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Non-Small Cell Lung Cancer Treatment (PDQ®): Treatment - Health Professional Information [NCI] - Stage Information for NSCLC

Background

In NSCLC, the determination of stage is important in terms of therapeutic and prognostic implications. Careful initial diagnostic evaluation to define the location and to determine the extent of primary and metastatic tumor involvement is critical for the appropriate care of patients.

In general, symptoms, physical signs, laboratory findings, or perceived risk of distant metastasis lead to an evaluation for distant metastatic disease. Additional tests such as bone scans and computed tomography (CT)/magnetic resonance imaging (MRI) of the brain may be performed if initial assessments suggest metastases or if patients with stage III disease are under consideration for aggressive local and combined modality treatments.

Stage has a critical role in the selection of therapy. The stage of disease is based on a combination of clinical factors and pathological factors.[1] The distinction between clinical stage and pathological stage should be considered when evaluating reports of survival outcome.

Procedures used to determine staging include the following:

  • History.
  • Physical examination.
  • Routine laboratory evaluations.
  • Chest x-ray.
  • Chest CT scan with infusion of contrast material.
  • Fluorodeoxyglucose-positron emission tomography (FDG-PET) scanning.

Procedures used to obtain tissue samples include bronchoscopy, mediastinoscopy, or anterior mediastinotomy. Pathological staging of NSCLC requires the following:

  • Examination of the tumor.
  • Resection margins.
  • Lymph nodes.

Prognostic and treatment decisions are based on some of the following factors:

  • Knowledge of histologic type.
  • Tumor size and location.
  • Involvement of pleura.
  • Surgical margins.
  • Status and location of lymph nodes by station.
  • Tumor grade.
  • Lymphovascular invasion.

At diagnosis, patients with NSCLC can be divided into the following three groups that reflect both the extent of the disease and the treatment approach:

  1. Surgically resectable disease (generally stage I, stage II, and selected stage III tumors).
    • Has the best prognosis, which depends on a variety of tumor and host factors.
    • Patients with resectable disease who have medical contraindications to surgery are candidates for curative radiation therapy.
    • Postoperative cisplatin-based combination chemotherapy may provide a survival advantage to patients with resected stage II or stage IIIA NSCLC.
  2. Locally (T3–T4) and/or regionally (N2–N3) advanced disease.
    • Has a diverse natural history.
    • Selected patients with locally advanced tumors may benefit from combined modality treatments.
    • Patients with unresectable or N2-N3 disease are treated with radiation therapy in combination with chemotherapy.
    • Selected patients with T3 or N2 disease can be treated effectively with surgical resection and either preoperative or postoperative chemotherapy or chemoradiation therapy.
  3. Distant metastatic disease (includes distant metastases [M1] that were found at the time of diagnosis).
    • May be treated with radiation therapy or chemotherapy for palliation of symptoms from the primary tumor.
    • Patients with good performance status, women, and patients with distant metastases confined to a single site live longer than others.[2]
    • Platinum-based chemotherapy has been associated with short-term palliation of symptoms and with a survival advantage.
    • Currently, no single chemotherapy regimen can be recommended for routine use.
    • Patients previously treated with platinum combination chemotherapy may derive symptom control and survival benefit from docetaxel, pemetrexed, or epidermal growth factor receptor inhibitors.
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