C H A P T E R 2 6
Cancer of the Lung
CHAPTER OUTLINE
Anatomic Alterations of the Lungs
Etiology and Epidemiology
Types of Cancers
Non–Small Cell Lung Carcinoma Small Cell Lung Carcinoma Other Types of Lung Tumors
Screening and Diagnosis
Staging of Non–Small Cell Lung Carcinoma Staging of Small Cell Lung Carcinoma
Overview of Cardiopulmonary Clinical Manifestations Associated With Cancer of the Lung
General Management of Lung Cancer
Treatment Options for Non–Small Cell Lung Cancer Treatment Options for Small Cell Lung Cancer
Case Study: Cancer of the Lung Self-Assessment Questions
CHAPTER OBJECTIVES
After reading this chapter, you will be able to:
•List the anatomic alterations of the lungs associated with lung cancer.
•Describe the causes of lung cancer.
•List the cardiopulmonary clinical manifestations associated with lung cancer.
•Describe the general management of lung cancer.
•Describe the clinical strategies and rationales of the SOAPs presented in the case study.
•Define key terms and complete self-assessment questions at the end of the chapter and on Evolve.
KEY TERMS
Adenocarcinoma
Aerosolized Morphine
Benign Tumors
Brachytherapy
Bronchogenic Carcinoma
Chemotherapy
Cigarette Smoking
Coin Lesion
End-of-Life Directives
Endobronchial Ultrasound (EBUS)
External Beam Radiation Therapy (EBRT)
Five-Year Survival Rate
Large Cell Carcinoma (Undifferentiated)
Lobectomy
Malignant Tumors
Malignant Pleural Effusion
Mediastinoscopy
Mesothelioma
Metastatic Cancer of the Lungs
Navigational Bronchoscopy
Neoplasm
Non–Small Cell Lung Carcinoma (NSCLC)
Pack-Years
PET/CT Imaging
Pneumonectomy
Positron Emission Tomography (PET) Lung Scan
Radiation Therapy
Radiofrequency Ablation (RFA)
Segmentectomy
Sleeve Resection
Small Cell (Oat Cell) Carcinoma
Small Cell Lung Carcinoma (SCLC)
Smoking Cessation Education
Squamous Cell (Epidermoid) Carcinoma
Staging of Lung Cancer
Stereotactic Body Radiation Therapy (SBRT)
Stereotactic Radiosurgery (SRS)
Video-Assisted Thoracic Surgery (VATS)
Wedge Resection
Anatomic Alterations of the Lungs
Cancer is a general term that refers to abnormal new tissue growth characterized by the progressive, uncontrolled multiplication of cells. This abnormal growth of new cells is called a neoplasm or tumor. A tumor may be localized or invasive, benign or malignant.
Benign tumors do not endanger life unless they interfere with the normal functions of other organs or affect a vital organ. They grow slowly and push aside normal tissue but do not invade it. Benign tumors are usually encapsulated, welldemarcated growths. They are not invasive or metastatic; that is, tumor cells do not travel by way of the bloodstream or lymphatics and invade or form secondary tumors in other organs.
Malignant tumors are composed of embryonic, primitive, or poorly differentiated cells. They grow in a disorganized manner and so rapidly that nutrition of the cells becomes a problem. For this reason, necrosis, ulceration, and cavity formation are commonly associated with malignant tumors. They also invade surrounding tissues and may be metastatic. Although malignant changes may develop in any portion of the lung, they most commonly originate in the epithelium of the tracheobronchial tree.
A tumor that originates in the bronchial mucosa is called bronchogenic carcinoma. The terms lung cancer and bronchogenic carcinoma are used interchangeably. As a tumor enlarges, the surrounding bronchial airways and alveoli become irritated, inflamed, and swollen. The adjacent alveoli may fill with fluid or become consolidated or collapse. In addition, as the tumor protrudes into the tracheobronchial tree, excessive mucus production and airway obstruction develop. As the surrounding blood vessels erode, blood enters the tracheobronchial tree causing hemoptysis. Peripheral tumors may also invade the pleural space and impinge on the mediastinum, chest wall, ribs, or diaphragm. A secondary pleural effusion is often seen in lung cancer. A pleural effusion further compresses the lung and causes atelectasis.
The major pathologic or structural changes associated with bronchogenic carcinoma are as follows:
•Inflammation, swelling, and destruction of the bronchial airways and alveoli
•Excessive mucus production
•Tracheobronchial mucus accumulation and plugging
•Airway obstruction (from blood, mucus accumulation, or a tumor projecting into a bronchus)
•Atelectasis
•Alveolar consolidation
•Cavity formation
•Pleural effusion (when a tumor invades the parietal pleura and mediastinum)
Etiology and Epidemiology
Lung cancer is the second most common cause of cancer in both men (prostate is first in men) and women (breast cancer is first in women). About 14% of all new cancers are lung cancer. In 2017 the American Cancer Society (ACS) reported that there were about 222,500 new cases of lung cancer (116,990 in men and 105,510 in women) and about 155,870 deaths from lung cancer (84,590 in men and 71,280 in women). Lung cancer is the leading cause of cancer deaths, accounting for about 1 in 4 cancer deaths. More people die from lung cancer deaths each year than from colon, breast, and prostate cancers combined. About 2 in 3 people diagnosed with lung cancer are 65 years or older. The average age at the time of diagnosis is about 70 years. Black men are about 20% more likely to develop lung cancer than white men. The rate is about 10% lower in black women than in white women. Risk factors for lung cancer include the following:
• Cigarette smoking1 is the most common cause of lung cancer. Although various studies and professional organizations report slightly different numbers, all figures are grim. Heavy smokers are 64 times more likely to develop lung cancer. According to the ACS, about 80% of lung cancer deaths are thought to be caused by smoking. The longer one smokes and the more packs a day (pack-years)2, the greater the risk is for developing lung cancer. Smoking low-tar or “light” cigarettes generates the same risk for lung cancer as regular cigarettes. In addition, smoking menthol cigarettes likely increases the risk for lung cancer even more because the
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menthol allows the smoker to inhale more deeply. Cigar smoking and pipe smoking are almost as likely to cause lung cancer. They are also commonly associated with cancer of the lip, mouth, and throat. Secondhand smoke can increase the risk for developing lung cancer. According to the ACS, secondhand smoke is thought to cause more than 7000 deaths from lung cancer each year.
•Radon exposure is the second leading cause of lung cancer in this country according to the US Environmental Protection Agency (EPA). Radon is a naturally occurring radioactive gas that is produced from the breakdown of uranium in the soil and rocks. Breathing radon increases the risk for lung cancer. Outdoors, radon is not likely to be dangerous. Indoors, however, radon can be more concentrated and, therefore, the risk for lung cancer increases.
•Exposure to other cancer-causing agents:
•Asbestos (e.g., in mines, mills, textile plants, insulation, and shipyards) exposure constitutes risk for developing mesothelioma, a cancer that starts in the pleura
•Radioactive ores (such as uranium)
•Inhaled chemicals or minerals (e.g., arsenic, beryllium, cadmium, silica, vinyl chloride, nickel compounds, chromium compounds, coal products, mustard gas, and chloromethyl ethers)
•Diesel exhaust
•Air pollution (especially near heavily trafficked roads)
•Arsenic in drinking water
•Radiation therapy to lungs (e.g., individuals who have had radiation therapy to the chest for other cancers, such as radiation after a mastectomy for breast cancer, are at higher risk for lung cancer)
•Personal or family history of lung cancer
Types of Cancers
As shown in Fig. 26.1, bronchogenic carcinomas can be divided into the following two major categories: non–small cell lung carcinoma (NSCLC) and small cell lung carcinoma (SCLC). The NSCLC category is further subdivided into the following three types of lung cancer: (1) squamous cell carcinoma, (2) adenocarcinoma (including bronchial alveolar cell carcinoma), and (3) large cell carcinoma. The SCLC category is composed of small cell carcinoma (also called oat cell carcinoma), or combined small cell carcinoma, or a mixture of SCLC and NSCLC.
FIGURE 26.1 Types of lung cancer.
Each type of lung cancer grows and spreads in a different way. For example, SCLC spreads aggressively and responds best to chemotherapy and radiation therapy. SCLC occurs almost exclusively in smokers and accounts for 15% to 20% of all lung cancers in the United States. NSCLCs are more common and account for 75% to 85% of all lung cancers in the United States. When confined to a small area and identified early, NSCLCs often can be removed surgically. Table 26.1 provides general characteristics of these cancer cell types, including growth rates, metastasis, and means of diagnosis. A more in-depth description of each cancer cell type follows.
TABLE 26.1
Characteristics of Lung Cancers
Tumor Type |
Growth |
Metastasis |
Means of Diagnosis |
Clinical Manifestations and |
|
Rate |
|
|
Treatment |
Non–Small Cell Lung Carcinoma (NSCLC) |
|
|
Squamous cell |
Slow |
Late; mostly to |
Biopsy, sputum analysis, |
Cough, sputum production, |
carcinoma |
|
hilar lymph |
bronchoscopy, electron microscopy, |
airway obstruction; treated |
|
|
nodes |
immunohistochemistry |
surgically, chemotherapy |
|
|
|
|
adjunctive |
Adenocarcinoma |
Moderate |
Early |
Radiography, fiberoptic bronchoscopy, |
Pleural effusion; treated |
|
|
|
electron microscopy |
surgically, chemotherapy |
|
|
|
|
adjunctive |
Large cell |
Rapid |
Early and |
Sputum analysis, bronchoscopy, |
Chest wall pain, pleural effusion, |
carcinoma |
|
widespread |
electron microscopy (by exclusion |
cough, sputum production, |
|
|
|
of other cell types) |
hemoptysis, airway |
|
|
|
|
obstruction resulting in |
|
|
|
|
pneumonia (if airways |
|
|
|
|
involved); treated surgically |
Small Cell Lung Carcinoma (SCLC) |
|
|
Small cell (oat |
Very rapid |
Very early; to |
Radiography, sputum analysis, |
Airway obstruction, signs and |
cell) |
|
mediastinum |
bronchoscopy, electron microscopy, |
symptoms of excessive |
carcinoma |
|
or distally in |
immunohistochemistry, and clinical |
hormone secretion; treated by |
|
|
lung |
manifestations (cough, chest pain, |
chemotherapy and ionizing |
|
|
|
dyspnea, hemoptysis, localized |
radiation to thorax and central |
|
|
|
wheezing) |
nervous system |
Non–Small Cell Lung Carcinoma
According to the ACS, non–small cell cancer is the most common type of lung cancer. About 85% of all lung cancers are non–small cell cancers. Subtypes of NSCLC are squamous cell carcinoma, adenocarcinoma, and large cell carcinoma (see Fig. 26.1).
Squamous Cell Carcinoma
Squamous cell (epidermoid) carcinoma constitutes about 25% to 30% of the bronchogenic carcinomas. The incidence of this type of cancer has sharply declined over the past two decades. This type of tumor is commonly located near a central bronchus or hilus and projects into the large bronchi. Squamous cell tumors are often seen projecting into the bronchi during bronchoscopy. The tumor originates from the basal cells of the bronchial epithelium and grows through the epithelium before invading the surrounding tissues.
The tumor has a slow growth rate and a late metastatic tendency (mostly to hilar lymph nodes). These tumors generally remain fairly well localized and tend not to metastasize until late in the course of lung cancer. Cavitation and necrosis within the center of the cancer are common findings. Surgical resection is the preferred treatment if metastasis has not taken place. Chemotherapy has limited effectiveness. In about one-third of cases, squamous cell carcinoma originates in the periphery. Because of the location in the central bronchi, obstructive manifestations are generally nonspecific and include a nonproductive cough and hemoptysis. Pneumonia and atelectasis are often secondary complications of squamous cell carcinoma. Cavity formation with or without an air-fluid interface is seen in 10% to 20% of cases (Fig. 26.2A).
FIGURE 26.2 Cancer of the lung. (A) Squamous cell carcinoma. (B) Adenocarcinoma. (C) Large cell carcinoma. (D) Small cell (oat cell) carcinoma.
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Adenocarcinoma
Adenocarcinoma (previously called bronchioloalveolar carcinoma) arises from the mucous glands of the tracheobronchial tree. In fact, the glandular configuration and mucous production caused by this type of cancer are the pathologic features that distinguish adenocarcinoma from the other types of bronchogenic carcinoma. Adenocarcinoma accounts for about 40% of all bronchogenic carcinomas. It has the weakest association with smoking. Among people who have never smoked, adenocarcinoma is the most common form of lung cancer.
Adenocarcinoma tumors are usually smaller than 4 cm and are most commonly found in the peripheral regions of the lung parenchyma. The growth rate is moderate, and the metastatic tendency is early. Secondary cavity formation and pleural effusion are common (see Fig. 26.2B). When the cancer is discovered early, surgical resection is possible in a high percentage of cases. These tumors typically arise from the terminal bronchioles and alveoli. They have a slow growth rate, and their metastasis pattern is unpredictable.
Large Cell Carcinoma (Undifferentiated)
Large cell carcinoma (undifferentiated) accounts for about 10% to 15% of all bronchogenic carcinoma cases. Because this tumor has lost all evidence of differentiation, it is commonly referred to as undifferentiated large cell anaplastic cancer. Although these tumors commonly arise peripherally, they also may be found centrally and often distort the trachea and large airways. Large cell carcinoma has a rapid growth rate and early and widespread metastasis. Common secondary complications include chest wall pain, pleural effusion, pneumonia, hemoptysis, and cavity formation (see Fig. 26.2C).
Small Cell Lung Carcinoma
Small cell (oat cell) carcinoma accounts for about 10% to 15% of all bronchogenic carcinomas. Most of these tumors arise centrally near the hilar region. They tend to arise in the larger airways (primary and secondary bronchi). Cell size ranges from 6 to 8 µm. The tumor grows very rapidly, becoming very large, and metastasizes early. Because the tumor cells are often compressed into an oval shape, this form of cancer is commonly referred to as oat cell carcinoma. Small cell carcinoma has the poorest prognosis. The average survival time for untreated small cell carcinoma is about 1 to 3 months. About 90% of patients respond to treatment (e.g., chemotherapy, radiation, or both), but nearly all relapse within 24 months. Small cell carcinoma has the strongest correlation with cigarette smoking and is associated with the worst prognosis (see Fig. 26.2D).
Other Types of Lung Tumors
In addition to the two main types of lung cancer discussed previously (i.e., SCLC and NSCLC), the following types of lung cancer can occur:
•Lung carcinoid tumor (also called lung carcinoids): A type of cancer that starts in the lungs. Lung carcinoid tumors are uncommon and tend to grow slower than other types of lung cancers. Lung carcinoid tumors are made up of special types of cells called neuroendocrine cells. Lung carcinoids account for about 1% to 2% of all lung cancers. Most carcinoid tumors originate in the digestive tract; only about 30% of all carcinoid tumors start in the lungs. There are four types of neuroendocrine lung tumors:
•Small cell lung cancer: The fastest growing and spreading of all cancers.
•Large cell neuroendocrine carcinoma: A rare cancer and a subtype of NSCLC.
•Typical carcinoids: Tend to grow slowly and rarely spread beyond the lungs. About 90% of lung carcinoids are typical carcinoids.
•Atypical carcinoids: Grow a little faster and are likely to spread outside of the lungs.
Carcinoids also may be classified based on where they are found in the lungs. For example:
•Central carcinoids are found in the walls of large bronchi near the center of the lungs. The majority of lung carcinoid tumors are central carcinoids and are also typical carcinoids.
•Peripheral carcinoids are found in the smaller bronchioles toward the periphery of lungs. Most peripheral carcinoids are typical carcinoids, although they are more likely than central carcinoids to be atypical.
•Additional lung tumors: For example, adenoid cystic carcinoma, lymphoma, sarcoma, and benign lung tumors (e.g., hamartomas) are rare.
•Cancers that spread to the lungs: Cancer that begins in other parts of the body, such as breast, pancreas, kidney, or skin, can metastasize to the lungs. However, it is important to point out that cancers that start in other organs and spread to the lungs are not lung cancer. For example, cancer that starts in the breast and metastasizes to the lungs is still breast cancer. The treatment for metastatic cancer of the lungs is based on where the cancer originated—that is, the primary cancer site.
Screening and Diagnosis
Unfortunately, most lung cancers are not diagnosed until after the patient presents with symptoms that suggest lung cancer. Symptoms associated with lung cancer include (1) a progressively worsening cough that often includes bloody or rust-colored sputum; (2) chest pain, especially with deep breathing, coughing, or laughing; (3) hoarse voice; (4) poor appetite and weight loss; (5) shortness of breath; (6) fatigue; (7) frequent bronchial infections or pneumonia episodes; and
(8) the sudden onset of wheezing.
When lung cancer spreads to other parts of the body, the patient may have other symptoms of cancer that include bone pain (e.g., back or hips), neurologic problems (e.g., headache, arm and leg weakness or numbness, dizziness or balance problems, seizures), jaundice, and enlarged lymph nodes (e.g., mediastinum, neck, or axillae). In addition, the patient may demonstrate a group of very specific syndromes associated with lung cancer, such as the following:
•Horner syndrome: Caused by a tumor near the apex of the lung that damages the nerve that passes from the upper chest to the neck; causing drooping or weakness of one eyelid, small pupil in the same eye, and reduced or no perspiration on the same side of the face.
•Superior vena cava syndrome: Caused by a tumor near the upper portion of the right lung
that compresses the superior vena cava and obstructs venous blood flow. This condition causes headaches, dizziness, and swelling in the face, neck, arms, and upper chest, sometimes with a bluish-red skin color.
• Paraneoplastic syndromes: These are the indirect effects of a variety of tumors that occur distant to the tumor or metastatic site. These tumors produce active proteins, polypeptides, or hormone-like substances that enter the bloodstream and cause problems distant from the tumor. Common paraneoplastic syndromes caused by NSCLC include (1) high blood calcium levels (hypercalcemia), (2) excess growth of certain bones (e.g., fingertips), and (3) blood clots.
When symptoms are present that suggest lung cancer, a full medical history and physical examination, along with a check for risk factors, are indicated. When the results of these activities further support the possibility of lung cancer, additional diagnostic tests are ordered—for example, imaging tests and tissue sampling techniques.
Table 26.2 provides an overview of the common screening and diagnostic tests for lung cancer. The primary goal of these diagnostic procedures is to (1) confirm the presence of a lung carcinoma, (2) establish the cancer cell type, and (3) confirm the stage of the cancer. The definitive diagnosis of lung cancer is made by a microscopic examination of a tissue sample (biopsy).
TABLE 26.2
Screening and Diagnostic Tests for Lung Cancer
Technique Description
Imaging for Lung Cancer
Imaging is performed to (1) identify suspicious areas of the lungs that might be cancerous, (2) determine if and where the cancer may have spread, (3) evaluate the effectiveness of treatment, and (4) assess signs that a cancer has returned after a treatment program.
Chest radiograph |
The chest x-ray is often the first test used to determine if there are any masses or spots on the |
|
lungs. If any suspicious areas are identified, one or more of the following imaging methods |
|
are ordered. |
Computed tomography |
The CT scan better identifies a lung tumor than a routine chest x-ray. It also provides excellent |
(CT) scan |
information about the size, shape, and location of the tumor. It can help identify enlarged |
|
lymph nodes that might contain cancer cells. |
Positron emission |
The PET scan is used to help determine if an abnormal area on the chest x-ray film or CT scan |
tomography (PET) |
might be cancer. It helps assess if the cancer has spread to nearby lymph nodes or other |
scan |
areas of the body, which helps determine if surgery is an option. |
Magnetic resonance |
The MRI scan may be used to determine if the cancer cells have spread from the lungs to the |
imaging (MRI) scan |
brain or spinal cord. |
Bone scan |
The bone scan can help determine if the cancer has spread to the bones. Because the PET scan |
|
can usually identify if cancer has spread to the bones, the bone scan is now primarily ordered |
|
only when the patient has bone pain symptoms. |
Diagnostic Tests for Lung Cancer
Identifying cancer cells under a microscope makes the actual diagnosis of lung cancer. The cells can be obtained from sputum samples, taken from a suspicious area (biopsy), or removed from pleural fluid (thoracentesis).
Sputum cytology |
A sputum sample is obtained and viewed under the microscope to determine if it contains any |
|
cancer cells. |
Bronchoscopy |
A bronchoscope is commonly used to visually evaluate the tracheobronchial tree of the patient. |
Needle biopsy |
In addition, small instruments can easily be passed down the bronchoscope to obtain tissue |
Bronchial brushing |
biopsies via needle aspiration, bronchial brushing, or bronchial washing. The tissue and cell |
Bronchial washing |
samples are then evaluated under a microscope. |
Navigational |
Navigational bronchoscopy is a diagnostic and treatment procedure that combines |
bronchoscopy (also |
electromagnetic navigation with real-time virtual three-dimensional (3-D) CT imaging that |
called |
allows the physician to reach distal tumors, take a biopsy sample, and administer treatment |
electromagnetic |
(see Fig. 9.5). |
navigation |
|
bronchoscopy) |
|
Endobronchial |
EBUS may be performed during a bronchoscopy to view lymph nodes and other structures in the |
ultrasound (EBUS) |
mediastinum area. EBUS also may be used for a needle biopsy. Tissue samples are viewed |
|
under the microscope. EBUS may provide sufficient information to stage a cancer without |
|
other more invasive procedures such as mediastinoscopy, thoracoscopy, or thoracotomy. |
Endoscopic |
Similar to EBUS, the endoscopic esophageal ultrasound can be passed into the esophagus and |
esophageal |
directed to view lymph nodes and other structures in the chest that appear suspicious for |
ultrasound |
cancer. When enlarged lymph nodes are identified, a biopsy needle can pass through the |
|
endoscope to obtain a tissue sample. |
Mediastinoscopy and |
These procedures are performed to view a suspicious area more directly and obtain a tissue |
mediastinotomy |
sample. They are performed in the operating room while the patient is under general |
|
anesthesia. Mediastinoscopy entails a small incision in the front of the neck, which allows a |
|
thin, hollow, lighted tube to be inserted behind the sternum and in front of the trachea. Tissue |
|
samples can be obtained from the lymph nodes along the trachea and major bronchi. |
|
Mediastinotomy entails a slightly larger incision (about 2 inches) between the left second and |
|
third ribs adjacent to the sternum. This permits the surgeon to reach some lymph nodes that |
|
cannot be reached by mediastinoscopy. |
Thoracentesis |
Thoracentesis is used to obtain fluid that accumulates (pleural effusion) between the chest wall |
|
and the lungs. Thoracentesis entails the insertion of a needle between the ribs to aspirate the |
|
fluid (and possible cancer cells) for microscopic study. |
Video-assisted thoracic VATS may be performed to determine if the cancer has spread to the intrapleural space. It also surgery (VATS) can be used to obtain tissue biopsy samples on the outer surface of the lungs, nearby lymph
nodes, and fluid. It may help assess if a tumor is growing into nearby organs or tissues.
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Because VATS is performed in the operating room under general anesthesia, it is not often done just to diagnose cancer unless other procedures have been unsuccessful in obtaining a tissue sample.
Analysis of Tissue Biopsy Samples
The tissue samples obtained from one of the above procedures may be used for additional tests to help better classify the cancer.
Immunohistochemistry |
This test entails treating the tissue sample with certain antibodies designed to attach only to |
|
specific substances found in certain cancer cells. |
Molecular tests |
In some cases, the identification of specific gene changes in the cancer cells may help pinpoint |
|
certain targeted drugs that might be effective in treating the cancer. |
Complete blood count |
Although blood tests are not used to diagnose lung cancer, they are useful in assessing the |
(CBC) |
overall health of the patient and, in some cases, to determine if the patient is healthy enough |
|
for surgery. In addition, a CBC is repeated regularly in patients being treated with |
|
chemotherapy, which often affects blood-forming cells of the bone marrow. Also, when a |
|
cancer has spread to the liver and bones, it may cause abnormal levels of certain chemicals in |
|
the blood (e.g., higher than normal level of lactate dehydrogenase). |
The treatment and prognosis of any cancer depend, to a large extent, on the stage of the cancer. The staging of NSCLC and small cell lung carcinoma is discussed in more detail as follows.
Staging of Non–Small Cell Lung Carcinoma
The most commonly used classification tool to stage NSCLC is the American Joint Committee on Cancer (AJCC) TNM system (Table 26.3). The staging of lung cancer is determined by a combination of all of the following factors:
TABLE 26.3
The American Joint Committee on Cancer Tumor, Node, Metastasis Staging System for Lung Cancer
TNM Description
Category
Primary Tumor (T)
TX |
The main (primary) tumor cannot be assessed, or cancer cells were seen on sputum cytology or bronchial |
|
washing but no tumor can be found. |
T0 |
There is no evidence of a primary tumor. |
Tis |
The cancer is found only in the top layers of cells lining the air passages. It has not invaded into deeper |
|
lung tissues. This is also known as carcinoma in situ. |
T1 |
The tumor is no larger than 3 cm—slightly less than 1.25 inches—across, has not reached the membranes |
|
that surround the lungs (visceral pleura), and does not affect the main branches of the bronchi. |
|
If the tumor is 2 cm (about 0.8 of an inch) or less across, it is called T1a. If the tumor is larger than 2 cm |
|
but not larger than 3 cm across, it is called T1b. |
T2 |
The tumor has one or more of the following features: |
|
• It is larger than 3 cm across but not larger than 7 cm. |
|
• It involves a main bronchus, but is not closer than 2 cm (about 0.75 of an inch) to the carina (the point |
|
where the windpipe splits into the left and right main bronchi). |
|
• It has grown into the membranes that surround the lungs (visceral pleura). |
|
The tumor partially clogs the airways, but this has not caused the entire lung to collapse or develop |
|
pneumonia. |
T2a |
Tumor >3 cm but ≤5 cm |
T2b |
Tumor >5 cm but ≤7 cm |
T3 |
The tumor has one or more of the following features: |
•It is larger than 7 cm across.
•It has grown into the chest wall, the breathing muscle that separates the chest from the abdomen (diaphragm), the membranes surrounding the space between the two lungs (mediastinal pleura), or membranes of the sac surrounding the heart (parietal pericardium).
•It invades a main bronchus and is closer than 2 cm (about 0.75 of an inch) to the carina, but it does not involve the carina itself.
•It has grown into the airways enough to cause an entire lung to collapse or to cause pneumonia in the entire lung.
•Two or more separate tumor nodules are present in the same lobe of a lung.
T4 |
The cancer has one or more of the following features: |
•A tumor of any size has grown into the space between the lungs (mediastinum), the heart, the large blood vessels near the heart (e.g., the aorta), the windpipe (trachea), the tube connecting the throat to the stomach (esophagus), the spine, or the carina.
•Two or more separate tumor nodules are present in different lobes of the same lung.
Regional Lymph Nodes (N)
NX |
Nearby lymph nodes cannot be assessed. |
|
|
N0 |
There is no spread to nearby lymph nodes. |
N1 |
The cancer has spread to lymph nodes within the lung and/or around the area where the bronchus enters |
|
the lung (hilar lymph nodes). Affected lymph nodes are on the same side as the primary tumor. |
N2 |
The cancer has spread to lymph nodes around the carina (the point where the windpipe splits into the left |
|
and right bronchi) or in the space between the lungs (mediastinum). Affected lymph nodes are on the |
|
same side as the primary tumor. |
N3 |
The cancer has spread to lymph nodes near the clavicle on either side, and/or spread to hilar or mediastinal |
|
lymph nodes on the side opposite the primary tumor. |
Distant Metastasis (M) |
|
|
M0 |
No spread to distant organs or areas. This includes the other lung, lymph nodes further away than those |
|
mentioned in the N stages above, and other organs or tissues such as the liver, bones, or brain. |
M1a |
Any of the following: |
|
• The cancer has spread to the other lung. |
|
• Cancer cells are found in the pleural fluid (called malignant pleural effusion). |
|
• Cancer cells are found in the fluid around the heart (called malignant pericardial effusion). |
M1b |
The cancer has spread to distant lymph nodes or to other organs such as the liver, bones, or brain. |
Modified from the American Cancer Society, http://www.cancer.org.
•T: Represents the size and location of the primary tumor
•N: Denotes the regional lymph node involvement
•M: Signifies the extent of metastasis (e.g., common sites are the brain, bones, adrenal glands, liver, kidneys, and other lung)
The numbers and letters after the T, N, and M classification provide more information about each of these factors. Higher numbers represent increased severity. Once the T, N, and M categories have been established, the information is grouped together to determine the overall stage grouping of the patient's lung cancer (see explanation later).
Stage Grouping for Lung Cancer
Stages 0, I, II, III, and IV are used to identify the overall stage of the lung cancer, with stage 0 and stage I being the least advanced and stage IV the most advanced. Some stages are subdivided into A and B. This process is called stage grouping. The lower the stage the better the prognosis. Table 26.4 provides an overview of the stage grouping for lung cancer.
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TABLE 26.4
Stage Groupings: Tumor, Node, Metastasis Subsets
After the T, N, and M categories have been established, the information is merged together to assign an overall stage of 0, I, II, III, or IV.
Stage Grouping |
TNM |
Description |
|
Subsets |
|
Occult (hidden) |
TX, NO, |
Cancer cells are found in sputum or other lung fluids, but the cancer is not |
cancer |
MO |
identified in other tests; thus the location cannot be established. |
Stage 0 |
Tis, NO, |
Cancer found only in the top layers of cells lining the airways. It has not invaded |
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MO |
deeper into other lung tissue and has not spread to lymph nodes or distant sites. |
Stage IA |
T1a-T1b, |
The cancer is no larger than 3 cm across, has not reached the membranes that |
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NO, MO |
surround the lungs, and does not affect the main branches of the bronchi. It has |
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not spread to lymph nodes or distant sites. |
Stage IB |
T2a, N0, |
The cancer has one or more of the following features: |
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M0 |
• The main tumor is larger than 3 cm across but not larger than 5 cm. |
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• The tumor has grown into a main bronchus, but is not within 2 cm of the carina |
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(and it is not larger than 5 cm). |
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• The tumor has grown into the visceral pleura (the membranes surrounding the |
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lungs) and is not larger than 5 cm. |
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• The tumor is partially obstructing the airways (and is not larger than 5 cm). |
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The cancer has not spread to lymph nodes or distant sites. |
Stage IIA |
T1a/T1b, |
The cancer is no larger than 3 cm across, has not grown into the membranes that |
(Three main |
N1, M0 |
surround the lungs, and does not affect the main branches of the bronchi. It has |
combinations |
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spread to lymph nodes within the lung and/or around the area where the bronchus |
of categories |
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enters the lung (hilar lymph nodes). These lymph nodes are on the same side as |
make up this |
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the cancer. It has not spread to distant sites. |
stage.) |
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T2a, N1, |
The cancer has one or more of the following features: |
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M0 |
• The main tumor is larger than 3 cm across but not larger than 5 cm. |
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• The tumor has grown into a main bronchus but is not within 2 cm of the carina |
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(and it is not larger than 5 cm). |
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• The tumor has grown into the visceral pleura (the membranes surrounding the |
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lungs) and is not larger than 5 cm. |
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• The tumor is partially obstructing the airways (and is not larger than 5 cm). |
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The cancer has also spread to lymph nodes within the lung and/or around the area |
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where the bronchus enters the lung (hilar lymph nodes). These lymph nodes are |
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on the same side as the cancer. It has not spread to distant sites. |
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T2b, N0, |
The cancer has one or more of the following features: |
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M0 |
• The main tumor is larger than 5 cm across but not larger than 7 cm. |
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• The tumor has grown into a main bronchus, but is not within 2 cm of the carina |
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(and it is between 5 and 7 cm across). |
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• The tumor has grown into the visceral pleura (the membranes surrounding the |
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lungs) and is between 5 and 7 cm across. |
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• The tumor is partially obstructing the airways (and is between 5 and 7 cm |
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across). |
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The cancer has not spread to lymph nodes or distant sites. |
Stage IIB |
T2b, N1, |
The cancer has one or more of the following features: |
(Two |
MO |
• The main tumor is larger than 5 cm across but not larger than 7 cm. |
combinations |
|
• The tumor has grown into a main bronchus, but is not within 2 cm of the carina |
of categories |
|
(and it is between 5 and 7 cm across). |
make up this |
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• The tumor has grown into the visceral pleura (the membranes surrounding the |
stage.) |
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lungs) and is between 5 and 7 cm across. |
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• The cancer is partially obstructing the airways (and is between 5 and 7 cm |
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across). |
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It has also spread to lymph nodes within the lung and/or around the area where the |
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bronchus enters the lung (hilar lymph nodes). These lymph nodes are on the same |
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side as the cancer. It has not spread to distant sites. |
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T3, N0, M0 |
The main tumor has one or more of the following features: |
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• It is larger than 7 cm across. |
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• It has grown into the chest wall, the breathing muscle that separates the chest |
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from the abdomen (diaphragm), the membranes surrounding the space between |
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the lungs (mediastinal pleura), or membranes of the sac surrounding the heart |
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(parietal pericardium). |
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• It invades a main bronchus and is closer than 2 cm (about 0.75 of an inch) to the |
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carina, but it does not involve the carina itself. |
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• It has grown into the airways enough to cause an entire lung to collapse or to |
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cause pneumonia in the entire lung. |
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• Two or more separate tumor nodules are present in the same lobe of a lung. |
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The cancer has not spread to lymph nodes or distant sites. |
Stage IIIA |
T1 to T3, |
The main tumor can be any size. It has not grown into the space between the lungs |
(Three main |
N2, M0 |
(mediastinum), the heart, the large blood vessels near the heart (such as the |
combinations |
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aorta), the windpipe (trachea), the tube connecting the throat to the stomach |
of categories |
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(esophagus), the spine, or the carina. It has not spread to different lobes of the |
make up this |
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same lung. |
stage.) |
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The cancer has spread to lymph nodes around the carina (the point where the |
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windpipe splits into the left and right bronchi) or in the space between the lungs |
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(mediastinum). These lymph nodes are on the same side as the main lung tumor. |
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The cancer has not spread to distant sites. |
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T3, N1, M0 |
The cancer has one or more of the following features: |
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