Jaime Palomino, MD

Pulmonary, Critical Care Medicine

Tulane University
Lung Cancer - Staging
Objectives/Content
7th Edition staging system NSCLC
LN anatomy
TNM classification
SCLC
Staging work up
Staging of mediastinum
Pleural mesothelioma
TNM Staging Lung CA
Initial proposal by Dr. Clifton Mountain
AJCC 1973, UICC 1974
2155 patients from MD Anderson
Last revision 1997
5319 patients
Lung Cancer Staging 6th ed.

Lababede O et al. CHEST 1999;115:233-35

Lung Cancer Staging. 7th Edition.
TNM Classification

Staging Manual In Thoracic Oncology. IASLC. 2009

Lung Cancer Staging 7th ed.

Goldstraw P et al. J Thorac Oncol 2007;2:706-714

 Lung Cancer Staging. 7th Edition. Nodal Chart

Staging Manual In Thoracic Oncology

IASLC. 2009
Staging Manual In Thoracic Oncology
IASLC. 2009
Staging Manual In Thoracic Oncology
IASLC. 2009
Staging Manual In Thoracic Oncology
IASLC. 2009
Staging Manual In Thoracic Oncology
IASLC. 2009
Staging Manual In Thoracic Oncology
IASLC. 2009
Staging Manual In Thoracic Oncology
IASLC. 2009
 Lung Cancer Staging. 7th Edition.
T1

Staging Manual In Thoracic Oncology

IASLC. 2009
 Lung Cancer Staging. 7th Edition.
T2

Staging Manual In Thoracic Oncology

IASLC. 2009
 Lung Cancer Staging. 7th Edition.
T3

Staging Manual In Thoracic Oncology

IASLC. 2009
 Lung Cancer Staging. 7th Edition.
T4

Staging Manual In Thoracic Oncology

IASLC. 2009
 Lung Cancer Staging. 7th Edition.
N0, N1

Staging Manual In Thoracic Oncology

IASLC. 2009
 Lung Cancer Staging. 7th Edition.
N2

Staging Manual In Thoracic Oncology

IASLC. 2009
 Lung Cancer Staging. 7th Edition.
N3

Staging Manual In Thoracic Oncology

IASLC. 2009
 Lung Cancer Staging. 7th Edition.
M1a

Staging Manual In Thoracic Oncology

IASLC. 2009
 Lung Cancer Staging. 7th Edition.
M1b

Staging Manual In Thoracic Oncology

IASLC. 2009
Lung Cancer Staging. 7th Edition.
TNM Classification

Clinical Stage Pathologic Stage

Detterbeck et al. CHEST 2009;136:260-271

Lung Cancer Staging. 7th Edition.
Stage 0, I

Detterbeck et al. CHEST 2009;136:260-271

Lung Cancer Staging. 7th Edition.
Stage II

Detterbeck et al. CHEST 2009;136:260-271

Lung Cancer Staging. 7th Edition.
Stage III

Detterbeck et al. CHEST 2009;136:260-271

Lung Cancer Staging. 7th Edition.
Stage IV

Detterbeck et al. CHEST 2009;136:260-271

 Lung Cancer Staging. 7th Edition.
TNM Classification

Staging Manual In Thoracic Oncology. IASLC. 2009

Lung Cancer Staging. 7th Edition.
TNM Classification

Detterbeck et al. CHEST 2009;136:260-271

Lung Cancer Staging 7th ed.

Goldstraw P et al. J Thorac Oncol 2007;2:706-714

Lung Cancer Staging. SCLC
Limited Disease
No detectable disease outside of hemithorax
With or without ipsilateral or contralateral, hilar,
mediastinal, or supraclavicular LN involvement
Unilateral pleural effusion
Single radiation therapy port
Extensive Disease
Any disease occurring beyond sites of limited disease
Lung Cancer Staging. 7th Edition.
SCLC

Shepherd et al. J Thorac Oncol. 2007;2:1067-1077

Lung Cancer Staging. 7th Edition.
SCLC

Vallieres et al. J Thorac Oncol. 2009;4:1049-1059

Lung Cancer Staging
Staging work up
History & PE (ECOG score)
CT chest with contrast down to adrenal glands
Whole body CT-PET
Brain imaging
MRI, CT head with contrast
Neurological symptoms
SCLC
Stage III and above
Adenocarcinoma?
Bone Scan + Abdominal CT (if CT-PET not available)
Full PFTs (Spirometry, DLCO)
 Sampling Of The Mediastinum
ACCP Lung Cancer Practice Guidelines 2007
Mediastinal LN biopsy indications:
LN 1cm regardless PET results (1B)

Abnormal PET in mediastinum (1B)

Central tumor or N1 disease (2C)

Non-malignant result from needle techniques should be

confirmed by mediastinoscopy (1C)

Detterbeck et al. CHEST 2007;132:202S-220S

 Sampling Of The Mediastinum
Mediastinoscopy Gold standard
Minimally Invasive
TBNA

EBUS FNA

EUS - FNA
Gomez et al. Proc Am Thorac Soc 2009;6:180-186
 TBNA Sampling Of The Mediastinum
Sensitivity:
15 - 85%

Meta-analysis:
Sensitivity 39%

Dependence on lung cancer prevalence

ROSE increases yield

Underutilized (1997)
10% fellows routinely

40% fellows occasionally

20% practicing pulmonologists

El Bayoumi et al. SRCCM 2008;29:261-270

Haponik et al. CHEST 1997;112:251-253
Rafanan et al. SRCC 2000;21:405-420
EUS/FNA Sampling Of The Mediastinum
 EUS/FNA Sampling Of The Mediastinum
Mediastinal approach from esophagus
Stations 3, 4L, 7, 8 and 9
Left adrenal gland
Left lobe of liver
Sensitivity:
72 100%

Specificity:
88 100%

El Bayoumi et al. SRCCM 2008;29:261-270

EBUS Linear (Convex) Probe

El Bayoumi et al. SRCCM 2008;29:261-270

EBUS Linear (Convex) Probe

Yasufuku et al. CHEST 2004;126:122-128

EBUS Linear Probe

Gomez et al. Proc Am Thorac Soc 2009;6:180-186

 EBUS/TBNA Sampling Of The Mediastinum
Linear (convex) Probe
Real time visualization and sampling

Depth 5cm

LN stations 8,9,6, and 5 are not accessible

8 and 9 EUS

5 and 6 Left median sternotomy (Chamberlain

procedure)
Sensitivity 92 94%

Specificity 100%

Maximum diagnostic values are achieved with three

aspirations per LN station

Herth et al. Eur Respir J 2006;28:910-914

Lee et al. CHEST 2008;134:368-374
EBUS/TBNA Sampling Of The Mediastinum

Shulman et al. Curr Opin Pulm Med 2007;13:271-277

Gomez et al. Proc Am Thorac Soc 2009;6:180-186
EBUS + EUS LN FNA

Wallace et al. JAMA 2008;299:540-546

Gomez et al. Proc Am Thorac Soc 2009;6:180-186
 Pleural Mesothelioma Staging. 7th Edition.
TNM Classification

Staging Manual In Thoracic Oncology. IASLC. 2009

 Pleural Mesothelioma Staging. 7th Edition.
TNM Classification

Staging Manual In Thoracic Oncology. IASLC. 2009