New TNM-8 Edition

1. Lung - Cancer TNM 8th edition
DR.RISHI KUMAR SAINI
ASST. PROF.
DEPTT OF RESPIRATORY MEDICINE.

2. Headings-
• TNM-8
– What is new in the TNM 8th edition
– Non-small lung cancer stages
• T-classification
– T0
– T1
– T2
– T3
– T4
• Pancoast tumor
• N - Staging
– Regional Lymph Node Classification System
– N1 - Nodes
– N2 - Nodes
– N3 - Nodes
– N3 - Nodes
• M-Staging

3. TNM
• Publication date 09-12-2017
• This is a summary of the 8th Edition of TNM in
Lung Cancer, which is the standard of non-
small cell lung cancer staging since January
1st, 2017.
• It is issued by the IASLC (International
Association for the Study of Lung Cancer) and
replaces the TNM 7th edition.

4. TNM-8
• The 8th edition of the TNM classification for non-small lung cancer
is shown in the table.
• Conform previous editions there are three components that
describe the anatomic extent of the tumor: T for the extent of the
primary tumor, N for lymph node involvement, and M for
metastatic disease.
T-classification is performed using CT, the N- and M-classification
using CT and PET-CT.
• It can be used in the pre-operative imaging and clinical classification
iTNM/cTNM, but it is also applicable for definitive pathological
staging pTNM, re-staging after therapy yTNM and staging of a
recurrence rTNM.
• Differences with the 7th edition are presented in red in coming
slide.

8. What is new in the TNM 8th edition
• In the new TNM 8th edition the size went down
for several T-categories, and some new pathology
based categories were introduced.
• Also, new M-categories were introduced
regarding extrathoracic metastatic disease.
• Size of a solid lesion is defined as maximum
diameter in any of the three orthogonal planes in
lung window.
• In subsolid lesions T-classification is defined by
the diameter of the solid component and not the
diameter of the complete groundglass lesion.

10. • Non-small lung cancer stages
• Subsets of T, N and M categories are grouped into certain stages, because these
patients share similar prognosis [1].
• For example cT1N0 disease (stage IA) has a 5-year survival of 77-92%.
On the other end of the spectrum is any M1c disease (stage IVB) that has a 5-year
survival of 0%.

11. • Lobectomy is generally not possible if there is:
• Transfissural growth.
• Pulmonary vascular invasion.
• Invasion of main bronchus.
• Involvement of upper and lower lobe bronchi.
• These are specific items to report.
• Thin-slice images and three-plane reconstructions
are necessary to best demonstrate the relation
with surrounding structures.
In case of indeterminate invasion, the
multidisciplinary oncology board should decide
whether the benefit of doubt is given, depending
on the individual case and co-morbidity.
Lungcancer with evident transfissural growth on both the
coronal and sagittal reconstructions; lobectomy is no longer
possible.

12. T-classification
T0
• There is no primary tumor on imaging
• Tis
• Carcinoma in situ, irrespective of size.
This can only be diagnosed after resection of the tumor.
T1
• Tumor size ≤3cm
• Tumor ≤1cm => T1a
• Tumor >1cm but ≤2cm =>T1b
• Tumor >2cm but ≤3cm => T1c
• T1a(mi) is pathology proven 'minimally invasive', irrespective of
size.
• T1a(ss) is a superficial spreading tumor in the central airways,
irrespective of location.
T1 tumor – A typical T1 tumor in the left lower
lobe, completely surrounded by pulmonary
parenchyma.

13. • T2
• Tumor size >3cm to ≤5cm or
• Tumor of any size that
– invades the visceral pleura
– involves main bronchus, but not the carina
– shows an atelectasis or obstructive pneumonitis that extends to the hilum
• T2a= >3 to 4cm
T2b= >4 to 5cm.
• T3
• Tumor size >5cm to 7cm or
• Pancoast that involves thoracic nerve roots T1 and T2 only.
• Tumor of any size that
– invades the chest wall
– invades the pericardium
– invades the phrenic nerve
– shows one or more satellite nodules in the same lung lobe

14. T3 tumor - A typical T3 tumor in the right
upper lobe with invasion of the chest wall.
T2 tumor - A typical T2 tumor with atelectasis/pneumonitis of the left
lower lobe up to the hilum, due to involvement of the left main
bronchus.

15. • T4
• Tumor size >7cm or
• Pancoast tumor that involves C8
or higher nerve roots, brachial
plexus, subclavian vessels or
spine
• Tumor of any size that
– invades mediastinal fat or
mediastinal structures
– invades the diaphragm
– involves the carina
– shows one or more satellite
nodules in another lobe on the
ipsilateral side
T4 tumor – A typical T4 tumor in the
right upper lobe with invasion of the
mediastinum

16. Pancoast tumor
• A Pancoast tumor is a tumor of the superior
pulmonary sulcus characterized by pain due to
invasion of the brachial plexus, Horner's
syndrome and destruction of bone due to
chest wall invasion.
MR is superior to CT for local staging.

17. An operable T3 Pancoast tumor on a sagittal contrast-enhanced T1-weighted
image.
The tumor abuts the root T1 (white arrow), but other nerve roots are not
involved (green arrow).
A = subclavian artery, ASM = anterior scalene muscle.
(Courtesy of Wouter van Es, MD. St. Antonius Hospital Nieuwegein, The
Netherlands)

18. N - Staging

19. • Regional Lymph Node Classification System
• Lymph node staging is done according to the American Thoracic Society mapping scheme.
• Supraclavicular nodes
• 1. Low cervical, supraclavicular and sternal notch nodes
• Superior mediastinal nodes
• 2. Upper Paratracheal: above the aortic arch, but below the clavicles.
• 3A. Pre-vascular: nodes not adjacent to the trachea like the nodes in station 2, but anterior to the
vessels.
• 3P. Pre-vertebral: nodes not adjacent to the trachea, but behind the esophagus, which is
prevertebral (3P).
• Inferior Mediastinal nodes
• 4. Lower Paratracheal (including Azygos Nodes): below upper margin of aortic arch down to level of
main bronchus.
• Aortic nodes
• 5. Subaortic (A-P window): nodes lateral to ligamentum arteriosum. These nodes are not located
between the aorta and the pulmonary trunk, but lateral to these vessels.
• 6. Para-aortic (ascending aorta or phrenic): nodes lying anterior and lateral to the ascending aorta
and the aortic arch.

20. Subcarinal nodes
7. Subcarinal.
Inferior Mediastinal nodes
8. Paraesophageal (below carina).
9. Pulmonary Ligament: nodes lying within the
pulmonary ligaments.
Pulmonary nodes
10-14. N1-nodes: these are located outside of the
mediastinum.

22. • The boundary between level 10 and level 4 is on the right the lower border of the
azygos vein and on the left the upper border of the pulmonary artery (N1 vs. N2).
• There is an important separation to be made between level 1 and level 2/3 nodes,
because it is N3-stage versus N2.
The lower border of level 1 is the clavicles bilaterally and, in the midline, the upper
border of the manubrium.
• The boundary between level 4R and 4L is the left lateral border of the trachea, and
not the anatomic midline.
• Paracardial, internal mammarian, diaphragmatic, axillary and intercostal lymph
nodes are not described in the IALSC lymph node map.
Occasionally these can be present.
It is proposed to regard these non-regional nodes as metastastic disease [2].
• CT is unrealiable in staging lymph nodes in patients with NSCLC regardless of the
threshold size that is chosen.
PET-CT is much more reliable in determining the N-status.
False-positives occur in patients with sarcoid, tuberculosis and other infections.
Because of the high negative predictive value, PET scanning should be performed
in all patients considered for surgery.

23. • N1 - Nodes
• N1-nodes are ipsilateral nodes within the lung up
to hilar nodes.
N1 alters the prognosis but not the management.
N2 - Nodes
• N2-nodes represent ipsilateral mediastinal or
subcarinal lymphadenopathy.
There is only a subset of patients with N2 disease
that benefits from resection.
Those are the patients who -after a negative
mediastinoscopy- are found to have microscopic
metastatic disease at the time of thoracotomy.
• These patients have a better prognosis than those
with evident N2-disease.
T2 tumor (> 3cm) in the right lower lobe
with ipsilateral hilar node (N1
N2-disease – Right sided tumor with ipsilateral
mediastinal node

24. • These are irresectable.
N3 - Nodes
N3-nodes represent
contralateral mediastinal or
contralateral hilar
lymphadenopathy or scalene
or supraclavicular nodes.

25. • For a tumor in the right lung
the N-stages are:
• N1
• Ipsilateral peribronchial
and/or hilar lymph nodes
• 10R-14R
• N2
• Ipsilateral mediastinal and/or
subcarinal lymph nodes
• 2R, 3aR, 3p, 4R, 7, 8R, 9R
• N3
• Contralateral mediastinal
and/or hilar, as well as any
supraclavicular lymph nodes
• 1, 2L, 3aL, 4L, 5, 6, 8L, 9L, 10L-
14L

26. • For a tumor in the left lung the
N-stages are:
• N1
• Ipsilateral peribronchial and/or
hilar lymph nodes
• 10L-14L
• N2
• Ipsilateral mediastinal and/or
subcarinal lymph nodes
• 2L, 3aL, 4L, 5, 6, 7, 8L, 9L
• N3
• Contralateral mediastinal and/or
hilar, as well as any
supraclavicular lymph nodes
• 1, 2R, 3aR, 3pR, 4R, 8R, 9R, 10-
14R

27. M-Staging
• Almost every organ may be involved in metastatic disease.
Common are adrenal, nodal, brain, bone and liver involvement.
M-staging in the current edition is based on the presence of
metastases, their location and multiplicity.
A distinction is made between regional metastatic disease (M1a)
and solitary (M1b) or multiple (M1c) distant metastatic disease.
• M0: No distant metastasis
• M1: Distant metastasis
– M1a: Regional metastatic disease defined as malignant pleural or
pericardial effusion/nodules, as well as contralateral or bilateral
pulmonary nodules.
– M1b: solitary extrathoracic metastasis
– M1c: Multiple extrathoracic metastases, either in a single organ or in
multiple organs

28. Thank You.