2. Global Epidemiology
• Burden of Lung cancer
– Most common cancer for both sexes combined
• 1.8 million new cases - 12.9% of all new cancers
– Most common cancer in men
• 1.2 million new cases - 16.7% of all new cancers
– Fourth most frequent cancer in women
• 583 000 cases new cases - 8.8% of all new cancers
– Most common cause of death from cancer
• 1.59 million deaths - 19.4% of all cancer related deaths
GLOBOCAN 2012; http://globocan.iarc.fr
3. Need for academic careers in lung
cancer:
• Most frequent cancer for both gender combined and in males
• Most important cause of cancer related mortality for both
gender combined
7 people diagnosed every 2 minutes
6 people die of LC every 2 min (3/min)
Cheng TYD, et al. J Thorac Oncol 2016; 11: 1653-71
Y1 01: Singh N, Planning an academic career in lung cancer
4. LC Epidemiology : time trends
• Relative ↑ in adenocarcinoma globally:
– Changes in smoking behaviour of population
– Changes in cigarette composition & manufacturing
• Filter cigarettes
• Lower content of tar and nicotine
– Tendency for cigarette smoke to be inhaled
more deeply (~ Bidi) 🡪 Higher concentration of
carcinogens in lung periphery (site for ADC)
Stellman SD, et al. Cancer 1997; 80: 382–8
Thun MJ, et al. J Natl Cancer Inst 1997; 89: 1580-6
Wynder EL, et al. Environ Health Perspect 1995; 103(Suppl 8): 143–8
Brooks DR, et al. Cancer Epidemiol Biomarkers Prev 2005; 14: 576–81
5.
6. 🡪 The symptoms produced by the primary tumour
depend on its location (i.e., central vs peripheral).
🡪 Central tumours generally produce symptoms of
cough, dyspnea, atelectasis, postobstructive
pneumonia, wheezing, and hemoptysis; whereas,
🡪 peripheral tumours, in addition to causing cough and
dyspnea, can lead to pleural effusion and severe pain
as a result of infiltration of parietal pleura and the chest
wall.
7. SYMPTOMS MECHANISM AND
PATHOPHYSIOLOGY
PRIMARY LUNG LESSION SYMPTOMS
1.COUGH(50-70%) •Presence of a mass irritates the
cough receptors in the airway
•More common in squamous cell
carcinoma andSCLC (more
commonly found in the central
airways)
•Obstruction from central airway
could also lead to post-obstructive
pneumonia and distal atelectasis
2.WEIGHT LOSS(46%) •Cancer induced lipolysis and
proteolysis leads to loss of adipose
and skeletal muscle. Protein
synthesis is also reduced via a
number of mechanisms
3.HAEMOPTYSIS(25-50%) •Tumour in the central airway
•Blood vessels resulting from
tumour-induced angiogenesis are
leaky and tortuous, predisposing
8. SYMPTOMS MECHANISM AND
PATHOPHYSIOLOGY
4.DYSPNOEA(25%) •Extrinsic or intraluminal airway
obstruction
•Activation of mechanoreceptors
and chemoreceptors in lungs due
to cachexia or hypoxemia/acidosis
5.CHEST PAIN (20%) •Tumour involving pleural surface
causing pleuritic chest pain
MEDIASTINALINVOLVEMENT
6.SUPERIOR VENACAVA SYNDROME •Obstruction of superior vena cava
by the tumour
•More common in SCLC (central
tumour)
•2-4% of lung cancer patients
develop it at some point
7.PERICARDIAL EFFUSION •Tumours can at times infiltrate into
the pericardium or press on the
9. 8.PLEURAL EFFUSION
a) chest pain
b) dyspnoea
•Benign pleural effusion may be due
to lymphatic obstruction, post-
obstructive pneumonitis, or
atelectasis
•Malignant pleural effusion occurs
when malignant cells are present in
pleural fluid
9.DYSPHAGIA •Enlargement of the subcarinal
lymph nodes compressing on the
middle third of the esophagus
10.PANCOAST TUMOUR •Tumour originates in the apical
portion of the lung
•Occurs in 5% of non-small cell
lung cancer
•Invasion of brachial plexus causes
pain and muscle wasting of arm
and hand
•Invasion of superior cervical
sympathetic ganglion leads to
Horner syndrome:
• Loss of sympathetic control of
Muller muscle that elevates the
upper eyelid leads to
10. •Anhidrosis (lack of sweating)
caused by impingement of
sweat gland fibres arising from
cervical sympathetic ganglion
•Phrenic nerve involvement can
lead to unilateral diaphragm
paralysis
•Recurrent pharyngeal nerve
involvement can lead to voice
hoarseness
11. LC vs. other lung diseases
• Clinical features may also occur in:
– Pulmonary Infections
• Tuberculosis
• Chronic necrotizing pulmonary aspergillosis
• Nocardiosis
• Lung abscess
– Non-infectious inflammatory diseases
• ANCA associated vasculitis (formerly called
Wegener’s granulomatosis)
12. SOLITARY PULMONARY NODULE
🡪 A lung nodule has been defined by the Nomenclature Committee
of the Fleischner Society as a rounded opacity, well or poorly
defined on a conventional radiograph, measuring up to 3 cm in
diameter. Further subdivisions of nodules are defined as acinar,
which usually measures 5–8 mm in diameter and is presumed to
represent consolidation in an acinus.
🡪 On computed tomography (CT) scan, a nodule appears as a
rounded or irregular opacity, well or poorly defined, measuring up
to 3 cm in diameter.Solitary pulmonary nodule (SPN) is found
incidentally on imaging studies unrelated to the respiratory system
in 0.09–0.2% of all chest radiographs. Opacity less than 3 mm is
defined as a micronodule. Mimics of pulmonary nodules include
pseudonodules, which represent a rib fracture, a skin lesion, a
device outside the patient, anatomic variants, or composite areas
of increased opacity.
13. 🡪 SPN is seen more often on CT scans. The overall reported incidence of
SPN is 8–51%.In one study of CT screening for lung cancer in smokers,
13% of patients had pulmonary nodules larger than 5 mm at baseline.
🡪 The initial step after discovery of a SPN is to determine its cause and
characterize it as definitely benign, equivocal, or definitely malignant
on radiologic features. Benign nodules include infectious granulomas
and hamartomas, whereas common malignant causes include
primary lung cancer, carcinoid tumors, and lung metastases.
🡪 Radiologic features, such as size, morphology, and rate of growth, help
to determine the likelihood of malignancy in a majority of
patients.Depending on their appearance and radiologic context,
certain nodular opacities may be judged sufficiently typical on
scanning that follow-up is not warranted
15. (a) Frontal chest radiograph demonstrates a 5-mm dense
pulmonary nodule projecting in the right mid lung zone. (b)
Axial CT image at the level of the heart displayed in bone
settings reveals a calcified pulmonary nodule in the right
middle lobe consistent with calcified granuloma.
16. (a) Frontal chest radiograph demonstrates a sharply demarcated left lower
lobe nodule. (b) Axial CT image at the level of the heart displayed in bone
settings shows the well-defined nodule with central calcification and
peripheral hypodensity consistent with pulmonary hamartoma.
17. (a) Axial CT image at the level of the right lung base
demonstrates a spiculated right lower lobe nodule with a
peripheral cavity. (b) Corresponding 18-F FDG
PET/fused PET CT image demonstrates intense FDG
uptake in the nodule in keeping with bronchogenic
18. Axial CT images at the level of the right lower lobe displayed in
mediastinal (a) and lung (b) windows demonstrate an
approximately 1 cm pleural based right lower lobe pulmonary
nodule. 18-F FDG PET/fused PET-CT images (c) reveal minimal
uptake within the nodule not exceeding the background
suggesting a benign etiology. Surgical pathology confirmed the
diagnosis of carcinoid tumor.
22. PARANEOPLASTIC SYNDROMES
1.ECTOPIC CUSHING SYNDROME •Ectopic secretion
of adrenocorticotrophic
hormone (ACTH) → adrenal cortisol
secretion → weight gain, hypertension,
hypokalemia, muscle weakness
•Most common form of ectopic
secretion in lung cancer,
especially SCLC
2.SIADH •Ectopic secretion of ADH → retain free
water in collecting ducts
•Euvolemic hyponatremia and
concentrated urine
•Mild symptoms include headache
and weakness,
•severe symptoms include altered
mental status, seizures, respiratory
depression, and death
•Common in SCLC
23. 3.HYPERCALCAEMIA •Increased secretion of PTHrP
→ acts like parathyroid hormone to
increase bone resorption and renal
calcium reabsorption
→ hypercalcemia
•Associated with squamous cell
carcinoma
4. Hypertrophic osteoarthropathy
and digital clubbing
•Associated with NSCLC, especially
the adenocarcinoma type
•Periosteal proliferation of the
tubular bones characterized by (i)
painful symmetrical arthritis of the
ankles, knees, wrists and elbows,
and (ii) digital clubbing.
•Mechanism is due to secretion of
various factors including VEGF,
PDGF, and prostaglandin E2
25. Non- invasive invasive
Chest radiography Mediastinoscopy : GOLD STANDARD
Computed tomography Video Assisted Thoracic Surgery
PET scan Anterior Mediastinotomy (Chamberlain procedure;
MRI Endobronchial Ultrasound with Fine Needle Aspiration
(EBUS-FNA)
Endoscopic Ultrasound with Fine Needle Aspiration(EUS-
FNA)
Transbronchial Fine Needle Aspiration (TBNA-FNA)
26. Findings on Chest Radiography
🡪 Nodule (< 3cm) vs. Mass (>= 3cm).
Location:
-Peripheral (Adenocarcinoma) vs.
-Central (Squamous).
-Single or multiple (metastases).
🡪 Endobronchial obstruction.
- Atelectasis of lobe or lung.
-Pneumonia
🡪 Hilar and mediastinal adenopathy.
🡪 Pleural effusions.
🡪 Elevated hemidiaphragm
27.
28. SPUTUM CYTOLOGY
🡪 Sputum examined as multiple samples will detect the more
central tumors, whereas bronchial washings and fine needle
aspirations will detect the remaining ones, usually occurring
as subpleural lesions.
🡪 Cytological examination of sputum has a dual purpose:
1.To determine the presence of tumor
2.To classify the tumor as accurately as possible
🡪 With three samples:
🡪 80% detection rate of centrally located tumors.
🡪 50% detection rate of peripheral lesions.
29.
30. PAP stain of sputum showing cells of
adenocarcinoma (magnification,
×400)
PAP stain of sputum showing
squamous cell carcinoma
(magnification, ×400)
31. CHEST CT SCAN
🡪 Unless a patient is clearly not a candidate for any treatment
,all patients should undergo a chest ct scan appropriately
modified for the purpose of lung cancer assessment.
🡪 The lung cancer ct scan includes the chest and the upper
abdomen.
🡪 The administration of iv contrast facilitates better
characterization of hilar and mediastinal lymph nodes by
differentiating them from vascular structures and also helps to
better characterize hepatic and adrenal lesions.
🡪 Nodule details: - Calcification, spiculation etc..
🡪 Evaluate extension into adjacent structures:
Endobronchial, great vessels, pericardium etc..
🡪 Evaluation of lymphadenopathy.
🡪 Upper abdominal pathology: -Metastatic lesions in liver,
adrenals, & kidneys.
36. Magnetic Resonance
Imaging
🡪 This is the investigation of choice when assessing for
intracranial metastatic disease.
🡪 It is more sensitive than CT scan of the brain .
🡪 Staging brain MRI should be considered in patients who
present with locally advanced or advanced NSCLC on
chest CT or PET scanning,patients with neurologic signs or
symptoms and in patients with SCLC.
🡪 MRI can be more accurate than CT in separating stage IIIa
(resectable) from IIIb (generally unresectable) tumours in
selected patients due to its ability to detect invasion of
major mediastinal structures, i.e. T4 disease
🡪 The advantages MRI has over CT include: better soft tissue
contrast, multiplanar imaging capability, and therefore
useful for superior sulcus tumours and evaluation of the
aortopulmonary window , and cardiac gating which
enables excellent delineation of the heart and great vessels
and removes cardiac pulsation artefact
39. Bone scan
🡪 A bone scan uses a radioactive tracer to look at the inside of the
bones. The tracer is injected into a patient’s vein. It collects in
areas of the bone and is detected by a special camera. Healthy
bone appears lighter to the camera, and areas of injury, such as
those caused by cancer, stand out on the image. PET scans (see
above) have been replacing bone scans to find NSCLC that has
spread to the bones.
Thoracentesis
🡪 After numbing the skin on the chest, a needle is inserted through
the chest wall and into the space between the lung and the wall
of the chest where fluid can collect. The fluid is removed and
checked for cancer cells by the pathologist.
40. VIDEO FLEXIBLE
BRONCHOSCOPY
🡪 Fibreoptic bronchoscopy is a safe and effective way to diagnose
and stage many patients with lung cancer. As well as obtaining
samples from endobronchial tumour it can be routinely
combined with non-ultrasound guided transbronchial needle
aspiration (non US-guided TBNA) to sample tumours beneath the
mucosa and hilar and mediastinal lymphadenopathy detected
by CT.
🡪 Brushings and bronchial biopsies are high yield for visible lesions.
🡪 Transbronchial biopsies of large peripheral lesions +/-
fluoroscopic guidance.
🡪 Evaluation of obstruction for stent placement & brachytherapy.
41.
42. 🡪 Fluorescence bronchoscopy
🡪 Also known as autofluorescence
bronchoscopy, this technique help
find some lung cancers earlier,
when they are likely to be easier to
treat. For this test, The end of the
bronchoscope has a special
fluorescent light on it, instead of a
normal (white) light.
🡪 The fluorescent light causes
abnormal areas in the airways to
show up in a different color than
healthy parts of the airway. Some of
these areas might not be visible
under white light, so the color
difference can help doctors find
these areas sooner.
🡪 Electromagnetic navigation
bronchoscopy
🡪 Lung tumors near the center of the
chest can be biopsied during
bronchoscopy, but bronchoscopes
have trouble reaching the outer
parts of the lungs, so tumors in these
areas often need to be biopsied by
passing a needle through the skin.
🡪 This newer approach can help a
doctor use a bronchoscope to
biopsy a tumor in the outer part of
the lung. First, CT scans are used to
create a virtual bronchoscopy. The
abnormal area is identified, and a
computer helps guide a
bronchoscope to the area so that it
can be biopsied. The bronchoscope
used has some special attachments
that allow it to reach further than a
regular bronchoscope.
🡪 This takes special equipment and
training, and it is not widely
43. LIQUID BIOPSY
🡪 Recently, the FDA approved the
first liquid biopsy for lung cancer which
utilizes free floating DNA in the
bloodstream for analysis. Tumors shed
this DNA material into the blood as the
cells within them die. The DNA is
collected and analyzed allowing
doctors to get a “snapshot” of the
genetic mutations and other
irregularities that drive a tumor’s growth.
Liquid biopsies offer some important
advantages, in that they are non-
invasive, inexpensive, provide timely
results and are easily repeatable.
44. Mediastinoscopy and surgical
diagnostic and staging techniques
🡪 Mediastinoscopy
🡪 Mediastinoscopy is a more invasive technique than
EBUS or EUS, but provides much larger samples. There
is currently debate about whether mediastinoscopy is
warranted in patients who are suitable for treatment
with curative intent who have had a negative EBUS
or EUS. This is partly because such patients, even if
found to have microscopic involvement of lymph
nodes, may still benefit considerably from treatment
with curative intent.
🡪 Anterior Mediastinotomy
🡪 Anterior (parasternal) mediastinotomy has
developed primarily as a means of staging
carcinoma of the lung located in the left upper lobe.
It has also been advocated to establish the diagnosis
of primary masses in the anterosuperior mediastinum,
especially in the setting of superior vena caval
obstruction when needle biopsy may be
contraindicated
45. TRANSBRONCHIAL NEEDLE
ASPIRATION
🡪 Transthoracic needle biopsy is used to obtain diagnostic
samples from lesions that are not accessible via the
bronchial tree and where there is no obvious lymph node
involvement.
🡪 This is usually where there are one or more peripheral
lesions. CT is used to guide biopsy where lesions are in
difficult to reach locations or where they are completely
surrounded by aerated lung. Ultrasound is used where the
lesion abuts the chest wall and is visible on ultrasound
🡪 Allows biopsy of subcarinal & paratracheal lymph nodes
during flexible bronchoscopy.
🡪 Helpful for staging.
🡪 Minimal risk to patient.
46. PET SCAN
🡪 PET imaging in oncology uses short-lived positron-emitting
radio-isotopes (radionuclides). The most commonly used
radionuclide is fluorine-18, which is used to label glucose,
resulting in F-18 fluorodeoxyglucose (F-18 FDG). Fluorine-18
emits positrons. These positrons after emission combine with
electrons.
🡪 The PET camera detects the gamma rays emitted from this
process, which is referred to as annihilation coincidence
detection.
🡪 PET imaging is now combined with CT, as the PET camera
provides high sensitivity for the distribution of the tracer, and
the CT provided precise anatomic localization and
attenuation correction. The combination makes PET/CT the
most sensitive and accurate modality to evaluate most
malignancies.
47. 🡪 PET/CT is a valuable modality in the evaluation of lung
cancer (NSCLC and also small cell lung cancer). One of the
important indications is in the evaluation of a solitary
pulmonary nodule (less than or equal to 3 cm in diameter).
These can be detected incidentally on chest radiographs or
chest CT scans .PET/CT has much greater sensitivity to
detect the metabolic changes seen in malignancy.
🡪 Solid pulmonary nodules greater than 8–10 mm in diameter
which show lack of uptake for F-18 FDG is much more likely
to be benign.
🡪 PET is more accurate than CT in the detection or exclusion of
mediastinal nodal metastases.
🡪 PET scanning detects malignancy in focal pulmonary
opacities with a sensitivity of 96%, specificity of 88% and an
accuracy of 94% in lesions of ≥10 mm
48. 🡪 False-negative studies are uncommon, and can be seen in small
nodules, generally less than 8–10 mm in diameter. False negative
results can also be seen with low-grade malignancies, such as
bronchoalveolar carcinoma
🡪 False positive results can be seen with infections, particularly
tuberculosis and granulomatous infections. Non-infectious
inflammatory conditions, especially sarcoid, can also cause false-
positive results. The degree of hypermetabolism in these infectious or
non-infectious inflammatory conditions can be similar to that of high-
grade malignancies.
🡪 PET/CT is critically important in radiation therapy planning. PET/CT
provides staging information and can detect previously unknown
metastasis, which can determine which patients can receive definitive
(i.e., potentially curative) radiotherapy and which patients should
receive palliative therapy. PET/CT can provide accurate delineation of
extent of disease, so that definitive radiotherapy has a better chance
of success.
51. EBUS
🡪 EBUS combines the bronchoscopic system and
ultrasound to define mediastinal structures and
parabronchial anatomy, in order to reduce biopsy
errors during transbronchial sampling.
🡪 It is currently used in the staging of lung cancer, in the
evaluation of endobronchial tumours, PPLs and
mediastinal masses.
🡪 Two types of EBUS are currently used for clinical
purposes: radial-probe EBUS (RP-EBUS) and convex-
probe EBUS (CP-EBUS).
52. 🡪 RP-EBUS, first described in 1992, is an important tool in
the evaluation of tracheo-bronchial wall structure; it is
also used to drive transbronchial needle aspiration
(TBNA) as well as to detect PPLs in combination with
navigation bronchoscopy.
🡪 CP-EBUS, first described in 2004, allows real-time TBNA
of mediastinal and hilar lymph nodes
53. VATS
🡪 Video-assisted thoracoscopic surgery VATS provides a highly
sensitive (97–100%) method of obtaining histological and
cytological material for confirmation of the diagnosis of lung
cancer in patients with pleural effusions or peripheral lesions
where this has not been possible to achieve by other less
invasive means. It is also a sensitive method of obtaining
material intraoperatively prior to definitive resection
🡪 Video-assisted thoracoscopic assessment may allow biopsies
direct from the tumour mass and can often establish whether
there is tumour invasion into the central mediastinal
structures. Lymph node stations 7, 8 and 9 can be sampled. It
may also be employed to establish the diagnosis in single
pulmonary nodules, especially where the lesion is in a peripheral
location
54. ENDOSCOPIC SAMPLING OF
MEDIASTINAL LYMPH NODES
🡪 Assessing the mediastinum with endobronchial ultrasound fine
needle aspiration (EBUS-FNA) and endoscopic ultrasound fine
needle aspiration (EUS-FNA) offers a less invasive technique
with higher sensitivity (94% vs 79%) and negative predicted
probability (93% vs 86%) than surgical staging alone. The
technique is associated with low risk and less need for general
anaesthesia and thoracotomy. The use of these techniques
readily allows for repeat sampling of the mediastinum which is
simpler than repeat mediastinoscopy
58. What is Cancer Staging?
❖ Staging describes the severity of an individual's cancer based on
the magnitude of the original (primary) tumor as well as on the
extent cancer has spread in the body.
❖ Stage of Cancer at time of diagnosis is a reflection not only of the
rate of growth and extension of the neoplasm but also the type of
tumour and the tumour–host relationship.
59. Staging and grading
Stage
Cancer stage refers to the size
and/or extent (reach) of the
original (primary) tumor and
whether or not cancer cells have
spread in the body
Grading
Tumor grade is the description of a tumor
based on how abnormal the tumor cells and
the tumor tissue look under a microscope. It
is an indicator of how quickly a tumor is
likely to grow and spread
60. Why we need Cancer
Staging?
❑ Aid the clinician in the planning of treatment
❑ Give some indication of prognosis for survival
❑ Assist in evaluation of the results of treatment
❑ Facilitate the exchange of information between
treatment centers
❑ Contribute to the continuing investigation of
human cancer
❑ Support cancer control activities.
64. T – Primary Tumor
🡪TX : Primary tumor cannot be assessed,
or tumor proven by the presence of
malignant cells in sputum or bronchial
washings but not visualized by imaging
or bronchoscopy
🡪T0 : No evidence of primary tumor
🡪Tis :Carcinoma in situ:
🡪Tis (AIS) for adenocarcinoma in situ
🡪Tis (SCIS) for squamous cell carcinoma in
situ
65. T1 tumours
🡪 T1 : Tumour <3cm 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)
🡪 T1mi : Minimally invasive adenocarcinoma
🡪 T1a : Tumour 1 cm or less in greatest dimension
🡪 T1b : Tumour >1 cm but < 2 cm in greatest dimension
🡪 T1c : Tumour >2 cm but < 3 cm in greatest dimension
*Changes in 8th edition: Size Change
67. Chest CT shows a
left lower lobe
nodule (arrow)
measuring >1 cm &
<2 cm in size, a
finding that is
consistent with a
stage T1b tumor
(>1cm & <2 cm)
(Previously T1a)
68. Chest CT shows a right
upper lobe nodule
(arrow) measuring 2.9
cm in size, a finding that
is consistent with a stage
T1c tumor (>2 cm but <3
cm).
Previously T1b
69. 🡪 Tumour >3cm but <5 cm; or tumour with any of the following features :
🡪 Involves main bronchus regardless of distance to the carina, but without
involvement of the carina
🡪 Invades visceral pleura
🡪 Associated with atelectasis or obstructive pneumonitis that extends to the
hilar region either involving part of or the entire lung
🡪 T2a : Tumour > 3 cm but <4 cm in greatest dimension
🡪 T2b : Tumour >4 cm but <5 cm in greatest dimension
70.
71. Stage T2a tumors ( >3
but <4 cm) Chest CT
shows a centrally
located lung nodule
causing airway
obstruction, with
atelectasis or post-
obstructive pneumonia
72. Chest CT shows a
mass in the right lung
measuring 4.8 cm, a
finding that is
consistent with a
stage T2b tumor (>4
cm but <5 cm).
previously T2a
73. VISCERAL PLEURAL INVASION
in T Classification
🡪 Invasion of visceral pleura (T2) defined as
“invasion beyond the elastic layer including
invasion to the visceral pleural surface”.
🡪 Recommendations included on the use of
elastic stains in the determination of VPI.
🡪 Sub-classification has been proposed by Japan
Lung Cancer Society.
74. T3 Tumours
🡪 Tumour >5 cm but <7 cm in greatest dimension or one
that directly invades any of the following:
🡪 Parietal pleura
🡪 Chest wall (including superior sulcus tumours)
🡪 Phrenic nerve
🡪 Parietal pericardium
🡪 Associated separate tumour nodule(s) in the same lobe as
the primary.
🡪 Tumour extending to rib
75.
76. Chest CT scan shows
a left lower lobe mass
>5cm but <7 cm in
diameter
T3 stage
77. T4 Tumours
🡪 Tumour >7 cm or one that invades any of the following:
🡪 Diaphragm
🡪 Mediastinum
🡪 Heart( visceral pericardium)
🡪 Great vessels
🡪 Trachea
🡪 Recurrent laryngeal nerve
🡪 Oesophagus
🡪 Vertebral body
🡪 Carina
🡪 Separate tumour nodule(s) in a different ipsilateral lobe to that of the
primary
79. Stage T4 tumors
Chest CT shows a
primary lung tumor in
the right upper lobe
(long arrow) with a
smaller separate
nodule in the right
lower lobe
80. Chest CT shows a right upper lobe mass (arrow)
with mediastinal and carinal invasion, ipsilateral
loculated pleural effusion, and thickening and
enhancement of the pleura.
81. “Pancoast” tumour
🡪 A Pancoast tumor is a tumor of the
superior pulmonary sulcus
🡪 Involves the inferior branches of the
brachial plexus (C8 and/or T1) and, in
some cases, the stellate ganglion
🡪 characterized by pain due to invasion
of the brachial plexus,
🡪 Horner's syndrome and destruction of
bone due to chest wall invasion.
🡪 Pancoast tumors are staged at least as
T3, because there is almost always
chest wall invasion
82. N Regional Lymph Nodes–
🡪 NX : Regional lymph nodes
cannot be assessed
🡪 N0 : No regional lymph node
metastasis
🡪 N1 : Metastasis in ipsilateral
peribronchial and/or ipsilateral
hilar lymph nodes and
intrapulmonary nodes,
including involvement by direct
extension
83. Chest CT scan
obtained in a
patient with right-
sided lung cancer
shows an
enlarged right
hilar lymph node
(level 10).
84. Chest CT shows a left
lower lobe mass and
an ipsilateral enlarged
interlobar lymph node
(level 11).
86. (a)Chest CT shows an enlarged (1.6-cm) right upper
paratracheal lymph node (2R)
(b)Chest CT shows an enlarged (1.5-cm) right lower
paratracheal lymph node (4R)
(c)Chest CT shows a right lower lobe mass with an enlarged
(1.6-cm) subcarinal lymph node (7).
87. N3 : Metastasis in
⮚ contralateral mediastinal, contralateral hilar,
⮚ ipsilateral or contralateral scalene, or supraclavicular lymph node(s)
88. (a)Axial PET/CT of the chest shows a primary mass in the left
lung and a right lower paratracheal lymph node (4R), both
demonstrate intense radiotracer uptake
(b)Chest CT scan obtained at the lung apex shows enlarged
bilateral supraclavicular lymph nodes (level 1)
90. M – Distant Metastasis
🡪 M0 : No distant metastasis
🡪 M1 : Distant metastasis
🡪 M1a :
🡪 Separate tumour nodule(s) in a contralateral lobe
🡪 Tumour with pleural nodules or malignant pleural or pericardial effusion.
🡪 Most pleural (pericardial)effusions with lung cancer are due to
tumour.
🡪 the effusion should be excluded as a staging descriptor – if tumor is
not exudative and no malignant cells are seen on multiple
microscopic examinations.
91.
92. Chest CT shows a primary mass in the left lung , with a separate tumour
nodule in the right lung. (M1a)
94. Axial contrast material–
enhanced T1-weighted
MR image of the brain
obtained in a patient
with known primary
lung cancer shows a
ring-enhancing lesion
with surrounding
edema in the right
occipital pole (arrow),
(M1b)
96. A) Abdominal CT shows multiple enhancing hepatic masses and a right
adrenal mass, findings that are consistent with metastatic disease.
B)Technetium-99m methylene diphosphonate nuclear bone show
multifocal areas of abnormal radiotracer uptake in the axial and
appendicular skeleton, findings that are consistent with metastases.
97. Recent changes in M
❖ Tumour foci in the ipsilateral parietal and visceral pleura that are
discontinuous from direct pleural invasion by the primary tumour are
classified M1a.
❖ Pericardial effusion/pericardial nodules are classified as M1a, same
as pleural effusion/nodules.
❖ Separate tumour nodules of similar histological appearance are
classed as M1a if in the contralateral lung (vide supra regarding
synchronous primaries).
❖ Distant metastases are classified as M1b if single and M1c if multiple
in one or in several organs.
❖ Discontinuous tumours outside the parietal pleura in the chest wall or
in the diaphragm are classified M1b or M1c depending on the
number of lesions.
98. Small Cell Lung Cancer Stages
Limited stage
🡪 cancer is only on one side of
the chest and can be treated
with a single radiation field
🡪 Involve only one lung and that
might have also reached the
lymph nodes on the same side
of the chest.
🡪 Only about 1 out of 3 people
with SCLC have limited stage
cancer when it is first found.
Extensive stage
🡪 cancers that have spread
widely throughout the lung, to
the other lung, to lymph nodes
on the other side of the chest,
or to other parts of the body
(including the bone marrow).
🡪 About 2 out of 3 people with
SCLC have extensive disease
when their cancer is first found.
99. SUMMARY
🡪 The TNM staging system for lung cancer is an
internationally accepted system used to determine the
extent of disease.
🡪 It provides description of the extent of cancer that can
be easily communicated to others, assist in treatment
decisions and serve as a prognostic indicator.
🡪 The TNM staging system predicts survival , but should
not be used alone to dictate treatment.
