Key Points for This Section

After lung cancer has been diagnosed, tests are done to find out if cancer cells have spread within the lungs or to other parts of the body. There are three ways that cancer spreads in the body. The following stages are used for non-small cell lung cancer: Occult (hidden) stage Stage 0 (Carcinoma in Situ) Stage I Stage II Stage IIIA Stage IIIB Stage IV

After lung cancer has been diagnosed, tests are done to find out if cancer cells have spread within the lungs or to other parts of the body.

The process used to find out if cancer has spread within the lungs or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. Some of the tests used to diagnose non-small cell lung cancer are also used to stage the disease. (See the General Information section.) Other tests and procedures that may be used in the staging process include the following:

• Laboratory tests: Medical procedures that test samples of tissue, blood, urine, or other substances in the body. These tests help to diagnose disease, plan and check treatment, or monitor the disease over time.
• MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body, such as the brain. This procedure is also called nuclear magnetic resonance imaging (NMRI).
• Radionuclide bone scan: A procedure to check if there are rapidly dividing cells, such as cancer cells, in the bone. A very small amount of radioactive material is injected into a vein and travels through the bloodstream. The radioactive material collects in the bones and is detected by a scanner.
• Endoscopic ultrasound (EUS): A procedure in which an endoscope is inserted into the body. An endoscope is a thin, tube-like instrument with a light and a lens for viewing. A probe at the end of the endoscope is used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. This procedure is also called endosonography. EUS may be used to guide fine needle aspiration (FNA) biopsy of the lung, lymph nodes, or other areas.

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  Endoscopic ultrasound-guided fine-needle aspiration biopsy. An endoscope that has an ultrasound probe and a biopsy needle is inserted through the mouth and into the esophagus. The probe bounces sound waves off body tissues to make echoes that form a sonogram (computer picture) of the lymph nodes near the esophagus. The sonogram helps the doctor see where to place the biopsy needle to remove tissue from the lymph nodes. This tissue is checked under a microscope for signs of cancer.

• Lymph node biopsy: The removal of all or part of a lymph node. A pathologist views the tissue under a microscope to look for cancer cells.
• Mediastinoscopy: A surgical procedure to look at the organs, tissues, and lymph nodes between the lungs for abnormal areas. An incision (cut) is made at the top of the breastbone and a mediastinoscope is inserted into the chest. A mediastinoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue or lymph node samples, which are checked under a microscope for signs of cancer.

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  Mediastinoscopy. A mediastinoscope is inserted into the chest through an incision above the breastbone to look for abnormal areas between the lungs. A mediastinoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a cutting tool. Tissue samples may be taken from lymph nodes on the right side of the chest and checked under a microscope for signs of cancer. In an anterior mediastinotomy (Chamberlain procedure), the incision is made beside the breastbone to remove tissue samples from the lymph nodes on the left side of the chest.

• Anterior mediastinotomy: A surgical procedure to look at the organs and tissues between the lungs and between the breastbone and heart for abnormal areas. An incision (cut) is made next to the breastbone and a mediastinoscope is inserted into the chest. A mediastinoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue or lymph node samples, which are checked under a microscope for signs of cancer. This is also called the Chamberlain procedure.

There are three ways that cancer spreads in the body.

The three ways that cancer spreads in the body are:

• Through tissue. Cancer invades the surrounding normal tissue.
• Through the lymph system. Cancer invades the lymph system and travels through the lymph vessels to other places in the body.
• Through the blood. Cancer invades the veins and capillaries and travels through the blood to other places in the body.

When cancer cells break away from the primary (original) tumor and travel through the lymph or blood to other places in the body, another (secondary) tumor may form. This process is called metastasis. The secondary (metastatic) tumor is the same type of cancer as the primary tumor. For example, if breast cancer spreads to the bones, the cancer cells in the bones are actually breast cancer cells. The disease is metastatic breast cancer, not bone cancer.

The following stages are used for non-small cell lung cancer:

Occult (hidden) stage

In the occult (hidden) stage, cancer cells are found in sputum (mucus coughed up from the lungs), but no tumor can be found in the lung by imaging or bronchoscopy, or the primary tumor is too small to be checked.

Stage 0 (Carcinoma in Situ)

In stage 0, abnormal cells are found in the innermost lining of the lung. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ.

Stage I

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Stage I non-small cell lung cancer. In stage IA, cancer is in the lung only. In stage IB, the cancer may do one or more of the following: (a) grow larger in the lung, (b) spread to the main bronchus of the lung, (c) spread to the innermost layer of the pleura that covers the lungs.

In stage I, cancer has formed. Stage I is divided into stages IA and IB:

• Stage IA: The tumor is in the lung only and is 3 centimeters or smaller.
• Stage IB: One or more of the following is true:
  • The tumor is larger than 3 centimeters.
  • Cancer has spread to the main bronchus of the lung, and is at least 2 centimeters from the carina (where the trachea joins the bronchi).
  • Cancer has spread to the innermost layer of the membrane that covers the lungs.
  • The tumor partly blocks the bronchus or bronchioles and part of the lung has collapsed or developed pneumonitis (inflammation of the lung).

Stage II

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Stage II non-small cell lung cancer. In stage IIA, cancer has spread to lymph nodes on the same side of the chest as the cancer. In stage IIB, cancer is either the same as in stage IB and has also spread to lymph nodes on the same side of the chest; or cancer has not spread to lymph nodes but has spread to one or more of the following: (a) the chest wall, (b) the diaphragm, (c) the pleura between the lungs, (d) the membrane around the heart, and/or (e) the main bronchus.

Stage II is divided into stages IIA and IIB:

• Stage IIA: The tumor is 3 centimeters or smaller and cancer has spread to nearby lymph nodes on the same side of the chest as the tumor.
• Stage IIB:
  • Cancer has spread to nearby lymph nodes on the same side of the chest as the tumor and one or more of the following is true:
    • The tumor is larger than 3 centimeters.
    • Cancer has spread to the main bronchus of the lung and is 2 centimeters or more from the carina (where the trachea joins the bronchi).
    • Cancer has spread to the innermost layer of the membrane that covers the lungs.
    • The tumor partly blocks the bronchus or bronchioles and part of the lung has collapsed or developed pneumonitis (inflammation of the lung).

    or

  • Cancer has not spread to lymph nodes and one or more of the following is true:
    • The tumor may be any size and cancer has spread to the chest wall, or the diaphragm, or the pleura between the lungs, or membranes surrounding the heart.
    • Cancer has spread to the main bronchus of the lung and is no more than 2 centimeters from the carina (where the trachea meets the bronchi), but has not spread to the trachea.
    • Cancer blocks the bronchus or bronchioles and the whole lung has collapsed or developed pneumonitis (inflammation of the lung).

Stage IIIA

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Stage IIIA non-small cell lung cancer. The cancer has spread to the lymph nodes on the same side of the chest as the cancer. It may also spread to one or more of the following: (a) the main bronchus, (b) the chest wall, (c) the diaphragm, (d) the pleura between the lungs, and/or (e) the pericardium (membrane around the heart).

In stage IIIA, cancer has spread to lymph nodes on the same side of the chest as the tumor. Also:

• The tumor may be any size.
• Cancer may have spread to the main bronchus, the chest wall, the diaphragm, the pleura around the lungs, or the membrane around the heart, but has not spread to the trachea.
• Part or all of the lung may have collapsed or developed pneumonitis (inflammation of the lung).

Stage IIIB

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Stage IIIB non-small cell lung cancer. The cancer has spread to (a) lymph nodes above the collarbone or lymph nodes on the opposite side of the chest from the cancer, and/or it may also spread to one or more of the following: (b) the heart, (c) the inferior vena cava and the aorta, (d) the chest wall, (e) the diaphragm, (f) the trachea, and (g) the sternum or esophagus. Cancer may also spread to the fluid between the pleura (thin layers of tissue lining the lungs and chest cavity).

In stage IIIB, the tumor may be any size and has spread:

• To lymph nodes above the collarbone or in the opposite side of the chest from the tumor; and/or
• To any of the following:
  • Heart.
  • Major blood vessels that lead to or from the heart.
  • Chest wall.
  • Diaphragm.
  • Trachea.
  • Esophagus.
  • Sternum (chest bone) or backbone.
  • More than one place in the same lobe of the lung.
  • The fluid of the pleural cavity surrounding the lung.

Stage IV

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Stage IV non-small cell lung cancer. The cancer has spread to another lobe of the same lung, to the other lung, and/or to one or more other parts of the body.

In stage IV, cancer may have spread to lymph nodes and has spread to another lobe of the lungs or to other parts of the body, such as the brain, liver, adrenal glands, kidneys, or bone.

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