Seventh Edition of the Cancer Staging Manual and Stage Grouping of Lung Cancer : Quick Reference Chart and

Diagrams
Omar Lababede, Moulay Meziane and Thomas Rice Chest 2011;139;183-189 DOI 10.1378/chest.10-1099 The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/139/1/183.full.html

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CHEST
Quick Reference Chart and Diagrams

Special Features

Seventh Edition of the Cancer Staging Manual and Stage Grouping of Lung Cancer
Omar Lababede, MD; Moulay Meziane, MD; and Thomas Rice, MD, FCCP

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

is the leading cause of cancer Lungincancermen and women in the United mortality both States.
1

Staging plays a critical role in guiding treatment selection and determining prognosis of cancer. Additionally, the evaluation of the response to treatment and the clinical research of cancer are facilitated 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 metastases (M). The seventh edition of TNM staging for lung tumors has been released recently. The revisions in the new edition were recommended by the International Association for the Study of Lung Cancer staging project and were accepted by both the International 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
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

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 primary 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 groupings are color coded and can be found at the intersections 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 carcinoma 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.
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Table 1Seventh Edition of TNM Staging of Lung Tumors: Denition of T, N, and M2-6
Descriptor Primary tumor (T) Tx T0 Tis T1 Denition Tumor that cannot be assessed or is not detected radiologically or bronchoscopically but is proven histopathologically (malignant cells in bronchopulmonary secretions) No evidence of primary tumor Carcinoma in situ 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) 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) 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 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 Regional lymph nodes cannot be assessed Absence of regional lymph node involvement Presence of metastasis to ipsilateral peribronchial and/or ipsilateral hilar lymph nodes (including direct extension to intrapulmonary nodes) Presence of metastasis to ipsilateral mediastinal and/or subcarinal lymph nodes Presence of metastasis to any of the following lymph node groups: contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular nodes

T2

T3

T4

Lymph nodes (N) Nx N0 N1 N2 N3

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.

Satellite nodule(s) in the same lobe as the primary tumor will now classify the tumor as T3 (previously T4), whereas their presence in a different lobe of the same lung is reclassied as T4 (previously M1).
Table 2Seventh Edition of TNM Staging of Lung Tumors: Stage Grouping2-6
Occult carcinoma Stage 0 Stage IA Stage IB Stage IIA Stage IIB Stage IIIA Stage IIIB Stage IV (TxN0M0) (TisN0M0) (T1a/bN0M0) (T2aN0M0) (T1a/bN1M0, T2aN1M0,T2bN0M0) (T2bN1M0, T3N0M0) (T(1-3)N2M0, T3N1M0, T4N(0-1)M0) (T4N2M0, T(1-4)N3M0) (Any T, any N, M1)

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. Malignant pleural and pericardial effusions were classied 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.
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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 stations was adopted by the International Association for the Study of Lung Cancer.2,3,8 The new map recwww.chestpubs.org

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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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 extension 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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Table 3IASLC Lymph Node Denition2,3,8

Denition Nodal Zone Supraclavicular Nodal Station 1 (R and L) Nodes Description Low cervical, supraclavicular and sternal notch Right upper paratracheal Left upper paratracheal Prevascular Retrotracheal Right lower paratracheal Upper Border Lower margin of cricoid cartilage Apex of right lung and pleural cavity and upper border of the manubrium Apex of left lung and pleural cavity and upper border of the manubrium Apex of chest Apex of chest Intersection of caudal margin of the innominate vein and trachea Upper limits of the aortic arch Lower Border Clavicles and upper border of the manubrium Intersection of caudal margin of the innominate vein and trachea Upper limits of the aortic arch Level of carina Level of carina Lower border of the azygos vein Upper rim of the left main pulmonary artery Upper rim of the left main pulmonary artery Lower border of the aortic arch Upper border of lower lobe bronchus on the left and lower border of the bronchus intermedius on the right Diaphragm Other Midline of the trachea denes R and L Left lateral margin of the trachea denes R and L

Upper mediastinal

2R

2L

3a 3p 4R

... Left lateral margin of the trachea denes R and L

4L Aortopulmonary 5

6 Subcarinal 7

Left lower paratracheal Subaortic Lower border of the aortic arch (aortopulmonary window) Paraaortic (ascending Line tangential to the upper aorta or phrenic) limits of the aortic arch Subcarinal The carina

Lateral to ligamentum arteriosum ... ...

Lower mediastinal

8 (R and L)

Paraesophageal

9 (R and L)

Pulmonary ligaments

Upper border of lower lobe bronchus on the left and lower border of the bronchus intermedius on the right The inferior pulmonary vein

The midline denes R and L

Diaphragm

Within the pulmonary ligament

b

Hilar/interlobar

10 (R and L)

Hilar

Peripheral

11 (R and L) 12 (R and L) 13 (R and L) 14 (R and L)

Interlobar Lobar Segmental Subsegmental

Lower rim of the azygos on the Interlobar regions right and upper rim of the left main pulmonary artery on the left Between the origin of the lobar bronchic Adjacent to the lobar bronchi Adjacent to the segmental bronchi Adjacent to the subsegmental bronchi

IASLC 5 International Association for the Study of Lung Cancer; L 5 left; R 5 right. aThe 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. bIncludes nodes adjacent to the main stem bronchi and hilar vessels, including the proximal aspects of the pulmonary arteries and veins. cCan 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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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 pulmonary 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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Figure 3. Continued.

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 discussed in this article.

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Seventh Edition of the Cancer Staging Manual and Stage Grouping of Lung Cancer : Quick Reference Chart and Diagrams Omar Lababede, Moulay Meziane and Thomas Rice Chest 2011;139; 183-189 DOI 10.1378/chest.10-1099 This information is current as of March 8, 2012
Updated Information & Services Updated Information and services can be found at: http://chestjournal.chestpubs.org/content/139/1/183.full.html References This article cites 6 articles, 2 of which can be accessed free at: http://chestjournal.chestpubs.org/content/139/1/183.full.html#ref-list-1 Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.chestpubs.org/site/misc/reprints.xhtml Reprints Information about ordering reprints can be found online: http://www.chestpubs.org/site/misc/reprints.xhtml Citation Alerts Receive free e-mail alerts when new articles cite this article. To sign up, select the "Services" link to the right of the online article. Images in PowerPoint format Figures that appear in CHEST articles can be downloaded for teaching purposes in PowerPoint slide format. See any online figure for directions.

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