TNM Staging of Lung Cancer - PowerPoint Presentation

Slide1

TNM Staging of Lung Cancer 7th Edition and v02.05 SSFs

Presentation developed by

April Fritz, RHIT, CTRReno, Nevadaapril@afritz.org

Slide2

Celebrities Who Had Lung Cancer

Slide3

The Crowded Thorax

Larynx

Thyroid

Trachea

Thymus

Pleura

Sternum (cut away)

Aorta

Intercostal

muscles

Ribs

Diaphragm

Heart

Lungs

Slide4

Upper lobe

Middle lobe

Lower lobe

C34.1

C34.2

C34.1

Carina

C34.3

C34.3

Trachea

C33.9

Lung Anatomy

showing ICD-O-3 codes

Slide5

Important Anatomical Landmarks

Graphics source: Mediclip, Williams and Wilkins.

Right Lung

Left Lung

Hilum

Lingula

Apex

Apex

Lower lobe

Upper lobe

Upper lobe

Middle lobe

Slide6

Trachea

Mainstem bronchus

Lobar bronchus

Segmental bronchus

Bronchiole

Alveolar duct

Alveolus

Adapted from R S Snell: Clinical Anatomy for Medical Students, 5th ed. 1995.

Respiratory Tract

Slide7

Alveoli

Source: http://www.webschoolsolutions.com/patts/systems/lungs.htm#anatomy

Slide8

The Mediastinum

Image source: mywebpages.comcast.net/ wnor/thoraxlesson3.htm

Clavicle

Superior mediastinum

Inferior mediastinum

Anterior mediastinum Middle mediastinum Posterior mediastinum

Slide9

Bronchioloalveolar Carcinoma – New Terminology

From IASLC 2011: terms BAC and mixed subtype adenocarcinoma no longer used.

≤ 3 cm, NO stromal, lymphatic, vascular or pleural invasion, no necrosis, no growth patterns other than lepidic



Adenocarcinoma in situ, either serous (8140/2) or mucinous (8253/2; rare)

≤ 3 cm, with ≤ 5 mm area of stromal invasion or growth pattern(s) other than lepidic



Minimally Invasive Adenocarcinoma (MIA): Non-mucinous 8250/2; Mucinous

8257/3

use 8253/3 until

2018

Source: 2015 WHO Classification of Tumors of the Lung

Slide10

Bronchioloalveolar Carcinoma – New Terminology

> 3 cm OR with lymphatic, vascular or pleural invasion OR necrosis OR > 5 mm area of stromal invasion OR growth pattern(s) other than lepidic



Serous: invasive adenocarcinoma, lepidic predominant (8250/3)

Mucinous: invasive mucinous adenocarcinoma (8253/3)

Source: 2015 WHO Classification of Tumors of the Lung

Slide11

Invasive Adenocarcinoma

Subtypes and variants

Lepidic (formerly most mixed subtype tumors with non-mucinous BAC) – 8250/3

Acinar – 8551/3

Papillary – 8260/3

Solid – 8230/3

Micropapillary added as a new histologic subtype – 8265/3

Invasive mucinous adenocarcinoma (formerly mucinous BAC) – 8253/3

Colloid – 8480/3

Fetal – 8333/3

Enteric adenocarcinoma – 8144/3

Slide12

Summary of Lung T Classification

TX Positive cytology only

T1 ≤ 3 cm

T1a ≤ 2 cm

T1b > 2–

<3

cm

T2 Main bronchus 2 cm from carina, invades visceral pleura, partial atelectasis

T2a > 3 cm to 5 cm

T2b > 5 cm to 7 cm

T3 > 7 cm; parietal pleura, chest wall, diaphragm,

pericardium, mediastinal pleura, main bronchus

< 2 cm from carina, total atelectasis, separate nodule(s) in same lobe

T4 Mediastinum, heart, great vessels, carina, trachea, esophagus, vertebral body; separate tumor nodule(s) in a different ipsilateral lobe

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T1 Lung Cancer

Tumor 3 cm or less in size, surrounded by lung or visceral pleura; no invasion more proximal than a lobar bronchus

T1a ≤ 2 cmT1b > 2 to 3 cm

Source: UICC TNM-interactive, Wiley-Liss, 1998

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T2 Lung Cancer

Source: UICC

TNM-interactive, Wiley-Liss, 1998

Tumor > 3 to 7 cm in size

T2a > 3 to 5 cm

T2b > 5 to 7 cm

Any of following:

Invading visceral

pleura (PL1, PL2)

In main bronchus

≥

2 cm from carina

Associated with atelectasis or

obstructive pneumonitis extending to hilar region but not involving entire lung

Slide15

Atelectasis/Obstructive Pneumonitis

Source: www.upstate.edu/radiology/ olla/lung_cancer.htm

T2

Obstructive Pneumonitis

Do not code bronchopneumonia

T3

Atelectasis of Right Lung

Source: Medi-clip: Grant’s Atlas Images I, Thorax and Abdomen. Williams and Wilkins, 1998.

Slide16

T3 Lung Cancer

(1)

Any of the following:Tumor > 7 cmAny of following:In main bronchus < 2 cm from carina without involving carinaAtelectasis or obstructive pneumonitis of entire lungSeparate tumor nodule(s) in same lobecontinued

Source: UICC TNM-interactive, Wiley-Liss, 1998

Slide17

T3 Lung Cancer (2)

Any of the following:Direct invasion ofA. Chest wallB. DiaphragmC. Mediastinal pleuraD. Parietal pericardium— Phrenic nerve

Superior sulcus

Clavicle

Trachea

Ribs

Pleura

Pleural space

Pericardium

Diaphragm

A

A

B

D

D

C

Slide18

Pancoast Tumor

T3 Pancoast tumor (superior sulcus tumor)T4 Superior sulcus tumor with encasement of subclavian vessels or involvement of superior branches of brachial plexus above C8

Superior

sulcus

Clavicle

Trachea

C8

Image source: http://www.mayoclinic.org/

brachial-plexus/details.html

Slide19

A

B

C

D

E

T4 Lung Cancer

(1)

Direct invasion of any

of the following:

Mediastinum

Heart

Trachea

Great vessels

Carina

Not shown:

Esophagus

(behind trachea)

Adjacent rib

Vertebral body

(posterior to lung)

continued

A

B

C

D

E

Slide20

T3 vs T4

T3

Multiple tumors in same lobe

Source: UICC TNM-interactive, Wiley-Liss, 1998

T4

Multiple tumors in different lobe

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Superior vena cava

Main pulmonary arteryR and L pulmonary artery trunks*R and L superior pulmonary veins*R and L inferior pulmonary veins*AortaInferior vena cava* intrapericardial segments

Great Vessels (T4)

Superior vena cava

Heart

Great vessels

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Direct Extension per TNM Manual

TNM

Phrenic nerve invasion

T3

Discontinuous pleural foci

T4

Vocal cord paralysis

T4*

SVC obstruction

T4*

Tracheal/esophageal compression

T4*

* unless primary is peripheral, then code in N

Details coming

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Summary of Lung N and M

N1 Ipsilateral peribronchial, ipsilateral hilar

N2 Ipsilateral mediastinal, subcarinal

N3 Contralateral mediastinal or hilar, scalene

or supraclavicular

M1 Distant metastasis

M1a Separate tumour nodule(s) in a contralateral

lobe;

pleural nodules or

malignant

pleural

or pericardial effusion

M1b Distant metastasis

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N3

N2

N1

N3

N3

N2

Adapted from R S Snell: Clinical Anatomy for Medical Students, 5th ed. 1995.

Lung Cancer Lymph Nodes

Lymph Nodes

N1 Same side

Intrapulmonary

Peribronchial

Hilar

By direct extension

N2 Same side

Mediastinal

Subcarinal

N3 Contralateral

Mediastinal

Hilar

Any scalene

Any supraclavicular

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Lymph Node Stations

Not the same as N categories

Stations are based on surgical landmarks

Source: UICC

TNM-interactive

, Wiley-Liss, 1998

Slide26

Lymph Nodes – N1 and N2

Ipsilateral bronchial

Hilar

Peribronchial

Image source: AJCC Cancer Staging Atlas, Springer-Verlag, 2006.

Hilar Adenopathy

Image source: www.uveitis.org/images/sarcoid7.jpg

Slide27

Lymph Nodes – N2

Image source: AJCC Cancer Staging Atlas, Springer-Verlag, 2006.

Subcarinal

Ipsilateral mediastinal

Source: Workbook for Staging of Cancer, 2nd ed., pages 110-111

N2

Ipsilateral mediastinal

Mediastinal

lymph node stations

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Lymph Nodes – N3; Distant Mets – M1a

N3

N3

M1a

Lymph Nodes

N3 Bilateral or contralateral

mediastinal,

scalene, supraclavicular

Distant Mets

M1a Distant lymph nodes including cervical nodes

Image source: AJCC Cancer Staging Atlas, Springer-Verlag, 2006.

Slide29

M1 Lung Cancer

M1a Separate

tumor nodules in contralateral lobe Pleural nodules Malignant pleural or pericardial effusionM1b Distant metastasis

Pleural effusion

Pleura

Pleural space

Pleural effusion

(malignant or NOS)

Contralateral

tumor nodule

Slide30

Pleural Effusion

TNM Guideline

Assume to be malignant (M1a) UNLESS

* Negative cytology on multiple exams AND

* Non-bloody, not an exudate AND

* Clinical judgement correlates with

benign diagnosis

Slide31

Clinical Staging Criteria: Lung

Limited to evidence acquired

before treatment

Physical examination

Imaging studies

Laboratory tests

Staging procedures

AJCC Cancer Staging Manual 7

th

Edition, page 255

Slide32

Clinical Staging Criteria: Lung

Imaging studies

computed and positron emission tomography)

Staging procedures

Bronchoscopy or esophagoscopy with ultrasound directed biopsies (EBUS, EUS)

Mediastinoscopy

Mediastinotomy

Thoracentesis

Thoracoscopy (VATS)

Exploratory thoracotomy

AJCC Cancer Staging Manual 7

th

Edition, page 255

Slide33

Pathologic Staging Criteria: LungAJCC Cancer Staging Manual 7th Edition, page 256

All evidence acquired before treatment AND

Supplemented or modified by the

additional evidence acquired during and after surgery, particularly from pathologic examination

.

Slide34

Pathologic Stage

Provides precise data used for estimating prognosis and calculating end results

pT requires

Resection of the primary tumor sufficient to evaluate the highest pT category OR

Biopsy that proves highest pT category

Slide35

Pathologic Stage Cont’d

When T is evaluated clinically, N must be cN

Unresectable lung tumor with positive biopsy of contralateral scalene LN = cN p 4 AJCC 7 ED*

Do not record post-treatment stage

pN ideally entails removal of a sufficient number of lymph nodes to evaluate the highest pN category

If pathologic assessment of lymph nodes reveals negative nodes but the number of lymph node stations examined are fewer than suggested above, classify the N category as pN0

Slide36

Stage Groups

Occult TX N0 M0

0 Tis N0 M0

IA T1a-b N0 M0

IB T2a N0 M0

IIA T1a-b, T2a N1 M0

T2b N0 M0

IIB T2b N1 M0

T3 N0 M0

IIIA T1-2 N2 M0

T3 N1-2 M0

T4 N0-1 M0

IIIB Any T N3 M0

T4 N2-3 M0

IV Any T Any N M1a-b

Slide37

SSF 1 – Separate Tumor Nodules/ Ipsilateral Lung

Required by COC, SEER, NPCR

Location of separate tumor nodules affects T

Codes

000 No separate nodules noted

010 Separate nodules in ipsilat lung, same lobe

020 Separate nodules in ipsilat lung, different lobe

030 Separate nodules, ipsilat lung, same and

different lobe

040 Separate nodules, ipsilat lung, unknown

if same or different lobe

988 Not applicable:  Information not collected

999 Unknown if separate tumor nodules; Not

documented in patient record

Slide38

SSF 2 – Visceral Pleural Invasion/ Elastic Layer

Required by COC, SEERFor tumor < 3 cm (T1), invasion of visceral pleura upstages T PL1-PL2  T2PL3  T3

Source: virtualmedicalcentre.com/uploads/VMC/ DiseaseImages/598_Normal_L_Pleura.jpg

Surface of

visceral

pleura (PL 2) Pleural space

Visceral pleura (PL 1) beyond elastic layer

Lung

Parietal pleura

(PL 3)

Slide39

Visceral Pleural Invasion

PL0—Within subpleural lung parenchyma or invading superficially into pleural connective tissue beneath elastic layer.

Not a T descriptor; T category should be assigned on other features. PL1—Invades beyond elastic layer PL2—Invades to pleural surfacePL1/PL2 indicate VPI; T2 descriptor PL3—Tumor invades into any part of parietal pleuraT3 descriptor

Reprinted from Journal of Thoracic Oncology.

Copyright © 2008 Aletta Ann Frazier, MD.

Slide40

SSF 2 – Visceral Pleural Invasion/ Elastic Layer

Required by COC, SEER

Codes

000 No evidence of visceral pleural invasion; not

through elastic layer (PL 0)

010 Beyond visceral elastic pleura, limited to

pulmonary pleura; through elastic layer (PL 1)

020 To surface of pulmonary pleura; Extends to

surface of visceral pleura (PL 2)

030 Extends to parietal pleura (PL 3)

040 Invasion of pleura, NOS

988 Not applicable:  Information not collected

998 No histology of pleura

999 Unknown if visceral pleural invasion is

present; Not documented in patient record

Slide41

Coding TNM Factoids

Slide42

cTNM – Blanks, X, or Number

Meets c classification criteria

Use x or numbers

M must be 0 or 1

Does not meet c classification criteria

T, N, and M all blank

Group stage 99

Example: incidental/surprise diagnosis

Chest x-ray your facility; no further information

Slide43

pTNM – Blanks, X, or Number

Meets p classification criteria

T and N either X or numbers

M0 or M1

Does not meet p classification criteria

T, N, and M blank

Group stage 99

Example: No resection of primary

Slide44

Source of Information?

Louanne Currance

Louanne spoke with Donna Gress to clarify when T, N, or M should be blank

Slide45

T4 Cont’d

Is it possible to code pT without gross tumor removal?

What do you think?

Example (verbal)

Slide46

Guess What – Information in Text

T2 invasion hilar fat (unless higher by size)

T2a

Invasion across fissure

Direct invasion adjacent lobe (unless higher by size)

Slide47

T3

Invasion mediastinal pleura (no matter what tumor size)

Pericardial invasion

Note T3 does not include malignant pericardial infusion

Invasion of sternum

Phrenic nerve invasion

Slide48

T4

Vocal

cord

paralysis can be:

Invasion of vocal cords T4 OR

LN involvement N2 (find out why)

Pancoast tumor

Involvement of brachial plexus

Invasion vertebra or spinal canal

Direct extension to mediastinal fat

Slide49

Must Know

Direct extension to LN coded as LN metastases

Example: 2.8 cm tumor confined to lung with invasion of intrapulmonary node – code

T1

N1

T based on size of tumor – N based on invasion of node

Slide50

Requirements for pN

First “drainage” station depends on lobe

Is one node enough for pN?

Cannot use molecular markers such as EGFR and K-

ras

Only sentinel node – specific circumstances

Lymphoma with one clinically positive node

Most chapters require 4 nodes

Lung – no evidence-based studies to confirm number of nodes

Slide51

How Many LN for pN

Still investigational p 255 AJCC 7 ED

Evidence to support

6 or more hilar AND mediastinal nodes

At least 3 nodes from N1 category

At least 3 mediastinal nodes (includes sub-carinal nodes)

Slide52

Lymph Node Stations – N Value

N2

Ipsilateral surgical stations 1-9

Rt

lung: Stations 2, 4, 7, 10, and 11

Lt lung: Stations 5, 6, 7, 10, and 11

LL tumors should include Station 9

N3

Ipsilateral surgical stations 10-14

Stations 12-14 lobectomy or pneumonectomy

Slide53

M1a

Discontinuous tumor foci parietal pleura

Ipsilateral

NOT direct extension

Discontinuous tumor foci visceral pleura

Ipsilateral

NOT direct extension

Malignant pericardial effusion

Discontinuous tumor nodules pericardium

Slide54

M1b

Discontinuous tumors chest wall

Not direct extension

Discontinuous tumors diaphragm

Not direct extension

Slide55

Questions?