Staging of lung cancer
description
Transcript of Staging of lung cancer
![Page 1: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/1.jpg)
Staging of lung cancer
Marwa Mohamed Abd El RadyM.Sc Chest Diseases and TuberculosisKobry El Koppa Military Chest Hospital
![Page 2: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/2.jpg)
Introduction• Definition of the stage is an essential part of
the approach to patients with cancer, and it has led to the development of a universally accepted stage classification systems for most tumors.
![Page 3: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/3.jpg)
• The Union Internationale Contre le Cancer (UICC) and the American Joint Committee on Cancer (AJCC) serve as the official bodies that define, periodically review, and refine the stage classification systems.
![Page 4: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/4.jpg)
What?Staging is a way of describing a cancer, such as
where it is located, if or where it has spread, and whether it is affecting the functions of other organs in the body.
Why? Decide what kind of treatment is best. Predict a patient’s prognosis.
![Page 5: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/5.jpg)
Staging of NSCLC
![Page 6: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/6.jpg)
TNM Staging System
Historical background:• Dr. Clifton Mountain that was adopted by the
AJCC in 1973 and by the UICC in 1974.• Database of 2,155 patients from the MD
Anderson Cancer Center in Houston, TX.• 5,319 cases at the time the lung cancer staging
system was last revised in 1997.
![Page 7: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/7.jpg)
• A proposal to develop an international effort to inform a future revision of the TNM staging classification for lung cancer originated in 1996.
• Data elements and definitions were finalized in October 2002. Data were collected from multiple sources and sites around the globe.
![Page 8: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/8.jpg)
• The proposed staging recommendations were presented to the AJCC and UICCin2007and published in the 7th edition of the UICC Staging Manual in 2009.
• At the time the database had been submitted from 45 sources in 20 countries. The final data set involved 81,015 cases after exclusion of ineligible cases.
![Page 9: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/9.jpg)
Fundamentals of the Staging System
• The T descriptor: defines the extent of the primary tumor.
• The N descriptor: the extent of involvement of regional lymph nodes.
• The M descriptor: the extent of spread to distant sites.
![Page 10: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/10.jpg)
Definitions for T, N, M DescriptorsT Descriptor
• T Primary tumor• T0 No primary tumor
• T1 Tumor ≤ 3 cm,† surrounded by lung or visceral pleura, not more proximal than the lobar bronchus• T1a Tumor ≤ 2 cm† • T1b Tumor > 2 but ≤ 3 cm†
• T2 Tumor > 3 but ≤ 7 cm† or tumor with any of the following:Invades visceral pleura, involves main bronchus > 2 cm distal to the carina, atelectasis/obstructive pneumonia extending to hilum but not involving the entire lung.
• T2a Tumor > 3 but ≤ 5 cm† • T2b Tumor > 5 but ≤ 7 cm†
• T3 Tumor > 7 cm; or directly invading chest wall, diaphragm, phrenic nerve, mediastinal pleura, or parietal pericardium;or tumor in the main bronchus < 2 cm distal to the carina§; or atelectasis/obstructive pneumonitis of entire lung; or separate tumor nodules in the same lobe .
• T4 Tumor of any size with invasion of heart, great vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body, or carina;or separate tumor nodules in a different ipsilateral lobe
![Page 11: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/11.jpg)
N Descriptor
• N Regional lymph nodes• N0 No regional node metastasis.• N1 Metastasis in ipsilateral peribronchial and/or
perihilar lymph nodes and intrapulmonary nodes, including involvement by direct extension.• N2 Metastasis in ipsilateral mediastinal and/or
subcarinal lymph nodes.• N3 Metastasis in contralateral mediastinal,
contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph nodes.
![Page 12: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/12.jpg)
M Descriptor
• M Distant metastasis• M0 No distant metastasis.• M1a Separate tumor nodules in a
contralateral lobe; or tumor with pleural nodules or malignant pleural dissemination .
• M1b Distant metastasis.
![Page 13: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/13.jpg)
Special situations
• TX, NX, MX T, N, or M status not able to be assessed.
• Tis Focus of in situ cancer.• T1§ Superficial spreading tumor of
any size but confined to the wall of the trachea or mainstem bronchus.
![Page 14: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/14.jpg)
![Page 15: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/15.jpg)
Points Of Differences
![Page 16: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/16.jpg)
T Descriptor
• The size threshold of 3 cm was confirmed as a significant cutpoint and retained as a definition of a T1 vs a T2 tumor.
• Significant cutpoints were identified at 2, 5, and 7cm.
• The 2-cm and 5-cm additional cutpoints were addressed by the definition of subgroups of T1 (T1a and T1b) and T2 (T2a and T2b).
![Page 17: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/17.jpg)
• Patients with additional satellite nodules in the same lobe as the primary tumor had relatively good survival, similar to T3 patients, and therefore are now classified as T3 (previously classified as T4).
• An ipsilateral nodule in a different lobe is now classified as T4(previously classified as M1).
![Page 18: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/18.jpg)
• Clinically staged patients with pleural dissemination clearly have statistically significant worse survival than T4 by invasion (T4Inv) or than patients with an additional nodule in a different ipsilateral lobe (T4Ipsi Nod).Therefore, patients with pleural dissemination are classified as M1a.
![Page 19: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/19.jpg)
N Descriptor
• No changes were made in the N descriptor as defined in the 6th edition of the staging manual.
• There was no difference in survival between patients with involvement of only peripheral N1 nodes or hilar N1 nodes,and no difference based on which N2 nodal stations were involved.
![Page 20: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/20.jpg)
• The number of involved nodal zones did appear to have a prognostic impact.
• The prognostic impact of the number of nodal zones involved could not be confirmed within T stage categories.
![Page 21: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/21.jpg)
![Page 22: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/22.jpg)
M Descriptor
• The prognostic impact of one vs more than one contralateral pulmonary nodule could not be assessed.
• Slightly worse survival was seen in patients with multiple vs a solitary distant metastasis.
![Page 23: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/23.jpg)
T definitions 6th ed. descriptor 7th ed. descriptor
Tumors = 2 cms. T1 T1a
Tumors > 2 cms and = 3 cms. T1 T1b
Tumors > 3cms and = 5cms. T2 T2a
Tumors > 5 cms and = 7 cms. T2 T2b
Tumors > 7 cms. T2 T3
Separate nodule(s) in the primary lobe. T4 T3
Separate nodule(s) in a different ipsilateral lobe. M1 T4
Malignant pericardial effusion. T4 M1a
Pleural dissemination. T4 M1a
![Page 24: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/24.jpg)
Stage Grouping
![Page 25: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/25.jpg)
Stage 0&I
![Page 26: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/26.jpg)
Stage II
![Page 27: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/27.jpg)
![Page 28: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/28.jpg)
Stage III
![Page 29: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/29.jpg)
![Page 30: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/30.jpg)
Stage IV
![Page 31: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/31.jpg)
![Page 32: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/32.jpg)
![Page 33: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/33.jpg)
Staging Of SCLC
![Page 34: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/34.jpg)
Staging of SCLC• The two stage system originally introduced by the
Veterans' Affairs Lung Study Group (VALSG) is widely utilized in staging of SCLC.
• Limited disease: is defined as disease confined to the ipsilateral hemithorax and within a single radiotherapy port (corresponding in part to TNM stages I through IIIB).
• Extensive disease: is defined as evident metastatic disease outside the ipsilateral hemithorax.
![Page 35: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/35.jpg)
Types of staging assessment
![Page 36: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/36.jpg)
Clinical-diagnostic stage
Medical history. Physical examination. laboratory testing. Radiologic testing. Tissue sampling.
![Page 37: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/37.jpg)
History and physical examination
• Identify symptoms or physical findings suggestive of locally advanced or metastatic disease.
• Assess pulmonary health status.• Identify significant comorbidities.• Assess overall health status.
![Page 38: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/38.jpg)
Value:
• Each impacts the therapeutic options.• The patient's ability to tolerate treatment. • The disease course independent of disease
stage.
![Page 39: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/39.jpg)
History and physical examination HistorySymptoms&Signs:• cough, dyspnea, hemoptysis, postobstructive
pneumonia.• Systemic symptoms.• Bone pain .• Dysphagia.• Neurologic abnormalities .
![Page 40: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/40.jpg)
• Horner's syndrome.• Hoarseness of voice.• Superior vena cava syndrome. • Pericardial tamponade.• Enlarged supraclavicular and scalene lymph
nodes.• Hepatomegaly.• Paraneoplastic syndromes.
![Page 41: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/41.jpg)
Clinical-diagnostic stage
Medical history. Physical examination. laboratory testing. Radiologic testing. Tissue sampling.
![Page 42: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/42.jpg)
Laboratory tests • Complete blood count.• Serum electrolytes.• Calcium.• (ALT)& (AST).• Alkaline phosphatase.• Creatinine.• Tumor markers.
![Page 43: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/43.jpg)
Clinical-diagnostic stage
Medical history. Physical examination. laboratory testing. Radiologic testing. Tissue sampling.
![Page 44: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/44.jpg)
Radiographic imagingPlain chest x-ray
![Page 45: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/45.jpg)
![Page 46: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/46.jpg)
![Page 47: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/47.jpg)
Radiographic imaging • Contrast-enhanced CT scanning:It can characterize the primary tumor. Define its relationship to the chest wall and
mediastinal structures. It can identify enlarged mediastinal lymph
nodes. Assess contralateral lung, chest wall, or upper
abdominal lesions that are suspicious for metastasis.
![Page 48: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/48.jpg)
![Page 49: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/49.jpg)
Radiographic imaging• PET scanning.
![Page 50: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/50.jpg)
Radiographic imaging
• Brain CT scanning.• Magnetic resonance imaging (MRI).• Bone scan.
![Page 51: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/51.jpg)
Clinical-diagnostic stage
Medical history. Physical examination. laboratory testing. Radiologic testing. Tissue sampling.
![Page 52: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/52.jpg)
Tissue sampling
• Both diagnosis and staging require histopathologic data.
• Target tissue for sampling:1-Sampling the primary tumor.2-Sampling potentially related abnormalities.
![Page 53: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/53.jpg)
Sampling the primary tumor
• Imaging-guided percutaneous needle aspiration or biopsy.
• Endobronchial ultrasound (EBUS)-guided forceps biopsy.
• Conventional flexible bronchoscopy with forceps biopsy, blind transbronchial fine needle aspiration (TBNA), or both
![Page 54: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/54.jpg)
Sampling potentially related abnormalities
• Regional lymph nodes:o Non-surgical approaches.o surgical approaches.
![Page 55: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/55.jpg)
o Non-surgical approaches:
• EBUS-guided TBNA.• Transesophageal endoscopic ultrasound-
guided fine needle aspiration (EUS-FNA).• Conventional bronchoscopy with blind TBNA.
![Page 56: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/56.jpg)
o Surgical approaches:
• Mediastinoscopy.• Thoracoscopy.
![Page 57: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/57.jpg)
• Pleural effusion: Confirmation that a pleural effusion is malignant is mandatory in all patients with lung cancer.
• Cytologic examination of pleural fluid.• A second thoracentesis with Closed pleural
biopsy.• Thoracoscopy.
![Page 58: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/58.jpg)
• Patients should be referred to a multidisciplinary team including thoracic surgeons, medical oncologists, radiation oncologists, and pulmonologists for efficient, individualized management.
![Page 59: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/59.jpg)
![Page 60: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/60.jpg)
Conclusions• Definition of the stage is an essential part of
the approach to patients with cancer.• The tumor node metastasis (TNM) staging
system is used for staging of NSCLC.• The major determinant chosen for
development of subgroups of T, N, and M descriptors as well as the stage groupings was the overall survival, based on the best stage.
• (VALSG) is widely utilized in staging of SCLC.
![Page 61: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/61.jpg)
• sampling the primary tumor is diagnostic only. In contrast, sampling abnormalities potentially related to the primary tumor may be diagnostic and provide additional staging information.
• The sampling target should be the lesion that will establish the highest disease stage.
• Team work.
![Page 62: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/62.jpg)
![Page 63: Staging of lung cancer](https://reader035.fdocuments.in/reader035/viewer/2022081502/568165a6550346895dd88cc2/html5/thumbnails/63.jpg)
Thank you for not smoking