CHEST Special Features

www.chestpubs.org CHEST / 139 / 1 / JANUARY, 2011 183

L
ung cancer is the leading cause of cancer mortal-
ity in both men and women in the United States.
1

Staging plays a critical role in guiding treatment
selection and determining prognosis of cancer.
Additionally, the evaluation of the response to treat-
ment and the clinical research of cancer are facili-
tated by a universal system. TNM staging provides a
consistent, reproducible description of cancers based
on the extent of anatomic involvement. This is achieved
by dening the characteristics of the primary tumor
(T), regional lymph node involvement (N), and metas-
tases (M). The seventh edition of TNM staging for
lung tumors has been released recently. The revisions
in the new edition were recommended by the Inter-
national Association for the Study of Lung Cancer
staging project and were accepted by both the Inter-
national Union Against Cancer and the American Joint
Committee on Cancer.
2-6

TNM staging of lung cancer is complex, and many
variables must be considered ( Tables 1, 2 ). It can be
difcult to use and remember. We have designed a
chart and two diagrams to present the new staging
system in a simple, but nevertheless comprehensive,
format. The comparative characteristics of the pri-
mary tumor are listed in the vertical columns of the
chart ( Fig 1 ). These features include size and extent
(endobronchial location, local invasion, and satellite
nodule[s]). The horizontal columns describe regional
lymph node involvement. The different stage group-
ings are color coded and can be found at the intersec-
tions of appropriately matched horizontal and vertical
columns. Stages with unique characteristics such
as stages 0 and IV are dened in separate boxes. The
basic design of the chart is based on our previously
published reference chart of the fth edition of lung
cancer staging.
7
The diagrams ( Fig 2 ) illustrate the
same information in a more concise visual format.
The recently adopted revisions of TNM staging are
reected in our chart and diagrams. These changes
include the following:
TNM system application to small cell lung car-
cinoma and carcinoid tumor of the lung (the
previous system was applicable to non-small
cell lung carcinoma only)
Redenition of the primary tumor classication
based on size:
T1 is subdivided into T1a and T1b
T2 is subdivided into T2a and T2b
Cancer larger than 7 cm is reclassied as T3.
Lung cancer remains the most common cause of cancer-related death in the United States. TNM
staging, which is an important guide to the prognosis and treatment of lung cancer, has been
revised recently. In this article, we propose a quick reference chart and diagrams that consolidate
TNM staging information in a simple format. The current classication of lymph node stations
and zones is illustrated as well. CHEST 2011; 139(1):183189
Abbreviations: M 5 metastases; N 5 regional lymph node involvement; T 5 primary tumor
Seventh Edition of the Cancer Staging
Manual and Stage Grouping of Lung Cancer
Quick Reference Chart and Diagrams
Omar Lababede , MD ; Moulay Meziane , MD ; and Thomas Rice , MD , FCCP
Manuscript received April 27, 2010; revision accepted June 14,
2010.
Afliations: From the Imaging Institute (Drs Lababede and
Meziane) and the Department of Thoracic and Cardiovascular
Surgery (Dr Rice), Cleveland Clinic, Cleveland, OH.
Correspondence to: Omar Lababede, MD, Imaging Institute,
Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195; e-mail:
lababeo@ccf.org
2011 American College of Chest Physicians. Reproduction
of this article is prohibited without written permission from the
American College of Chest Physicians ( http://www.chestpubs.org/
site/misc/reprints.xhtml ).
DOI: 10.1378/chest.10-1099
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184 Special Features
Redefinition of metastases (M): subdivision
of M into M1a and M1b. M1a includes both
satellite nodule(s) in the contralateral lung and
malignant pleural and pericardial effusions. Malig-
nant pleural and pericardial effusions were clas-
sied previously as T4 N0 Mx.
Changes to stage groupings, including
T4N0M0 and T4N1M0 tumors are reassigned
from stage IIIB to stage IIIA.
The newly dened T2b tumors with no lymph
node or distant metastases (T2bN0M0) are
grouped under IIA instead of IB.
The newly dened T2a tumors with N1
lymph node but without distant metastases
(T2aN1M0) are grouped under IIA rather
than IIB.
Satellite nodule(s) in the same lobe as the pri-
mary tumor will now classify the tumor as T3
(previously T4), whereas their presence in a dif-
ferent lobe of the same lung is reclassied as T4
(previously M1).
Table 1 Seventh Edition of TNM Staging of Lung Tumors: Denition of T, N, and M
2-6

Descriptor Denition
Primary tumor (T )
Tx Tumor that cannot be assessed or is not detected radiologically or bronchoscopically but is proven histopathologically
(malignant cells in bronchopulmonary secretions)
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1 Tumor with the following characteristics:
Size 3 cm
Airway location: in lobar bronchus or more distal airways
Local invasion: none, surrounded by lung or visceral pleura
Subdivisions: T1a (size 2 cm) and T1b (2 cm , size 3 cm)
T2 Tumor with size . 3 cm but 7 cm or tumor with any of the following characteristics:
Airway location: involvement of the main bronchus (distance to the carina is 2 cm) or presence of atelectasis or
obstructive pneumonitis that extends to hilar region but does not involve the entire lung
Local invasion: involvement of visceral pleura
Subdivisions: T2a (3 cm , size 5 cm) and T2b (5 cm , size 7 cm)
T3 Tumor . 7 cm in size or tumor with any of the following:
Airway location: tumor in the main bronchus (within 2 cm of the carina), or tumor with atelectasis or obstructive
pneumonitis of the entire lung
Local invasion: direct invasion of chest wall (including superior sulcus tumors), diaphragm, phrenic nerve, mediastinal
pleura, or parietal pericardium
Satellite tumor nodule(s) in the same lobe as the primary tumor
T4 Tumor of any size invading any of the following: mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve,
esophagus, vertebral body, or carina; or tumor with satellite tumor nodule(s) in a different lobe, ipsilateral to that of
the primary tumor

Lymph nodes (N)
Nx Regional lymph nodes cannot be assessed
N0 Absence of regional lymph node involvement
N1 Presence of metastasis to ipsilateral peribronchial and/or ipsilateral hilar lymph nodes (including direct extension to
intrapulmonary nodes)
N2 Presence of metastasis to ipsilateral mediastinal and/or subcarinal lymph nodes
N3 Presence of metastasis to any of the following lymph node groups: contralateral mediastinal, contralateral hilar,
ipsilateral or contralateral scalene, or supraclavicular nodes
Distant metastasis (M)
M0 Absence of distant metastasis
M1 Presence of distant metastasis
Subdivisions:
M1a (satellite tumor nodule(s) in a contralateral lobe to that of the primary tumor or tumors with malignant pleural
or pericardial effusion)
M1b (distant metastasis)
The uncommon supercial spreading tumor of any size with its invasive component limited to the bronchial wall is classied as T1a even in the case
of extension to main bronchus.
Table 2 Seventh Edition of TNM Staging of Lung
Tumors: Stage Grouping
2-6

Occult carcinoma (TxN0M0)
Stage 0 (TisN0M0)
Stage IA (T1a/bN0M0)
Stage IB (T2aN0M0)
Stage IIA (T1a/bN1M0, T2aN1M0,T2bN0M0)
Stage IIB (T2bN1M0, T3N0M0)
Stage IIIA (T(1-3)N2M0, T3N1M0, T4N(0-1)M0)
Stage IIIB (T4N2M0, T(1-4)N3M0)
Stage IV (Any T, any N, M1)
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www.chestpubs.org CHEST / 139 / 1 / JANUARY, 2011 185
Figure 1. Reference chart for 2009 TNM staging system of lung cancer. M 5 metastases; N 5 regional
lymph node involvement; T 5 tumor .
Although regional lymph node (N) classications
have not changed, a unied map of lymph node sta-
tions was adopted by the International Association
for the Study of Lung Cancer.
2,3,8
The new map rec-
onciles discrepancies among previous nodal mapping
proposals and introduces the concept of lymph node
zones ( Table 3 ). Figures 3A and 3B demonstrate the
new lymph nodes stations.
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186 Special Features
Figure 2. Reference diagrams for 2009 TNM staging system of lung cancer. The T classication can be
dened by evaluating the size rst (upper left), then upgrading the classication (if necessary) based on
the presence of the other criteria of primary tumor invasion/extent (A, B, and C). The criteria of extent
should not be used to assign a lower classication. The lower diagram can be used to dene the N and
M classication and to determine the corresponding stage. Note that N1, N2, N3, and the separate
tumor nodule of M1a were depicted in the lower illustration based on a right-sided tumor (T). For left
lung tumors, a mirror image of these descriptors should be used. Additionally, the endobronchial exten-
sion and local invasion (A and B of the criteria of extent) were shown in the upper illustration based on
a left-sided tumor to simplify the drawing. See Figure 1 legend for expansion of abbreviations.
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www.chestpubs.org CHEST / 139 / 1 / JANUARY, 2011 187
Table 3 IASLC Lymph Node Denition
2,3,8

Nodal Zone Nodal Station Nodes Description
Denition
Upper Border Lower Border Other
Supraclavicular 1 (R and L) Low cervical,
supraclavicular
and sternal notch
Lower margin of cricoid
cartilage
Clavicles and upper border
of the manubrium
Midline of the
trachea denes
R and L
Upper
mediastinal
2R Right upper
paratracheal
Apex of right lung and
pleural cavity and upper
border of the manubrium
Intersection of caudal
margin of the innominate
vein and trachea
Left lateral margin
of the trachea
denes R and L
2L Left upper
paratracheal
Apex of left lung and pleural
cavity and upper border of
the manubrium
Upper limits of the aortic
arch
3a Prevascular Apex of chest Level of carina
a

3p Retrotracheal Apex of chest Level of carina ...
4R Right lower
paratracheal
Intersection of caudal margin
of the innominate vein and
trachea
Lower border of the azygos
vein
Left lateral margin
of the trachea
denes R and L
4L Left lower
paratracheal
Upper limits of the aortic arch Upper rim of the left main
pulmonary artery
Aortopulmonary 5 Subaortic
(aortopulmonary
window)
Lower border of the aortic arch Upper rim of the left main
pulmonary artery
Lateral to
ligamentum
arteriosum
6 Paraaortic (ascending
aorta or phrenic)
Line tangential to the upper
limits of the aortic arch
Lower border of the aortic
arch
...
Subcarinal 7 Subcarinal The carina Upper border of lower lobe
bronchus on the left and
lower border of the bronchus
intermedius on the right
...
Lower
mediastinal
8 (R and L) Paraesophageal Upper border of lower lobe
bronchus on the left and
lower border of the bronchus
intermedius on the right
Diaphragm The midline
denes R and L
9 (R and L) Pulmonary ligaments The inferior pulmonary vein Diaphragm Within the
pulmonary
ligament
Hilar/interlobar 10 (R and L) Hilar Lower rim of the azygos on the
right and upper rim of the
left main pulmonary artery
on the left
Interlobar regions
b

11 (R and L) Interlobar Between the origin of the lobar bronchi
c

Peripheral 12 (R and L) Lobar Adjacent to the lobar bronchi
13 (R and L) Segmental Adjacent to the segmental bronchi
14 (R and L) Subsegmental Adjacent to the subsegmental bronchi
IASLC 5 International Association for the Study of Lung Cancer; L 5 left; R 5 right.

a
The posterior sternum forms the anterior border of the prevascular nodes, whereas the posterior border is limited by the anterior border of the
superior vena cava on the right side and the left carotid artery on the left side.

b
Includes nodes adjacent to the main stem bronchi and hilar vessels, including the proximal aspects of the pulmonary arteries and veins.

c
Can be subdivided on the right into 11s (between the right upper lobe and bronchus intermedius) and 11i (between the middle and lower lobe
bronchi).
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188 Special Features
Figure 3. The International Association for the Study of Lung Cancer lymph node map depicted on
views of the chest. A, right lateral view. B, left lateral view. The lymph node stations are color coded and
grouped into zones. The colored arrows dene the anatomic limits of certain color-matching stations.
AA 5 aortic arch; AAo 5 ascending aorta; Ao 5 aorta; AzV 5 azygos vein; BI 5 bronchus intermedius;
C 5 carina; E 5 esophagus; IPV 5 inferior pulmonary vein; IV 5 innominate vein; L 5 left; LLLB 5 left
lower lobe bronchus; LPA 5 left main pulmonary artery; PA 5 main pulmonary artery; PUL. LIG. 5 pulmo-
nary ligament; R 5 right; RLLB 5 right lower lobe bronchus; SVC 5 superior vena cava; T 5 trachea.
2,3,8

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www.chestpubs.org CHEST / 139 / 1 / JANUARY, 2011 189
Acknowledgments
Financial/nonnancial disclosures: The authors have reported
to CHEST that no potential conicts of interest exist with any
companies/organizations whose products or services may be dis-
cussed in this article.
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Figure 3. Continued.
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