1. TNM Staging: Lung TONYA BRANDENBURG, MHA, CTR KENTUCKY CANCER REGISTRY

2. Overview  Lung Anatomy  Clinical Staging vs Pathological Staging  Changes in T,N,M Staging from AJCC 6 th edition to 7 th edition  Elements of Staging: TX-T4, NX-N3, and M0-M1b  Stage Groups and Prognostic Factors  Helpful Hints  Lung Examples

3. Lung Anatomic subsites of the lung. Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. ©American Joint Committee on Cancer

4.  Bronchioles: The passageways by which air passes through the nose or mouth to the lungs. They are branches of the bronchi.  Alveolus ("little cavity") is an anatomical structure that has the form of a hollow cavity. [ The pulmonary alveoli are the terminal ends of [ the respiratory tree. The alveolar sacs or alveolar ducts are both sites of gas exchange with the blood as well. Source of definitions: Wikipedia.com

5.  Pancoast Tumor - A superior sulcus tumor that arises in the apex of the lung and spreads into chest wall (coded to upper lobe, C34.1)  Hilum – The root of the lung is located at the hilum of each lung, just above the middle of the mediastinal surface and behind the cardiac impression of the lung. (coded to main bronchus, C34.0)  Apex – The apex is at the top of the lung. It extends into the root of the neck, reaching between 2.5 centimeters and 4 centimeters above the level of the sternal end of the first rib. (coded to upper lobe, 34.1)  Mesothelioma - A malignancy that arises in the pleura (coded and staged to pleura, C38.4) Topography Review

6.  Mediastinum - The mediastinum is the central compartment of the thoracic cavity. The mediastinum contains the heart and its vessels, the esophagus, trachea, phrenic and cardiac nerves, the thoracic duct, thymus and lymph nodes of the central chest.  Pleura – The pleural cavity is the thin fluid-filled space between the two pulmonary pleurae (visceral and parietal) of each lung. A pleura is a serous membrane which folds back onto itself to form a two-layered membranous pleural sac.  Great Vessels – The great vessels include the aorta, superior vena cava, inferior vena cava, main pulmonary artery, intrapericardial segments of the trunk of the right and left pulmonary artery, intrapericardial segements of the superior and inferior right and left pulmonary veins Common Terms

7. Clinical Staging  Clinical staging based on evidence acquired before treatment  Includes physical exam, imaging procedures (CT, PET) lab tests, and staging procedures such as scopes, thoracentesis and exploratory thoracotomy.  Within 4 months or before treatment, whichever is shorter

8. Pathological Staging  Pathological staging based on clinical staging info, definitive surgical resection operative findings, and path report of resected specimen  Or within 4 months of dx, whichever is longer  There can be no systemic treatment or radiation prior to resection  If a patient has systemic treatment before definitive surgery, you must stage using the y descriptor  Surgical resection must meet criteria for the chapter in order to stage the case pathologically

9. When to use blanks and X’s  Blanks should be used if:  There is no info in the chart to assign an AJCC value  If the patient isn’t eligible for pathological staging  If AJCC criteria for this stage classification is not met  X should be used if:  Criteria for this stage classification is met  T cannot be assessed  N cannot be assessed  Cannot use X in the M category; MX is not a valid value

10. Does patient meet criteria for that stage classification? Yes – patient meets classification criteria If physician could not assess T and/or N for the patient, and definitive information for T and N not in chart – Use TX and/or NX (Use of X is rare) If there is no information about diagnostic workup or resection pathology in chart – Use blank Indicates registrar could not find information in chart – Do not use X No – patient does NOT meet classification criteria – Do NOT use X Indicates patient eligible for staging Implies physician did not assess or have info on patient’s T and/or N – Must use blanks Indicates patient did not meet classification criteria

11. Changes in T,N,M Staging for Lung from 6 th edition to 7 th edition  Classification recommended for:  Non-small cell carcinomas, Small cell lung carcinomas, and Carcinoid tumors  T:  New tumor sizes and sub-classifications  Multiple tumors in same lobe now T3  Multiple tumors in same lung different lobe now T4  N:  New international lymph node map  M:  Malignant pleural effusion now M1a

12. Elements of Staging: TX, T0, and Tis  TX: Tumor not seen on bronchoscopy or films, but diagnosed by sputum cytology (occult carcinoma)  T0: No evidence of primary tumor (use when you have metastasis that is consistent with lung primary, but no evidence of a primary tumor can be found)  Tis- Carcinoma in situ (rare in lung) – This is increasing because bronchio – alveolar carcinoma is now called adenocarcinoma in situ

13. Elements of Staging: T1  T1- Tumor 3 cm or less, surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus ( not in the main bronchus )  T1a = Tumor 2 cm or less in greatest dimension  T1b = Tumor more than 2 cm but less than 3 cm in greatest dimension

14. T1 is defined as a tumor 3 cm or less in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e., not in the main bronchus). T1a is defined as a tumor 2 cm or less in greatest dimension (upper left). T1a is also defined as a superficial spreading tumor of any size with its invasive component limited to the bronchial wall, which may extend proximally to the main bronchus (lower left). T1b is defined as a tumor more than 2 cm but 3 cm or less in greatest dimension (right). Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. ©American Joint Committee on Cancer

15. Elements of Staging: T2  T2- Tumor more than 3 cm but less than 7 cm or tumor with any of the following features:  Involves main bronchus, 2 cm or more distal to the carina  Invades visceral pleura (PL1 or PL 2)  Associated with atelectasis or obstructive pneumonitis that extends to the hilar region, but does not involve the entire lung  T2a = more than 3 cm but 5 cm or less in greatest dimension  T2b = Tumor more than 5 cm but 7 cm or less in greatest dimension

16. T2 is defined as a tumor more than 3 cm but 7 cm or less or tumor with any of the following features (T2 tumors with these features are classified T2a if 5 cm or less); involves main bronchus, 2 cm or more distal to the carina (middle left and middle right); invades visceral pleura (PL1 or PL2) (upper right); associated with atelectasis or obstructive pneumonitis that extends to the hilar region but does not involve the entire lung (bottom left). T2a is defined as tumor more than 3 cm but 5 cm or less in greatest dimension (upper left). T2b is defined as tumor more than 5 cm but 7 cm or less in greatest dimension (bottom right). Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. ©American Joint Committee on Cancer

17. Elements of Staging: T3  T3- Tumor more than 7 cm that has any of the following:  Parietal pleura (PL3)  Chest wall (including superior sulcus “pancoast” tumors, but see T4 as well)  Diaphragm, Phrenic nerve, Mediastinal pleura, or Parietal pericardium  Tumor in main bronchus less than 2 cm distal to the carina without carina involvement  Associated atelectasis or obstructive pneumonitis of the entire lung  Separate tumor nodules in the same lobe

18. T3 is defined as a tumor more than 7 cm (upper middle left) or one that directly invades any of the following: parietal pleural (PL3), chest wall (including superior sulcus tumors) (upper left), diaphragm (lower left), phrenic nerve, mediastinal pleura, parietal pericardium; or tumor in the main bronchus (less than 2 cm distal to the carina but without involvement of the carina) (lower middle left); or associated atelectasis or obstructive pneumonitis of the entire lung (right) or separate tumor nodule(s) in the same lobe. Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. ©American Joint Committee on Cancer

19. T3 includes separate tumor nodule(s) in the same lobe. T4 includes separate tumor nodule(s) in a different ipsilateral lobe. Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. ©American Joint Committee on Cancer

20. Elements of Staging: T4  Mediastinum  Heart  Great vessels  Trachea  Recurrent laryngeal nerve  Esophagus  Vertebral body (including extension from a Pancoast Tumor)  Carina  Separate tumor nodules in a different ipsilateral lobe T4 is tumor of any size that invades any of the following:

21. T4 is defined as tumor of any size that invades any of the following: mediastinum, heart, great vessels (upper right), trachea (upper left), recurrent laryngeal nerve, esophagus (lower right), vertebral body (lower left), carina (middle left and right), separate tumor nodule(s) in a different ipsilateral lobe. Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. ©American Joint Committee on Cancer

22. N1 Nodes: Numbers 8 through 11 and including interlobar (not shown) N2 Nodes: Numbers 1 through 7 N3 Nodes (not shown): Supraclavicular, scalene, any node contralateral to primary tumor AP Window Nodes are N2 Nodes

23. Elements of Staging: NX, N0, and N1  NX: Regional lymph nodes cannot be assessed  N0: No regional lymph node metastasis  N1: Metastasis in ipsilateral peribronchial and or ipsilateral hilar lymph nodes and intrapulmonary nodes, including involvement by direct extension

24. Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. ©American Joint Committee on Cancer

26. Elements of Staging: N2 and N3  N2: Metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s)  N3: Metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph nodes  Don’t forget: N3 is DISTANT disease in SEER Summary Staging

27. Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. ©American Joint Committee on Cancer

30. Elements of Staging: MX, M0, and M1  MX: No longer exists in TNM Staging  M0: No distant metastasis (Remember: not possible for pathologic staging)  M1: Distant Metastasis  M1a includes:  Separate tumor nodule(s) in a contralateral lobe  Tumor with pleural nodules  Malignant pleural or pericardial effusion  M1b- Metastasis in distant organs or lymph nodes

31. Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. ©American Joint Committee on Cancer

32. Stage Groups

33. Prognostic Factor: Plueral/Elastic Layer Invasion A tumor that falls short of completely traversing the elastic layer of the visceral pleura is defined as PL0. A tumor that extends through the elastic layer is defined as PL1 and one that extends to the surface of the visceral pleural as PL2. Extension of the tumor to the parietal pleura is defined as PL3. Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. ©American Joint Committee on Cancer

34.  TNM Staging Scheme DOES NOT match the SEER Summary Staging Scheme for lung cancer!  Pages 260 through 262 have a listing of the different lymph node stations in Japan Lung Cancer Society Map, MD-ATS Map, and IASLC Map (now the recommended means of describing regional node involvement for lung cancer)  Additional notes for TNM staging can be found on page 266 under “Additional Notes Regarding TNM Descriptors” Helpful Hints

35. Lung Case 1 Answers  Topography: C34.3  Histology: 8041/3  This case is one primary per rule M12 Clinical Staging cT2a cN2 cM1a Clinical Stage Group IV Pathological Staging pTBlank pNBlank pMBlank Pathologic Stage Group Blank SEER Summary Stage: 7- Distant

36. Lung Case 2 Answers  Topography: C34.3  Histology: 8140/3  This case is one primary per rule M2 Clinical Staging cT1a cN0 cM0 Clinical Stage Group IA Pathological Staging pT2a pN0 pMcM0 Pathologic Stage GroupIB SEER Summary Stage: 1 – Local disease