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Lung Cancer Staging: TNM Classification

Lung cancer staging helps to determine the disease prognosis and to select an appropriate treatment strategy.

TNM is the most commonly used staging system for lung cancer. It uses mainly 3 parameters: “T” stands for “Tumor”; “N” for “Lymph Nodes”; and “M” for “Metastasis”.

Numbers and/or letters after T (0, is, 1, 2, 3, and 4), N (0, 1, 2, and 3), and M (0 and 1) provide more details about each of these parameters. Once T, N, and M are determined, it is used to assign an overall stage (from 0 to IV).

Following table describes the detailed TNM staging for lung cancer.

STAGE TNM DESCRIPTION
0 Tis N0 M0 Pre-cancerous changes or carcinoma in situ. No spread to nearby lymph nodes or distant body parts.
IA1 T1mi N0 M0 Cancer is minimally invasive adenocarcinoma </=3 cm in greatest dimension and invasion </=5 mm in greatest dimension. No spread to nearby lymph nodes or distant body parts.
OR
T1a N0 M0 A tumor </=1 cm in the greatest dimension without invasion of the pleural membrane or main bronchus. No spread to nearby lymph nodes or distant body parts.
IA2 T1b N0 M0 A tumor >1 cm but </=2 cm in the greatest dimension without invasion of the pleural membrane or main bronchus. No spread to nearby lymph nodes or distant body parts.
IA3 T1c N0 M0 A tumor >2 cm but </=3 cm in the greatest dimension without invasion of the pleural membrane or main bronchus. No spread to nearby lymph nodes or distant body parts.
IB T2a N0 M0 A tumor >3 cm but </=4 cm in the greatest dimension that:
· has invaded into the main bronchus but has not affected the carina (the point where the trachea divides into the 2 bronchi), or

· invades the visceral pleura, or

· is partially choking the airway

No spread to nearby lymph nodes or distant body parts.
IIA T2b N0 M0 A tumor >4 cm but </=5 cm in the greatest dimension that:
· has invaded into the main bronchus but has not affected the carina (the point where the trachea divides into the 2 bronchi)

· has grown into the visceral pleura

· is partially choking the airway

No spread to nearby lymph nodes or distant body parts.
IIB T1a-2b N1 M0 A tumor </=5 cm in the greatest dimension that has might/might not:
· invaded into the main bronchus but has not affected the carina (the point where the trachea divides into the 2 bronchi), or

· grown into the visceral pleura, or

· partially choked the airway

Cancer has spread to nearby lymph nodes (within the lung or along the bronchus or around the area where the bronchus enters the lung), but not to the distant body parts.
OR
T3 N0 M0 A tumor >5 cm but </=7 cm in the greatest dimension that has invaded into the parietal pleura, chest wall, phrenic nerve, or the membranes surrounding the heart (parietal pericardium); or

There are 2 separate primary tumor nodules within the same lobe. No spread to nearby lymph nodes or distant body parts.
IIIA T1a-2b N2 M0 A tumor </=5 cm in the greatest dimension that has might/might not:
· invaded into the main bronchus but has not affected the carina (the point where the trachea divides into the 2 bronchi)

· grown into the visceral pleura

· partially choked the airway

Cancer has spread to nearby lymph nodes (subcarinal or ipsilateral mediastinal), but not to the distant body parts.
OR
T3 N1 M0 A tumor >5 cm but </=7 cm in the greatest dimension that has invaded into the parietal pleura, chest wall, the phrenic nerve, or the membranes surrounding the heart (parietal pericardium); or

there are 2 separate primary tumor nodules within the same lobe.

Cancer has spread to nearby lymph nodes (within the lung or along the bronchus or around the area where the bronchus enters the lung), but not to the distant body parts.
OR
T4 N0-1 M0 A tumor >7 cm in the greatest dimension that has invaded into the diaphragm, mediastinum, heart, large blood vessels, trachea, recurrent laryngeal nerve, esophagus, backbone, or carina; or

there is another tumor nodule in the adjacent lobe of the same lung. Cancer may/may not have spread to nearby lymph nodes (within the lung or along the bronchus or around the area where the bronchus enters the lung) without any spread to the distant body parts.
IIIB T1a-2b N3 M0 A tumor </=5 cm in the greatest dimension that has might/might not:
· invaded into the main bronchus but has not affected the carina (the point where the trachea divides into the 2 bronchi)

· grown into the visceral pleura

· partially choked the airway

Cancer has spread to nearby lymph nodes (around the area where the bronchus enters the lung or mediastinal lymph nodes on the other side of the primary tumor, or near the collarbone), but not to the distant body parts.
OR
T3-4 N2 M0 A tumor >5 cm in the greatest dimension that has invaded into the parietal pleura, chest wall, the phrenic nerve, parietal pericardium, diaphragm, mediastinum, heart, large blood vessels, trachea, recurrent laryngeal nerve, esophagus, backbone, or carina; or

there is another tumor nodule within the same lobe or in the adjacent lobe of the same lung.

Cancer has spread to nearby lymph nodes (subcarinal or ipsilateral mediastinal), but not to the distant body parts.
IIIC T3-4 N3 M0 A tumor >5 cm in the greatest dimension that has invaded into the parietal pleura, chest wall, the phrenic nerve, parietal pericardium, diaphragm, mediastinum, heart, large blood vessels, trachea, recurrent laryngeal nerve, esophagus, backbone, or carina; or
there is another tumor nodule within the same lobe or in the adjacent lobe of the same lung.

Cancer has spread to nearby lymph nodes (around the area where the bronchus enters the lung or mediastinal lymph nodes on the other side of the primary tumor, or near the collarbone), but not to the distant body parts.
IVA Any T Any N M1a Tumor nodules in the opposite lung, or
Tumor nodules on pleural membrane or pericardium, or

spread of cancer cells into the pleural fluid (malignant pleural effusion) or into the pericardial fluid (malignant pericardial effusion).
OR
Any T Any N M1b Single tumor deposit in a single distant organ (for example, liver, bones, brain, etc) or to a non-regional lymph node.
IVB Any T Any N M1c Multiple tumor deposits in single or multiple distant organs.

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Additionally, SCLC is divided into following 2 stages based on the extent of disease spread and type of treatment approach to be followed:

Limited-Stage: This means that cancer is only on one side of the chest and might have spread to lymph nodes (including lymph nodes above the collarbone) on the same side.

This type of SCLC is generally confined to a specific small region of the lung that can be treated with a single radiation field.

Extensive-Stage: This means that cancer has extensively spread throughout the lung, to other lung, lymph nodes on the other side of the chest, pleural membrane, distant lymph nodes, or distant organ.

This type of SCLC cannot be treated with a single radiation therapy and require chemotherapy for their management.

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