2009 Non-Small Cell Lung Cancer Staging System (3)

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As a radiologist, it may be easier to memorize "T" classification based on imaging appearance. The scheme below may be used as a guidance to stage these tumors, however a full text of the New Staging System should be reviewed for comprehensiveness.

1. Peripheral mass abutting chest wall or diaphragm --- see if there is evidence of invasion of chest wall or diaphragm (T3)
2. Peripheral mass, distal to lobar bronchus, completely surrounded by lung --- measuring size (less than 3cm = T1, 3-7cm = T2, more than 7cm = T3)
3. Mass distal to 2 cm from the carina but proximal to lobar bronchus --- T2 by definition
4. Endobronchial mass: distal to 2 cm from the carina = T2; within 2 cm from the carina = T3
5. Central mass with postobstructive pneumonitis or atelectasis: lobar or segmental = T2;entire lung = T3
6. Central mass abutting the mediastinum: invade mediastinal pleura, parietal pericardium = T3; diaphramatic paralysis (phrenic nerve involvement) = T3; invade heart, great vessels, trachea, esophagus, carina, vertebral body = T4
7. Additional malignant lung nodules: same lobe = T3; ipsilateral different lobe = T4; contralateral = M1a
8. Malignant pleural effusion or pleural nodule = M1a

Reference:

Detterbeck FC, Boffa DJ, Tanoue LT. The new lung cancer staging system. Chest 2009:136;260-271.

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2009 Non-Small Cell Lung Cancer Staging System (2)

Axial CT images show a large mass (stars) in the left lower lobe with a large left pleural effusion with focal pleural thickening (arrowheads). The lung mass is better seen on a post-thoracentesis image. Transbronchial biopsy revealed adenocarcioma and pleural fluid cytology confirmed the presence of malignant cells. Based on the new staging system, this patient has at least M1a disease.

Based on multiple data sources and available clinical outcome (overall survival), additional schemes to stage NSCLC are implemented in this 7th edition. The subgroups and staging grouping are based on the overall survival as a major determinant. For example, overall survival of patients with "satellite nodule in the same lobe" is similar to those with T3 -- therefore it is classified as T3.

What Have Changed in the New Edition?

• Additional "satellite nodule in the same lobe" now classified as T3 (previously T4)
• Additional "satellite nodule in the different ipsilateral lobe" now classified as T4 (previously M1)
• No change in N staging, but a new node map has been developed to address the issue of boundaries between different nodal stations
• M staging is now subdivided into M1a and M1b to address significantly different prognosis: "contralateral pulmonary nodule (malignant)" and "pleural dissemination" now classified as M1a; distant metastasis as M1b

Reference:

Detterbeck FC, Boffa DJ, Tanoue LT. The new lung cancer staging system. Chest 2009;136:260-271.

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2009 Non-Small Cell Lung Cancer Staging System (1)

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The latest (7th edition) version has been accepted by the UICC (Union Internationale Contre le Cancer) and the AJCC (American Joint Committee on Cancer) and was published earlier this year.

Non-Small Cell Lung Cancer (NSCLC) Staging System

• Based solely on anatomic extent of disease (clinical symptoms or molecular behavior of tumors not included)
• T = tumor; increasing T meaning larger tumor or invasive into more peripheral or central structures
• N = lymph node location (not number)
• M = metastasis
• Two methods of staging = clinical (c) and pathological (p); clinical staging includes all information available PRIOR to any treatment (including invasive staging technique); pathological staging include information AFTER a resection

Sources of Data for the 7th Edition

• 81,015 included cases from 45 sources in 20 countries
• Only NSCLC included
• Major determinant is the overall survival

Reference:

Detterbeck FC, Boffa DJ, Tanoue LT. The new lung cancer staging system. Chest 2009;136:260-271.

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Peer Review in Radiology (2)

Scoring Language for Peer Review

By the American College of Radiology's RADPEER

1. Score 1 = concur with interpretation
2. Score 2 = discrepancy in interpretation/not ordinarily expected to be made (understandable miss)
3. Score 3 = discrepancy in interpretation/should be made most of the time
4. Score 4 = discrepancy in interpretation/should be made almost every time - misinterpretation of finding

How These Could Be Utilized?

• For individual radiologists: maintenance of certification, ongoing quality improvement in diagnostic accuracy, opportunity for education
• For institution: monitoring of radiologist performance as an individual and a group, tracking data over time, monitoring trends, conforming with requirements of several controlling agencies

Ideal Peer Review

• Reveals opportunity for quality improvement
• Ensures radiologist competence
• Improves individual radiologist outcome
• Should be unbiased, fair, balanced, timely, ongoing and nonpunitive
• Should allow easy participation
• Should have minimal effect on work flow

The most popular system in use at present is the American College eRADPEER

Reference:

Mahgerefteh S, Kruskal JB, Yam CS, et al. Peer review in diagnostic radiology: current state and a vision for the future. Radiographics 2009;29:1221-1231.

2. Jackson VP, Cushing T, Abujudeh HH, et al. RADPEER scoring white paper. J Am Coll Radiol 2009;6:21-25.

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Posterior Acoustic Features of Breast Mass

Transverse ultrasound image of the breast shows an irregularly shaped hypoechoic mass (between calipers) with posterior attenuation of the acoustic transmission ("shadowing"). The shadowing obscures the posterior margin of the mass.

Posterior Acoustic Features

• Attenuation characteristics of a mass with respect to its acoustic transmission
• Four patterns: no posterior acoustic features, enhancement, shadowing and combined

Posterior Shadowing

• Attenuation of sound beam deeper to a mass
• Associated with fibrosis, with or without underlying carcinoma
• DDx: scars, fibrous mastopathy and cancer with desmoplastic response
• Helpful feature when present (suggesting above diagnoses)
• Should be distinguished from "refraction or edge shadowing" which is a thin shadow seen at the edges of curved masses that is of no significance

Our case: invasive ductal carcinoma

Reference:

Madjar H, Mendelson EB. The practice of breast ultrasound, 2nd edition, 2008.