Lung Cancer Staging

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Staging is a way of describing where the cancer is located, if or where it has spread, and whether it is affecting other parts of the body.

Doctors use diagnostic tests to determine the cancer’s stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient’s prognosisThe likely outcome or course of a disease; the chance of recovery or recurrence

Lung cancer is often staged twice. The first staging is done before treatment begins and is called clinical staging. Some cancers cannot be accurately staged until after surgical treatment. For example, lymph nodes can be sampled only after surgery. This second staging is called pathologic staging.1

The staging system described here is based on the 8th edition American Joint Committee on Cancer lung cancer stage classification, which is now being implemented in the U.S.

Stages have been developed based on "TNM" (tumor, node, metastasis) classifications:

T:  The size of the primary tumorAn abnormal mass of tissue that results when cells divide more than they should or do not die when they should and where it has grown
N:  Whether and how regional lymph nodesA rounded mass of lymphatic tissue surrounded by a capsule of connective tissue are affected by the cancer
M:  Whether there is distant metastasisThe spread of cancer from the primary site, or place where it started, to other places in the body

(This is the staging system always used for non-small cell lung cancer. It is also used for small cell lung cancerA fast-growing cancer that forms in tissues of the lung and can spread to other parts of the body; named "small" for how the cancer cells look under a microscope, although another staging system may be used for this type of lung cancer: limited-stageCancer that is in the lung where it started and may have spread to the area between the lungs or to the lymph nodes above the collarbone and extensive-stageCancer that has spread widely throughout a lung, to the other lung, to lymph nodes on the other side of the chest, or to distant organs; this system uses less specific descriptions.)

Stages using TNM classifications are designated by a number, zero (0) through four. For one through four, the Roman numerals I through IV are used. 

Stage 0

This is called in situ disease, meaning that the cancer is “in place” and has neither invaded nearby tissues nor spread outside the lung.1,2,3,4,5

Lung cancer: stage 0

Stage IA and Stage 1B

A stage I lung cancer is a small tumor that is in the lungs only and has not spread to any lymph nodesA rounded mass of lymphatic tissue surrounded by a capsule of connective tissue. Lymph nodes filter lymph, the clear fluid that carries cells to fight infections and other diseases, and store lymphocytes (white blood cells). In addition, no stage I lung cancers have metastasized. Stage I is divided into two substages: stage IA and stage IB, based on the size of the tumor. Smaller tumors, those no more than 3 centimeters (cm) in the greatest dimension, are stage 1A, while slightly larger ones—more than 3 cm but no more than 4 cm in the greatest dimension—are stage 1B.1,2,3,4,5

Lung cancer: stage Ia

Lung cancer: stage Ib

Stage IIA and Stage IIB

Stage II lung cancer is divided into two stages: Stage IIA and stage IIB. No stage II lung cancers have metastasized.

Stage IIA tumors are more than 3 cm but no more than 4 cm in the greatest dimension and have not spread to nearby lymph nodes. The tumors may or may not have grown into the main bronchus or into the lung's inner lining, or have caused lung collapse or swelling. 

Lung cancer: stage IIa

Stage IIB tumors are either:

  • more than 5 cm but no more than 7 cm in the greatest dimension and have not spread to nearby lymph nodes. They may have grown into the lung's outer lining or nearby sites including the chest wall, phrenic nerve, or the heart's lining, or there are primary and secondary tumors in the same lobe

OR

  • no more than 5 cm in the greatest dimension and have spread to the peribronchial nodes and/or to the hilar and intrapulmonary nodes of the lung with the primary tumor. They may have grown into the main bronchus or into the lung's inner lining, or have caused lung collapse or swelling.1,2,3,4,5

 Lung cancer: stage IIb

Stage IIIA, Stage IIIB, and Stage IIIC

Stage III lung cancer is divided into three stages: stage IIIA, stage IIIB, and stage IIIC. No stage III lung cancers have metastasized. 

Stage IIIA tumors are either:

  • more than 7 cm in the greatest dimension and have not spread to nearby lymph nodes. They may have grown into the diaphragm, mediastinum, heart or its major blood vessels, windpipe, recurrent laryngeal nerve, carina, esophagus, or spine, or there are secondary tumors in the same lung but a different lobe than the primary tumor

OR

  • more than 5 cm in the greatest dimension and have spread to the peribronchial nodes and/or to the hilar and intrapulmonary nodes of the lung with the primary tumor. The tumors have grown into the lung's outer lining or nearby sites, including the chest wall of the heart's lining, or there are primary or secondary tumors in the same lobe; and/or tumors have grown into the diaphragm, mediastinum, heart or its major blood vessels, windpipe, recurrent laryngeal nerve, carina, esophagus, or spine, or there are secondary tumors in the same lung but a different lobe than the primary tumor

OR

  • no more than 5 cm in the greatest dimension and have spread to mediastinal lymph nodes, which include subcarinal nodes, near the lung with the primary tumor. They may be in the lungs only, or may have grown into the main bronchus or the lung's inner lining, or have caused lung collapse or swelling.

Stage IIIB tumors are either:

  • more than 5 cm in the greatest dimension and have spread to mediastinal lymph nodes, which include subcarinal nodes, near the lung with the primary tumor

OR

  • no more than 5 cm in the greatet dimension and have spread to the mediastinal or hilar nodes near the lung without the primary tumor, or to any supraclavicular or scalene lymph nodes. They may be in the lungs only, or may have grown into the main bronchus or the lung's inner lining, or have caused lung collapse or swelling.

Stage IIIC tumors are larger than 5 cm in the greatest dimension and have spread to mediastinal or hilar nodes near the lung without the primary tumor, or to any supraclavicular or scalene lumph nodes.1,2,3,4,5

 

Lung cancer: stage IIIa

Lung cancer: stage IIIb

Stage IVA and Stage IVB

Stage IV lung cancer is divided into two stages: stage IVA and stage IVB. The tumors may be of any size and may or may not have spread to lymph nodes. However, all stage IV cancers have metastasized.

Stage IVA tumors have metastasized, either from one lung into the other lung, into the lung's lining (and have formed secondary  nodules), into the heart's lining (and have formed secondary nodules), or into the fluid around the lungs or the heart or to one site outside the chest area (e.g., adrenal gland).

Stage IVB tumors have metastasized to multiple sites outside the chest area (e.g., adrenal gland and bones).1,2,3,4,5

Lung cancer: stage IV

Recurrence

Recurrent lung cancerLung cancer that has come back after a period of time during which the cancer could not be detected. The lung cancer may come back in the lung near the original tumor, in lymph nodes or in a distant organ. is lung cancer that has come back after treatment. If there is a recurrence, the cancer may need to be staged again (called restaging) using the system above.4

Prognosis

In addition to the patient's type and stage of lung cancer, the patient's overall health and strength contribute to the determination of the patient's prognosis as well as to the treatment plan.

Doctors can measure a patient's overall strength and health by using one of several measurement tools, called perfomance status scales. Those patients who are able to engage in their normal activities with no assistance, for example, are better able to tolerate aggressive cancer treatments and are likely to have better outcomes than those who are weaker and need nusing care. Note that performance status is more critical than a patient's age in predicting how well a patient is likely to do. A patient's age should not be the sole determinant for selecting a treatment plan.4,6,7

Updated April 6, 2018


References

1.  NCCN Guidelines fo Patients ®: Lung Cancer—Non-Small Cell Lung Cancer. The National Comprehensive Care Network website. https:  NCCN.org/patients/guidelines/content/PDF/nsclc.pdf. Posted November 30, 2017. Accessed December 20, 2017.
2.  Detterbeck F, Boffa D, Kim A, Tanoue L. The Eighth Edition Lung Cancer Stage Classification. CHEST 2017; 151(1):193-203. https://journal.chestnet.org/article/S0012.3692(16)60780-8/pdf. Accessed April 6, 2018.
3.  Kay FU, Kandathil A, Batra K, et al. Revisions to the tumor, node, metastasis staging of lung cancer (8th edition): rationale, radiologic findings and clinical implications. World Journal of Radiology. 2017 Jun 28:9(6):269-279. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5491654/. Accessed January 3, 2018. 
4.  Lung Cancer—Non-Small Cell: Stages. Cancer.net website. https://www.cancer.net/Cancer-types/lung-cancer-non-small-cell/stages. Approved August 2017. Accessed January 3, 2018.
5.  Rami-Porta R, Asamura H, Travis W, Rusch V. Lung Cancer—major changes in the American Joint Committee on Cancer eigth edition cancer staging manual. CA: A Cancer Journal for Clinicians. Volume 67, Issue 2. March/April 2017. Pages 138-155. https://onlinelibrary. wiley.com/doi/10.3322/caac.21390/full. Accessed December 12, 2017.
6.  West H, Jin JO. Performance status in patients with cancer. JAMA Oncol. 2015; 1(7):998. https://jamanetwork.com/journals/jamaoncology/fullarticle/2432463. Accessed March 7, 2018.
7.  ECOG Performance Status. ECOG-Acrin website. https:///ecog-acrin.org/resources/ecog-performance-status. Accessed March 7, 2018. 

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