suggestive of malignancy. As its larger diameter measures between 3 and 5 cm, it is classified as stage T2a.

10. IMAGING FINDINGS T descriptor The differences with previous T staging are: - A 2 cm cutpoint subdivides T1a and T1b - A 5 cm cutpoint subdivides T2a and T2b - The presence of satellite nodules in the same lobe as the primary tumor is now T3 - The presence of an ipsilateral nodule in a different lobe is now T4

11. IMAGING FINDINGS T3 descriptor Satellite nodules in the same lobe as the primary tumor T3 Previously: T4 Fig 10.- 20 x 13 mm lobulated pulmonary nodule located in the right lower lobe suggestive of lung cancer. Other small nodules are seen adjacent to the malignant one. The presence of these satellite nodules located in the same lobe as the primary tumor indicates a T3 stage. In the previous staging system it was classified asT4.

12. IMAGING FINDINGS T descriptor The differences with previous T staging are: - A 2 cm cutpoint subdivides T1a and T1b - A 5 cm cutpoint subdivides T2a and T2b - The presence of satellite nodules in the same lobe as the primary tumor is now T3 - The presence of an ipsilateral nodule in a different lobe is now T4

13. IMAGING FINDINGS T4 descriptor An ipsilateral satellite nodule in a different lobe T4 Previously: M1 Fig 11.- Left hilar mass invading the left main bronchus and the left upper lobe bronchus causing left lower lobe obstruction and obstructive pneumonitis. There are satellite nodules in the left upper lobe. In the new TNM staging system it is now classified as T4, whereas it was considered M1 in the previous clasiffication.

14. IMAGING FINDINGS N descriptor The N descriptor defines the extent of involvement of regional lymph nodes: - N0: No regional node metastasis. - N1: Metastasis in ipsilateral peribronchial or perihilar lymph nodes and intrapulmonary nodes. - N2: Metastasis in ipsilateral mediastinal or subcarinal lymph nodes. - N3: Metastasis in contralateral mediastinal or hilar nodes and ipsilateral or contralateral scalene or supraclavicular lymph nodes. No changes have been made in the N descriptor as defined in the previous staging system

15. IMAGING FINDINGS N descriptor N1 Ipsilateral peribronchial or perihilar lymph nodes Fig 12.- A.- Parahilar irregularly shaped mass in the upper segment of the left lower lobe of the lung that infiltrates the inferior pulmonary vein and the adjacent bronchus. B.- Left hilar lymph nodes were observed and classified as stage N1. AB

16. IMAGING FINDINGS N descriptor The N descriptor defines the extent of involvement of regional lymph nodes: - N0: No regional node metastasis. - N1: Metastasis in ipsilateral peribronchial or perihilar lymph nodes and intrapulmonary nodes. - N2: Metastasis in ipsilateral mediastinal or subcarinal lymph nodes. - N3: Metastasis in contralateral mediastinal or hilar nodes and ipsilateral or contralateral scalene or supraclavicular lymph nodes. No changes have been made in the N descriptor as defined in the previous staging system

17. IMAGING FINDINGS N descriptor N2 Ipsilateral mediastinal or subcarinal lymph nodes Fig 13.- A.- Lobulated irregular lung mass with pleural tails of 53 x 38 mm in a smoking patient with significant centrilobular emphysema. B.- In the mediastinal window subcarinal lymphadenopathies were observed and classified as stage N2. A B

18. IMAGING FINDINGS N descriptor The N descriptor defines the extent of involvement of regional lymph nodes: - N0: No regional node metastasis. - N1: Metastasis in ipsilateral peribronchial or perihilar lymph nodes and intrapulmonary nodes. - N2: Metastasis in ipsilateral mediastinal or subcarinal lymph nodes. - N3: Metastasis in contralateral mediastinal or hilar nodes and ipsilateral or contralateral scalene or supraclavicular lymph nodes. No changes have been made in the N descriptor as defined in the previous staging system

19. IMAGING FINDINGS N descriptor N3 Contralateral mediastinal or hilar nodes and ipsilateral or contralateral scalene or supraclavicular lymph nodes Fig 14.- A.- Locally advanced lung mass in the right parahilar region infiltrating bronchovascular structures and causing atelectasis of the entire right upper lobe. B.- Right hilar, subcarinal and left-sided superior mediastinal lymphadenopathies were depicted (N3 stage). BA

20. IMAGING FINDINGS N descriptor No changes have been made in the N descriptor as defined in the previous TNM staging system but the IASLC International Staging Committee has developed a new node map: -UPPER ZONE: stations 1 to 4 - AORTOPULMONARY ZONE: stations 5 and 6 - SUBCARINAL ZONE: station 7 - LOWER ZONE: stations 8 and 9 - HILAR ZONE: stations 10 and 11 - PERIPHERAL ZONE: stations 12 to 14 Frank C. Chest 2009;136;260-271

21. IMAGING FINDINGS N descriptor -UPPER ZONE: stations 1 to 4 1.- Supraclavicular zone 2R.- Right Upper Paratracheal 2L. - Left Upper Paratracheal 3A.- Prevascular 3B.- Retrotracheal 4R.- Right Lower Paratracheal 4L. - Left Lower Paratracheal Detterbeck FC. Chest 2009;136;260-271

22. IMAGING FINDINGS N descriptor -UPPER ZONE: stations 1 to 4 1.- Supraclavicular zone Fig 15.- Left supraclavicular lymphadenopathies in a patient with lung cancer Detterbeck FC. Chest 2009;136;260-271

23. IMAGING FINDINGS N descriptor -UPPER ZONE: stations 1 to 4 2R.- Right Upper Paratracheal 2L. - Left Upper Paratracheal Fig 16.- A.- Lymphadenopathy in the right upper paratracheal nodal group. B.- Lymphadenopathies in the right and left upper paratracheal nodal groups. B A Detterbeck FC. Chest 2009;136;260-271

24. IMAGING FINDINGS N descriptor -UPPER ZONE: stations 1 to 4 3A.- Prevascular Fig 17.- Patient with lung malignancy and mediastinal lymphadenopathies in the prevascular chains. Detterbeck FC. Chest 2009;136;260-271

25. IMAGING FINDINGS N descriptor -UPPER ZONE: stations 1 to 4 4R.- Right Lower Paratracheal Fig 18.- Lymphadenopathies in the right and left lower paratracheal nodal groups. Detterbeck FC. Chest 2009;136;260-271

26. IMAGING FINDINGS N descriptor -AORTOPULMONARY ZONE: stations 5 and 6 5.- Subaortic 6.- Para-aortic Fig 19.- Paraaortic lymphadenopathies in a patient with lung cancer. Detterbeck FC. Chest 2009;136;260-271

27. IMAGING FINDINGS N descriptor - SUBCARINAL ZONE: Station 7 7.- Subcarinal Fig 20.- Subcarinal lymphadenopathies in two patients with lung cancer located in the left lower lobe. In both cases, the mass produced lower lobe atelectasis. Detterbeck FC. Chest 2009;136;260-271

28. IMAGING FINDINGS N descriptor - LOWER ZONE: Stations 8 and 9 8.- Paraesophageal 9.- Pulmonary ligament Fig 21.- Lymphadenopathies in the paraesophageal node group. Detterbeck FC. Chest 2009;136;260-271

29. IMAGING FINDINGS N descriptor - HILAR ZONE: Stations 10 and 11 10.- Hilar 11.- Interlobar Detterbeck FC. Chest 2009;136;260-271

30. IMAGING FINDINGS N descriptor - HILAR ZONE: Stations 10 and 11 10.- Hilar Fig 22.- Right hilar lymphadenopathies in a patient with a left lower lobe lung mass. Detterbeck FC. Chest 2009;136;260-271

31. IMAGING FINDINGS N descriptor - HILAR ZONE: Stations 10 and 11 11.- Interlobar Fig 23.- Interlobar lymphadenopathies in a patient with lung cancer. Detterbeck FC. Chest 2009;136;260-271

32. IMAGING FINDINGS N descriptor - PERIPHERAL ZONE: Stations 10 and 11 12.- Lobar 13.- Segmental 14.- Subsegmental Fig 24.- Segmental lymphadenopathies in a patient with lung cancer. Detterbeck FC. Chest 2009;136;260-271

33. IMAGING FINDINGS M descriptor The M descriptor defines the extent of spread to distant sites: - Mo: No distant metastasis. - M1a: Separate tumor nodules in a contralateral lobe or tumor with pleural nodules or malignant pleural dissemination. - M1b: Distant metastasis.

34. IMAGING FINDINGS M descriptor M1a Separate tumor nodules in a contralateral lobe or tumor with pleural nodules or malignant pleural dissemination. Fig 25.- MSCT shows the presence of multiple bilateral pulmonary nodules with random distribution and different sizes in a patient with lung cancer. Due to the presence of metastases in the contralateral lung the tumor was classified as stage M1a. Previously: M1

35. IMAGING FINDINGS M descriptor M1a Separate tumor nodules in a contralateral lobe or tumor with pleural nodules or malignant pleural dissemination. Fig 26.- The presence of malignant pleural involvement in a patient with lung cancer stage M1a. In the previous staging system pleural involvement was classified as stage T4. Previously: T4

36. IMAGING FINDINGS M descriptor M1b Distant metastasis. Fig 27.- Locally advanced lung mass infiltrating the left upper lobe bronchus and causing atelectasis. This malignant lesion infiltrated left upper lobe pulmonary artery and veins. The patient had distant sternal metastasis at the time of diagnosis (M1b). Previously: M1