Onno Mets the Robin Smithuis
Department of Radiology, Academic Medical Center, Amsterdam and Alrijne Hospital, Leiderdorp, The Netherlands
date of issue
This is a summary of it8th edition of TNM in lung cancer, which is the staging standard for non-small cell lung cancer as of January 1, 2017.
It is published by the IASLC (International Association for the Study of Lung Cancer) and replaces the 7th edition of the TNM.
TNM-8
TNM-stage staging 8th edition. Changes in version 7 in red.
The eighth edition of the TNM classification for non-small cell lung cancer is shown in the table.
According to previous versions, there are three items that describe the anatomic extent of a tumor: T for the extent of the primary tumor, N for lymph node involvement, and M for metastatic disease.
T classification is done by CT, N and M classification by CT and PET-CT.
It can be used in preoperative imaging and clinical staging of iTNM/cTNM, but is also applicable for final staging of pathologic pTNM, restaging after yTNM treatment, and staging of recurrent rTNM.
Differences compared to the 7th edition are shown in red.
News of the 8th edition of TNM
In the new eighth edition of the TNM, the size has been reduced by several T categories and some new pathology-based categories have been introduced.
In addition, new M categories have been introduced for extrathoracic metastatic disease.
The size of a solid lesion was defined as the largest diameter in any of the three orthogonal planes in the lung window.
In subsolid damage, the T classification is defined by the diameter of the solid component, not the diameter of the entire glass damage.
Lung cancer staging adapted from the 8th edition of TNM in lung cancer
Non-small cell lung cancer stages
Subgroups of the T, N, and M categories are grouped into specific stages because these patients have a similar prognosis [1].
For example, cT1N0 disease (stage IA) has a 5-year survival rate of 77-92%.
At the other end of the spectrum is any M1c (stage IVB) disease that has a 0% five-year survival rate.
Lung cancer with apparent transischial growth in coronary and sagittal reconstruction. Lobectomy is no longer possible.
Lobectomy is generally not possible if there is:
- translational development.
- Pulmonary vascular infiltration.
- Invasion of the main bronchus.
- Involvement of the bronchi of the upper and lower lobes.
These are specific items to report.
Thin-section images and three-layer reconstruction are needed to best show the relationship to surrounding structures.
In case of indeterminate invasion, the multidisciplinary oncology committee must decide whether to consider suspicion, depending on the individual case and comorbidity.
type T
T0
- There is no primary tumor on examination.
They are
- Carcinoma in situ, regardless of size.
This can only be diagnosed after resection of the tumor.
T1 tumor: A typical T1 tumor in the left lower lobe, completely surrounded by lung parenchyma.
T1
Tumor size ≤3cm
- Tumor ≤1cm => T1a
- Tumor >1cm ali ≤2cm =>T1b
- Tumor >2cm ali ≤3cm => T1c
T1a(mi) is a proven "minimally invasive" pathology, regardless of size.
T1a(ss) is also aLittle onessurfaceLittle onesvolume in the central airways, regardless of their location.
T2 tumor: typical T2 tumor with atelectasis of the left lower lobe/tunica pneumonitis due to involvement of the left mainstem bronchus.
T2
- Tumor size >3cm to ≤5cm or
- A volume of any size that
- affects the visceral pleura
- affects the main bronchus, but not the carina
- has atelectasis or obstructive pneumonitis extending to the lip
T2a=>3 by 4cm
T2b= >4 by 5 cm
T3 tumor: A typical T3 tumor in the right upper lobe with invasion of the chest wall.
T3
- Tumor size >5 cm to 7 cm o
- Pancoast affecting only the T1 and T2 thoracic nerve roots.
- A volume of any size that
- affects the chest wall
- affects the pericardium
- attacks the phrenic nerve
- shows one or more satellite nodules in the same lung lobe
T4 tumor: typical T4 tumor in the right upper lobe with mediastinal infiltration.
T4
- Tumor size > 7 cm or
- Global mass involving C8 or superior nerve roots, brachial plexus, subclavian vessels, or spine
- A volume of any size that
- affects mediastinal adipose tissue or mediastinal structures
- involves the diaphragm
- hook the keel
- shows one or more satellite nodules in the second lobe on the ipsilateral side
Pancoast tumor
Pancoast tumor. scroll through images
Pancoast tumor is a tumor of the superior sulcus characterized by pain due to invasion of the brachial plexus, Horner's syndrome, and bone destruction due to invasion of the chest wall.
MRI is better than CT for local staging.
Tumor de Pancoast. (Ljubaznošću Wouter van Es, MD. Hospital St. Antonius Nieuwegein, Nizozemska)
Operable T3 Pancoast tumor on contrast-enhanced T1-weighted sagittal image.
The tumor adjoins the T1 root (white arrow), but no other nerve roots are involved (green arrow).
A = subclavian artery, ASM = anterior scalene muscle.
(Courtesy of Wouter van Es, MD. St. Antonius Hospital Nieuwegein, The Netherlands)
Tumor de Pancoast. (Ljubaznošću Wouter van Es, MD. Hospital St. Antonius Nieuwegein, Nizozemska)
Here, an inoperable T4 Pancoast tumor on a contrast-enhanced T1-weighted sagittal image.
Apparent invasion of the brachial plexus (white arrow) and occlusion of the subclavian artery (A).
ASM = anterior scalene muscle.
N - Staging
Adapted from the American Thoracic Society mapping scheme
Regional lymph node classification system
Determination of the grade of lymph nodes is carried out according to the classification scheme of the American Thoracic Society.
supraclavicular nodules
- 1. Low cervical, supraclavicular, and sternal notch nodes
superior mediastinal nodes
- 2. Paratraqueal superior: above the arch of the aorta, but below the clavicle.
- 3A. Provascalni: nodules that are not next to the trachea like the nodules in station 2, but in front of the blood vessels.
- 3P. prevertebral: the nodes are not next to the trachea, but behind the esophagus, which is prevertebral (3P).
Inferior mediastinal nodes
- 4. Paratraqueal inferior(including azygos nodes) - below the upper edge of the aortic arch to the level of the main bronchus.
aortic node
- 5. subaortic(AP window): lymph nodes lateral to the ligamentum arteriosus. These nodes are not located between the aorta and the pulmonary trunk, but rather lateral to these vessels.
- 6. Paraaortic(ascending or phrenic aorta): nodes located anterior and lateral to the ascending aorta and aortic arch.
Subcarinal nodules
- 7. Subcarinales.
Inferior mediastinal nodes
- 8. Paraesophageal(under the keel).
- 9. Pulmonary Association: ganglia located within the pulmonary ligaments.
lung nodules
- 10-14 (screen, others). n1-nodesThey are outside the mediastinum.
The limit between level 10 and level 4 is on the right the lower border of the azygos vein and on the left the upper border of the pulmonary artery (N1 vs. N2).
An important distinction must be made between level 1 and level 2/3 nodes because they are grades N3 versus N2.
The lower limit of level 1 is the clavicles on both sides, and on the center line the upper limit of the manubrium.
The boundary between levels 4R and 4L is the left lateral border of the trachea, not the anatomical midline.
Paracardial, internal mammary, diaphragmatic, axillary, and intercostal lymph nodes are not depicted on the IALSC lymph node map.
Occasionally there may be.
It is suggested that these non-regional nodes be considered as metastatic disease [2].
Computed tomography is not feasible for determining lymph node staging in patients with NSCLC, regardless of the selected threshold size.
PET-CT is much more reliable in determining the status of N.
False positives are found in patients with sarcoid, tuberculosis, and other infections.
Due to its high negative predictive value, PET should be performed in all patients being considered for surgery.
T2 tumor (> 3 cm) in the right lower lobe with ipsilateral iliac node (N1)
N1 - Nodes
N1 nodes are ipsilateral nodules within the lungs to the atrial nodes.
N1 changes the prognosis but not the management.
Disease N2: tumor on the right side with ipsilateral mediastinal nodes
N2 - Nodes
N2 nodules represent ipsilateral mediastinal or subcarinal lymphadenopathy.
There is only a subgroup of patients with N2 disease who benefit from resection.
These are patients who, after a negative mediastinoscopy, were found to have microscopic metastatic disease at the time of thoracotomy.
These patients have a better prognosis than those with overt N2 disease.
Stage N3 disease.
N3 - Nodos
N3 nodes represent contralateral mediastinal or contralateral iliac lymphadenopathy, ie, scalene or supraclavicular nodes.
These are inoperable.
Two patients with N3 disease.
The images show two patients with lung cancer in the right and contralateral nodes.
If these lymph nodes contain tumor cells, it means inoperable stage IIIB disease.
N3 nodes on the contralateral side and in the supraclavicular region. Scroll through the images.
N3 - Nodos
N3 nodes represent contralateral mediastinal or contralateral iliac lymphadenopathy or any splenic or supraclavicular node.
These are inoperable.
For a tumor in the right lung, the N stages are:
N1
Ipsilateral peribronchial and/or iliac lymph nodes 10R-14R
N2
Ipsilateral mediastinal and/or subcarinal lymph nodes 2R, 3aR, 3p, 4R, 7, 8R, 9R
N3
Bilateral mediastinal and/or iliac and any supraclavicular lymph nodes 1, 2L, 3aL, 4L, 5, 6, 8L, 9L, 10L-14L
For a tumor in the left lung, the N stages are:
N1
Ipsilateral peribronchial and/or iliac lymph nodes 10L-14L
N2
Ipsilateral mediastinal and/or subcarinal lymph nodes 2L, 3aL, 4L, 5, 6, 7, 8L, 9L
N3
Bilateral mediastinal and/or iliac and any supraclavicular lymph nodes 1, 2R, 3aR, 3pR, 4R, 8R, 9R, 10-14R
M-Staging
Almost any organ can be involved in metastatic disease.
The adrenal glands, ganglia, brain, bones, and liver are often affected.
The M staging in the current version is based on the presence of metastases, their location and number.
A distinction is made between regional metastatic disease (M1a) and distant single (M1b) or multiple (M1c) metastatic disease:
- M0: No distant metastases
- M1: distant metastasis
- M1a: Regional metastatic disease defined as malignant pleural or pericardial effusion/nodules, as well as contralateral or bilateral pulmonary nodules.
- M1b:solitary extrathoracic metastasis
- M1c:Multiple extrathoracic metastases, either in one organ or in several organs
FAQs
How do you write TNM Classification? ›
The TNM staging system stands for Tumour, Node, Metastasis. The system uses letters and numbers to describe the cancer. So for example a small cancer that has spread to the lymph nodes but not to anywhere else in the body may be T2 N1 M0. Or a more advanced cancer that has spread may be T4 N3 M1.
What is TNM Classification M1? ›M1: Cancer has spread to other parts of the body.
What does TNM Classification stand for? ›The abbreviation “TNM” stands for tumor (T), nodes (N), and metastases (M).
How do you classify the tumor based on the TNM stage classification? ›Each individual aspect of TNM is termed as a category: T category describes the primary tumour site and size. N category describes the regional lymph node involvement. M category describes the presence or otherwise of distant metastatic spread.
How do I remember TNM staging? ›- Tx: Tumor can not be assessed. ...
- T0: No evidence of primary tumor. ...
- Tis: Carcinoma in situ. ...
- T1: Tumor ≤ 2 cm in greatest dimension. ...
- T1a: Tumor > 0.1 cm but ≤ 0.5 cm in greatest dimension. ...
- T2:Tumor > 2 cm but ≤ 5 cm in greatest dimension.
T2 means the tumour has grown into the muscle layer of the bowel wall. T3 means the tumour has grown into the outer lining of the bowel wall but has not grown through it.
What is M0 vs M1 staging? ›M0 and M1. There are 2 stages of metastasis – M0 and M1. M0 means the cancer hasn't spread to another lobe of the lung or any other part of the body. M1 means the cancer has spread to other areas of the body.
What does M0 mean in the TNM Classification system? ›Metastasis (M) describes whether the cancer has spread to a different part of the body. M0 means that there is no sign that the cancer has spread.
What is M0 in TNM? ›The "M" in the TNM system describes cancer that has spread to other parts of the body, such as the liver or lungs. This is called metastasis. M0 (M zero): The disease has not spread to a distant part of the body. M1a: The cancer has spread to 1 other part of the body beyond the colon or rectum.
What does stage 4 mean? ›Stage IV. This stage means that the cancer has spread to other organs or parts of the body. It may be also called advanced or metastatic cancer.
What is pas code 8? ›
Assign code 8:
• Clinical diagnosis only, other than 5, 6 or 7. • The physician makes a clinical diagnosis based on the information from the equivocal tests and the patient's clinical presentation (history and physical exam).
Grade 3 and stage 3 cancer are not the same. Staging and grading cancer use different criteria to evaluate treatment options. Staging is an important factor in determining cancer treatment options, since it establishes the tumor's size and spread within the body.
What is the TNM scoring system? ›A system to describe the amount and spread of cancer in a patient's body, using TNM. T describes the size of the tumor and any spread of cancer into nearby tissue; N describes spread of cancer to nearby lymph nodes; and M describes metastasis (spread of cancer to other parts of the body).
How many stages are there in TNM staging? ›Stage I means the cancer is small and only in one area. This is also called early-stage cancer. Stage II and III mean the cancer is larger and has grown into nearby tissues or lymph nodes. Stage IV means the cancer has spread to other parts of your body.
What is the difference between staging and grading in TNM? ›Doctors use the stage and grade of breast cancer to help them decide which treatment you need. Staging means how big the cancer is and whether it has spread. Grading means how abnormal the cancer cells look under a microscope.
What stage is a 2 cm tumor? ›Stage IA: The tumor is up to 2 centimeters (cm). It has not spread to the lymph nodes (T1, N0, M0).
What size tumor is considered large? ›T1a tumors are over 1 mm and no more than 5 mm in diameter. T1b tumors are over 5 mm and no more than 10 mm in diameter. T1c tumors are greater than 10 millimeters and no more than 20 millimeters. The tumor is larger than 20 millimeters (2 centimeters) and no more than 50 millimeters (5 centimeters).
When did TNM staging start? ›Developed in France in the 1940s by Pierre Denoix, the TNM classification has become the accepted basis of cancer staging.
What stage is T2 N1 M0? ›Stage IIB: Either of these conditions: The tumor is larger than 20 mm but not larger than 50 mm and has spread to 1 to 3 axillary lymph nodes (T2, N1, M0).
What is NX in TNM staging? ›Nx means that there is no information about nearby lymph nodes. N0 means that the cancer hasn't spread to nearby lymph nodes. N1 means the cancer has spread to nearby lymph nodes.
What stage is t3 n1 M0? ›
For example your diagnosis may be 'T3N1M0'. This means the cancer has grown into the outer lining of the bowel to up to three nearby lymph nodes, but has not spread to other parts of the body.
Does M1 mean metastasis? ›Metastasis (M) describes whether the cancer has spread to a different part of the body. There are 2 stages of metastasis – M0 and M1: M0 means the cancer hasn't spread to another part of the body. M1 means the cancer has spread to another part of the body.
What does M0 M1 and M2 mean? ›The smallest and most liquid measure, M0, is strictly currency in circulation plus commercial bank reserve balances at Federal Reserve Banks; M0 is often referred to as the "monetary base." M1 is defined as the sum of currency in circulation, demand deposits at commercial banks, and other liquid deposits; it is often ...
What does M0 mean that metastasis Cannot be evaluated in TNM tumour staging system? ›Metastasis (M)
M0 means that there is no sign that the cancer has spread. , or lymph nodes far away from the breast. The cells are found by laboratory tests. cM1 means the cancer has spread to another part of the body.
TNM staging system
T describes the size of the tumour, with numbers 1 to 4 (1 for small, 4 for large) N stands for lymph nodes, with numbers 0 to 3 (0 means no lymph nodes have cancer, 3 means many do)
Stage 4 is the most severe stage of cancer. Metastatic cancer is another name for this stage. It conveys that the cancer has metastasized — spread to distant areas of the body. Cancer is a group of diseases that cause rapid cell growth.
What stage 5 means? ›Stage 5 means the construction stage, which is to manage, administer and monitor the construction contracts and processes, including the preparation and co-ordination of the procedures and documentation to facilitate practical completion of the works.
How long can you live on stage 4? ›Stage 4 cancer is a serious disease that requires immediate expert care. Patients may live for years following treatment for stage 4 cancer.
What is PAS code 9? ›Code 9 indicates cell type not determined, not stated, or not applicable.
What is a Level 3 biopsy? ›Grade 1 or well-differentiated: Cells appear normal and are not growing rapidly. Grade 2 or moderately-differentiated: Cells appear slightly different than normal. Grade 3 or poorly differentiated: Cells appear abnormal and tend to grow and spread more aggressively.
What are PAS codes? ›
PAS-Code is an exclusively academic application founded on the clinical, scientific, and modern technology premise to support healthcare and enable scientific data retrieval using efficient mobile-based tools.
What does Stage 1 Grade 3 mean? ›Stage I through Stage III are for cancers that haven't spread beyond the primary tumor site or have only spread to nearby tissue. The higher the stage number, the larger the tumor and the more it has spread. Stage IV cancer has spread to distant areas of the body.
What stage is 3a? ›Stage III non-small cell lung cancer is divided into stages IIIA, IIIB, and IIIC. In stage IIIA, the tumor is 5 centimeters or smaller and cancer has spread to lymph nodes on the same side of the chest as the primary tumor.
What does Grade 2 tumor mean? ›Grade 2 – the cells don't look like normal cells and are growing more quickly than normal (intermediate grade) Grade 3 – the cancer cells look very abnormal and are growing quickly (high grade) Some systems have more than 3 grades. GX means that doctors can't assess the grade. It is also called undetermined grade.
What does N1 mean in TNM? ›In colorectal cancer, N1 indicates the involvement of 1-3 regional nodes. N2 can be 4-6 regional nodes, while N3 indicates 7+ regional nodes involved. Nx is used when lymph nodes are unable to be assessed. M - Metastasis. Used to identify the presence of distant metastases of the primary tumor.
What is TNM Classification radiopaedia? ›TNM systematically describes the extent of malignancies - primarily on their anatomy - and categorises each malignancy by the status of the primary tumour (T), nodal involvement (N) and metastatic disease (M).
How does tumor grading work? ›Tumor grade describes how normal or abnormal cancer cells look under a microscope. The more normal the cells look, the less aggressive the cancer and the more slowly it grows and spreads. On the other hand, the more abnormal the cells look, the more aggressive the cancer and the faster it is likely to grow and spread.
What is the seer stage? ›Surveillance, Epidemiology and End Results (SEER) - Program of the National Cancer Institute that collects and publishes cancer incidence and survival data from 19 population-based cancer registries. Stage at diagnosis - The extent of disease spread from the organ of origin at time of diagnosis.
What are the 4 stages of carcinogenesis? ›Carcinogenesis can be divided conceptually into four steps: tumor initiation, tumor promotion, malignant conversion, and tumor progression (Figure 17-1). The distinction between initiation and promotion was recognized through studies involving both viruses and chemical carcinogens.
What is the classification of a malignant tumor? ›TMN. The TNM Classification of Malignant Tumors (TNM) is a globally recognised standard for classifying the extent of spread of cancer. It is a classification system of the anatomical extent of tumor cancers and is used in classifying malignant tumors mostly.
What is TNM Classification tumor size? ›
Using the TNM system, the “T” plus a letter or number (0 to 4) is used to describe the size and location of the tumor. Tumor size is measured in centimeters (cm). A centimeter is roughly equal to the width of a standard pen or pencil.
What category is a tumor of 7cm in size staged as in the TNM staging of lung tumors? ›| T classification | T components on CT | |
|---|---|---|
| T1 | T1c | >2–3 cm solid tumor |
| T2 | T2a | 3.1–4 cm |
| T2b | 4.1–5 cm | |
| T3 | 5.1–7 cm |