STAGING LUNG CARCINOMA

IJ
 LUNG CARCINOMAS
Nonsmall cell lung cancer (NSCLC):
Most cases of lung cancer [adenocarcinoma,
squamous cell carcinoma, and large cell carcinoma ]
37.5% classified as adenocarcinoma
The most prevalent histology in both smokers and
nonsmokers

Small cell lung cancer (SCLC):

A highly aggressive neuroendocrine lung tumor
Kligerman Imaging Characteristics of Lung Cancer
 PRIMARY THERAPY FOR EARLY-STAGE
DISEASE
• Surgical resection lung cancer  offers the best chance of cure
• Accurate staging  crucial for selection patients for surgery.

• Good performance status

• Clinical stage I or II disease
 considered for surgery.
• Some patients with stage IIIA disease

• Most patients with stage IIIB (except those with T4N0) and all of
those with stage IV disease are not considered for surgery
• Patients contraindications to surgery  should be offered
radiation therapy (RT) with or without Chemotherapy

Radiology: 246:
2,2008
 PRIMARY THERAPY FOR STAGE IA
TO IIB NSCLC

• Anatomic resection  Lobectomy or

pneumonectomy

• Dissection of hilar and mediastinal nodes remains

the preferred treatment in patients with clinical
 SURVIVAL RATE
• Stage I A  61%
• Stage I B  38%
• Stage II A  34%
• Stage II B  24%
• Stage IIIA  13 %
• Stage III B  5 %
• Stage IV  1%

Method of treatment is based on clinical staging and diagnostic imaging is a

critical component in the evaluation of the primary tumor (T descriptor), lymph
nodes

Ref…
 IMAGING MODALITIES

1. Chest radiography .
2. Computed tomography (CT) .
3. Magnetic resonance (MR) imaging .
4. Positron emission tomography (PET)
5. Fused PET/CT .

Radiology 􏰆 December 2005

Volume 237Number
 PRIMARY TUMOR (T DESCRIPTOR)

• Necessary for
staging
• For surgical
treatment plan
• Important for
radiologists to
describe
primary tumor
in the reports.
T1
• Tumor < 3 cm,
surrounded by lung/
visceral pleura
1. T1a < 2 cm
2. T1b = 2-3 cm
• Without
bronchoscopic
evidence of
invasion more
proximal than the
lobar bronchus (not
in the main
bronchus)
T2
• Tumor 3-7 cm
1. T2a : Tumor 3-5 cm in
greatest dimension
2. T2b : Tumor 5-7 cm in
greatest dimension

• Tumors with any of the

following features :
- involve main bronchus,
≥ 2 cm to the carina
- invades visceral pleura
(PL1/ PL 2)
- associated atelectasis
or obstructive
pneumonitis that does
not include the entire
lobe
 T2 b

man 35 yo
Larger than 3 cm largest dimension (5-7cm)  T2b)
Man with adenocarcinoma right lower lung
 Tumor > 7 cm or one that
directly invades any of
T3 the following:

1. Parietal pleura (PL 3)

2. chest wall (include sup
sulcus tumors)
3. Diaphragm
4. Phrenic nerve
5. mediastinal pleura
parietal pericardium, or
6. tumor in the main
bronchus < 2 cm jarak
dari carina tapi tidak di
carina
6.have associated
atelectasis or
pneumonitis of the entire
lobe or
7. separate tumor nodule
(s) in the same lobe
 T3

55-yo man, adeno carcinoma in the right low

lung
Any size, Chest wall invasion  T3
ANATOMIC STAGE/PROGNOSTIC GROUPS T3
Occult Carcinoma TX N0 M0
Stage0 Tis N0 M0
StageIA T1a N0 M0
T1b N0 M0
StageIB T2a N0 M0
StageIIA T2b N0 M0
T1a N1 M0
T1b N1 M0
T2a N1 M0
StageIIB T2b N1 M0
ADENO CA T3N0M0 CHEST WALL
T3 N0 M0
STAGE I, II  CONSIDER FOR
StageIIIA T1a N2 M0 SURGERY
T1b N2 M0 CORONAL CT SHOW AFTER
SURGERY
 T4
Tumor of any size that
invades any of the
following :

-Mediastinum, heart, great

vessels, trachea,
esophagus, vertebral body,
-or carina
- or have a malignant
pleural or pericardial
effusion
- or have separate tumor
nodule (s) in a different
ipsilateral lobe
 T4

Patient adenocarcinoma was obstructing right lower bronchus causing left

lower lobe collapse. The large right pleural effusion was positive for
malignant cells making this a T4 lesion
 T4

Superior Sulcus (Pancoast) tumor

a 53-year-old man shows asymmetric left apical density with destruction of left posterior rib
Axial CT images show a large left apical mass invading and destroying the T2 vertebral body
and left posterior rib
 T 3? T4???

NsClC
 T4 Check dr fifi ?

60 YEARS OLD MAN LUNG ADENO CARCINOMA

COLLAPSE RIGHT UPPER LOBE, EVEN ON CT, CENTRAL TUMORS CAN BE
DIFFICULT TO ACCURATELY CHARACTERIZE
ATELECTASIS  T2
INVOLVEMENT OF MEDIASTINAL PLEURA, PHRENIC NERVE  T3
INVASION OF TRACHEA  T4
 NODAL DISEASE
• Radiologists need to determine the presence and location of
regional lymph node metastases (N descriptor)  for best
treatment and prognosis in patients with NSCLC
• Accurate assessment lymph nodes of mediastinum is essential
for selecting treatment and prognosis

Expert Rev. Respir. Med. 5(6), (2011)

MEDIASTINAL STAGING OF NON-SMALL-CELL LUNG
CANCER

Expert Rev. Respir. Med. 5(6), (2011)

 MEDIASTINAL NODES

International Association for the Study of Lung Cancer nodal chart with
station and zones. Left upper lobe to the subaortic and paraaortic (5 and 6)
Expert Rev. Respir. Med. 5(6), (2011)
N1-2 Mediastinal Nodes

LUNG CANCER
ENLARGED LYMPH NODES
IN THE RIGHT HILAR ..
(WHITE ARROW)  N1

AND TRACHEOBRONCHIAL
(YELLOW ARROW)
REGIONS  N 2

SUGESTING N1 AND N2
DISEASE
Cancer Imaging (2007) 7, 159
 N 2 IPSILATERAL SUPERIOR
MEDIASTINAL NODES
(NODAL STATION 4R LOWER PARATRACHEA)

4R

Woman NSCLC right lower lung

Nodes zone 4R right lower paratrachea and 6 node
 N2 Ipsilateral Mediastinal Nodes
(nodal station 4R Lower paratrachea )

66 yo man with right lung carcinoma

a) Ct contrast show at level of aortic arch 2 lymph nodes arrows in the right
lower paratracheal region (nodal station 4R)
b) MRI 3T, T2W fat spin-echo at level similar shows 19mm, 10mm. Both node
contain metastatic cells RADIOLOGY: VOL 246: NUMBER 2FEB 2008
MEDIASTINAL NODES
AORTIC NODES

Zone 5
Subaor
tic
Nodes
N2 MEDIASTINAL NODES
7 SUBKARINA NODES
 N3 SUPRACLAVICULAR NODES
(NODAL STATION 1R STERNAL NOTCH NODES)

1
R

Supra clavicular zone

1 low cervical, sternal
notch nodes
Supraclavicular nodes
 EVALUATING N STATUS
• Tumors (N2 disease)  potentially resectable, generally after
neoadjuvant chemotherapy and/or RT as long as nodes are not
numerous and/or bulky

• Contralateral hilar or mediastinal node disease or metastases to any

scalene or supraclavicular lymph nodes (N3 disease)  Precludes
surgery

• CT scans show the size, shape, and location of mediastinal lymph

nodes
• A short-axis nodal diameter of 13 mm a upper limit for normal nodes in
the subcarinal, precarinal, and tracheobronchial regions and 10 mm
for the remaining regions can reduce number false-positive results

Cancer Imaging (2007) 7, 1

 LIMITATIONS OF MODALITIES
• No perfect threshold for what is considered metastatic
lymphadenopathy by CT or PET
Small lymph nodes can harbor occult malignancy and some
lesions
that are not highly fluorodeoxyglucose (FDG) – avid are
malignant

• Neither CT or PET can stage NSCLC with a high degree of

accuracy
Can not bypass histologic assessment of mediastinal lymph
nodes for accurate staging

Feng Feng .IAEA trainning course CT cancer staging 2015

 T2N1 left lower lobe squamous cell cancer with hilar
lymph node metastases
3D PET image a shows uptake in the lung yellow arrow
and in the region of the left hilum (black arrow)
Coronal b and axial c integrated CT PET images confirm CANCER IMAGING (2007)
uptake in the lung mass and a hilar lymph node 7, 148 -159
 METASTATIC DISEASE
• Metastases to the adrenal glands, liver, brain, bones, and
lymph nodes may be present in patients with NSCLC at
diagnosis
• The adrenal glands should be evaluated during
diagnostic chest CT because adrenal metastases are
common, with a reported detection rate as high as 20% at
initial presentation
• Although metastatic disease of the brain has been
reported to be present in up to 18% of patients with
NSCLC, the large majority will have signs and symptoms
of a neurologic abnormality, and therefore routine CT of
the brain is not recommended

Radiology December 237 ,200

 METASTATIC DISEASE
Skeletal metastases are usually symptomatic or have
laboratory test result abnormalities suggestive of bone
metastases
It is recommended that :
• Bone radiography
• Tc 99m methylene diphosphonate bone
scintigraphy
• MR imaging be performed only to evaluate a
history of focal bone pain or an elevated alkaline
phosphatase level
• The controversy surrounding extrathoracic staging
in patients with NSCLC may become moot,
because whole-body imaging with FDG PET is
being routinely performed for staging of NSCLC in
patients
Ref 2 Radiology 􏰆 December 2005 Volume 237 Number
 Stage IV

A WOMAN WITH LUNG ADENO CARCINOMA

PRIMARY TUMORS RIGHT UPPER LOBE ASSOCIATED
WITH PERICARDIAL EFFUSION AND SATELLITE NODULES IN SAME LOBE  T4
AND MULTIPEL NODULES CONTRA LATERAL LOBES AS M1A  T4M1A STAGE IV
 Stage IV

A MAN WITH LEFT LUNG CANCER

METASTATIC TO ADRENAL GLAND AND TO BONES AS M1B
ANY T, ANY N, M1B  STAGE IV
THANK YOU