| I. Staging Process
A. Histology
- small cell vs.. non-small cell
B. Sputum
1. 20- 70% sensitive, but tumor location plays a significant
role
2. histology is predictive of yield, i.e. squamous is more often
positive followed by adenocarcinoma, and finally small cell
3. when cytology is positive it predicts the cell type with
85% accuracy
C. Bronchoscopy
1. direct visualization or positive biopsy in 25-50% of patients
with lung cancer
D. Fine needle aspiration
1. percutaneous or transbronchial
2. 84-95% accurate with peripheral lesions
E. VATS
F. Thoracotomy
II. Staging Classification
A. International Staging System for Non- Small Cell Carcinoma
1. T Primary Tumor
Tx - positive cytology only
To - no evidence of tumor
Tis - carcinoma in situ
T1 - size < 3 cm
no pleural
invasion
distal
to lobar bronchus
T2 - size > 3 cm
any size
invading the visceral pleura
associated
atelectesis or pneumonitis to the hilum
>2 cm
from the carina
T3 - any size with chest wall, diaphragm, mediastinal
pleura, or pericardium, (i.e. locally metastatic to resectable ipsilateral
hemithorax)
< 2 cm from the
carina
T4 - invasion of the mediastinum, heart, great vessels,
vertebral body, esophagus, or carina
2. N Nodal Involvement
N0 - no nodes
N1 - peribronchial or ipsilateral hilar
N2 - ipsilateral mediastinum or subcarinal
N3 - any contralateral node
ipsilateral
supraclavicular or scalene nodes
3. M Distant Metastasis
Mo - no mets
M1 - distant mets
B. Small Cell Carcinoma
1. localized - disease of the ipsilateral hemithorax including
the supraclavicular nodes and a positive pleural effusion
2. extensive - disease beyond the ipsilateral hemithorax
III. Clinical Presentation
A. Sputum
1. bronchopulmonary
2. extrapulmonary intrathoracic
3. extrapulmonary metastatic
4. extra pulmonary nonmetastatic ( i.e. paraneoplastic)
a. carcinomatous neuromyopathy is the most common paraneoplastic syndrome
with 15% of patients with lung cancer affected
1) mysthenia gravis - like syndrome
2) polymyositis
b. Cushing's - small cell
c. SIADH - small cell
d. hypercalcemia - squamous
e. gynecomastia - small cell
f. Gonadotropin - undifferentiated large cell
B. Signs
1. clubbing is the most common
2. Hypertrophic pulmonary osteoarthropathy
a. periosteal elevation at the ends of long bones
b. 2-12% of all lung cancer patients
c. not seen in small cell
C. Tumor Makers/ Oncogenes
1. generally not help for diagnosing lung cancer
V. Diagnostic Evaluation
A. CXR
- CXR findings proceed symptoms by 7 months
- sensitive to 1 cm
- nodule most common finding
1. squamous
a. obstructive pneumonitis
b. collapse
c. consolidation
d. 1/3 are peripheral
e. 20% have cavitation
2. adenocarcinoma
a. peripheral
b. < 3 cm
c. bronchoalveolar have parenchymal changes
3. Large cell (undifferentiated)
1. 60% are peripheral
2. 2/3 > 4 cm
4. small cell
1. 80% hilar abnormalities
2. 2/5 associated parenchymal changes
B. Other Studies
1. CT
a. best for evaluating the mediastinal adenopathy and
adrenals
b. chest wall invasion is poorly seen
c. paraesophageal and inferior pulmonary nodes not well
seen
d. nodes < 1 cm have a 7% chance of being malignant
e. nodes > 1 cm have a 55-65% chance of being malignant
2. MRI
a. better than CT at evaluating vascular invasion and
chest wall invasion esp. superior sulcus
3. Ultrasound
a. ? TEE for evaluating mediastinal adenopathy
4. PET
a. may help determine malignant vs. benign peripheral
nodules
5. Bone Scan
a. helpful in stage IIIA and IIIB disease
VI. Lymph Nodes
A. Biopsy
1. biopsy palpable neck nodes
2. mediastinoscopy is controversial
B. FNA
1. 85-95% sensitive
C. VATS
1. good for evaluating aortopulmonary window
VII. Completion of Staging
-25% of patients worked up will be resectible
-25% will have stage IIIB
-50% will have stage IV
VIII. Posthoracotomy provides the definitive stage and should be the
basis of treatment plans
IX. Functional Status
A. Associated with prohibitive operative risk
1. FEV1 < 40%
2. Predicted postop FEV1 < 30%
3. MVV < 45-50%
4. DLCO < 40%
5. PCO2 > 45 mmHg
6. peak VO2 < 10 ml/kg |
