Anatomy of the Lung: The Role it Plays in Staging

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1 Anatomy of the Lung: The Role it Plays in Staging Kirk D. Jones, MD UCSF Dept. of Pathology College of American Pathologists, Cancer Committee Member Overview Historical notes on staging Airway anatomy related to staging Parenchymal anatomy related to staging Size of tumor Pleural anatomy related to staging Lymph nodes and staging 1

2 Historical Notes Professor Pierre Denoix 1953 Uniform Technique for Clinical Classification by the TNM System UICC Union Internationale Contre le Cancer 1966 Lung tumor fascicle 1968 UICC TNM Classification of Malignant Tumours AJCC American Joint Committee on Cancer Dr. Clifton Fletcher Mountain (with Carr and Anderson) 1st edition

3 IASLC Lung Cancer Staging Project Problems with the Mountain Database One country Older cases (collected over 20 years) Mostly surgical cases International Association for the Study of Lung Cancer (IASLC) Set up database in institutions in 12 countries >80,000 cases. Call for data increased number to >100,000. Analysis looking at survival data. Help define specific structures Pleural invasion, Nodal stations 3

4 Henry Gray ( ). Anatomy of the Human Body Tracheo-Bronchial Anatomy Trachea Pass through vocal cords Extends down cm Anterior cartilage rings Posterior membrane 4

5 Tracheo-Bronchial Anatomy Carina Bifurcation of the trachea Mainstem bronchi Right and left Right is shorter 2.5 cm and steeper Left is longer 5.0 cm and flatter Has to get past the heart Tracheo-Bronchial Anatomy Right lung Three lobes Three lobar bronchi Each with 2-5 branches 10 segments Left lung Two lobes Two lobar bronchi 8 segments 5

6 Staging of Tumors with Respect to Bronchus Many staging criteria are based on surgical decision making. The further into the bronchial tree, the less surgery needs to be performed Past lobar branchpoint can take that lobe Past carina can take the lung Close to carina difficulty obtaining margin At carina? T2 - involves a main bronchus 2 cm from carina. T3 - involves a main bronchus < 2 cm from carina. T4 - at the carina. 6

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8 Airway Staging Issues In lobectomies, there is usually no issue. The staging question is whether tumor is in mainstem bronchus, not lobar bronchus. In pneumonectomy specimens with tumor in mainstem bronchus. Distance to carina should be correlated with pre-operative measurement if within 2 cm of margin. 8

9 Parenchymal Staging Size of tumor One of the clear criteria for lung cancer size stratifies patients into prognostic categories. What do we know about lung anatomy that would make size an important criterion? The Pulmonary Lobule 9

10 Tumor Size and Lung Anatomy As a tumor grows to exceed 1 cm, the likelihood that it will extend into a lymphatic space increases. The lymphatics lie in both the central and peripheral portions of the secondary pulmonary lobule Bronchovascular bundles Interlobular septa Subpleural region 10

11 T Component - Tumor Size T Component - Tumor Size AJCC 6 th T1: Size 3 cm T2: Size > 3 cm AJCC 7 th T1a: 2 cm T1b: >2 to 3 cm T2a: > 3 to 5 cm T2b: > 5 to 7 cm T3: > 7 cm 11

12 Parenchymal Staging Issues Tumor size is one of the most powerful prognostic indicators in lung cancer. Accurate measurement is often performed in the fresh state, but can be done post-fixation. Subtracting out regions of adjacent pneumonia may be required. 12

13 Pleural Anatomy The pleura has various layers that provide specific functions Mesothelial surface Long microvilli and hyaluronic acid-like mucins for low friction Elastic layers For passive exhalation Connective tissue layers Carries lymphatic and blood vessels 13

14 Pleura in Lung Cancer Staging Invasion of the pleura as a poor prognostic sign has been a criterion since the earliest staging guides. Pleural invasion has been poorlydefined until recently. 14

15 What Constitutes Pleural Invasion? Invasion into visceral pleura Extension past alveolar elastica? Invasion past visceral pleura elastica? Pleural puckering? Visceral pleural invasion: pathologic criteria and use of elastic stains: proposal for the 7th edition of the TNM classification for lung cancer. J Thorac Oncol Dec;3(12): Defining Pleural Invasion Sam Hammar 1988 Px, P0-3, T2 defined by P1 Japan Lung Cancer Society P0-3, T2 defined by P2 15

16 Studies of Prognostic Value Osaki et al, 2004: 5 yr survival rates PL0 = 68.0% PL1 = 43.9% PL2 = 54.9% Shimizu et al, 2004: 5 yr survival rates ( 3 cm, > 3 cm) PL0 = 79%, 60% PL1 = 63%, 39% PL2 = 42%, 35% 16

17 Visceral Pleural Invasion Kawase et al examined 2725 consecutive cases of NSCLC. Otherwise T1 tumors with visceral pleural invasion show prognosis similar to T2 tumors Otherwise T2 tumors with visceral pleural invasion show prognosis similar to T3 tumors J Thorac Oncol. 2010; 5: Analysis of Pleural Invasion with EVG Staining Once visceral pleural invasion is defined, need of EVG stain is apparent. Butnor et al, 2007 Some cases are easy, others there is a lack of agreement. Taube et al, 2007 Pleural invasion is an elusive finding Need EVG stain 19% of 100 T1 peripheral tumors understaged Butnor KJ, et al. AJCP 128: Taube JM, et al. AJSP 31(6):

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22 Staging Lung Cancer - Pleura Elastic tissue stain is helpful for determining invasion. Currently, invasion results in increasing the stage of small tumors from T1 to T2. Further data needed to interpret whether larger tumors with pleural invasion should be upstaged also (e.g. T2 to T3). Pleural Effusions Metastatic disease split into local and distant categories. M1a: Pleural effusion, pericardial effusion, contralateral lung M1b: Outside of the thoracic cavity Formerly T4 wet T4 Known poor prognosis 22

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24 Staging of Effusions More involved to stage, as it requires correlation of multiple specimens. Similar to former gynecologic cancer staging May require further workup by pathologist on the fluid sample. More accurately reflects the prognostic data in patients with involvement of pleural space. 24

25 Lymph Node Anatomy The lymph nodes of the lung, as in the rest of the body, are the drain stations of immune surveillance. Located along bronchi (N1 nodes). Located in mediastinum (N2+ nodes). As the nodal station increases, the N status decreases: 1 = N3 = supraclavicular or sternal notch 2-9 = N2 = nodes in mediastinum 10+ = N1 =nodes in lung 25

26 Possibly Tricky Nodes Level 7 nodes extend to the first segmental branch (i.e. former inferior mainstem bronchial nodes are now subcarinal). Level 5 node may come out with some pneumonectomy specimens. These should be designated by the surgeon to avoid confusion. Pleural reflections Lymph node with Partially compressed vessel 26

27 Caveo numeros Romanorum Lymph Node Staging Issues As the tumor spreads from bronchial to mediastinal to opposite side mediastinal or supraclavicular nodes, the N status increases from N1 to N2 to N3. Nodes beyond these regions (e.g. cervical nodes or chest wall) are metastases (M1b). 27

28 Conclusions Knowledge of anatomy of the lung aids in the staging of lung cancer. Several issues become more obvious as clinically relevant. Bronchial invasion Lymph node spread Several issues demonstrate reasons why a particular finding leads to upstaging Pleural invasion Size of tumor Thank you 28

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