Imaging of Lung Cancer: A Review of the 8 th TNM Staging System

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1 Imaging of Lung Cancer: A Review of the 8 th TNM Staging System Travis S Henry, MD Associate Professor of Clinical Radiology Cardiac and Pulmonary Imaging Section University of California, San Francisco Do you have the 7 th TNM Staging System memorized? A. Yes B. At one point I knew it, but not anymore C. No, but I wish I did D. No, and I have no intention of memorizing it E. What is the TNM staging system? 1

2 7th TNM Staging System 1 1 Occult Carcinoma TX N0 M0 2 Stage 0 Tis N0 M0 3 Stage IA T1a N0 M0 4 T1b N0 M0 5 Stage IB T2a N0 M0 6 Stage IIA T2b N0 M0 7 T1a N1 M0 8 T1b N1 M0 9 T2a N1 M0 10 Stage IIB T2b N1 M0 11 T3 N0 M0 12 Stage IIIA T1a N2 M0 13 T1b N2 M0 14 T2a N2 M0 15 T2b N2 M0 16 T3 N1 M0 17 T3 N2 M0 18 T4 N0 M0 19 T4 N1 M0 20 Stage IIIB T1a N3 M0 21 T1b N3 M0 22 T2a N3 M0 23 T2b Ne M0 24 T3 N3 M0 25 T4 N2 M0 26 T4 N3 M0 27 Stage IV Any T Any N M1a 28 Any T Any N M1b 1 Adapted from AJCC Lung Cancer Staging 7 th Edition The EIGHTH edition of the TNM classification for lung cancer became the worldwide standard January 1, 2017 except in the US, where it is to be adopted in Detterbeck FC, Boffa DJ, Kim AW, Tanoue LT. The Eighth Edition Lung Cancer Stage Classification. Chest 2017; 151:

3 8th TNM Staging System 2 1 Occult Carcinoma TX N0 M0 2 Stage 0 Tis N0 M0 3 Stage IA1 T1a(mi) N0 M0 4 T1a N0 M0 5 Stage IA2 T1b N0 M0 6 Stage IA3 T1c N0 M0 7 Stage IB T2a N0 M0 8 Stage IIA T2b N0 M0 9 Stage IIB T1a-c N1 M0 10 T2a N1 M0 11 T2b N1 M0 12 T3 N0 M0 13 Stage IIIA T1a-c N2 M0 14 T2a-b N2 M0 15 T3 N1 M0 16 T4 N0 M0 17 T4 N1 M0 18 Stage IIIB T1a-c N3 M0 19 T2a-b N3 M0 20 T3 N2 M0 21 T4 N2 M0 22 Stage IIIC T3 N3 M0 23 T4 N3 M0 24 Stage IVA Any T Any N M1a 25 Any T Any N M1b 26 Stage IVB Any T Any N M1c 2 Adapted from Goldstraw P et al. The IASLC Lung Cancer Staging Project: Proposals for Revision of the TNM Stage Groupings in the Forthcoming (Eighth) Edition of the TNM Classification for Lung Cancer. Journal of Thoracic Oncology 2016; 11:39-51 Any metastases: Stage IV N3 nodes: Stage IIIB Surgery rarely performed beyond IIIA 8th TNM Staging System 2 1 Occult Carcinoma TX N0 M0 2 Stage 0 Tis N0 M0 3 Stage IA1 T1a(mi) N0 M0 4 T1a N0 M0 5 Stage IA2 T1b N0 M0 6 Stage IA3 T1c N0 M0 7 Stage IB T2a N0 M0 8 Stage IIA T2b N0 M0 9 Stage IIB T1a-c N1 M0 10 T2a N1 M0 11 T2b N1 M0 12 T3 N0 M0 13 Stage IIIA T1a-c N2 M0 14 T2a-b N2 M0 15 T3 N1 M0 16 T4 N0 M0 17 T4 N1 M0 18 Stage IIIB T1a-c N3 M0 19 T2a-b N3 M0 20 T3 N2 M0 21 T4 N2 M0 22 Stage IIIC T3 N3 M0 23 T4 N3 M0 24 Stage IVA Any T Any N M1a 25 Any T Any N M1b 26 Stage IVB Any T Any N M1c 2 Adapted from Goldstraw P et al. The IASLC Lung Cancer Staging Project: Proposals for Revision of the TNM Stage Groupings in the Forthcoming (Eighth) Edition of the TNM Classification for Lung Cancer. Journal of Thoracic Oncology 2016; 11:

4 Any metastases: Stage IV N3 nodes: Stage IIIB Surgery rarely performed beyond IIIA 8th TNM Staging System 2 1 Occult Carcinoma TX N0 M0 2 Stage 0 Tis N0 M0 3 Stage IA1 T1a(mi) N0 M0 4 T1a N0 M0 5 Stage IA2 T1b N0 M0 6 Stage IA3 T1c N0 M0 7 Stage IB T2a N0 M0 8 Stage IIA T2b N0 M0 9 Stage IIB T1a-c N1 M0 10 T2a N1 M0 11 T2b N1 M0 12 T3 N0 M0 13 Stage IIIA T1a-c N2 M0 14 T2a-b N2 M0 15 T3 N1 M0 16 T4 N0 M0 17 T4 N1 M0 18 Stage IIIB T1a-c N3 M0 19 T2a-b N3 M0 20 T3 N2 M0 21 T4 N2 M0 22 Stage IIIC T3 N3 M0 23 T4 N3 M0 24 Stage IVA Any T Any N M1a 25 Any T Any N M1b 26 Stage IVB Any T Any N M1c 2 Adapted from Goldstraw P et al. The IASLC Lung Cancer Staging Project: Proposals for Revision of the TNM Stage Groupings in the Forthcoming (Eighth) Edition of the TNM Classification for Lung Cancer. Journal of Thoracic Oncology 2016; 11:39-51 Any metastases: Stage IV N3 nodes: Stage IIIB Surgery rarely performed beyond IIIA 8th TNM Staging System 2 1 Occult Carcinoma TX N0 M0 2 Stage 0 Tis N0 M0 3 Stage IA1 T1a(mi) N0 M0 4 T1a N0 M0 5 Stage IA2 T1b N0 M0 6 Stage IA3 T1c N0 M0 7 Stage IB T2a N0 M0 8 Stage IIA T2b N0 M0 9 Stage IIB T1a-c N1 M0 10 T2a N1 M0 11 T2b N1 M0 12 T3 N0 M0 13 Stage IIIA T1a-c N2 M0 14 T2a-b N2 M0 15 T3 N1 M0 16 T4 N0 M0 17 T4 N1 M0 18 Stage IIIB T1a-c N3 M0 19 T2a-b N3 M0 20 T3 N2 M0 21 T4 N2 M0 22 Stage IIIC T3 N3 M0 23 T4 N3 M0 24 Stage IVA Any T Any N M1a 25 Any T Any N M1b 26 Stage IVB Any T Any N M1c 2 Adapted from Goldstraw P et al. The IASLC Lung Cancer Staging Project: Proposals for Revision of the TNM Stage Groupings in the Forthcoming (Eighth) Edition of the TNM Classification for Lung Cancer. Journal of Thoracic Oncology 2016; 11:

5 Objectives Table the table Letter-by-letter: findings that alter staging (and what should be in the report) Review changes for the 8 th TNM system Staging does not dictate management T4N0M0 Stage IIIA T1BN0M0 Stage IA 5

6 Staging is a guide to management T4N0M0 Stage IIIA Pneumonectomy Staging is a guide to management Radiation 6

7 Staging is a guide to management and prognosis Year 2 Year 2 Where does the TNM Staging Apply? Non-small cell lung cancer Small cell lung cancer Bronchopulmonary carcinoid* 7

8 T primary Tumor N lymph Node involvement M Metastases 64-year-old man 8

9 What is the minimum M descriptor based on these images? A. M0 B. M1a C. M1b D. M1c 9

10 M Distant Metastasis Thorax M1a M1a Brain Bone Liver Adrenal Lymph nodes M1b Or M1c M Distant Metastasis Thorax M1a M1a Brain Bone Liver Adrenal Lymph nodes M1b Or M1c 10

11 M Distant Metastasis M1a intrathoracic 65-year-old woman Pleura Pericardium Contralateral lung Pericardiocentesis (+) for adenocarcinoma 2.3 cm (T1c) adenocarcinoma referred for SBRT Pleural fluid (+ adenocarcinoma) à M1a 11

12 Diffuse adenocarcinoma Bilateral pulmonary disease à M1a M1b 8 th TNM M1c One extrathoracic metastasis Multiple extrathoracic metastasis (in 7 th TNM all extrathoracic metastases were M1b) 12

13 M1b One extrathoracic metastasis M1c Multiple extrathoracic metastasis Eberhardt WE et al. The IASLC Lung Cancer Staging Project: Proposals for the Revision of the M Descriptors in the Forthcoming Eighth Edition of the TNM Classification of Lung Cancer. J Thorac Oncol 2015; 10: % of lung cancers have metastases at presentation 1 1 Niu FY et al. Distribution and prognosis of uncommon metastases from non-small cell lung cancer. BMC Cancer 2016; 16:149 13

14 T1bN0 ONE Extrathoracic Metastasis à M1b M1c - Multiple Metastases in one organ 14

15 M1c - Multiple Organs Adenocarcinoma T2bN0M1c M Intrathoracic metastases (M1a)? Pleura/pericardium Contralateral lung Extrathoracic metastases? One metastasis à M1b Multiple à M1c 15

16 27-year-old man with LLL squamous cell carcinoma This patient s N classification is likely? A. N0 B. N1 C. N2 D. N3 16

17 N3 N2 N1 No Changes to N for 8 th TNM Staging System 17

18 N3 N2 N1 N1: T1cN1M0 -Ipsilateral hilar (or further out in the lung) 18

19 N1 Nodes but metastatic disease (M1c) Subcarinal Nodes are N2 (regardless of side of cancer) 19

20 T2b LLL adenocarcinoma N2: Subcarinal Ipsilateral mediastinal 20

21 N2: Subcarinal Ipsilateral mediastinal Left Lower Lobe Primary Right lung cancer Left lung cancer Paratracheal left versus right? 21

22 N2 (right) N2 (left) The LEFT border of the trachea is midline Clinical (c) vs Pathologic (p) staging 22

23 Clinical (c) vs Pathologic (p) staging ct2an1m0 c = Data obtained before definitive treatment -imaging -physical exam -biopsy/fluid analysis At surgery: 2/2 level 4R lymph nodes à positive for adenocarcinoma 1/1 level 2R lymph node à positive for adenocarcinoma 23

24 Clinical (c) vs Pathologic (p) staging pt2an2m0 p = Data obtained from surgery as part of definitive treatment N3 N3 lymph nodes Contralateral mediastinal/hilar Supraclavicular/scalene 24

25 N3 Contralateral mediastinal/hilar Supraclavicular/scalene (either side) Other node chains still not included in 8 th TNM staging 25

26 N N0 No mets N1 Same lung/same hilum N2: Subcarinal Ipsilateral mediastinal N3: Contralateral mediastinum/hilum Supraclavicular/scalene 66-year-old woman 26

27 What is the correct measurement and T-descriptor (8 th TNM)? 2.3 cm A. 2.3cm, T=1b B. 2.3cm, T=1c C. 1.8cm, T=1b D. 1.8cm, T=1c 1.5 cm Longest Dimension Measurement for T (short axis for N) 2.3 cm 27

28 T Tumor Size (cm) 7th 8th 1 T1a T1a >1-2 T1b >2-3 T1b T1c >3-4 T2a T2a >4-5 T2b >5-6 T2b T3 2.3 cm >6-7 >7 T3 T4 T Tumor Size (cm) 7th 8th 1 T1a T1a >1-2 T1b >2-3 T1b T1c >3-4 T2a T2a >4-5 T2b >5-6 T2b T3 2.3 cm >6-7 >7 T3 T4 28

29 Rami-Porta R et al. The IASLC Lung Cancer Staging Project: Proposals for the Revisions of the T Descriptors in the Forthcoming Eighth Edition of the TNM Classification for Lung Cancer. J Thorac Oncol 2015; 10: Two components of the T descriptor Size: -Longest dimension -1 cm increments Invasion: T2 à Bronchus T3 à Chest Wall/Apex * T4à Everything Else * (Also includes phrenic nerve) 29

30 Size à T1c Invasion à T2 T2 Invasion: Bronchus invasion/ obstruction* *Carina/trachea T4 30

31 Distance from carina no longer important in 8 th TNM* 4cm 1cm Both are T2 tumors T3 Invasion: Chest Wall Pancoast Tumor Phrenic Nerve 3.2cm tumor; chest wall invasion à T3 31

32 T3 Invasion: Chest Wall Pancoast Tumor Phrenic Nerve T4 Invasion: (everything else) Mediastinum Heart Great vessels Trachea/carina Vertebral body Diaphragm 32

33 T4 Invasion: (everything else) Mediastinum Heart Great vessels Trachea/carina Vertebral body Diaphragm T4 Invasion: (everything else) Mediastinum Heart Great vessels Trachea/carina Vertebral body Diaphragm Left atrial invasion; tumor still resected 33

34 T Satellite Nodules Same lobe T3 Same lung, different lobe T4 Other lung M1a Two components of the T descriptor Size: -Longest dimension -1 cm increments Invasion: T2 à Bronchus T3 à Chest Wall/Apex phrenic nerve satellite nodules in same lobe T4à Everything Else satellite nodules in same lung 34

35 SPECIAL SITUATIONS: Small Cell Carcinoma 35

36 TNM applies to Small Cell Carcinoma Prior to 7th staged as limited or extensive Few SCC patients treated surgically Underwent LLLectomy and PA resection 36

37 SPECIAL SITUATIONS: Adenocarcinoma Mixed solid and groundglass nodule Multiple Adenocarcinomas Pneumonic Adenocarcinoma Mixed solid and GGO: Solid (invasive component) measured separately (total lesion diameter should also be reported) Carter BW, Godoy MCB, Wu CC, Erasmus JJ, Truong MT. Current Controversies in Lung Cancer Staging. Journal of Thoracic Imaging 2016; 31:

38 Pneumonic type of mucinous adenocarcinoma T3 (same lobe) T4 (same lung) M1a if both lungs 39-year-old (Often have better prognosis) Pneumonic type of mucinous adenocarcinoma Original T3 (same lobe) T4 (same lung) M1a if both lungs 38

39 Pneumonic type of mucinous adenocarcinoma Original T3 (same lobe) T4 (same lung) M1a if both lungs 1 year later For multifocal GGO: T stage of largest nodule 39

40 For multifocal GGO: T stage of largest nodule SPECIAL SITUATIONS: Synchronous Lung Cancers 40

41 Squamous cell carcinoma Synchronous primaries Each TNM separate Small cell carcinoma Should you expect a stage in the report? 41

42 Glastonbury CM, et al. Do Radiologists Have Stage Fright? Tumor Staging and How We Can Add Value to the Care of Patients with Cancer. Radiology 2016; 278: cm left upper lobe mass with possible mediastinal invasion à T2a Enlarged, enhancing subaortic lymph node à N2 Left pleural effusion with enhancing nodularity à M1a 42

43 Conclusion T and M have changed for the 8 th TNM system T Size, Invasion N further away from primary, higher N M: Intrathoracic M1a Extrathoracic One M1b Multiple M1c Thank You! For references and more information please see my website (below) Lymph node map app: travis.henry@ucsf.edu THrads.com 43

44 References Goldstraw P, Chansky K, Crowley J, et al. The IASLC Lung Cancer Staging Project: Proposals for Revision of the TNM Stage Groupings in the Forthcoming (Eighth) Edition of the TNM Classification for Lung Cancer. Journal of Thoracic Oncology 2016; 11: Rami-Porta R, Bolejack V, Crowley J, et al. The IASLC Lung Cancer Staging Project: Proposals for the Revisions of the T Descriptors in the Forthcoming Eighth Edition of the TNM Classification for Lung Cancer. J Thorac Oncol 2015; 10: Asamura H, Chansky K, Crowley J, et al. The International Association for the Study of Lung Cancer Lung Cancer Staging Project: Proposals for the Revision of the N Descriptors in the Forthcoming 8th Edition of the TNM Classification for Lung Cancer. J Thorac Oncol 2015; 10: Eberhardt WE, Mitchell A, Crowley J, et al. The IASLC Lung Cancer Staging Project: Proposals for the Revision of the M Descriptors in the Forthcoming Eighth Edition of the TNM Classification of Lung Cancer. J Thorac Oncol 2015; 10: Boxer MM, Vinod SK, Shafiq J, Duggan KJ. Do multidisciplinary team meetings make a difference in the management of lung cancer? Cancer 2011; 117: Pillay B, Wootten AC, Crowe H, et al. The impact of multidisciplinary team meetings on patient assessment, management and outcomes in oncology settings: A systematic review of the literature. Cancer Treat Rev 2016; 42: Friedman EL, Kruklitis RJ, Patson BJ, Sopka DM, Weiss MJ. Effectiveness of a thoracic multidisciplinary clinic in the treatment of stage III non-small-cell lung cancer. J Multidiscip Healthc2016; 9: El-Sherief AH, Lau CT, Wu CC, Drake RL, Abbott GF, Rice TW. International association for the study of lung cancer (IASLC) lymph node map: radiologic review with CT illustration. Radiographics 2014; 34: De Ruysscher D, Wanders R, van Baardwijk A, et al. Radical treatment of non-small-cell lung cancer patients with synchronous oligometastases: long-term results of a prospective phase II trial (Nct ). J Thorac Oncol 2012; 7: Detterbeck FC, Nicholson AG, Franklin WA, et al. The IASLC Lung Cancer Staging Project: Summary of Proposals for Revisions of the Classification of Lung Cancers with Multiple Pulmonary Sites of Involvement in the Forthcoming Eighth Edition of the TNM Classification. J Thorac Oncol 2016; 11: Carter BW, Godoy MCB, Wu CC, Erasmus JJ, Truong MT. Current Controversies in Lung Cancer Staging. Journal of Thoracic Imaging 2016; 31: Kligerman S, Abbott G. A radiologic review of the new TNM classification for lung cancer. AJR Am J Roentgenol 2010; 194: Nicholson AG, Chansky K, Crowley J, et al. The International Association for the Study of Lung Cancer Lung Cancer Staging Project: Proposals for the Revision of the Clinical and Pathologic Staging of Small Cell Lung Cancer in the Forthcoming Eighth Edition of the TNM Classification for Lung Cancer. J Thorac Oncol 2016; 11: AJCC Lung Cancer Staging 7th Edition (accessed ) 44