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Stages of non–small cell lung cancer

Staging is a way of describing or classifying a cancer based on the extent of cancer in the body. The most common staging system for non–small cell lung cancer (NSCLC) is the TNM system. The Union for International Cancer Control (UICC) uses the TNM system to describe the extent of many solid tumour cancers.

TNM

TNM stands for tumour, nodes, metastasis. TNM staging describes:

  • the size of the primary tumour
  • the number and location of any regional lymph nodes that have cancer cells in them
  • whether the cancer has spread or metastasized to another part of the body

 

In non–small cell lung cancer, there are 4 main stages (I, II, III and IV). The first 3 are divided into A and B subgroups. As a general rule, the outlook (prognosis) is best for stage I and worst for stage IV. How stages are defined is complicated, particularly for stages II and III. However, the following can be applied to most tumours:

  • stage I – Tumours are 3 cm or less in diameter and are completely within the lung (no evidence of spread to the pleura, other lung, lymph nodes or organs outside the chest).
  • stage II – Tumours have spread (metastasized) to the bronchial or hilar lymph nodes.
  • stage III – Tumours have spread (metastasized) to mediastinal lymph nodes.
  • stage IV – Tumours have spread (metastasized) to the pleura, other lung or organs outside of the chest.

Complete staging descriptions are given below.

Primary tumour (T)

TX

Primary tumour cannot be assessed.

or

Cancer cells are found in sputum or bronchial washings, but the cancer is not seen with imaging tests or bronchoscopy.

T0

No evidence of primary tumour

Tis

Carcinoma in situCarcinoma in situA very early stage of cancer in which tumour cells have not yet invaded surrounding tissues.

T1

Tumour is 3 cm or less in size and has not spread to the visceral pleura or the main bronchi.

T1a – Tumour is smaller than 2 cm.

T1b – Tumour is larger than 2 cm, but smaller than 3 cm

T2

Tumour is larger than 3 cm, but smaller than 7 cm.

or

The tumour has any of the following features:

  • Cancer has spread to the main bronchi, but is not closer than 2 cm to the carina.
  • Cancer has spread to the visceral pleura.
  • Tumour is associated with inflammation in the lung (obstructive pneumonitis) or a partially collapsed lung (atelectasis).

T2a – Tumour is larger than 3 cm, but 5 cm or less in size.

T2b – Tumour is larger than 5 cm, but 7 cm or less in size

T3

Tumour is larger than 7 cm.

or

The tumour has spread to any of the following:

  • chest wall
  • diaphragmdiaphragmThe thin muscle below the lungs and heart that separates the chest cavity from the abdomen.
  • the nerve that controls the movement of the diaphragm (phrenic nerve)
  • pleura surrounding the space between the lungs (mediastinal pleura)
  • outer wall of the sac surrounding the heart (parietal pericardium)

or

The tumour has any of the following features:

  • Tumour has spread to the main bronchi and is closer than 2 cm to the carina, but has not spread to the carina.
  • Tumour is associated with atelectasis or obstructive pneumonitis of the entire lung.
  • There are one or more separate tumour nodules in the same lobe of the lung as the primary tumour.

T4

Tumour is any size and has spread to any of the following:

  • mediastinummediastinumThe space in the chest between the lungs, breastbone and spine that contains the heart, great blood vessels, thymus, trachea (windpipe), esophagus and lymph nodes.
  • heart
  • major blood vessels that lead to or from the heart
  • tracheatracheaThe tube-shaped airway in the neck and chest that leads from the larynx (voice box) and branches to form the bronchi (the large tubes, or airways, that connect to each of the lungs).
  • the nerve that controls movement and sensation in the larynxlarynxThe tube-shaped organ in the neck, between the pharynx (throat) and trachea (windpipe), that is part of the airway and contains the vocal cords, which produce sound. (recurrent laryngeal nerve)
  • esophagusesophagusThe muscular tube in the neck and chest through which food passes from the pharynx (throat) to the stomach.
  • vertebrae
  • carina

or

There are one or more separate tumour nodules in a different lobe of the same lung.

Regional lymph nodes (N)

NX

Regional lymph nodes cannot be assessed

N0

No regional lymph node metastasis

N1

Regional lymph node metastasis or direct cancer spread to one or more of the following:

  • lymph nodes surrounding the bronchi (peribronchial lymph nodes)
  • lymph nodes in the area where a main bronchus enters the lung (hilar lymph nodes) on the same side of the body as the primary tumour
  • lymph nodes inside the lung (intrapulmonary lymph nodes)

N2

Regional lymph node metastasis to either or both of the following:

  • mediastinal lymph nodes on the same side of the body as the primary tumour
  • lymph nodes below the carina (subcarinal lymph nodes)

N3

Regional lymph node metastasis to one of the following:

  • mediastinal or hilar lymph nodes on the opposite side of the body as the primary tumour
  • lymph nodes in muscles of the neck (scalene nodes)
  • lymph nodes above the collarbone (supraclavicular lymph nodes) on the same or opposite side of the body as the primary tumour

Distant metastasis (M)

M0

No distant metastasis

M1

Distant metastasis

M1a – Any one of the following:

M1b – Distant metastasis

Stage grouping for non–small cell lung cancer

The UICC further groups the TNM data into the stages listed in the table below.

UICC staging – non–small cell lung cancer
UICC stageTNMExplanation

occult

T0

N0

M0

The primary tumour is too small to be seen with imaging tests or bronchoscopy, but cancer cells are found in the sputum or bronchial washings.

stage 0

Tis

N0

M0

The cancer is found only in the layer of cells that lines the air passages, but does not invade the lung itself.

stage IA

T1

N0

M0

The tumour is 3 cm or less and has not spread to the visceral pleura or the main bronchi.

stage IB

T2a

N0

M0

The tumour is larger than 3 cm, but 5 cm or less.

or

The tumour has any of the following features:

  • Cancer has spread to the main bronchi, but is not closer than 2 cm to the carina.
  • Cancer has spread to the visceral pleura.
  • The tumour is associated with obstructive pneumonitis or atelectasis not involving an entire lung.

stage IIA

T2b

N0

M0

The tumour is larger than 5 cm, but 7 cm or less.

or

The tumour has any of the following features:

  • Cancer has spread to the main bronchi, but is not closer than 2 cm to the carina.
  • Cancer has spread to the visceral pleura.
  • The tumour is associated with obstructive pneumonitis or atelectasis not involving an entire lung.

The cancer has not spread to the lymph nodes.

The cancer has not spread to distant parts of the body.

T1

N1

M0

The tumour is smaller than 3 cm and has not spread to the visceral pleura or the main bronchi.

There is spread to the regional lymph nodes or direct cancer spread to peribronchial or hilar lymph nodes on the same side of the body as the primary tumour.

The cancer has not spread to distant parts of the body.

T2a

N1

M0

The tumour is larger than 3 cm,but 5 cm or less.

or

The tumour has any of the following features:

  • Cancer has spread to the main bronchi, but is not closer than 2 cm to the carina.
  • Cancer has spread to the visceral pleura.
  • Tumour is associated with obstructive pneumonitis or atelectasis, not involving an entire lung.

There is spread to the regional lymph nodes or direct cancer spread to peribronchial or hilar lymph nodes on the same side of the body as the primary tumour and intrapulmonary lymph nodes.

The cancer has not spread to distant parts of the body.

stage IIB

T2b

N1

M0

The tumour is larger than 5 cm, but smaller than 7 cm.

or

The tumour has any of the following features:

  • Cancer has spread to the main bronchi, but is not closer than 2 cm to the carina.
  • Cancer has spread to the visceral pleura.
  • Tumour is associated with obstructive pneumonitis or atelectasis not involving an entire lung.

The cancer has spread to the regional lymph nodes or there is direct cancer spread to peribronchial or hilar lymph nodes on the same side of the body as the primary tumour and intrapulmonary lymph nodes.

The cancer has not spread to distant parts of the body.

T3

N0

M0

The tumour is larger than 7 cm or has spread to any of the following:

  • chest wall
  • diaphragm
  • phrenic nerve
  • mediastinal pleura
  • outer wall of the sac surrounding the heart (parietal pericardium)

or

The tumour has spread to the main bronchi and is closer than 2 cm to the carina, but has not spread to the carina.

or

The tumour is associated with atelectasis or obstructive pneumonitis of the entire lung.

or

There are one or more separate tumour nodules in the same lobe of the lung as the primary tumour.

The cancer has not spread to the lymph nodes.

The cancer has not spread to distant parts of the body.

stage IIIA

T1, T2

N2

M0

The tumour is smaller than 3 cm and has not spread to the visceral pleura or the main bronchi.

or

The tumour is larger than 3 cm, but 7 cm or less, or the tumour has any of the following features:

  • Cancer has spread to the main bronchi, but is not closer than 2 cm to the carina.
  • Cancer has spread to the visceral pleura.
  • The tumour is associated with obstructive pneumonitis or atelectasis.

There is spread to the mediastinal lymph nodes (on the same side of the body as the primary tumour) or subcarinal lymph nodes.

The cancer has not spread to distant parts of the body.

T3

N1, N2

M0

The tumour is larger than 7 cm or has spread to any of the following:

  • chest wall
  • diaphragm
  • phrenic nerve
  • mediastinal pleura
  • parietal pericardium

or

The tumour has spread to the main bronchi and is closer than 2 cm to the carina, but has not spread to the carina.

or

Tumour is associated with atelectasis or obstructive pneumonitis of the entire lung.

or

There are one or more separate tumour nodules in the same lobe of the lung as the primary tumour.

The cancer has spread to the regional lymph nodes or there is direct cancer spread to the peribronchial or hilar lymph nodes on the same side of the body as the primary tumour and intrapulmonary lymph nodes.

or

The cancer has spread to the mediastinal lymph nodes (on the same side of the body as the primary tumour) or subcarinal lymph nodes.

The cancer has not spread to distant parts of the body.

T4

N0, N1

M0

Tumour is any size and has spread to any of the following:

  • mediastinum
  • heart
  • major blood vessels that lead to or from the heart
  • trachea
  • recurrent laryngeal nerve
  • esophagus
  • vertebrae
  • carina

or

There are one or more separate tumour nodules in a different lobe of the same lung.

No regional lymph node metastasis.

or

The cancer has spread to the regional lymph nodes or there is direct cancer spread to the peribronchial or hilar lymph nodes on the same side of the body as the primary tumour and intrapulmonary lymph nodes.

The cancer has not spread to distant parts of the body.

stage IIIB

T4

N2

M0

Tumour is any size and has spread to any of the following:

  • mediastinum
  • heart
  • major blood vessels that lead to or from the heart
  • trachea
  • recurrent laryngeal nerve
  • esophagus
  • vertebrae
  • carina

or

There are one or more separate tumour nodules in a different lobe of the same lung.

The cancer has spread to the mediastinal lymph nodes (on the same side of the body as the primary tumour) or subcarinal lymph nodes.

The cancer has not spread to distant parts of the body.

any T

N3

M0

The tumour is any size and may or may not have spread into any nearby structures.

The tumour may or may not be associated with atelectasis or obstructive pneumonitis of the entire lung.

There may or may not be separate tumour nodules in the same lung.

The cancer has spread to either:

  • mediastinal or hilar lymph nodes on the opposite side of the body as the primary tumour
  • scalene or supraclavicular lymph nodes on the same or opposite side of the body as the primary tumour

The cancer has not spread to distant parts of the body.

stage IV

any T

any N

M1

The tumour is any size and may or may not have spread into any nearby structures.

Tumour may or may not be associated with atelectasis or obstructive pneumonitis of the entire lung.

There may or may not be separate tumour nodules in the same lung.

There may or may not be regional lymph node metastasis.

The cancer has spread to a distant site in the body

or

There are one or more separate tumour nodules in the opposite lung.

 or

There are:

  •  tumour nodules on the parietal pleura
  • malignant pleural effusion or pericardial effusion

Recurrent non–small cell lung cancer

Recurrent non–small cell lung cancer means that the cancer has come back after it has been treated. It may recur in the same location as the original cancer or it may recur in another part of the body (metastatic lung cancer).

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