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The Staging of Lung Cancer

  • David C. Rice
Chapter

Abstract

Staging is one of the most important components in the management of lung cancer. Accurate staging is important because it allows the clinician to predict prognosis and assign appropriate therapy and also provides a system that allows clinicians and researchers to stratify patients into reasonably homogenous groups so that treatment outcomes can be appropriately compared. Tumor staging is broadly broken down into clinical staging and pathologic staging. Clinical stage refers to the best prediction of lung cancer stage prior to the commencement of therapy. Pathologic stage refers to the best prediction of stage following pathologic analysis of the patient’s tumor, lymph nodes, and/or metastases and is usually applied following surgical resection or exploration. The distinction between clinical and pathologic stage becomes slightly less clear, however, when patients undergo some form of histologic staging without surgical resection or exploration. Thus, a patient may undergo histologic assessment of mediastinal nodes by endobronchial ultrasound (EBUS) fine-needle aspiration (FNA) prior to surgical resection. The information thus gained is considered to contribute to the clinical not pathologic stage, which would be determined by the pathologic findings at surgery. If the same patient was found to have ipsilateral lymph node metastases at EBUS and then went on to receive nonsurgical therapy, he would be considered to have pathologic-stage N2 (p-stage IIIa) disease. Ultimately, pathologic stage is determined by the highest-level histologic evidence that is available. Following preoperative therapy (such as chemotherapy and radiation), subsequent pathologic staging is associated with the prefix “y.” Thus a patient with ipsilateral nodal metastases might be downstaged by preoperative chemotherapy from pN2 prior to treatment to yp-N0 after pathologic analysis of the post-chemotherapy surgical specimen.

Keywords

Positron Emission Tomography Aortopulmonary Window Transbronchial Needle Aspiration Endobronchial Ultrasound Chest Wall Invasion 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. 1.
    Mountain CF. Revisions in the international system for staging lung cancer. Chest. 1997;111(6):1710–7.PubMedCrossRefGoogle Scholar
  2. 2.
    Goldstraw P, Crowley J, Chansky K, Giroux DJ, Groome PA, Rami-Porta R, et al. 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. J Thorac Oncol. 2007;2(8):706–14.PubMedCrossRefGoogle Scholar
  3. 3.
    Groome PA, Bolejack V, Crowley JJ, Kennedy C, Krasnik M, Sobin LH, et al. The IASLC Lung Cancer Staging Project: validation of the proposals for revision of the T, N, and M descriptors and consequent stage groupings in the forthcoming (seventh) edition of the TNM classification of malignant tumours. J Thorac Oncol. 2007;2(8):694–705.PubMedCrossRefGoogle Scholar
  4. 4.
    Postmus PE, Brambilla E, Chansky K, Crowley J, Goldstraw P, Patz Jr EF, et al. The IASLC Lung Cancer Staging Project: proposals for revision of the M descriptors in the forthcoming (seventh) edition of the TNM classification of lung cancer. J Thorac Oncol. 2007;2(8):686–93.PubMedCrossRefGoogle Scholar
  5. 5.
    Rami-Porta R, Ball D, Crowley J, Giroux DJ, Jett J, Travis WD, et al. The IASLC Lung Cancer Staging Project: proposals for the revision of the T descriptors in the forthcoming (seventh) edition of the TNM classification for lung cancer. J Thorac Oncol. 2007;2(7):593–602.PubMedCrossRefGoogle Scholar
  6. 6.
    Rusch VW, Crowley J, Giroux DJ, Goldstraw P, Im JG, Tsuboi M, et al. The IASLC Lung Cancer Staging Project: proposals for the revision of the N descriptors in the forthcoming seventh edition of the TNM classification for lung cancer. J Thorac Oncol. 2007;2(7):603–12.PubMedCrossRefGoogle Scholar
  7. 7.
    Detterbeck FC, Boffa DJ, Tanoue LT. The new lung cancer staging system. Chest. 2009;136(1):260–71.PubMedCrossRefGoogle Scholar
  8. 8.
    Boffa DJ, Detterbeck FC, Smith EJ, Rami-Porta R, Crowley J, Zelterman D, et al. Should the 7th edition of the lung cancer stage classification system change treatment algorithms in non-small cell lung cancer? J Thorac Oncol. 2010;5(11):1779–83.PubMedCrossRefGoogle Scholar
  9. 9.
    Kameyama K, Takahashi M, Ohata K, Igai H, Yamashina A, Matsuoka T, et al. Evaluation of the new TNM staging system proposed by the International Association for the Study of Lung Cancer at a single institution. J Thorac Cardiovasc Surg. 2009;137(5):1180–4.PubMedCrossRefGoogle Scholar
  10. 10.
    Kassis ES, Vaporciyan AA, Swisher SG, Correa AM, Bekele BN, Erasmus JJ, et al. Application of the revised lung cancer staging system (IASLC Staging Project) to a cancer center population. J Thorac Cardiovasc Surg. 2009;138(2):412–8.e1–2.PubMedCrossRefGoogle Scholar
  11. 11.
    Suzuki M, Yoshida S, Tamura H, Wada H, Moriya Y, Hoshino H, et al. Applicability of the revised International Association for the Study of Lung Cancer staging system to operable non-small-cell lung cancers. Eur J Cardiothorac Surg. 2009;36(6):1031–6.PubMedCrossRefGoogle Scholar
  12. 12.
    Lyons G, Quadrelli S, Jordan P, Colt H, Chimondeguy D. Clinical impact of the use of the revised International Association for the Study of Lung Cancer staging system to operable non-small-cell lung cancers. Lung Cancer. 2011;74(2):244–7.PubMedCrossRefGoogle Scholar
  13. 13.
    Truong MT, Munden RF, Movsas B. Imaging to optimally stage lung cancer: conventional modalities and PET/CT. J Am Coll Radiol. 2004;1(12):957–64.PubMedCrossRefGoogle Scholar
  14. 14.
    Gross BH, Brown RK, Kalemkerian GP. Optimal anatomic coverage for CT in staging lung cancer: lessons from PET-CT correlation. Lung Cancer. 2011;73(1):59–62.PubMedCrossRefGoogle Scholar
  15. 15.
    Gdeedo A, Van Schil P, Corthouts B, Van Mieghem F, Van Meerbeeck J, Van Marck E. Comparison of imaging TNM [(i)TNM] and pathological TNM [pTNM] in staging of bronchogenic carcinoma. Eur J Cardiothorac Surg. 1997;12(2):224–7.PubMedCrossRefGoogle Scholar
  16. 16.
    Glazer HS, Duncan-Meyer J, Aronberg DJ, Moran JF, Levitt RG, Sagel SS. Pleural and chest wall invasion in bronchogenic carcinoma: CT evaluation. Radiology. 1985;157(1):191–4.PubMedGoogle Scholar
  17. 17.
    Webb WR, Gatsonis C, Zerhouni EA, Heelan RT, Glazer GM, Francis IR, et al. CT and MR imaging in staging non-small cell bronchogenic carcinoma: report of the Radiologic Diagnostic Oncology Group. Radiology. 1991;178(3):705–13.PubMedGoogle Scholar
  18. 18.
    Eggeling S, Martin T, Bottger J, Beinert T, Gellert K. Invasive staging of non-small cell lung cancer – a prospective study. Eur J Cardiothorac Surg. 2002;22(5):679–84.PubMedCrossRefGoogle Scholar
  19. 19.
    Daly BD, Mueller JD, Faling LJ, Diehl JT, Bankoff MS, Karp DD, et al. N2 lung cancer: outcome in patients with false-negative computed tomographic scans of the chest. J Thorac Cardiovasc Surg. 1993;105(5):904–10; discussion 10–1.PubMedGoogle Scholar
  20. 20.
    McLoud TC, Bourgouin PM, Greenberg RW, Kosiuk JP, Templeton PA, Shepard JA, et al. Bronchogenic carcinoma: analysis of staging in the mediastinum with CT by correlative lymph node mapping and sampling. Radiology. 1992;182(2):319–23.PubMedGoogle Scholar
  21. 21.
    Kerr KM, Lamb D, Wathen CG, Walker WS, Douglas NJ. Pathological assessment of mediastinal lymph nodes in lung cancer: implications for non-invasive mediastinal staging. Thorax. 1992;47(5):337–41.PubMedCrossRefGoogle Scholar
  22. 22.
    Toloza EM, Harpole L, McCrory DC. Noninvasive staging of non-small cell lung cancer: a review of the current evidence. Chest. 2003;123(1 Suppl):137S–46.PubMedCrossRefGoogle Scholar
  23. 23.
    Prenzel KL, Monig SP, Sinning JM, Baldus SE, Brochhagen HG, Schneider PM, et al. Lymph node size and metastatic infiltration in non-small cell lung cancer. Chest. 2003;123(2):463–7.PubMedCrossRefGoogle Scholar
  24. 24.
    Berghmans T, Dusart M, Paesmans M, Hossein-Foucher C, Buvat I, Castaigne C, et al. Primary tumor standardized uptake value (SUVmax) measured on fluorodeoxyglucose positron emission tomography (FDG-PET) is of prognostic value for survival in non-small cell lung cancer (NSCLC): a systematic review and meta-analysis (MA) by the European Lung Cancer Working Party for the IASLC Lung Cancer Staging Project. J Thorac Oncol. 2008;3(1):6–12.PubMedCrossRefGoogle Scholar
  25. 25.
    Marom EM, McAdams HP, Erasmus JJ, Goodman PC, Culhane DK, Coleman RE, et al. Staging non-small cell lung cancer with whole-body PET. Radiology. 1999;212(3):803–9.PubMedGoogle Scholar
  26. 26.
    Lardinois D, Weder W, Hany TF, Kamel EM, Korom S, Seifert B, et al. Staging of non-small-cell lung cancer with integrated positron-emission tomography and computed tomography. N Engl J Med. 2003;348(25):2500–7.PubMedCrossRefGoogle Scholar
  27. 27.
    Cerfolio RJ, Bryant AS. Ratio of the maximum standardized uptake value on FDG-PET of the mediastinal (N2) lymph nodes to the primary tumor may be a universal predictor of nodal malignancy in patients with nonsmall-cell lung cancer. Ann Thorac Surg. 2007;83(5):1826–9; discussion 9–30.PubMedCrossRefGoogle Scholar
  28. 28.
    Silvestri GA, Gould MK, Margolis ML, Tanoue LT, McCrory D, Toloza E, et al. Noninvasive staging of non-small cell lung cancer: ACCP evidenced-based clinical practice guidelines (2nd edition). Chest. 2007;132(3 Suppl):178S–201.PubMedCrossRefGoogle Scholar
  29. 29.
    Reed CE, Harpole DH, Posther KE, Woolson SL, Downey RJ, Meyers BF, et al. Results of the American College of Surgeons Oncology Group Z0050 trial: the utility of positron emission tomography in staging potentially operable non-small cell lung cancer. J Thorac Cardiovasc Surg. 2003;126(6):1943–51.PubMedCrossRefGoogle Scholar
  30. 30.
    Cerfolio RJ, Bryant AS. Survival of patients with unsuspected N2 (stage IIIA) nonsmall-cell lung cancer. Ann Thorac Surg. 2008;86(2):362–6; discussion 6–7.PubMedCrossRefGoogle Scholar
  31. 31.
    Veeramachaneni NK, Battafarano RJ, Meyers BF, Zoole JB, Patterson GA. Risk factors for occult nodal metastasis in clinical T1N0 lung cancer: a negative impact on survival. Eur J Cardiothorac Surg. 2008;33(3):466–9.PubMedCrossRefGoogle Scholar
  32. 32.
    Park HK, Jeon K, Koh WJ, Suh GY, Kim H, Kwon OJ, et al. Occult nodal metastasis in patients with non-small cell lung cancer at clinical stage IA by PET/CT. Respirology. 2010;15(8):1179–84.PubMedCrossRefGoogle Scholar
  33. 33.
    Lee PC, Port JL, Korst RJ, Liss Y, Meherally DN, Altorki NK. Risk factors for occult mediastinal metastases in clinical stage I non-small cell lung cancer. Ann Thorac Surg. 2007;84(1):177–81.PubMedCrossRefGoogle Scholar
  34. 34.
    Carlens E. Mediastinoscopy: a method for inspection and tissue biopsy in the superior mediastinum. Dis Chest. 1959;36:343–52.PubMedCrossRefGoogle Scholar
  35. 35.
    Ginsberg RJ. Evaluation of the mediastinum by invasive techniques. Surg Clin North Am. 1987;67(5):1025–35.PubMedGoogle Scholar
  36. 36.
    Sortini A, Navarra G, Santini M, Occhionorelli S, Sartori A, Bresadola V, et al. ]Video-assisted mediastinoscopy. A new application of television technology in surgery]. Minerva Chir. 1994;49(9):803–5.PubMedGoogle Scholar
  37. 37.
    Lemaire A, Nikolic I, Petersen T, Haney JC, Toloza EM, Harpole Jr DH, et al. Nine-year single center experience with cervical mediastinoscopy: complications and false negative rate. Ann Thorac Surg. 2006;82(4):1185–9; discussion 9–90.PubMedCrossRefGoogle Scholar
  38. 38.
    Toloza EM, Harpole L, Detterbeck F, McCrory DC. Invasive staging of non-small cell lung cancer: a review of the current evidence. Chest. 2003;123(1 Suppl):157S–66.PubMedCrossRefGoogle Scholar
  39. 39.
    Ginsberg RJ, Rice TW, Goldberg M, Waters PF, Schmocker BJ. Extended cervical mediastinoscopy. A single staging procedure for bronchogenic carcinoma of the left upper lobe. J Thorac Cardiovasc Surg. 1987;94(5):673–8.PubMedGoogle Scholar
  40. 40.
    McNeill TM, Chamberlain JM. Diagnostic anterior mediastinotomy. Ann Thorac Surg. 1966;2(4):532–9.PubMedCrossRefGoogle Scholar
  41. 41.
    Landreneau RJ, Hazelrigg SR, Mack MJ, Fitzgibbon LD, Dowling RD, Acuff TE, et al. Thoracoscopic mediastinal lymph node sampling: useful for mediastinal lymph node stations inaccessible by cervical mediastinoscopy. J Thorac Cardiovasc Surg. 1993;106(3):554–8.PubMedGoogle Scholar
  42. 42.
    Cerfolio RJ, Bryant AS, Eloubeidi MA. Accessing the aortopulmonary window (#5) and the paraaortic (#6) lymph nodes in patients with non-small cell lung cancer. Ann Thorac Surg. 2007;84(3):940–5.PubMedCrossRefGoogle Scholar
  43. 43.
    Wang KP. Transbronchial needle aspiration and percutaneous needle aspiration for staging and diagnosis of lung cancer. Clin Chest Med. 1995;16(3):535–52.PubMedGoogle Scholar
  44. 44.
    Harrow EM, Abi-Saleh W, Blum J, Harkin T, Gasparini S, Addrizzo-Harris DJ, et al. The utility of transbronchial needle aspiration in the staging of bronchogenic carcinoma. Am J Respir Crit Care Med. 2000;161(2 Pt 1):601–7.PubMedGoogle Scholar
  45. 45.
    Dasgupta A, Mehta AC. Transbronchial needle aspiration. An underused diagnostic technique. Clin Chest Med. 1999;20(1):39–51.PubMedCrossRefGoogle Scholar
  46. 46.
    Herth FJ, Becker HD, Ernst A. Ultrasound-guided transbronchial needle aspiration: an experience in 242 patients. Chest. 2003;123(2):604–7.PubMedCrossRefGoogle Scholar
  47. 47.
    Herth F, Becker HD, Ernst A. Conventional vs endobronchial ultrasound-guided transbronchial needle aspiration: a randomized trial. Chest. 2004;125(1):322–5.PubMedCrossRefGoogle Scholar
  48. 48.
    Yasufuku K, Chiyo M, Sekine Y, Chhajed PN, Shibuya K, Iizasa T, et al. Real-time endobronchial ultrasound-guided transbronchial needle aspiration of mediastinal and hilar lymph nodes. Chest. 2004;126(1):122–8.PubMedCrossRefGoogle Scholar
  49. 49.
    Yasufuku K, Nakajima T, Motoori K, Sekine Y, Shibuya K, Hiroshima K, et al. Comparison of endobronchial ultrasound, positron emission tomography, and CT for lymph node staging of lung cancer. Chest. 2006;130(3):710–8.PubMedCrossRefGoogle Scholar
  50. 50.
    Adams K, Shah PL, Edmonds L, Lim E. Test performance of endobronchial ultrasound and transbronchial needle aspiration biopsy for mediastinal staging in patients with lung cancer: systematic review and meta-analysis. Thorax. 2009;64(9):757–62. Epub 2009 May 18. Review.PubMedCrossRefGoogle Scholar
  51. 51.
    Gu P, Zhao YZ, Jiang LY, Zhang W, Xin Y, Han BH. Endobronchial ultrasound-guided transbronchial needle aspiration for staging of lung cancer: a systematic review and meta-analysis. Eur J Cancer. 2009;45(8):1389–96. Epub 2009 Jan 3. Review.PubMedCrossRefGoogle Scholar
  52. 52.
    Herth FJ, Eberhardt R, Krasnik M, Ernst A. Endobronchial ultrasound-guided transbronchial needle aspiration of lymph nodes in the radiologically and positron emission tomography-normal mediastinum in patients with lung cancer. Chest. 2008;133(4):887–91.PubMedCrossRefGoogle Scholar
  53. 53.
    Ernst A, Anantham D, Eberhardt R, Krasnik M, Herth FJ. Diagnosis of mediastinal adenopathy-real-time endobronchial ultrasound guided needle aspiration versus mediastinoscopy. J Thorac Oncol. 2008;3(6):577–82.PubMedCrossRefGoogle Scholar
  54. 54.
    Annema JT, van Meerbeeck JP, Rintoul RC, Dooms C, Deschepper E, Dekkers OM, et al. Mediastinoscopy vs endosonography for mediastinal nodal staging of lung cancer: a randomized trial. JAMA. 2010;304(20):2245–52.PubMedCrossRefGoogle Scholar
  55. 55.
    Yasufuku K, Pierre A, Darling G, de Perrot M, Waddell T, Johnston M, et al. A prospective controlled trial of endobronchial ultrasound-guided transbronchial needle aspiration compared with mediastinoscopy for mediastinal lymph node staging of lung cancer. J Thorac Cardiovasc Surg. 2011;142(6):1393–400.e1.PubMedCrossRefGoogle Scholar
  56. 56.
    Gress FG, Savides TJ, Sandler A, Kesler K, Conces D, Cummings O, et al. Endoscopic ultrasonography, fine-needle aspiration biopsy guided by endoscopic ultrasonography, and computed tomography in the preoperative staging of non-small-cell lung cancer: a comparison study. Ann Intern Med. 1997;127(8 Pt 1):604–12.PubMedGoogle Scholar
  57. 57.
    Eloubeidi MA, Cerfolio RJ, Chen VK, Desmond R, Syed S, Ojha B. Endoscopic ultrasound-guided fine needle aspiration of ­mediastinal lymph node in patients with suspected lung cancer after positron emission tomography and computed tomography scans. Ann Thorac Surg. 2005;79(1):263–8.PubMedCrossRefGoogle Scholar
  58. 58.
    Savides TJ, Perricone A. Impact of EUS-guided FNA of enlarged mediastinal lymph nodes on subsequent thoracic surgery rates. Gastrointest Endosc. 2004;60(3):340–6.PubMedCrossRefGoogle Scholar
  59. 59.
    Vilmann P, Krasnik M, Larsen SS, Jacobsen GK, Clementsen P. Transesophageal endoscopic ultrasound-guided fine-needle ­aspiration (EUS-FNA) and endobronchial ultrasound-guided ­transbronchial needle aspiration (EBUS-TBNA) biopsy: a ­combined approach in the evaluation of mediastinal lesions. Endoscopy. 2005;37(9):833–9.PubMedCrossRefGoogle Scholar
  60. 60.
    Wallace MB, Pascual JM, Raimondo M, Woodward TA, McComb BL, Crook JE, et al. Minimally invasive endoscopic staging of ­suspected lung cancer. JAMA. 2008;299(5):540–6.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Minimally Invasive Surgery Program, Thoracic SurgeryThe University of Texas MD Anderson Cancer CenterHoustonUSA

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