Jaime Palomino, MD
Pulmonary, Critical Care Medicine
Tulane University
Lung Cancer - Staging
 Objectives/Content
 7th Edition staging system NSCLC
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LN anatomy
TNM classification
 SCLC
 Staging work up
 Staging of mediastinum
 Pleural mesothelioma
TNM Staging – Lung CA
 Initial proposal by Dr. Clifton Mountain
 AJCC 1973, UICC 1974
 2155 patients from MD Anderson
 Last revision 1997
 5319 patients
Lung Cancer – Staging 6th ed.
Lababede O et al. CHEST 1999;115:233-35
Lung Cancer Staging. 7th Edition.
TNM Classification
Staging Manual In Thoracic Oncology. IASLC. 2009
Lung Cancer – Staging 7th ed.
Goldstraw P et al. J Thorac Oncol 2007;2:706-714
Lung Cancer Staging. 7th Edition. Nodal Chart
Staging Manual In Thoracic Oncology
IASLC. 2009
Staging Manual In Thoracic Oncology
IASLC. 2009
Staging Manual In Thoracic Oncology
IASLC. 2009
Staging Manual In Thoracic Oncology
IASLC. 2009
Staging Manual In Thoracic Oncology
IASLC. 2009
Staging Manual In Thoracic Oncology
IASLC. 2009
Staging Manual In Thoracic Oncology
IASLC. 2009
Lung Cancer Staging. 7th Edition.
T1
Staging Manual In Thoracic Oncology
IASLC. 2009
Lung Cancer Staging. 7th Edition.
T2
Staging Manual In Thoracic Oncology
IASLC. 2009
Lung Cancer Staging. 7th Edition.
T3
Staging Manual In Thoracic Oncology
IASLC. 2009
Lung Cancer Staging. 7th Edition.
T4
Staging Manual In Thoracic Oncology
IASLC. 2009
Lung Cancer Staging. 7th Edition.
N0, N1
Staging Manual In Thoracic Oncology
IASLC. 2009
Lung Cancer Staging. 7th Edition.
N2
Staging Manual In Thoracic Oncology
IASLC. 2009
Lung Cancer Staging. 7th Edition.
N3
Staging Manual In Thoracic Oncology
IASLC. 2009
Lung Cancer Staging. 7th Edition.
M1a
Staging Manual In Thoracic Oncology
IASLC. 2009
Lung Cancer Staging. 7th Edition.
M1b
Staging Manual In Thoracic Oncology
IASLC. 2009
Lung Cancer Staging. 7th Edition.
TNM Classification
Clinical Stage
Pathologic Stage
Detterbeck et al. CHEST 2009;136:260-271
Lung Cancer Staging. 7th Edition.
Stage 0, I
Detterbeck et al. CHEST 2009;136:260-271
Lung Cancer Staging. 7th Edition.
Stage II
Detterbeck et al. CHEST 2009;136:260-271
Lung Cancer Staging. 7th Edition.
Stage III
Detterbeck et al. CHEST 2009;136:260-271
Lung Cancer Staging. 7th Edition.
Stage IV
Detterbeck et al. CHEST 2009;136:260-271
Lung Cancer Staging. 7th Edition.
TNM Classification
Staging Manual In Thoracic Oncology. IASLC. 2009
Lung Cancer Staging. 7th Edition.
TNM Classification
Detterbeck et al. CHEST 2009;136:260-271
Lung Cancer – Staging 7th ed.
Goldstraw P et al. J Thorac Oncol 2007;2:706-714
Lung Cancer Staging. SCLC
 Limited Disease
 No detectable disease outside of hemithorax
 With or without ipsilateral or contralateral, hilar,
mediastinal, or supraclavicular LN involvement
 Unilateral pleural effusion
 Single radiation therapy port
 Extensive Disease
 Any disease occurring beyond sites of limited disease
Lung Cancer Staging. 7th Edition.
SCLC
Shepherd et al. J Thorac Oncol. 2007;2:1067-1077
Lung Cancer Staging. 7th Edition.
SCLC
Vallieres et al. J Thorac Oncol. 2009;4:1049-1059
Lung Cancer Staging
 Staging work up
 History & PE (ECOG score)
 CT chest with contrast down to adrenal glands
 Whole body CT-PET
 Brain imaging
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MRI, CT head with contrast
Neurological symptoms
SCLC
Stage III and above
Adenocarcinoma?
 Bone Scan + Abdominal CT (if CT-PET not available)
 Full PFTs (Spirometry, DLCO)
Sampling Of The Mediastinum
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ACCP Lung Cancer Practice Guidelines 2007
Mediastinal LN biopsy indications:
 LN ≥ 1cm regardless PET results (1B)
 Abnormal PET in mediastinum (1B)
 Central tumor or N1 disease (2C)
 Non-malignant result from needle techniques should be
confirmed by mediastinoscopy (1C)
Detterbeck et al. CHEST 2007;132:202S-220S
Sampling Of The Mediastinum


Mediastinoscopy  Gold standard
Minimally Invasive
 TBNA
 EBUS – FNA
 EUS - FNA
Gomez et al. Proc Am Thorac Soc 2009;6:180-186
TBNA – Sampling Of The Mediastinum
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
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Sensitivity:
 15 - 85%
Meta-analysis:
 Sensitivity 39%
 Dependence on lung cancer prevalence
 ROSE increases yield
Underutilized (1997)
 10% fellows  routinely
 40% fellows  occasionally
 20% practicing pulmonologists
El Bayoumi et al. SRCCM 2008;29:261-270
Haponik et al. CHEST 1997;112:251-253
Rafanan et al. SRCC 2000;21:405-420
EUS/FNA – Sampling Of The Mediastinum
EUS/FNA – Sampling Of The Mediastinum
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Mediastinal approach from esophagus
Stations 3, 4L, 7, 8 and 9
Left adrenal gland
Left lobe of liver
Sensitivity:
 72 – 100%
Specificity:
 88 – 100%
El Bayoumi et al. SRCCM 2008;29:261-270
EBUS – Linear (Convex) Probe
El Bayoumi et al. SRCCM 2008;29:261-270
EBUS – Linear (Convex) Probe
Yasufuku et al. CHEST 2004;126:122-128
EBUS – Linear Probe
Gomez et al. Proc Am Thorac Soc 2009;6:180-186
EBUS/TBNA – Sampling Of The Mediastinum

Linear (convex) Probe
 Real time visualization and sampling
 Depth 5cm
 LN stations 8,9,6, and 5 are not accessible
 8 and 9  EUS
 5 and 6  Left median sternotomy (Chamberlain
procedure)
 Sensitivity 92 – 94%
 Specificity 100%
 Maximum diagnostic values are achieved with three
aspirations per LN station
Herth et al. Eur Respir J 2006;28:910-914
Lee et al. CHEST 2008;134:368-374
EBUS/TBNA – Sampling Of The Mediastinum
Shulman et al. Curr Opin Pulm Med 2007;13:271-277
Gomez et al. Proc Am Thorac Soc 2009;6:180-186
EBUS + EUS LN FNA
Wallace et al. JAMA 2008;299:540-546
Gomez et al. Proc Am Thorac Soc 2009;6:180-186
Pleural Mesothelioma Staging. 7th Edition.
TNM Classification
Staging Manual In Thoracic Oncology. IASLC. 2009
Pleural Mesothelioma Staging. 7th Edition.
TNM Classification
Staging Manual In Thoracic Oncology. IASLC. 2009