LUNG CANCER remains the leading cause of cancer-related mortality in men and women in the United States, accounting for over 157,000 deaths annually.Despite advances in imaging, lung cancer is often detected when the disease has spread from the primary tumour to regional lymph nodes or distant sites. Appropriate therapy is dependent on accurate staging to identify those patients who are surgical candidates and those patients for whom chemotherapy and radiation therapy is indicated. In this review, the current staging system for lung cancer is discussed, along with practical imaging approaches.

1. LUNG CANCER STAGING
Professor
Abdulsalam Y Taha
School of Medicine
University of Sulaimani
Iraq
https://sulaimaniu.academia.edu/AbdulsalamTaha

2. INTRODUCTION
 LUNG CANCER remains the leading cause
of cancer-related mortality in men and
women in the United States, accounting for
over 157,000 deaths annually.
 Despite advances in imaging, lung cancer is
often detected when the disease has spread
from the primary tumour to regional lymph
nodes or distant sites.
10/14/14 Prof. Abdulsalam Y Taha 2

3. INTRODUCTION…
 Appropriate therapy is dependent on
accurate staging to identify those patients
who are surgical candidates and those
patients for whom chemotherapy and
radiation therapy is indicated.
 In this review, the current staging system
for lung cancer is discussed, along with
practical imaging approaches.
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4. LUNG CANCER STAGING
 A number of imaging modalities have
historically been used in staging lung
cancer. These have included standard and
conventional tomography as well as
computed tomography( CT) and MRI.
 In some instances, accurate staging and
the determination of appropriate treatment
for patients with lung cancer can be made
noninvasively with imaging modalities
alone, although in most cases, some
degree of surgical staging and biopsy
evidence is also necessary.
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5. OVERVIEW OF STAGING
 Staging of any tumour is done to determine the
extent of disease.
 Staging information is important for 2 reasons:
1. to determine prognosis and 2. to select patients for
surgical intervention and/or a different modality.
 Lung cancer staging is based on criteria accepted
by the American Joint Committee on Cancer.
 This classification system is based:
• On the characteristics of the primary tumor (T),
• The presence or absence of mediastinal and/or
supraclavicular lymph node (N) metastases,
• And the presence or absence of distant metastatic (M)
disease
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6. HISTORY
 In the old (pre 1985) lung cancer classification, stage
I and II tumours were considered amenable to
surgical management, and stage III tumours were
considered unresectable.
 In the previous classification, tumours with limited
invasion of the chest wall and mediastinum were
included in the inoperable category, but under the
new classification, such tumours are considered to be
potentially resectable provided that vital structures
in the mediastinum, such as the great vessels, heart,
and aerodigestive tract, are not involved.
 Stage III has been redefined and divided into stages
IIIa and IIIb. Stage III b is also considered
unresectable disease.
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7. HISTORY..
 T4 is now used to describe lesions with extensive
invasion of the mediastinum or diaphragm.
 In addition in the current system, patients with
ipsilateral nodal metastasis are also considered to
have resectable cancer. However, for the most part,
only patients with limited mediastinal nodal disease
fall into the operable category.
 N3 was added to the TNM staging to refer to
contralateral mediastinal or hilar lymph node or
supraclavicular LN metastases. N3 disease is
considered to be nonsurgical or unresectable
category.
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8. HISTORY..
 In 1997, stage I has been divided
into 2 groups: IA and IB.
 T4 has also been slightly redefined
to include satellite tumour nodule
(s) within the ipsilateral primary
lobe of the lung. Previously, any
additional nodules had been
considered evidence of distant
metastatic disease (M1).
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9. OVERVIEW OF STAGING
 Symptoms.
 Sputum examination.
 Chest radiograph
 CT.
 MRI.
 PET.
 PET CT.
 Bone scintigraphy.
 Endoscopic and endobronchial ultrasound.
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10. SPUTUM EXAMINATION
If a tumour is proven by the
presence of malignant cells in
the sputum but not visualized
by imaging or bronchoscopy;
then it is designated as Tx.
Clinical symptoms often herald
the presence of metastatic
disease.
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11. Clinical Findings Suggestive of Metastatic
Disease
Test Finding
Symptoms Weight loss greater than 10 lb
Skeletal pain
Headache, seizures, syncope
Mental status change
Lymphadenopathy
Hoarseness
Bone tenderness
Hepatosplenomegaly
Neurologic signs, papilledema
Laboratory Hematocrit < 40% in men or <35% in women
Elevated calcium, alkaline
phosphatase, liver function tests
____________________________________________________________
____
 Data from Silvestri et al
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12. CHEST RADIOGRAPHY
 The vast majority of primary lung cancers are
initially detected on routine chest radiographs.
 There may be certain instances in which the
chest radiograph alone is a sufficient imaging
procedure for staging-for example, when an
obvious metastatic bone lesion is detected or
when large bulky contralateral mediastinal
lymph nodes are present.
 However, numerous studies have shown that
the chest radiograph lacks sensitivity in
detecting mediastinal LN metastases and in
detecting chest wall and mediastinal invasion.
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13. Regional lymph node
stations for staging
lung cancer.
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14. Regional lymph node
stations for staging lung cancer.
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15. Regional lymph node
stations for staging lung cancer.
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16. 10/14/14 Prof. Abdulsalam Y Taha 16

17. LUNG CANCER STAGING
 The map published in 1997 was recognized
by the American Joint Committee on Cancer and
the TNM Committee of the Union Internationale
Contre le Cancer .
 The three groups of mediastinal LNs are indicated by
a single digit:
superior (1–4), aortic (5 or 6), and inferior (7–9).
Hilar (10) and intrapulmonary (11–13) LNs have a double
digit.
 This map can be used to interpret imaging studies
and to guide LN sampling procedures such as
endoscopic needle aspirations or mediastinoscopy.
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18. NODAL STAGE
 N1 nodes are ipsilateral intrapulmonary,
peribronchial, and hilar lymph nodes.
 N2 nodes are ipsilateral mediastinal nodes
including the midline groups, levels 3 and
7.
 N3 nodes are contralateral to the primary
tumour or involve the scalene or the
supraclavicular lymph node regions.
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19. N1 nodes - All N1 nodes lie distal to the mediastinal pleural
reflection and within the visceral pleura
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20. N2 nodes –
All N2 nodes
lie within the
mediastinal
pleural envelope
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21. PATTERN OF LN SPREAD
 The pattern of LN spread;
depends, in general, on the site of the primary tumor.
Right upper- and middle-lobe tumors often
spread to the right hilar and right superior mediastinal
nodes, right lower-lobe tumors often spread
to the right hilar and inferior mediastinal stations.
Left upper-lobe tumors have a predilection for left
hilar, aortic, and left paratracheal nodes; left lowerlobe
tumors spread to the left hilar nodes and the
inferior mediastinal nodes, with a high tendency
to cross the midline.
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22. TUMOUR SIZE
 T1 tumors are less than 3 cm in
greatest dimension and do not invade
the visceral pleura or the main
bronchi.
 Whereas T2 tumours are lesions
greater than 3 cm and those that
involve the visceral pleura or the
main bronchi at least 2 cm from the
carina.
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23. TUMOUR SIZE
 T3 tumors may be of any size and directly
invade the chest wall, diaphragm,
mediastinal pleura, parietal pericardium, or
are within 2 cm of but do not involve the
carina.
 T4 tumours are those that invade the
heart, great vessels, esophagus, or
vertebral bodies.
 In general, T4 tumours can not be resected
because of the involvement of vital
structures.
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24. TNM
 Based on their TNM denominators,
patients are grouped into stages with
more-or-less homogenous prognosis.
The current system distinguishes
seven stages of disease, each with a
different outcome.
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25. LUNG CANCER STAGING
 For therapeutic considerations, stage
I and stage II disease are often
referred to as `` early stage``; for
these patients the standard of care is
local treatment, preferably resection
followed by adjuvant chemotherapy
except for stage IA. or radical
radiotherapy in case of poor
cardiopulmonary function.
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26. LUNG CANCER STAGING
 Patients who have stage III disease,
have locally advanced disease, either
IIIA (N2: LN spread in the ipsilateral
mediastinal nodes only) or IIIB (N3:
LN spread in the contralateral
mediastinal or supraclavicular nodes).
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27. LUNG CANCER STAGING
 Patients who have stage IV
(advanced or metastatic) are no
longer amenable to cure.
Chemotherapy results in a moderate
improvement of the median survival,
subjective clinical benefit , or quality
of life.
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28. LUNG CANCER STAGING
Table 1. Staging of NSCLC Based on TNM Classification
Stage TNM
0------------------------ Carcinoma in situ
1A ------------------------- T1N0M0
1B------------------------- T2N0M0
2A--------------------------T1N1M0
2B -------------------------T2N1M0
T3N0M0
3A-------------------------T3N1M0
T1-3N2M0
3B------------------------- Any T4
Any N3
4---------------------------Any M1
 Abbreviations: T, tumor; N, lymph node; M, distant metastasis
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31. LUNG CANCER STAGE I
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32. LUNG CANCER STAGE II
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33. LUNG CANCER STAGE III
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34. LUNG CANCER STAGING
 The current imaging approach to lung
cancer staging can be divided into 2 distinct
categories: anatomic and physiologic.
 Anatomic imaging is done by CT and MRI.
The major limitations of the anatomic
approach are the use of size criteria to
define benign and malignant mediastinal
lymph nodes and the nonspecific
appearance of metastatic disease.
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35. LUNG CANCER STAGING
 Computed tomography (CT) remains
the major tool for imaging primary
lung lesions, mediastinal
lymphadenopathy, and distant
metastatic disease.
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36. LUNG CANCER STAGING
 CT criteria for probable resectability
in masses contigous with the
mediastinum are a contact with
mediastinum of less than 3 cm, less
than 90 contact with aorta, and
preserved mediastinal fat layer
between the mass and mediastinal
structures.
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37. MRI
 Magnetic resonance imaging (MRI) is
occasionally used to evaluate chest
wall and brachial plexus involvement
and image indeterminate adrenal and
hepatic lesions.
 MRI is the primary method of
detection of cerebral metastases.
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38. PET
 Positron emission tomography (PET)
overcomes some of the limitations of
anatomic imaging by providing an
analysis of metabolic activity.
 In general, increased metabolic
activity on PET indicates the
presence of neoplastic tissue.
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39. PET
 There are 2 methods of PET interpretation
that may be regarded as qualitative and
quantitative.
 Some interpret activity when compared
with background mediastinal activity,
whereas others calculate a standard uptake
value (SUV), regarding a value over 2.0 as
suspicious for malignancy.
 Overall, PET has a 96.8% sensitivity and a
77.8% specificity in the detection of
malignancy.
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40. LUNG CANCER STAGING
 For staging of the mediastinum, PET
must be evaluated in conjunction
with CT. A combined interpretive
approach provides more definitive
localization of the abnormality and
may help to determine the
appropriate diagnostic procedure.
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41. LUNG CANCER STAGING
 Because PET is limited by spatial resolution, it is
critical to interpret the PET images in conjunction with
a modality that depicts anatomy such as CT.
 Currently, researchers favor staging lung cancer
with PET CT to acquire anatomic and physiologic
data in one examination.
 Bone scintigraphy has been used for the detection
of osseous metastases, and, ultimately, bone scans
may be replaced by PET.
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42. PET TRACERS
 The standard tracer in lung cancer PET imaging is
the glucose analogue 18F-fluoro-2-deoxy-D-glucose
(FDG). FDG allows excellent discrimination
between normal tissues and tissues with enhanced
glucose metabolism,
 But false-positive uptake of
FDG in inflammatory tissues is one of its major limitations.
Therefore, tracers with an equally high
sensitivity but a better specificity are the focus of ongoing research.

Other tracers such as 11C-methionine
(a marker of protein metabolism), 11C-choline
(a marker of the cell membrane component
phosphaditylcholine), and 18F-fluoro-thymidine
(a marker of cell proliferation) have been studied.
The experience with these tracers is still limited.
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43. FDG PET: advantages for staging the
mediastinum?
 It has been shown clearly that FDG PET is
more accurate than CT for the detection of
mediastinal lymph-node metastases. Dual-modality
scanners might be even more exact in
staging the mediastinum. However, currently only
a few studies are available.
In view of the high negative-predictive value of
PET a patient with a negative PET scan of the
mediastinum can proceed directly to thoracotomy.
In contrast, a positive finding on the PET scan
implies that these lymph nodes have to be examined
by invasive methods (e.g. mediastinoscopy). Until
now a systemic comparison between PET and FNA
procedures (transbronchial or transoesophageal)
have not been performed.
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44. T1 lung cancer. Contrast-enhanced CT
reveals a 2-cm nodule in the left lower lobe.
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45. T2 lung cancer. Contrast-enhanced CT reveals a
4.5-cm cavitary mass abutting the visceral pleura without
invasion of the chest wall.
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46. T3 lung cancer. Contrast-enhanced CT reveals a
right upper lobe mass with invasion of the chest wall and rib
destruction (arrow).
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47. T4 lung cancer. Contrast-enhanced CT reveals a
confluent right lower lobe mass invading the mediastinum,
surrounding the right inferior pulmonary vein, and growing
into the interatrial septum (arrows).
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48. Superior sulcus tumor. T1-weighted coronal gadolinium
enhanced MRI reveals a left upper lobe mass
extending into the supraclavicular fossa.
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49. Solitary pulmonary nodule. (A) CT reveals a 1.5-cm ill-defined
right upper lobe nodule, suspicious for malignancy. (B)
Coronal FDG PET shows increased metabolic activity in the lesion.
Biopsy revealed NSCLC.
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50. False-negative PET. (A) CT reveals a 2.0-cm spiculated nodule, suspicious for
malignancy. (B) FDG PET shows slightly
increased activity (arrow) but below 2.0 SUV and the mediastinal
background. The study was interpreted as negative for
malignancy. The nodule was resected because of its morphologic features,
and NSCLC was shown on histopathology.
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51. Left panel: Coronal MR scan demonstrates transdiaphragmatic extension of
a right lower lobe squamous cell carcinoma into the liver. This is a T4, stage
IIIB tumor. Right panel: Sagittal sequence demonstrates
transdiaphragmatic extension into the liver and a small pleural effusion
(arrow). Courtesy of Paul Stark, MD.
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52. N1 lymph nodes in a patient with SCLC. Contrast enhanced
CT reveals two enlarged lymph nodes adjacent to
the right lower lobe pulmonary artery.
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53. N2 and N3 lymph nodes in a patient with NSCLC.
Contrast-enhanced CT in a patient with a right upper lobe
cancer reveals enlarged level 4R (N2) and level 5 and 6
(N3) lymph nodes.
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54. Value of PET in lymph node staging in a patient with
adenocarcinoma of the lung. (A) CT shows normal sized
level 4R lymph node (arrow). (B) CT shows borderline level
7 lymph node (arrow).
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55. FDG PET reveals increased metabolic activity in
multiple mediastinal lymph nodes
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56. Value of endoscopic ultrasound in mediastinal staging.
(A) Contrast-enhanced CT reveals a left lower lobe tumor
(T) associated with a mildly enlarged level 8 lymph node.
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57.  FDG PET shows
increased
activity in the
primary tumor
(T) but
not in the
mediastinal
lymph nodes
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58. Endoscopic ultrasound
reveals a small level 8 lymph node (arrow). FNAB confirmed
NSCLC. (LA, left atrium; A, aorta).
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59. ENDOSCOPIC ULTRASOUND
 Endoscopic ultrasound with FNAB is a
minimally invasive technique to image and
sample lymph nodes in the mediastinum.
 Using the esophagus as a window,
endoscopic ultrasound is able to directly
visualize lymph nodes at levels 4L, 5,
selected 6, 7, and 8.
 Right-sided nodes are often not visualized
because of air within the trachea.
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60. ENDOSCOPIC ULTRASOUND
 By sonographic characteristics alone,
sensitivity (78%) and specificity(71%) are
modest.
 Endoscopic ultrasound-guided FNAB
increases the specificity to almost 100%.
 Endoscopic ultrasound with FNAB is best for
evaluating enlarged lymph nodes, and it
may yield positive results in up to one third
of patients with negative mediastinal lymph
nodes on CT.
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61. Value of PET in detecting occult metastatic disease. (A) FDG PET
performed to evaluate a left upper lobe solitary
pulmonary nodule (arrowhead) reveals an unsuspected region of
increased uptake in the right chest wall (arrows).
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62. T1-weighted
axial gadolinium-enhanced MRI reveals an enhancing mass
between the right fifth and sixth ribs. Biopsy confirmed
metastatic adenocarcinoma.
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63. Value of PET in detecting
bone metastases.
 Technetium 99m medronate
scintigraphy interpreted as
normal in a patient with left
upper lobe mass. In retrospect,
there is minimally increased
activity in the region of the left
lesser trochanter (arrow).
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64. Value of PET in detecting
bone metastases.
 Coronal FDG PET clearly
shows increased metabolic
activity in the region of the
left lesser trochanter (arrow).
CT and subsequent biopsy
revealed cortical metastases.
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65. SMALL CELL LUNG CANCER
 SCLC accounts for about 14% of all
new cases of lung cancer.
 It is more aggressive than the non-small
cell form, with median survival
of 2-4 months if untreated.
 The system of staging SCLC is a two-stage
system based on studies of the
Veterans Administration Lung Study
Group.
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66. SCLC STAGING
 In this system, patients are classified as
having either limited or extensive disease.
 Limited disease: the tumour is confined to
one hemithorax and to the regional LNs.
 Extensive disease: tumour is beyond this
area in contralateral lung or extrathoracic
sites; 60-80% of newly diagnosed SCLC.
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67. SMALL CELL LUNG CANCER
 Posterior-anterior
chest radiograph
reveals a mass in
the aortopulmonary
window.
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68. SMALL CELL LUNG CANCER
 Contrast-enhanced CT reveals a
large mass invading the
mediastinum, surrounding the
left main bronchus (B), and
attenuating the left pulmonary
artery.
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69. SCLC with superior vena cava syndrome. (A) Contrast-enhanced
CT reveals mediastinal lymphadenopathy
obstructing the superior vena cava. (B) At the level of the
thoracic inlet, bilateral internal jugular venous thrombosis
(*) is present
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70. Value of PET in the detection of
extensive stage SCLC
 Unenhanced CT reveals
enlarged lymph nodes
surrounding
the left upper lobe bronchus
(arrows)
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71. SMALL CELL LUNG CANCER..
 Level 6
lymphadenopathy
(arrows)
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72. FDG PET reveals increased uptake in the left
pedicle and the left facet joint of the L4 vertebra
(arrows), unsuspected by physical exam or by bone
scintigraphy.
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73. Coronal T1-weighted MRI reveals low-signal
intensity (arrow). Biopsy confirmed metastatic
SCLC.
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74. Endobronchial ultrasonography bronchoscope
with a curved linear array ultrasound transducer
allowing real-time fine-needle aspiration.
618 Wynants et al
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75. METASTATIC DISEASE
 Metastases (M) status may be either M0 (no distant
metastasis) or M1 (distant metastasis).
 Clinical symptoms often herald the presence of
metastatic disease and the absence of symptoms
results in a negative predictive value of 95% for liver,
adrenal, and brain metastases and 90% for bone
metastases.
 CT and whole-body PET are often used to assess for
occult metastatic disease.
 Other imaging modalities include radionuclide bone
scan for detecting skeletal metastases and MRI for
identifying adrenal, liver, and brain metastases.
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76. Chest radiograph shows a solitary pulmonary nodule in the right lower lobe,
measuring less than 3 cm in diameter (arrow). This was a stage IA,
T1N0M0 bronchogenic carcinoma. Courtesy of Paul Stark, MD.
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77. CT scan of a stage IB, T2N0M0 bronchoalveolar cell carcinoma
demonstrates a right lower lobe mass, measuring 3.5 cm in diameter with a
so-called rabbit ear sign and with central lucencies that probably represent
air bronchograms rather than cavitation. Courtesy of Paul Stark, MD.
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78. CT scan of a stage IIB, T2N1M0 bronchogenic carcinoma shows a mass in
lingula, measuring 5 cm in diameter (large arrow), with dystrophic
calcification and hilar lymph node enlargement (small arrow). A small left
pleural effusion proved to be benign, and therefore did not affect staging of
the tumor. Courtesy of Paul Stark, MD.
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79. T2 lesion seen on chest radiograph in the left lung. Patient
presents with joint pain and hypertrophic osteoarthropathy.
Courtesy of Paul Stark, MD.
Primary mucinous
adenocarcinoma
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80. Squamous cell carcinoma of the left upper lobe bronchus
leading to left upper lobe atelectasis. Oblique linear
tomogram shows the tumor to be more than 2 cm from the
carina. This is still a T2 tumor. Courtesy of Paul Stark, MD.
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81. Squamous cell carcinoma of the left upper lobe bronchus
leading to left upper lobe atelectasis. Oblique linear
tomogram shows the tumor to be more than 2 cm from the
carina. This is still a T2 tumor. Courtesy of Paul Stark, MD.
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82. CT scan shows peripheral mass, in the right lung
representing a T3 bronchogenic carcinoma, invading and
extending through the intercostal space. Courtesy of Paul
Stark, MD.
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83. Peripheral bronchogenic carcinoma in left upper lobe, invading the
chest wall (arrow). CT shows infiltration of the left pectoralis
muscle and tumor extension into the deep axillary subcutaneous
fat. The findings are consistent with a T3 lesion. Courtesy of Paul
Stark, MD.
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84. Coronal, axial, and sagittal MR sequences in a superior sulcus tumor (arrows). Left
panel: Coronary sequence shows large peripheral right upper lobe mass invading the
superior chest wall and extending into the base of the neck. The vertebral body and
the spinal canal are not involved. Middle panel: Axial sequence also shows the mass
invading the superior chest wall and extending into the base of the neck. Right panel:
Sagittal sequence of the mass shows that right subclavian vein and artery are patent
and a pleural effusion is apparent (small arrow). The malignant effusion changes the
classification from T3 to T4. Courtesy of Paul Stark, MD.
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85. CT scan in a patient with bronchogenic carcinoma shows a central mass encasing the
right mainstem bronchus (large arrow), in close proximity to the carina. There are
also speckled calcifications in the hilar mass and in subcarinal nodes (small arrow)
from previous granulomatous disease. The location of this hilar mass is consistent
with a T3 tumor. Courtesy of Paul Stark, MD.
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86. Squamous cell carcinoma of the left mainstem bronchus with
almost total atelectasis of the left lung, producing opacification of
the left hemithorax. The trachea is deviated to the left. These
findings indicate a T3 tumor. Courtesy of Paul Stark, MD.
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87. CT scan shows a large mediastinal mass in close proximity to the
ascending aorta (Ao), invading the precarinal, retroaortic space.
There is also marked narrowing of the superior vena cava. This is
radiologically a T4, stage IIIB tumor. Courtesy of Paul Stark, MD.
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88. CT scan shows a large tumor encasing the mainstem bronchi and
the ascending aorta (Ao). A small right paravertebral mass is also
seen (small arrow). This is radiologically a T4, stage IIIB tumor.
Courtesy of Paul Stark, MD.
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89. Chest frontal radiograph shows right lower lobe atelectasis (arrow)
with accompanying right pleural effusion due to a bronchogenic
carcinoma. Courtesy of Paul Stark, MD.
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90. Left panel: CT scan of an advanced bronchogenic carcinoma shows right
lower lobe atelectasis with accompanying right pleural effusion. Right panel:
Barium esophagram from this patient demonstrates an esophagopulmonary
fistula (arrow) that indicates mediastinal extension and invasion by this T4,
stage IIIB tumor. Courtesy of Paul Stark, MD.
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91. Left panel: Chest radiograph shows diffuse left sided mediastinal
widening (arrow). Right panel: A barium esophagram reveals a
fistula between the left mainstem bronchus and the esophagus.
This is a T4, stage IIIB bronchogenic carcinoma. Courtesy of Paul
Stark, MD.
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92. Poorly differentiated adenocarcinoma of the lung with extensive
mediastinal invasion and bronchoesophageal fistula. A stent was
inserted into the esophagus as a palliative measure. Courtesy of
Paul Stark, MD.
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93. PET scan with FDG shows a right upper lobe solitary
pulmonary nodule in cross-sectional (A), sagittal (B),
coronal (C) views. This was a stage IA, T1N0M0
bronchogenic carcinoma. Courtesy of Paul Stark, MD.
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94. Stage 1, T1N0M0 peripheral bronchogenic carcinoma in left upper
lobe. FDG PET scan shows a small peripheral left upper lobe nodule
in cross-sectional display. Courtesy of Paul Stark, MD.
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95. CT scan shows bilateral calcified hilar lymph nodes, station 10 by
the 1997 classification (arrows). When enlarged due to an
ipsilateral bronchogenic carcinoma, they represent N1 nodes.
Courtesy of Paul Stark, MD.
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96. CT scan in a patient with bronchogenic carcinoma and right hilar
lymph node enlargement (arrow). This represents nodal station 10
involvement by the 1997 classification (N1 disease). Courtesy of
Paul Stark, MD.
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97. CT scan shows right high paratracheal lymph node (arrow), group
2R. This indicates an N2, stage IIIA tumor, provided the primary
cancer is on the ipsilateral side. Courtesy of Paul Stark, MD.
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98. CT scan shows left (left panel) and right (right panel)
supraclavicular node enlargement (N) in patients with
bronchogenic carcinoma. Spread to the supraclavicular lymph
nodes indicates N3 involvement. Courtesy of Paul Stark, MD.
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99. CT scan from a patient with left upper lobe poorly differentiated adenocarcinoma
invading the mediastinum. Left panel: Left lower (large arrow) and right lower (small
arrow) paratracheal lymph node involvement, stations 4R and 4L. Right panel: More
caudal view shows tumor encasing the left pulmonary artery (arrow) and the
descending aorta (Ao). Enlarged subcarinal lymph nodes are present, station 7. The
tumor is stage IIIB, unresectable on account of the T4 disease and the N3
contralateral lymph nodes. Courtesy of Paul Stark, MD.
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100. CT scan shows extensive mediastinal lymph node involvement in
lung cancer. Enlarged prevascular lymph nodes, station 3,
indicating a stage IIIB unresectable tumor. Courtesy of Paul Stark,
MD.
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101. Peripheral left upper lobe bronchogenic carcinoma with amorphous
central calcification and with aortopulmonary window (station 5,
long arrow) and contralateral pretracheal, retrocaval lymph nodes
(station 4R, short arrow), probable stage IIIB. Courtesy of Paul
Stark, MD.
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102. CT scan shows slightly enlarged lymph nodes located anterior to
the tracheal bifurcation (arrow). Courtesy of Paul Stark, MD.
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103. Left panel: Bronchogenic carcinoma with a right-sided drowned lung. CT scan of the
lower chest shows a large, opacified right lung with mucoid bronchograms appearing
as low attenuation branching structures. Right panel: Upper abdominal CT scan shows
several large low attenuation metastases in the liver. This is a T4, M1, stage IV tumor.
Courtesy of Paul Stark, MD.
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104. CT scan of the upper abdomen shows a large low attenuation necrotic left
adrenal metastasis (small arrow) and another low attenuation necrotic
metastatic focus in the pancreas (large arrow). This is a stage IV lung
cancer because there is metastatic (M1) disease. Courtesy of Paul Stark,
MD.
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105. TTHHAANNKKSS
FFOORR
YYOOUURR
PPAATTIIEENNCCEE
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