Staging Diagram 
5.1 Classification Criteria for Non Small Cell Lung Cancer
The staging definitions (UICC, TNM, 1997) and stage groups are as follows:
T (Tumour) Definitions
| TX |
Tumour proved by the presence of malignant cells in sputum or bronchial washings but not visualized by imaging or bronchoscopy or any tumour that cannot be assessed. |
| TO |
No evidence of a primary tumour |
| TIS |
Carcinoma in situ. |
| T1 |
Tumour is 3.0 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) |
| T2 |
Tumour with any of the following features of size or extent: a) >3 cm in greatest dimension. b) involves the main bronchus, > 2 cm distal to the carina. c) invades the visceral pleura. d) associated with atelectasis or obstructive pneumonitis that extends to the hilar region but does not involve the entire lung. |
| T3 |
Tumour of any size that directly invades any of the following: the chest wall (including superior sulcus tumors), diaphragm, mediastinum pleura, parietal pericardium (no invasion of the heart, great vessels, trachea, esophagus or vertebral body) or tumour involving a main bronchus less than 2.0 cm distal to the tracheal carina but not involving the carina or associated atelectasis or obstructive pneumonitis of the entire lung. |
| T4 |
Tumour of any size which invades any of the following: mediastinum, heart, great vessels, trachea, esophagus, vertebral body, carina; or tumour associated with a malignant pleural or pericardial effusion,** or with satellite tumour nodule(s) within the ipsilateral primary-tumour lobe of the lung. |
N (Node) Definitions
| NX |
Regional lymph nodes cannot be assessed. |
| N0 |
No metastasis to regional lymph nodes. |
| N1 |
Metastasis to lymph nodes in the ipsilateral peribronchial and/or the ipsilateral hilar lymph nodes, and intrapulmonary nodes involved by direct extension of the primary tumour. |
| N2 |
Metastasis to ipsilateral mediastinal lymph nodes and/or subcarinal lymph nodes. |
| N3 |
Metastasis to contralateral hilar or mediastinal lymph nodes, ipsilateral or contralateral scalene, or supraclavicular lymph node(s). |
M (Metastasis) Definitions
| MX |
Presence of distant metastasis cannot be assessed. |
| M0 |
No known distant metastasis. |
| M1 |
Distant metastasis present.*** |
- *The uncommon superficial tumour of any size with its invasive component limited to the bronchial wall, which may extend proximal to the main bronchus is also classified as T1.
- **Most pleural effusions associated with lung cancer are due to tumour. However, there are a few patients in whom multiple cytopathologic examinations of pleural fluid show no tumor. In these cases, the fluid is non-bloody and is not an exudate. Thoracoscopy assessment of the pleura should be considered. If these factors and clinical judgement indicate that the effusion is not related to the tumour, the effusion should be excluded as a staging element and the patient's disease should be staged as T1, T2, or T3. Pericardial effusion is classified according to the same rules.
- ***Separate metastatic tumour nodules(s) in the ipsilateral nonprimary-tumour lobe(s) of the lung also are classified M1.
- The letter P is used to denote classification which is determined histologically after resection. A staging diagram to assist in classification of individual nodes is appended.
Stage Groupings:TNM Subsets*
| Occult carcinoma: |
TX |
NO |
MO |
| Stage 0: |
TIS |
N0 |
M0 |
| Stage IA |
TI |
N0 |
M0 |
| Stage IB |
T2 |
N0 |
M0 |
| Stage IIA |
TI |
NI |
M0 |
| Stage IIB |
T2
T3 |
NI
N0 |
M0
M0 |
| Stage IIIA |
T3 |
N1 |
M0 |
| |
T1
T2
T3 |
N2
N2
N2 |
M0
M0
M0 |
| Stage IIIB |
T4 |
N0 |
M0 |
| |
T4
T4
T1
T2
T3
T4 |
N1
N2
N3
N3
N3
N3 |
M0
M0
M0
M0
M0
M0 |
| Stage IV: |
AnyT |
AnyN |
MI |
* Staging is not relevant for occult carcinoma, designated TXN0M0.
Reference:
- Mountain CF. Revisions in the International System for Staging Lung Cancer. Chest 1997;111:1710-17.
5.2 Staging Definitions for Small Cell Lung Cancer (SCLS)
SCLC grows and spreads quickly. It is important to recognise this tumour because it responds readily to both chemotherapy and radiotherapy and in some cases can be cured with appropriate treatment. The Veterans Administration Lung Group system divides SCLC patients into either limited or extensive stages.
Using current staging procedures, 30-40% of SCLC patients have limited stage SCLC. Limited SCLC patients fit enough to receive combined modality therapy are treated with curative intent. Extensive stage SCLC patients are generally treated with palliative intent. After the diagnosis of SCLC, accurate staging should be completed as expediently as possible.
Limited Stage Small Cell Lung Cancer
The original operational definition of limited disease was tumour quantity and configuration that could be encompassed by a "reasonable" radiotherapy treatment volume including the primary tumour site and the adjacent hilar, mediastinal and ipsilateral supraclavicular lymph nodes. The presence of massive intrathoracic tumour may preclude a "reasonable" thoracic radiotherapy volume and allow palliative therapy only.
Extensive Stage Small Cell Lung Cancer
Disease beyond the limited stage criteria is defined as extensive stage. Patients with "regional" extensive stage disease (pleural effusion, contralateral supraclavicular nodes or cervical lymph nodes) have a prognosis that is intermediate between limited and extensive and may benefit from a limited stage type treatment plan (as defined below).
Key Reference:
- Zelen M. Keynote address on biostatistics and data retrieval, part 3, Cancer Chemo Rep 1973;4(2):31.