Lung Cancer Staging Explained Clearly by

well welcome to another MedCram lecture
at med cram comm good to talk about lung cancer staging so once you’ve made a
diagnosis of lung cancer there’s two major types of lung cancer the first one
that you should know is something called non-small cell lung cancer and what are
the types of non-small cell lung cancer you’ve got squamous you’ve got
adenocarcinoma and you’ve got large cell now another type of adenocarcinoma is
known as bronchial alveolar carcinoma which name has recently changed to an O
carcinoma in situ typically looks like ground glass opacification squamous cell
carcinoma it’s your p63 positive cytokeratin five
and six positive usually has hypercalcemia typically at the later
stages if that’s the case it’s going to be positive for the parathyroid
hormone-related peptide which is a paraneoplastic syndrome for small cell
which is the second type so not non-small-cell but small cell lung
carcinoma this is the small blue cell or oat cell as it used to be called and it
can have a paraneoplastic syndrome of various different things it could be
eaten Lambert syndrome you could have a SIADH or even a Cushing syndrome type
and so these two are very different the small cell lung carcinoma typically is
more aggressive than non small cell lung carcinoma is not as aggressive in some
cases you can even cure these if they’re found early enough so the way that we’re
going to talk about this is usually the something called the T or the tumor the
N or the node and the EM stage now these combined to give you your overall stage
which will determine the treatment for lung cancer so the T stands for tumor or
tumor size the n is how many nodes are positive and the M is if there are
metastases and where the metastases are you can use the T mmm
for small cell lung carcinoma but it’s actually not as useful typically we use
something called limited or extensive staging we can talk about that in
another lecture where the T and an M staging is used almost exclusively is in
a non small cell lung carcinoma so that’s what we’re going to talk about is
the staging for non small cell lung carcinoma and the reason why this is
important is because there are different treatments for each of the overall
stages so I don’t want you to get confused there is a T stage there is an
end stage and there is an M stage and then we put those all together and we
come up with a total stage and so the question is how does that happen well I
want to explain that to you because it is a somewhat complex way of doing it
and you always wonder well how do they come up with the overall stage from a T
and an M staging so let’s get into that what we have here is the T stages so
there’s a t1 a a t1 b a t2 a at e2 b and a t3 and finally a t4 that is combined
with n 0 through n 3 stages has to do the lymph nodes and then finally there
is a m0 m1 a and an m1 B and those will give us our stages so the first thing I
want to do is I want to talk a little bit about the T stages and now the T
stages have to do with the actual tumor itself so generally speaking a t1 a is
any tumor that is less than 2 centimeters in size a t1 b is anything
that is 2 to 3 centimeters inclusive i put a underline there a t2 a would be
anything from 3 to 5 centimeters a t2 B would be 5 to 7 centimeters a t3 is 7
plus centimeters and by the way these are inclusive here and then finally a t4
is anything that is large it involves the mediastinum
so if you have invasion of the mediastinum structures of the beanie
Steinem for instance the trachea or the esophagus and sometimes there are
multiple different things that are going to be included and so you always pick
the worst okay now there are other things that can give you a t2 a or a t
to be for instance if and these are sort of combined here so I’m going to erase
this little dividing line okay because this would put it into a t2 stage
anything that is greater than two centimeters from the karana
remember what the corona is it is where the trachea divides into the two main
stem bronchi so if there’s a main stem bronchi tumor if it is greater than two
centimeters from the Carina it could fit into the t2 stage anything that causes a
lobe to collapse okay as opposed to a whole lung to collapse or anything that
causes a lobe or anything that involves the visceral pleura
now that’s opposed to anything that is less than 2 centimeters from the karana
which would be at t3 anything that causes a lung to collapse or anything
that involves the parietal pleura okay visceral pleura parietal pleura now
there is one more thing that could give you a three and I’ll put it up here and
kind of pink so you can see it but if you have two nodules in the same lobe
obviously in the same lung what could give you a t4 is if you have two nodules
in different lobes of the same lung okay so for instance if you had a nodule that
you found or cancer that you found in the right upper lobe and in the right
lower lobe they would be two nodules that are different
Loubs but in the same law that would get you into a t4 regardless of how big they
were however if you had two nodules that were in the right upper lobe they would
be in the same lobe same lung that would get you to a t3 okay so we’re looking
for the worst combination if you had complete collapse of the right lung that
would get you a t3 because you have complete lung collapse if you had
something involving the chest wall that is the parietal pleura that would get
you a t3 so the first thing you need to do whenever you see a tumor is figure
out what T level it’s going to be once you figure out what T level it is then
the next thing you need to do is you need to figure out what the N level is
so n o means that there are no nodes involved so you can find that out early
by looking at a CT scan to see if there are enlarged lymph nodes you can
somewhat confirm that by getting a PET scan to see if those nodes light up or
not but if it makes the difference between surgery or no surgery you really
want to confirm that with either a mediastinum skippy which is more
invasive or which is less invasive would be EBUS okay
that’s endoscopic bronchial ultrasound where you actually go down there and
take a sample with a needle so if you have a tumor on the right side and you
see no nodes so no EPSA lateral lymph nodes mediastinal lymph nodes so coronal
lymph nodes then you would get an n zero which is very good if you however you
had hilar lymph adenopathy and these are going to be double digit numbers if they
tell you it’s lymph node number 12 L that means on the left side it would be
the 12 lymph node anything with double digits is gonna get you out into the
hilum which is pretty peripheral and if that’s involved that would be an n1 if
on the other hand you are talking about mediastinal lymph nodes so not hilar but
mediastinal that would be an N – those are just typically single digit and that
would also include sub coronal okay sub coronal lymph nodes so
mediastinal or sub coronal lymph nodes is going to be an N – typically single
digit lymph nodes and three would be back again – double digit but it would
be contralateral so this is not good this would be where you have a
right-sided tumor but a left-sided lymph node that is lighting up that would be
an n3 so that would be a hilar lymph node on the other side could also be
double digits okay and then mo would be no metastasis anywhere else okay
so no mats so the default would be zero there’s two situations that would get
you an m1 a number one if you had a malignant pleural effusion so if you did
a thoracentesis and sent the cells off or cytology and they were positive that
would give you a malignant pleural effusion you would be at a stage m1 a
another way is if you had two nodules in different lungs so again if you have two
nodules in the same lobe right upper lobe that would be a t3 if you had two
nodules in the same lung but different lobes that would be a t4 if you have two
nodules in different lungs so right upper lobe left lower lobe for instance
that would give you a m1 a and m1 B would be anywhere outside of the chest
and I’ll just say that if you meet the criteria unfortunately for m1 a or an m1
B that’s an automatic stage for we’re going to write these stages in Roman
numerals so regardless of your N or T if you meet any of these criteria you’re
automatically at stage 4 so that’s important because if you’ve got a
patient with a malignant pleural effusion that automatically puts them at
a stage m one-a which automatically gives them a stage 4 okay so let’s go
through these stages so the first stage that you’re
going to have is overall stage 1a and that’s going to be here
1 a and 1 a this would be 1 B and that’s where it would end the next stage you
would have is 2a and 2b down here you would have 2a 2a and 2a this would be 2
B this would be 3 a this would be 3 a and this also would be 3a all of these
down here are 3 A’s except for one this one here is 3b and of course all of
these along here are also 3b join us for the next video when I talk
about how to remember this and the mnemonics and the treatments for all of
these stages thanks for joining us and join us at med cram com you