Extent Of Local Tumour Spread

Border: pushing/infiltrative. Lymphocytic reaction: prominent/sparse. Distance to the proximal bronchial limit (mm). Distance to the mediastinal limit (mm). Distance to the pleura (mm).

— visceral pleural invasion is recognized by direct perforation of the mesothelium and also infiltration of the inner elastin layer in the sub-mesothelial plane. Note that the pleura can be distorted without actual true invasion and use of an elastin stain is helpful.

Distance to the pericardium (mm). Mucosa, cartilage plates, parenchyma. Tumour necrosis.

The TNM classification applies to all type of lung carcinoma but not carcinoid tumour.

pTx positive cytology pTis carcinoma in situ pT1 tumour <3 cm diameter, surrounded by lung/visceral pleura and not invasive proximal to a lobar bronchus

Figure 17.1. Lung carcinoma. |W

Atelectasis or obstructive pneumonia

Atelectasis or obstructive pneumonia

Figure 17.2. Lung carcinoma. |W

Tumour > 3 cm diameter or involves main bronchus 2 cm or more distal to carina, or visceral pleura. Partial atelectasis, extending to hilum but not the entire lung pT2

Figure 17.2. Lung carcinoma. |W

pT2 tumour >3cm diameter or involves main bronchus 2 cm or more distal to the carina, or visceral pleura. Partial atelectasis, extending to hilum but not the entire lung pT3 tumour of any size invading any of: chest wall, diaphragm, medi-astinal pleura, parietal pericardium or tumour of main bronchus <2 cm distal to the carina or total lung atelectasis/obstructive pneumonitis pT4 tumour of any size invading the mediastinum, heart, great vessels, trachea, oesophagus, vertebral body, carina, or tumour with pT3

Pleural effusion with negative cytology pT3

Pleural effusion with negative cytology

Atelectasis or obstructive pneumonitis of the entire lung

Tumour of any size directly invading any of: chest wall, diaphragm, mediastinal pleura, parietal pericardium: or, tumour in the main bronchus <2 cm distal to the carcina (but not involving it), or atelectasis/ obstructive pneumonitis of the entire lung

Figure 17.3. Lung carcinoma. |W

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Tumour invading any of: mediastinum, heart, great vessels, trachea, oesophagus, vertebral body, carina. Separate tumour nodule(s) in the same lobe. Tumour with malignant pleural effusion.

Figure 17.4. Lung carcinoma. |W

Figure 17.4. Lung carcinoma. |W

malignant pleural effusion. Separate tumour nodules in the same lobe.

Involvement of parietal pericardium, rib and phrenic nerve are pT3.

Vocal cord paralysis, superior vena cava syndrome, compression of trachea or oesophagus, involvement of visceral pericardium or discontinuous pleural deposits are classified as pT4.

Some 60-75% of lung cancers are incurable at presentation due to extensive local or distant spread with symptoms developing late in the disease course. Spread is by direct extension along the bronchus (proxi-mally and distally), direct into the lung parenchyma and to the mediastinum and pleura when diaphragm and chest wall may be involved. Distant metastases are commonly seen in the liver, lung elsewhere (by lymphovascular or aerogenous spread), adrenals, bone, kidney and CNS (particularly adenocarcinoma). A majority of small cell carcinomas have extensive metastatic spread at the time of diagnosis.

5. LYMPHOVASCULAR INVASION

Present/absent. Intra-/extratumoral.

Common (80%) in lung cancer and along with nodal metastases is an adverse prognostic indicator.

6. LYMPH NODES

Site/number/size/number involved/limit node/extracapsular spread. Regional nodes: intrathoracic, scalene, supraclavicular. A regional lymphadenectomy will ordinarily include a minimum of six lymph nodes and the surgeon will often submit separately dissected and labelled lymph node stations.

pN0 no regional lymph node metastasis pN1 metastasis in ipsilateral peribronchial/hilar/intrapulmonary nodes including involvement by direct extension pN2 metastasis in ipsilateral mediastinal/subcarinal nodes pN3 metastasis in contralateral mediastinal, contralateral hilar, ipsi-/contralateral scalene or supraclavicular nodes. pM1 is distant metastasis and includes separate tumour nodule(s) in a different lobe (ipsilateral or contralateral) or discontinuous tumour in the chest wall or diaphragm.

Peribronchial pN1

Hilar pN1

Peribronchial

Metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodes, including involvement by direct extension

Figure 17.5. Lung carcinoma: regional lymph nodes.

Metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodes, including involvement by direct extension

Figure 17.5. Lung carcinoma: regional lymph nodes.

Cervical, scalene or mediastinal lymph node FNA or biopsy is sometimes used to establish a diagnosis of carcinoma in patients suspected of having a malignancy but in whom bronchial biopsy and cytology are negative, when it represents recurrent disease, or who are medically unfit for invasive procedures.

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