Workup/Staging

Question 1

What are the types of M+ Dz in the AJCC 8th edition?

Answer 1

M1a: Separate tumor nodule(s) in a contralat lobe; tumor with pleural or pericardial nodule(s) or malignant pleural or pericardial effusion

M1b: Single extrathoracic mets

M1c: Multiple extrathoracic mets in 1 or more organs

Question 2

What is the TNM staging (AJCC 8th edition) that defines advanced NSCLC?

Answer 2

Stage IIIA: T3N1, T1–T3N2, T4N0–1

Stage IIIB: T1–T2N3, T4N2

Stage IIIC: T3–T4N3

Stage IVA: TXNXM1a/b

Stage IVB: TXNXM1c

Question 3

What is the MS of pts who present with malignant pleural effusion with NSCLC?

Answer 3

MS is 3–9 mos. These pts are staged as M1a Dz in the new staging system.

Question 4

What are the survival outcomes of stage IIIA Dz with T3N1 vs. TXN2 Dz?

Answer 4

Stage IIIA is a heterogeneous group, with 5-yr survival ranging from 25%–30% for T3N1 and 15%–20% for T1–3N2 Dz. There is a lot of heterogeneity in the prognosis of the T1–3N2 group d/t the # and bulk of LNs involved.

Question 5

What is the utility of PET/CT to determine the resectability of the lung cancer pts?

Answer 5

PET/CT may improve the staging to spare pts from futile thoracotomies b/c of unresectable Dz that is not detectable by conventional imaging. A Danish RCT (Fischer B et al., NEJM 2009) randomized 189 pts using either conventional staging with CT + mediastinoscopy or conventional staging and PET/CT staging. PET reduced the # of futile thoracotomies and the total # of thoracotomies (both SS). But the overall mortality did not differ b/t groups.

Question 6

What is the % of occult distant metastatic Dz found on PET/CT at initial Dx?

Answer 6

PET/CT can diagnose occult mets 10%–15% at the time of initial diagnostic workup.