Lung Nodule... What do I start attacking?

Major changes have been made this year on the staging system for Lung Cancer. This may cause some confusion as to the flow of patient work-up and clinical staging. The staging system is still based on the TNM system. This staging system is now based on a 10 year validation study involving 81,015 patients after exclusion of ineligible cases.

Remember that when dealing with a potential lung tumor, we should always biopsy the one that gives the highest stage. Restaging is always done once surgery has been made. This is the difference between clinical and pathologic staging.

The following changes were made:

• There are new size cut-offs of 2, 3, 5, and 7 cm
• T1 is divided into T1a and T1b
• T2 is divided into T2a and T2b
• Separate tumor nodule(s) located in the same lobe as the primary tumor are reclassified as T3, instead of T4
• Separate tumor nodule(s) located in a different lobe of the ipsilateral lung are reclassified as T4, instead of M1
• Malignant pleural nodules, pleural effusions, or pericardial effusions are reclassified as M1, instead of T4

This means that there are several scenarios:

1. If you have a pleural effusion, tap it. If it's malignant - Stage IV.
2. If you have another tumor on the other lung, or a lymph node on the other side (Basically anything on the other side) - Stage IIIB. No surgery.
3. If you have a tumor that invades the mediastinum, or a lymph nodes in the mediastinum or subcarinal area. - Stage IIIB. Likely not a surgical candidate. (This is where endoscopic endobronchial ultrasound has found some use).
3. Otherwise, assess as a surgical candidate, but do thorough staging first (MRI, CT, PET) to maximize your clinical staging.

Of course, after you do the surgery, you have to reassess the staging to make the staging pathology based. This is an oversimplification, but you get the idea.

Simple.