For AJCC staging, a pleural effusion is considered malignant unless cytologic examination has been proven negative on two or more occasions. These pleural effusions are non-bloody and non-exudative. Clinical judgment and negative cytologies will determine that the effusion is non-malignant. Otherwise, a malignant effusion is staged to T4.
If a lung cancer is detected by positive sputum cytology but cannot be seen on imaging or endoscopy, the tumor should be staged TX. If there are no positive lymph nodes or distant metastases, the case is stage-grouped to the category "Occult carcinoma."
The size of tumor must be recorded in order to stage the case in the AJCC staging system.
Use TX if the primary tumor was excised at another facility and no information about tumor size is available.
The dividing line between T2 and T3 lesions is the pleural cavity. If the tumor extends only to the visceral pleura, it is T2. If the tumor invades the parietal pleura or pericardial, diaphragmatic, or mediastinal surfaces, it is at least T3.
Tumors or lesions in the lung that are not a direct extension of the primary tumor are considered M1.
Simultaneous multiple tumors of different histologies should be staged as individual primary cancers. Simultaneous is defined as being diagnosed within two months. Different histologies refer to the first three digits of the ICD-O morphology code.
Patients with evidence of superior vena cava syndrome, compression of the esophagus or trachea, or vocal cord paralysis most likely have involvement of mediastinal lymph nodes. These should be staged as N2 or N3 depending on the location of the involved nodes.
If a mediastinal mass or mediastinal adenopathy is reported on x-ray or mediastinoscopy, assume that mediastinal lymph nodes are involved.
If the report states "remaining examination negative" or indicates no evidence of spread and there is no other statement regarding lymph nodes, assume that regional lymph nodes are negative.
"Obstructive pneumonitis" is a radiologic diagnosis that affects TNM staging; it should not be confused with "bronchopneumonia."
Record "Size of Tumor" as 998 if involvement of lung is described as diffuse or entire lobe of lung.
Do not add together the sizes of pieces of tumor removed at biopsy and at resection. Use the largest size of tumor, even if this is from the biopsy specimen. If no size is stated, record as 999 in the field "Size of Tumor."
If a lobectomy was performed, assume that the tumor was more than 2 cm distal to the carina.
If a chest x-ray is done and the radiologist makes no comment about the opposite lung, assume that it is not involved.
The terms adenopathy, enlargement, and mass in the hilum or mediastinum should be coded as involvement for lung primaries only.
Regional lymph nodes are not palpable for inaccessible sites such as lung. The best description concerning regional lymph nodes will be on imaging studies or in the surgeon's evaluation at the time of exploratory surgery or definitive surgery. If regional lymph nodes for these inaccessible sites are not mentioned on imaging or exploratory surgery, they are presumed to be clinically negative.