TNM Staging:
Lung
TONYA BRANDENBURG, MHA, CTR
KENTUCKY CANCER REGISTRY
Overview

Lung Anatomy

Clinical Staging vs Pathological Staging

Changes in T,N,M Staging from AJCC 6th
edition to 7th edition

Elements of Staging: TX-T4, NX-N3, and
M0-M1b

Stage Groups and Prognostic Factors

Helpful Hints

Lung Examples
Lung
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas,
2nd Edition. New York: Springer, 2012. ©American Joint Committee on
Cancer
Anatomic subsites of the lung.

Bronchioles: The
passageways by which
air passes through the
nose or mouth to the
lungs. They are branches
of the bronchi.

Alveolus ("little cavity") is
an anatomical structure
that has the form of a
hollow cavity.[ The
pulmonary alveoli are
the terminal ends of
the respiratory tree. The
alveolar sacs or alveolar
ducts are both sites of
gas exchange with the
blood as well.
Source of definitions: Wikipedia.com
Topography Review

Pancoast Tumor - A superior sulcus tumor that arises in the
apex of the lung and spreads into chest wall (coded to upper
lobe, C34.1)

Hilum – The root of the lung is located at the hilum of each
lung, just above the middle of the mediastinal surface and
behind the cardiac impression of the lung. (coded to main
bronchus, C34.0)

Apex – The apex is at the top of the lung. It extends into the
root of the neck, reaching between 2.5 centimeters and 4
centimeters above the level of the sternal end of the first rib.
(coded to upper lobe, 34.1)

Mesothelioma - A malignancy that arises in the pleura
(coded and staged to pleura, C38.4)
Common Terms

Mediastinum - The mediastinum is the central compartment of
the thoracic cavity. The mediastinum contains the heart and its
vessels, the esophagus, trachea, phrenic and cardiac nerves,
the thoracic duct, thymus and lymph nodes of the central chest.

Pleura – The pleural cavity is the thin fluid-filled space between
the two pulmonary pleurae (visceral and parietal) of each lung.
A pleura is a serous membrane which folds back onto itself to
form a two-layered membranous pleural sac.

Great Vessels – The great vessels include the aorta, superior vena
cava, inferior vena cava, main pulmonary artery, intrapericardial
segments of the trunk of the right and left pulmonary artery,
intrapericardial segements of the superior and inferior right and
left pulmonary veins
Clinical Staging



Clinical staging based on evidence acquired before
treatment
Includes physical exam, imaging procedures (CT, PET)
lab tests, and staging procedures such as scopes,
thoracentesis and exploratory thoracotomy.
Within 4 months or before treatment, whichever is
shorter
Pathological Staging





Pathological staging based on clinical staging info,
definitive surgical resection operative findings, and
path report of resected specimen
Or within 4 months of dx, whichever is longer
There can be no systemic treatment or radiation prior
to resection
If a patient has systemic treatment before definitive
surgery, you must stage using the y descriptor
Surgical resection must meet criteria for the chapter
in order to stage the case pathologically
When to use blanks and
X’s

Blanks should be used if:
 There is no info in the chart to assign an AJCC
value
 If the patient isn’t eligible for pathological
staging
 If AJCC criteria for this stage classification is not
met

X should be used if:
Criteria for this stage classification is met
 T cannot be assessed
 N cannot be assessed
 Cannot use X in the M category; MX is not a valid
value

Does patient meet criteria for
that stage classification?
Yes – patient meets
classification criteria
If physician could not assess T and/or N for the
patient, and definitive information for T and N
not in chart
–
Use blank
•
–
–
Use TX and/or NX (Use of X is rare)
If there is no information about diagnostic
workup or resection pathology in chart
–
No – patient does NOT meet
classification criteria
Indicates registrar could not find information in
chart
Do not use X
–
Do NOT use X
•
Indicates patient eligible for staging
•
Implies physician did not assess or have
info on patient’s T and/or N
Must use blanks
•
Indicates patient did not meet
classification criteria
Changes in T,N,M Staging for Lung
from 6th edition to 7th edition

Classification recommended for:



T:

New tumor sizes and sub-classifications

Multiple tumors in same lobe now T3

Multiple tumors in same lung different lobe now T4
N:


Non-small cell carcinomas, Small cell lung carcinomas, and
Carcinoid tumors
New international lymph node map
M:

Malignant pleural effusion now M1a
Elements of Staging:
TX, T0, and Tis
TX: Tumor not seen on bronchoscopy or films,
but diagnosed by sputum cytology (occult
carcinoma)
 T0: No evidence of primary tumor (use when
you have metastasis that is consistent with
lung primary, but no evidence of a primary
tumor can be found)
 Tis- Carcinoma in situ (rare in lung) – This is
increasing because bronchio – alveolar
carcinoma is now called adenocarcinoma in
situ

Elements of Staging: T1

T1- Tumor 3 cm or less, surrounded by lung or
visceral pleura, without bronchoscopic
evidence of invasion more proximal than the
lobar bronchus (not in the main bronchus)


T1a = Tumor 2 cm or less in greatest dimension
T1b = Tumor more than 2 cm but less than 3 cm in
greatest dimension
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas,
2nd Edition. New York: Springer, 2012. ©American Joint Committee on
Cancer
T1 is defined as a tumor 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).
T1a is defined as a tumor 2 cm or less in greatest dimension (upper left). T1a is also defined as a superficial
spreading tumor of any size with its invasive component limited to the bronchial wall, which may extend
proximally to the main bronchus (lower left). T1b is defined as a tumor more than 2 cm but 3 cm or less in
greatest dimension (right).
Elements of Staging: T2

T2- Tumor more than 3 cm but less than 7 cm or
tumor with any of the following features:

Involves main bronchus, 2 cm or more distal to the carina

Invades visceral pleura (PL1 or PL 2)

Associated with atelectasis or obstructive pneumonitis that extends to
the hilar region, but does not involve the entire lung
T2a = more than 3 cm but 5 cm or less in
greatest dimension
 T2b = Tumor more than 5 cm but 7 cm or less
in greatest dimension

Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas,
2nd Edition. New York: Springer, 2012. ©American Joint Committee on
Cancer
T2 is defined as a tumor more than 3 cm but 7 cm or less or tumor with any of the following features (T2 tumors
with these features are classified T2a if 5 cm or less); involves main bronchus, 2 cm or more distal to the
carina (middle left and middle right); invades visceral pleura (PL1 or PL2) (upper right); associated with
atelectasis or obstructive pneumonitis that extends to the hilar region but does not involve the entire lung
(bottom left). T2a is defined as tumor more than 3 cm but 5 cm or less in greatest dimension (upper left). T2b
is defined as tumor more than 5 cm but 7 cm or less in greatest dimension (bottom right).
Elements of Staging: T3

T3- Tumor more than 7 cm that has any of the
following:
 Parietal pleura (PL3)
 Chest wall (including superior sulcus “pancoast”
tumors, but see T4 as well)
 Diaphragm, Phrenic nerve, Mediastinal pleura, or
Parietal pericardium
 Tumor in main bronchus less than 2 cm distal to
the carina without carina involvement
 Associated atelectasis or obstructive pneumonitis
of the entire lung
 Separate tumor nodules in the same lobe
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas,
2nd Edition. New York: Springer, 2012. ©American Joint Committee on
Cancer
T3 is defined as a tumor more than 7 cm (upper middle left) or one that directly invades any of the
following: parietal pleural (PL3), chest wall (including superior sulcus tumors) (upper left), diaphragm
(lower left), phrenic nerve, mediastinal pleura, parietal pericardium; or tumor in the main bronchus
(less than 2 cm distal to the carina but without involvement of the carina) (lower middle left); or
associated atelectasis or obstructive pneumonitis of the entire lung (right) or separate tumor
nodule(s) in the same lobe.
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas,
2nd Edition. New York: Springer, 2012. ©American Joint Committee on
Cancer
T3 includes separate tumor nodule(s) in the same lobe. T4 includes
separate tumor nodule(s) in a different ipsilateral lobe.
Elements of Staging: T4
T4 is tumor of any size that invades any of the
following:






Mediastinum
Heart
Great vessels
Trachea
Recurrent laryngeal
nerve
Esophagus



Vertebral body
(including extension
from a Pancoast
Tumor)
Carina
Separate tumor
nodules in a different
ipsilateral lobe
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas,
2nd Edition. New York: Springer, 2012. ©American Joint Committee on
Cancer
T4 is defined as tumor of any size that invades any of the following: mediastinum, heart, great vessels
(upper right), trachea (upper left), recurrent laryngeal nerve, esophagus (lower right), vertebral
body (lower left), carina (middle left and right), separate tumor nodule(s) in a different
ipsilateral lobe.
AP Window Nodes are
N2 Nodes
N1 Nodes: Numbers 8 through 11 and including
interlobar (not shown)
N2 Nodes: Numbers 1 through 7
N3 Nodes (not shown): Supraclavicular, scalene, any
node contralateral to primary tumor
Elements of Staging: NX,
N0, and N1
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

Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas,
2nd Edition. New York: Springer, 2012. ©American Joint Committee on
Cancer
Elements of Staging: N2
and N3
N2: Metastasis in ipsilateral mediastinal and/or
subcarinal lymph node(s)
 N3: Metastasis in contralateral mediastinal,
contralateral hilar, ipsilateral or contralateral
scalene, or supraclavicular lymph nodes
 Don’t forget: N3 is DISTANT disease in SEER
Summary Staging

Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas,
2nd Edition. New York: Springer, 2012. ©American Joint Committee on
Cancer
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas,
2nd Edition. New York: Springer, 2012. ©American Joint Committee on
Cancer
Elements of Staging: MX,
M0, and M1

MX: No longer exists in TNM Staging

M0: No distant metastasis (Remember: not possible for pathologic
staging)

M1: Distant Metastasis

M1a includes:




Separate tumor nodule(s) in a contralateral lobe
Tumor with pleural nodules
Malignant pleural or pericardial effusion
M1b- Metastasis in distant organs or lymph nodes
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas,
2nd Edition. New York: Springer, 2012. ©American Joint Committee on
Cancer
Stage Groups
Prognostic Factor: Plueral/Elastic
Layer Invasion
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas,
2nd Edition. New York: Springer, 2012. ©American Joint Committee on
Cancer
A tumor that falls short of completely traversing the elastic layer of the visceral pleura is defined as
PL0. A tumor that extends through the elastic layer is defined as PL1 and one that extends to the
surface of the visceral pleural as PL2. Extension of the tumor to the parietal pleura is
defined as PL3.
Helpful Hints
TNM Staging Scheme DOES NOT match the
SEER Summary Staging Scheme for lung cancer!
 Pages 260 through 262 have a listing of the
different lymph node stations in Japan Lung
Cancer Society Map, MD-ATS Map, and IASLC
Map (now the recommended means of
describing regional node involvement for lung
cancer)
 Additional notes for TNM staging can be found
on page 266 under “Additional Notes
Regarding TNM Descriptors”

Lung Case 1 Answers

Topography: C34.3

Histology: 8041/3

This case is one primary per rule M12
Clinical Staging
Pathological Staging
cT
2a
pT
Blank
cN
2
pN
Blank
cM
1a
pM
Blank
Clinical Stage
Group
IV
Pathologic Stage Blank
Group
SEER Summary Stage: 7- Distant
Lung Case 2 Answers

Topography: C34.3

Histology: 8140/3

This case is one primary per rule M2
Clinical Staging
Pathological Staging
cT
1a
cN
0
cM
0
Clinical Stage
Group
IA
pT
2a
pN
0
pM
cM0
Pathologic Stage Group
IB
SEER Summary Stage: 1 – Local disease