Oncology
Lung cancer staging1

https://doi.org/10.1016/j.jss.2003.11.006Get rights and content

Abstract

The staging of lung cancer is a continuously progressing field, with advances in technology not only improving prognostic accuracy, but fundamentally changing pre-operative investigation algorithms. Noninvasive staging is currently undergoing revolutionary developments with the advent of Positron Emission Tomography, whereas Video-Assisted Thoracic Surgery has already been established as an essential, minimally invasive diagnostic tool for invasive histological staging. Molecular staging may transform future lung cancer staging, promising extremely accurate substaging, and potentially prompting a revision of our anatomically based conceptualization of lung cancer spread. This review presents an appraisal of current lung cancer staging modalities, and presents an overview of recent developments in molecular staging.

Introduction

Lung cancer is the leading cause of cancer death in the developed world. In the United States alone, in 2002 there were 170,000 new cases, and lung cancer accounted for 28% of all cancer deaths [1]. Accurate staging remains the cornerstone of lung cancer management and prognostication. The TNM system currently in use for the classification of non-small cell lung cancer (NSCLC) was first proposed more than 50 years ago by Denoix [2], and was later adapted by the American Joint Committee for Cancer Staging in 1974 [3]. This staging system since went through further revisions in 1986 [4] and, more recently, in 1997 [5].

The TNM system gauges the overall anatomical spread of cancer by considering the factors of tumor size and invasion, extent of lymphatic spread, and presence of metastatic disease. This anatomical basis has shaped current strategies for clinical and surgical staging investigations. Emphasis is on the detection of cytological and histological spread by means of noninvasive staging, such as imaging, or invasive staging, such as surgical biopsy. However, with advances in molecular biology rapidly expanding our understanding of cancer, this purely anatomical framework is increasingly being challenged.

This review critically appraises the roles of current staging modalities, and also presents an overview of recent developments in molecular staging.

Section snippets

Noninvasive staging

All NSCLC patients should have a thorough history taken and undergo a complete physical examination. It has been estimated that symptoms and signs may identify up to 95% of NSCLC patients with advanced, inoperable disease [6], [7], [8]. A thorough history and examination, coupled with a routine array of laboratory tests (such as alkaline phosphatase), constitute the “expanded” clinical evaluation [9]. Abnormal findings from such an evaluation are associated with an approximate 50% incidence of

Invasive staging

It is acknowledged that each noninvasive staging modality has specific drawbacks. Ultimately, not even the latest imaging techniques, such as PET, can provide infallible staging; hence cytological or histological confirmation of suspected metastases (invasive staging) is frequently required [26].

Molecular staging

The advent of molecular biology represents the most significant development in lung cancer staging in the past few decades and promises to revolutionize the way clinicians conceptualize the spread of this disease through the human body. The current anatomically based TNM system for lung cancer staging has well-recognized limitations. Within the conventional staging system, there remain patients whose progress and prognosis defy their accorded stage. For example, patients with stage IA NSCLC

Conclusion

Accurate staging remains essential for lung cancer management. Recent developments in both noninvasive and invasive staging investigations are changing the algorithms for lung cancer staging. For example, a negative PET scan for the mediastinum now renders mediastinoscopy unnecessary in most instances, while VATS offers a minimally invasive yet highly accurate means of preresection histological staging. These imaging and surgical techniques will continue to evolve, and surgeons should keep

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    Presented at Advances in Surgery, a scientific symposium in honor of David B. Skinner, M.D., Chicago, IL, October 19, 2003.

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