LUNG CANCER

CT SCAN STAGING

dr. Netty D. Lubis Sp.Rad

RSUP H.Adam Malik Medan
WORK SHOP JAKARTA
13 AGUSTUS 2016
CT Technique
• IV contrast dosis 80 - 100 cc dengan flow
3- 4 cc / sec
• Apical – Adrenal gland
• Lung Window
• Mediastinal window
• Bone Window
There are 4 major types :

1. epidermoid (squamous) 35%

2. adeno carcinoma 30%
3. large cell carcinoma 15%

4. small cell lung cancer 20%

APA TUJUAN UTAMA
STAGING ?
RESEKTABILITAS
Lung cancer - treatment concepts

T 1- 2 N 0 Curative surgery
± adjuvant therapy
T 1 -2 N 1

T 1 -3 N2 Chemo-/(radio-)therapy
and surgery
T 4 N 0-1
T 1 -2 N 3
T 4 N3 M1 Palliative therapy
T-Staging
 Bagaimana Kriteria
Invasi ke Mediastinum?
Bagaimana Kriteria Invasi
ke Chest Wall?
Chest wall infiltration ?
Bagaimana Kriteria Infiltrasi/
perluasan ke pleura?
 BAGAIMANA KRITERIA
KELENJAR GETAH BENING
ABNORMAL?
N-Staging
 N-Staging

N1: resectable through lobectomy

N2: resectable through lateral thoracotomy

N3: irresectable through lateral thoracotomy

M1: irresectable, prognosis worse

Is it predictable which lymph nodes would be
involved based on primary tumor location?

1. Yes
2. No
3. Don’t know
New International LN Map (IASLC)
7 lymph node zones
Supraclavicular zone (1)
Upper zone (2-4)
Aortopulmonary zone (5-6)
Subcarinal zone (7)
Lower zone (8-9)
Hilar/interlobar zone (10-11)
Peripheral zone (12-14)

Rusch VW – J Thorac Oncol 2009; 4:568

lymphatic spread in the lung
is usually sequential
from ipsilateral peripheral
LNs to ipsilateral
interlobar/hilar LNs (N1)

to ipsilateral mediastinal LNs

(N2) and contralateral mediastinal
ones (N3)

mediastinal lymphatic pathways are related to the lobe

of pulmonary lymphatic origin

… according to the lobe of tumor origin……

Right Upper LobeTumor (RUL)
right hilar LNs
right paratracheal LNs (most common)
isolated subcarinal LNs (rare)
Kim AW- Semin Thorac Cardiovasc Surg 2009
Watanabe S - Interactive Cardiovasc Thoracic Surg 2004
 Right Middle Lobe Tumor (RML)
right paratracheal LNs
subcarinal LNs
Kim AW- Semin Thorac Cardiovasc Surg 2009
Watanabe S - Interactive CardiovascThoracic Surg 2004
Left Upper Lobe Tumor (LUL)
aortopulmonary zone
subcarinal zone (lingula)
Kim AW- Semin Thorac Cardiovasc Surg 2009
Watanabe S - Interactive Cardiovasc Thoracic Surg 2004
Lower Lobe Tumor (LL)
basal segments to the upper
zone LNs mostly through
subcarinal LNs
superior segment directly to the
upper zone LNs w/out subcarinal
involvement
Watanabe S – Ann Thorac Surg 2008; 85:1026
What is the N stage on CT scans?
1. N0
2. N1
3. N2
4. N3
Enlarged lymph nodes
R hilum
R tracheo-bronchial angle
R lower paratracheal station

Ipsilateral mediastinal nodes N2

 N Staging NSCLC
N0: no regional node metastasis
N1: ipsilateral peribronchial and/or perihilar nodes
and intrapulmonary nodes
N2: ipsilateral mediastinal and/or subcarinal nodes
N3: contralateral mediastinal or hilar nodes, ipsilateral or
contralateral scalene nodes or supraclavicular nodes
Detterbeck – Chest 2009; 136:260

N1 N2 N3
 Distant metastases
 Lung
 Tumor in contralateral lung
 Tumor with pleural nodules
 Malignant pleural/pericardial effusion
 Adrenal gland
 Malignancy favored if > 3 cm, poorly defined
margin, irregular rim enhancement, invasion of
adjacent structures
 Benign etiology favored if attenuation values <
10 HU on CT (sensitivity 71%, specificity 98%)
 Bone
 Vertebral bodies, ribs, pelvis, proximal
appendicular skeleton
 Osteolytic lesions more common than
osteoblastic
 CT alone insufficient to exclude bone
metastases
 Brain
 M-Staging

• haematogenous distant metastases

(brain, liver, adrenal, bones etc.): new M1b

• lymphatic distant metastases

(cervical, abdominal lymph nodes): new M1b

• malignant pleural/pericardial effusion: new M1a

• satellite nodules in contralateral lung: new M1a

 M-Staging

satellite nodules in contralateral lung: new M1a

 M-Staging

malignant pleural/pericardial effusion: new M1a

 M-Staging
Haematogenous distant metastases: new
M1b
(brain, liver, adrenal, bones, …..)
 M-Staging
Lymphatic distant metastases:
new M1b
(cervical, abdominal lymph nodes)
 Pancoast tumors
(superior sulcus tumors)
Tumor of the apex of the lung
with possible infiltration of the
chest wall brachial plexus,
stellate ganglion, ribs, vertebae

< 5% of all bronchogenic

carcinoma
PET/CT for staging
(mediastinum,
distant metastases)

Determination of the
radiation field
Pancoast tumor / Superior Sulcus Tumor
Pancoast tumor / Superior Sulcus Tumor

• infiltration of thoracic outlet by NSCLC

• invasion of nerves & vessels
•  pain
•  paralysis of arm
•  Horner syndrome
•  thrombosis