3. Lungs are conical in shape , with
• Apex: projecting upward into the
neck for approximately 2 to 3 cm
above the clavicle
• Base: sitting on the diaphragm, a
costal surface along the chest wall,
• mediastinal surface : that is molded
to the heart and other mediastinal
structures.
• right lung: divided into the upper,
middle, and lower lobes by the
oblique (major) and horizontal
(minor) fissures.
• left lung: divided by only the
oblique fissure into two lobes—the
upper and lower lobes.
ANATOMY
4. AIRWAY PROGRESSION
- Segmental Bronchus divides into Sub segmental
Bronchi
-Sub segmental Bronchus Divides into Bronchioles .
-Tubes smaller than 1 mm diameter called bronchioles
-Smallest terminal bronchioles are less than 0.5 mm
diameter
-Respiratory Bronchioles: 2 or more branches from each
terminal bronchioles with air sac buds. This is first level
of gas exchange.
-Respiratory bronchioles end in alveoli.
- Pores of khan & channels of Lambert are present to
connect two alveoli
16
5. • Each Segmental bronchus passes to a structurally and functionally independent
unit of lung lobe called as Broncho Pulmonary Segment.
• These are well defined Anatomic, Functional and surgical units of lungs
11. • Smoking
• Asbestos exposure
• Radon
• Smoke from cooking and heating
• Air pollution and diesel exhaust
• Radiation therapy (RT)
• Inflammation and benign lung disease
• Chronic obstructive pulmonary disease
12. SMOKING:
• the relative risk of lung cancer in the long-term smoker compared with the lifetime
nonsmoker vary from 10- to 30-fold.
• cumulative lung cancer risk among heavy smokers may be as high as 30 percent, compared
with a lifetime risk of lung cancer of 1 percent or less in never smokers (1)
Secondhand smoking:
• SHS exposure is associated with an increased risk of lung cancer.
• While the doses of carcinogens received from SHS exposure are far less than with active
smoking, there is a dose-response relationship between intensity of exposure and relative
risk
1)Samet JM, Wiggins CL, Humble CG, Pathak DR. Cigarette smoking and lung cancer in New Mexico.
Am Rev Respir Dis. 1988 May;137(5):1110-3. doi: 10.1164/ajrccm/137.5.1110. PMID: 3264122.
13. • Spousal exposure –
A 2006 meta-analysis including 52 studies found that the relative risk of lung cancer among
nonsmokers who were ever exposed to SHS from the smoking of their partner was 1.21 (a)
• Workplace exposure – A 2006 meta-analysis of 25 studies of lung cancer and exposure to
SHS in the workplace estimated a pooled relative risk of 1.22
a). Taylor R, Najafi F, Dobson A. Meta-analysis of studies of passive smoking and lung cancer: effects of study
type and continent. Int J Epidemiol. 2007 Oct;36(5):1048-59. doi: 10.1093/ije/dym158. Epub 2007 Aug 9. PMID:
17690135.
14. Smoking cessation —
• Smoking cessation decreases the risk of lung cancer
• Estimates of risk reduction vary from 20 to 90 percent.
• The reduction in risk becomes evident within five years with a progressive decline
associated with an increasing duration of abstinence
• Case-control studies show that former smokers who had been abstinent for more than 15
years had an 80 to 90 percent reduction in risk of lung cancer compared with current
smokers
a)Peto R, Darby S, Deo H, Silcocks P, Whitley E, Doll R. Smoking, smoking cessation, and lung cancer
in the UK since 1950: combination of national statistics with two case-control studies. BMJ. 2000 Aug
5;321(7257):323-9. doi: 10.1136/bmj.321.7257.323. PMID: 10926586; PMCID: PMC27446.
s
15. • International Agency for Research on Cancer (IARC) has classified both cigarette smoke
and smokeless tobacco as Group 1 carcinogens ( carcinogenic to human)
• Implicated carcinogens in tobacco :
• N-nitrosamines
o 4- (methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK),
o N′- nitrosonornicotine (NNN),
• Benzene
• 1,3-butadiene,
• aromatic amines
• Heavy metals – cadmium
CARCINOGENESIS OF SMOKING :
16. carcinogen exposure
induce the cytochrome
P450 system,
metabolic activation of
carcinogens to electrophilic
entities
formation of carcinogen–DNA
adducts,
Repair
miscoding during
DNA replication.
• G:A and G:T mutations
• mutations in the KRAS oncogene
• mutation p53 tumor suppressor gene
apoptosis
cell transformation processes leading to
cancer
17. • Asbestos : group of naturally occurring fibers composed of hydrated magnesium silicates.
• Malignant mesothelioma, which is highly associated with asbestos exposure,
• risk higher for workers exposed to Amphibole fibers >> chrysotile fibers
• Dutch cohort study found that asbestos exposure was associated with a relative risk of
lung cancer of 3.5 (a)
• risk of lung cancer associated with asbestos is greatly magnified by coexisting exposure
to tobacco smoke.
• risk of dying of lung cancer increased 16-fold if they smoked more than 20 cigarettes per
day and 9-fold if they smoked fewer than 20 cigarettes per day, compared with asbestos
workers without a regular smoking history. (b)
ASBESTOS
a) van Loon AJ, Kant IJ, Swaen GM, Goldbohm RA, Kremer AM, van den Brandt PA. Occupational
exposure to carcinogens and risk of lung cancer: results from The Netherlands cohort study. Occup
Environ Med. 1997 Nov;54(11):817-24. doi: 10.1136/oem.54.11.817. PMID: 9538355; PMCID:
PMC1128954.
b) Hammond EC, Selikoff IJ, Seidman H. Asbestos exposure, cigarette smoking and death rates. Ann N Y
Acad Sci. 1979;330:473-90. doi: 10.1111/j.1749-6632.1979.tb18749.x. PMID: 294198.
18. • gaseous decay product of uranium-238 and radium-226
• capable of damaging respiratory epithelium via the emission of alpha particles.
• Underground uranium miners who were occupationally exposed to radon and its decay
products have an increased risk of lung cancer
• Based on a collaborative analysis study,absolute risks of lung cancer by age 75 years at
usual radon concentrations of 0, 100, and 400 Bq/m3 would be about 0.4%, 0.5%, and
0.7%, respectively, for lifelong non-smokers, and about 25 times greater (10%, 12%, and
16%) for cigarette smokers.
RADON:
(a) Darby S, Hill D, Auvinen A, Barros-Dios JM, Baysson H, Bochicchio F, Deo H, Falk R, Forastiere F, Hakama M,
Heid I, Kreienbrock L, Kreuzer M, Lagarde F, Mäkeläinen I, Muirhead C, Oberaigner W, Pershagen G, Ruano-Ravina
A, Ruosteenoja E, Rosario AS, Tirmarche M, Tomásek L, Whitley E, Wichmann HE, Doll R. Radon in homes and risk
of lung cancer: collaborative analysis of individual data from 13 European case-control studies. BMJ. 2005 Jan
29;330(7485):223. doi: 10.1136/bmj.38308.477650.63. Epub 2004 Dec 21. PMID: 15613366; PMCID: PMC546066.
19. • indoor burning of unprocessed biomass fuels (wood, coal) has been associated with
multiple respiratory problems, including an increase in the incidence of lung cancer.
• retrospective cohort study in China showed lifelong burning of bituminous coal, was
associated with a significant increase in the incidence of lung cancer compared with those
individuals who used anthracite (smokeless) coal
• The lifetime risk of developing lung cancer was approximately 20 percent for both men
and women who used bituminous coal compared with 0.5 percent for those who used
anthracite coal.
INDOOR POLLUTION:
Barone-Adesi F, Chapman RS, Silverman DT, He X, Hu W, Vermeulen R, Ning B, Fraumeni JF Jr, Rothman N,
Lan Q. Risk of lung cancer associated with domestic use of coal in Xuanwei, China: retrospective cohort study.
BMJ. 2012 Aug 29;345:e5414. doi: 10.1136/bmj.e5414. PMID: 22936785; PMCID: PMC3431444.
20. • Radiation therapy (RT) can increase the risk of a second primary lung cancer in patients
who have been treated for other malignancies
• RT for Hodgkin lymphoma has been associated with an increased risk of secondary lung
cancer. A systematic review of the literature suggested that the relative risk of
developing lung cancer was approximately 2.6 to 7.0, and that the increased risk may last
for 20 to 25 years. (a)
RADIATION THERAPY
Lorigan P, Radford J, Howell A, Thatcher N. Lung cancer after treatment for Hodgkin's lymphoma: a systematic
review. Lancet Oncol. 2005 Oct;6(10):773-9. doi: 10.1016/S1470-2045(05)70387-9. PMID: 16198983.
21. • benign lung diseases have been associated with an increased risk of lung cancer, which
appears to be mediated through chronic inflammation.
• Analysis from the International Lung Cancer Consortium, which analyzed the risk of lung
cancer was elevated in patients with:
o history of emphysema (odds ratio [OR] 2.44)
o chronic bronchitis (OR 1.47)
o pneumonia (OR 1.57)
o tuberculosis (OR 1.48)
• Individuals with diffuse pulmonary fibrosis have an 8- to 14-fold increased risk for lung
cancer
• Carriers of an allele for alph.a-1 antitrypsin deficiency (usually the S or Z allele) have an
approximately twofold increased risk of lung cancer.
INFLAMMATION AND BENIGN LUNG DISEASE :
22. • independently associated with an increased risk of developing lung cancer, related to the
inflammation and scarring
• most common independent risk factor, other than smoking, for lung cancer, increasing the
risk of lung cancer by 2- to 5-fold
COPD
Hopkins RJ, Duan F, Chiles C, Greco EM, Gamble GD, Aberle D, Young RP. Reduced Expiratory Flow Rate
among Heavy Smokers Increases Lung Cancer Risk. Results from the National Lung Screening Trial-
American College of Radiology Imaging Network Cohort. Ann Am Thorac Soc. 2017 Mar;14(3):392-402. doi:
10.1513/AnnalsATS.201609-741OC. PMID: 28076701; PMCID: PMC5686299.
24. • multistep process involving genetic and epigenetic alterations.
• classification of pre-invasive lung lesions by the World Health Organization (WHO) lists
three main morphologic forms of preneoplastic lesions:
(a) squamous dysplasia and CIS,
(b) AAH (Atypical adenomatous hyperplasia)
(c) Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH)
26. • Mucosal changes in the large airways that may precede or accompany invasive squamous
cell carcinoma include hyperplasia, squamous metaplasia, squamous dysplasia, and CIS
• Dysplastic squamous lesions are considered true preneoplastic lesions represent a
continuum of cytologic and histologic atypical changes:
o Mild squamous dysplasia : characterized by minimal architectural and cytological
disturbance
o Moderate dysplasia exhibits more cytological irregularity
o severe dysplasia : cytological irregularity, accompanied by considerable cellular
polymorphism.
• CIS : demonstrates
o extreme cytological aberrations
o complete architectural disarray
o but with an intact basement membrane
o absence of stromal invasion.
o Foci of CIS usually arise near bifurcations in the segmental bronchi, subsequently
extending proximally into the adjacent lobar bronchus and distally into subsegmental
branches. T
28. • Clara cells and the type II pneumocytes are believed to be the progenitor cells of the
peripheral airways, and peripherally arising adenocarcinomas.
• Recent data indicate that at least two molecular pathways are involved, the KRAS and
EGFR pathways in smoker and nonsmoker populations.
• Atypical adenomatous hyperplasia. AAH:
o considered a putative precursor of adenocarcinoma.
o discrete parenchymal lesion arising in alveoli near terminal and respiratory bronchioles
o lesions maintain an alveolar structure lined by rounded, cuboidal, or low columnar cells.
The alveolar walls may be slightly thickened by collagen, occasional fibroblasts, and
lymphocytes.
o measure 5 mm or less.
o Cellularity and cytological atypia vary from minimal to high grade.
o air-filled structures, they may appear as ground glass opacities on computed tomography
scans
29. Adenocarcinoma in situ (AIS)
• localized (≤3 cm) adenocarcinoma
• growth is restricted to tumor cells growing along alveolar structures (lepidic growth
pattern) and lacks any component of invasion.
30. • Precursor lesions for SCLC, are unknown
• Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPENECH) has been
associated with the development of other neuroendocrine tumors of the lung, typical and
atypical carcinoids
• generalized proliferation of scattered single cells, small nodules, or linear proliferations
of neuroendocrine cells present in the bronchial and bronchiolar epithelium.
• Normal and hyperplastic bronchial epithelium accompanying SCLC demonstrated a
significantly higher incidence of genetic abnormalities than those adjacent to NSCLC
tumor types
• Suggests that SCLC may arise directly from histologically normal or mildly abnormal
epithelium, without passing through a more complex histologic sequence (parallel theory
of cancer development)
Pathogenesis of Small cell lung carcinoma
32. • Ca lung presents with wide range of symptoms
o Intrathoracic manifestations
o Extra thoracic manifestations
o Paraneoplastic symptoms
33. 1. Cough:
o present in 50 to 75 % of ca lung patients
o occurs most frequently with squamous cell and small cell carcinomas because of their
tendency to involve central airways
o bronchorrhea or cough productive : a feature of mucinous adenocarcinoma
o Both NSCLC and SCLC may cause a post obstructive pneumonia
2. Hemoptysis:
o presenting symptom in approximately 25% of patients.
o May result from tumor eroding into a blood vessel or bleeding from the neovasculature
supplying the tumor .
3. Dyspnoea:
o presentation in approximately 25% of cases
o Result due to blockage of airflow through a portion of the lung by tumor
o or due to the development of atelectasis, postobstructive pneumonia, or a pleural or
pericardial effusion.
INTRATHORACIC MANIFESTATIONS
34. 4. Chest pain:
o Pain is typically present on the same side
of the chest as the primary tumor.
o Dull, aching, persistent pain may occur
from mediastinal, pleural, or chest wall
extension
o Unilateral paralysis of the diaphragm may
be due to damage of the phrenic nerve
X-ray shows an elevated right
hemidiaphragm that is caused by phrenic
nerve palsy
35. 5. Hoarseness
o In patients with lung cancer, this is due
to malignancy involving the recurrent
laryngeal nerve along its course under
the arch of the aorta and back to the
larynx.
36. 6. Superior vena cava syndrome
o sensation of fullness in the head and dyspnea
o Physical findings include dilated neck veins; a prominent venous pattern on the chest;
edema of the face, neck, and upper extremities; and a plethoric appearance
o more common in patients with SCLC than NSCLC
37. 7. Pancoast tumor:
o Seen in cancers arising in the superior sulcus , manifested
by
-pain (usually in the shoulder, and less commonly in the arm,
scapula, and fingers),
-Horner syndrome (miosis, ptosis, and anhidrosis.)
-bony destruction
-atrophy of hand muscles.
o most commonly caused by NSCLC (typically squamous cell)
rght apical mass (M) involving the posterior chest wall and rib in close proximity to the right axillary
artery (arrow), which is suspicious for brachial plexus involvement by tumor
38. • most frequent sites of distant metastasis are the liver, adrenal
glands, bones, and brain
1. Bone :
o frequently symptomatic.
o Presents with pain in the back, chest, or extremity
o Associated elevated levels of serum alkaline phosphatase and
elevated serum calcium
o An osteolytic radiographic appearance is more frequent than an
osteoblastic one
o most common sites of involvement are the vertebral bodies
• more frequent in SCLC and can be found in 30 to 40 percent of
patients on presentation
EXTRATHORACIC MANIFESTATIONS
39. 2. Adrenals:
o The adrenal glands are a frequent site of metastasis
o only rarely symptomatic
o Adrenal metastases do not usually result in adrenal insufficiency unless both adrenal
glands are significantly (>90 percent) involved
o patients can present with loss of appetite, weight loss, nausea, abdominal pain, weakness,
and electrolyte imbalances secondary to adrenal insufficiency.
3. Brain:
o Clinical manifestations: headache, vomiting, visual field loss, hemiparesis, cranial nerve
deficit, and seizures
o In patients with SCLC, metastasis to brain is present in approximately 20 to 30 percent
of patients at presentation
o In patients with NSCLC, the frequency of brain metastasis, adenocarcinoma >> squamous
cell carcinoma
40. 4. Liver
o Symptomatic hepatic metastases are
uncommon early in the course of disease.
o Asymptomatic liver metastases may be
detected at presentation by liver enzyme
abnormalities.
41. PARANEOPLASTIC SYNDROMES
• A paraneoplastic syndrome is a disease or symptom
that is the consequence of cancer cells in the body
but is not attributable to the local presence of
tumor, thought to be mediated by humoral factors
secreted by tumor cells or by an immune response
against the tumor.
• Cushing Syndrome
o Due to Ectopic production of adrenocorticotropic
hormone (ACTH)
o typically present with muscle weakness, weight
loss, hypertension, hirsutism, and osteoporosis.
o Hypokalemic alkalosis and hyperglycemia are
usually present.
o relatively common in patients with SCLC and with
carcinoid tumors of the lung.
42. 2. Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)
o frequently caused by SCLC and results in hyponatremia.
o Symptoms include headache, muscle cramps, anorexia, and decreased urine output.
o If left untreated, cerebral edema can develop, leading to mental status changes, coma,
seizures, and respiratory arrest.
o Treatment :
-Treating the underlying cancer
-demeclocycline is the agent of choice.
3. Hematologic manifestations:
o Anemia
o Leukocytosis , likely due to overproduction of granulocyte-colony stimulating factor
o Thrombocytosis
o Eosinophilia – Eosinophilia in tissue or blood is rare but has been reported in patients with
large cell carcinoma
o Hypercoagulable disorders
43. 4. Hypertrophic osteoarthropathy
o defined by the presence of clubbing)
and periosteal proliferation of the
tubular bones associated with lung
cancer or other lung disease.
o Clinically, characterized by a
symmetrical, painful arthropathy and
long-bone pain that usually involves the
ankles, knees, wrists, and elbows
o Treatment: nonsteroidal anti-
inflammatory agents, corticosteroids, or
a bisphosphonate
Radiographs of wrists (A and B) and legs (C)
showing periostosis (arrows) at metacarpals, distal
ends of the radius, ulna, tibia and fibula.
45. o identify signs or symptoms suggestive of locally extensive or metastatic disease
o identify significant comorbidities,
o elicit tobacco use
o past exposure to environmental carcinogens.
o Weight loss >5% from baseline has direct prognostic implications for survival in lung
cancer
o Physical examination of the chest may detect signs of partial or complete obstruction of
the airways, pneumonia, or pleural effusion.
o Examination of the neck : evidence of supraclavicular lymphadenopathy.
o Abdominal examination :detect hepatomegaly.
o Neurologic examination: detect signs of brain metastasis.
DETAILED HISTORY PHYSICAL EXAMINATION
46. o Complete blood count
o Calcium
o Alkaline phosphatase
o Alanine aminotransferase (ALT) and aspartate aminotransferase (AST), total bilirubin
o Creatinine
LABORATORY INVESTIGATIONS :
47. 1. Computed Tomography:
o All patients with suspected lung cancer, with or without an abnormal chest x-ray, should
undergo a contrast-enhanced CT scan of the chest and upper abdomen to include the
entire liver and adrenal glands
o establish T-stage by determining
-tumor size
- presence of separate tumor nodules,
- presence of atelectasis
- postobstructive pneumonia
- invasion of adjacent structures
- and proximal extent of the tumor.
RADIOLOGIC EVALUATION:
48. 2. Positron Emission Tomography or Positron Emission Tomography– Computed Tomography
o benefit provided by PET :
- the identification of malignant disease in lymph nodes of normal size
- distant metastasis not seen on CT scan
- aid in the target delineation process for involved-field radiotherapy (IFRT).
49. 1. Percutaneous Fine Needle Aspiration CT-guided fine needle aspiration (FNA)
o excellent method for establishing a tissue diagnosis from a suspicious peripheral
pulmonary nodule that cannot be reached by bronchoscopy.
o risk of a pneumothorax is 25%.
o overall diagnostic yield is 80%.
o FNA cannot rule out malignancy unless another benign diagnosis can clearly be established
2. Bronchoscopy Fiberoptic bronchoscopy
o enables visualization of the tracheobronchial tree to the second or third segmental
divisions.
o Cytologic brushings or biopsy forceps specimens can be obtained from identified lesions.
o Even when no visible lesion is identified, the bronchus draining the area of suspicion can
be lavaged for cytologic analysis.
DIAGNOSTIC PROCEDURES:
50. 3. Endoscopic Ultrasound
o Endobronchial ultrasound-guided needle transbronchial aspiration (EBUS-TBNA)
involves FNA sampling of ultrasound-suspicious lymph nodes, especially those located in the
paratracheal (lymph node levels 2 and 4), subcarinal (level 7), or hilar lymph node stations
(level 10)
o Transesophageal Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA)
-Useful in sampling of mediastinal nodes that are posterior or inferior, such as the
retrotracheal (lymph node station 3p), subcarinal (level 7), paraesophageal (level 8), and
pulmonary ligament lymph nodes (level 9).
4. Thoracentesis
o Most pleural effusions in lung cancer patients are owing to tumor and should be evaluated
with thoracentesis
o diagnosis of cancer can be established in 70% to 80% of malignant effusions.
51. 5. Mediastinoscopy and Mediastinotomy
o considered the gold standard,
o most accurate technique to assess upper and lower paratracheal (lymph node stations 2
and 4), prevascular (station 3a), retrotracheal (station 3p), subcarinal (station 7), and
hilar lymph nodes (station 7)
o anterior mediastinotomy (also known as the Chamberlain procedure) or video-assisted
thoracoscopic techniques for accessing lymph nodes within the aortopulmonary window
(lymph node station 5) and along the ascending aorta (station 6).
52. 6. Thoracoscopy:
o frequently used for the diagnosis, staging, and resection of lung cancer.
o Peripheral nodules can be identified and excised using video-assisted, minimally invasive
techniques.
o valuable for evaluation of suspected pleural disease when thoracentesis has been
nondiagnostic.
61. TX Primary tumour cannot be assessed, or tumour proven by the presence of malignant cells in
sputum or bronchial washings but not visualized by imaging or
bronchoscopy
TO No evidence of primary tumour
T1 Tumour 3 cm or less in greatest dimension, surrounded by lung or visceral pleura, without
bronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e., not in the
main bronchus)
Tis Minimally invasive adenocarcinoma: adenocarcinoma (≤3 cm in greatest dimension) with a
predominantly lepidic pattern and ≤5 mm invasion in greatest dimension
T1a Tumour is ≤1 cm in greatest dimension
T1b Tumour >1 cm but ≤2 cm in greatest dimension
T1c Tumour >2 cm but ≤3 cm in greatest dimension
T2 Tumour >3 cm but ≤5 cm or having any of the following features: involves the main bronchus
but without involvement of the carina; invades the visceral pleura; or associated with
atelectasis or obstructive pneumonitis that extends to the hilar region, involving part or all of
the lung
T2a tumour >3 cm but ≤4 cm in greatest dimension
T2b tumour >4 cm but ≤5 cm in greatest dimension
T3 tumour >5 cm but ≤7 cm in greatest dimension or directly invading any of the following:
parietal pleura, chest wall (including superior sulcus tumours), phrenic nerve, parietal
pericardium, or separate tumour nodule(s) in same lobe as the primary
T4 Tumour >7 cm or tumour of any size of that invades diaphragm, mediastinum, heart, great
62. No No regional lymph node involvement
N1 Involvement of ipsilateral intrapulmonary, or peri bronchial,
hilar lymph nodes
N2 Involvement of mediastinal or subcarinal lymph nodes
N3 Involvement of contralateral mediastinal or hilar lymph
nodes. Involvement of ipsilateral or contralateral scalene or
supraclavicular nodes
N: Regional lymph node involvement
63. Mo No distant metastasis
M1 Distant metastasis present
M1a
Separate tumour nodule(s) in a contralateral lobe; tumour with pleural or
pericardial nodule(s) or malignant pleural or pericardial effusion.
M1b
Single extra thoracic metastasis
M1c
Multiple extra thoracic metastases in one or several organs
M: Distant metastasis
64. Occult carcinoma TX N0 M0
Stage 0 Tis N0 M0
Stage IA1 T1(mi) N0 M0
T1a N0 M0
Stage IA2 T1b N0 M0
Stage IA3 T1c N0 M0
Stage IB T2a N0 M0
Stage IIA T2b N0 M0
Stage IIB T1a-c N1 M0
T2a N1 M0
T2b N1 M0
T3 NO M0
Stage IIIA T1a-c N2 M0
T2a-b N2 M0
T3 N1 M0
T4 N0 M0
T4 NI M0
Stage IIIB T1a-c N3 M0
T2a-b N3 M0
T3 N2 M0
T4 N2 M0
Stage IIIC T3 N3 M0
T4 N3 M0
Stage IVA Any T Any N M1a
Any T Any N M1b
