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TNM classification 8th edition

Onno Mets and Robin Smithuis
Department of Radiology of the Academical Medical Centre, Amsterdam and the Alrijne Hospital, Leiderdorp, the
Netherlands

TNM-8
What is new in the TNM 8th edition Publicationdate 2017-12-09
Non-small lung cancer stages
T-classification This is a summary of the 8th Edition of TNM in Lung
T0 Cancer, which is the standard of non-small cell lung
T1 cancer staging since January 1st, 2017.
T2
T3 It is issued by the IASLC (International Association
T4 for the Study of Lung Cancer) and replaces the TNM
Pancoast tumor 7th edition.
N - Staging
Regional Lymph Node Classification System
N1 - Nodes
N2 - Nodes
N3 - Nodes
N3 - Nodes
M-Staging

TNM-8

The 8th edition of the TNM classification for non-

small lung cancer is shown in the table.

Conform previous editions there are three compo-

nents that describe the anatomic extent of the tu-
mor: T for the extent of the primary tumor, N for
lymph node involvement, and M for metastatic dis-
ease.
T-classification is performed using CT, the N- and M-
classification using CT and PET-CT.
It can be used in the pre-operative imaging and
clinical classification iTNM/cTNM, but it is also ap-
plicable for definitive pathological staging pTNM, re-
staging after therapy yTNM and staging of a recur-
rence rTNM.

Differences with the 7th edition are presented in

red.

TNM-staging 8th edition. Changes to 7th edition in red.

What is new in the TNM 8th edition

In the new TNM 8th edition the size went down for
several T-categories, and some new pathology
based categories were introduced.

Also, new M-categories were introduced regarding

extrathoracic metastatic disease.

Size of a solid lesion is defined as maximum diame-

ter in any of the three orthogonal planes in lung
window.
In subsolid lesions T-classification is defined by the
diameter of the solid component and not the diame-
ter of the complete groundglass lesion.

Non-small lung cancer stages

Subsets of T, N and M categories are grouped into
certain stages, because these patients share similar
prognosis [1].

For example cT1N0 disease (stage IA) has a 5-year

survival of 77-92%.
On the other end of the spectrum is any M1c dis-
ease (stage IVB) that has a 5-year survival of 0%.

Stages of lung cancer adapted from the 8th Edition of TNM in

Lung Cancer

Lobectomy is generally not possible if there is:

Transfissural growth.
Pulmonary vascular invasion.
Invasion of main bronchus.
Involvement of upper and lower lobe bronchi.
These are specific items to report.

Thin-slice images and three-plane reconstructions

Lungcancer with evident transfissural growth on both the
coronal and sagittal reconstructions; lobectomy is no longer
possible.
are necessary to best demonstrate the relation with
surrounding structures.
In case of indeterminate invasion, the multidiscipli-
nary oncology board should decide whether the ben-
efit of doubt is given, depending on the individual
case and co-morbidity.

T-classification

T0
There is no primary tumor on imaging
Tis
Carcinoma in situ, irrespective of size.
This can only be diagnosed after resection of
the tumor.

T1
Tumor size ≤3cm
Tumor ≤1cm => T1a
Tumor >1cm but ≤2cm =>T1b
Tumor >2cm but ≤3cm => T1c
T1a(mi) is pathology proven 'minimally invasive',
irrespective of size.

T1a(ss) is a superficial spreading tumor in the cen-

T1 tumor – A typical T1 tumor in the left lower lobe, tral airways, irrespective of location.
completely surrounded by pulmonary parenchyma.

T2
Tumor size >3cm to ≤5cm or
Tumor of any size that
invades the visceral pleura
involves main bronchus, but not the carina
shows an atelectasis or obstructive
pneumonitis that extends to the hilum
T2a= >3 to 4cm
T2b= >4 to 5cm

T2 tumor - A typical T2 tumor with atelectasis/pneumonitis of

the left lower lobe up to the hilum, due to involvement of the
left main bronchus.

T3
Tumor size >5cm to 7cm or
Pancoast that involves thoracic nerve roots T1
and T2 only.
Tumor of any size that
invades the chest wall
invades the pericardium
invades the phrenic nerve
shows one or more satellite nodules in the
same lung lobe
T3 tumor - A typical T3 tumor in the right upper lobe with
invasion of the chest wall.

T4
Tumor size >7cm or
Pancoast tumor that involves C8 or higher
nerve roots, brachial plexus, subclavian vessels
or spine
Tumor of any size that
invades mediastinal fat or mediastinal
structures
invades the diaphragm
involves the carina
shows one or more satellite nodules in
another lobe on the ipsilateral side

T4 tumor – A typical T4 tumor in the right upper lobe with

invasion of the mediastinum.

Pancoast tumor

A Pancoast tumor is a tumor of the superior pul-

Enable Scroll monary sulcus characterized by pain due to invasion
of the brachial plexus, Horner's syndrome and de-
struction of bone due to chest wall invasion.
MR is superior to CT for local staging.

Pancoast tumor. Scroll through the images

An operable T3 Pancoast tumor on a sagittal con-

trast-enhanced T1-weighted image.

The tumor abuts the root T1 (white arrow), but oth-

er nerve roots are not involved (green arrow).
A = subclavian artery, ASM = anterior scalene mus-
cle.
(Courtesy of Wouter van Es, MD. St. Antonius Hospi-
tal Nieuwegein, The Netherlands)

Pancoast tumor. (Courtesy of Wouter van Es, MD. St. Antonius

Hospital Nieuwegein, The Netherlands)

Here an inoperable T4 Pancoast tumor on a sagittal

contrast-enhanced T1-weighted image.

Evident invasion of brachial plexus (white arrow)

and encasement of the subclavian artery (A).

ASM = anterior scalene muscle.

Pancoast tumor. (Courtesy of Wouter van Es, MD. St. Antonius

Hospital Nieuwegein, The Netherlands)

N - Staging

Regional Lymph Node Classification System

Lymph node staging is done according to the Ameri-
can Thoracic Society mapping scheme.

Supraclavicular nodes
1. Low cervical, supraclavicular and sternal
notch nodes
Superior mediastinal nodes
2. Upper Paratracheal: above the aortic arch,
but below the clavicles.
3A. Pre-vascular: nodes not adjacent to the
trachea like the nodes in station 2, but anterior
to the vessels.
3P. Pre-vertebral: nodes not adjacent to the
trachea, but behind the esophagus, which is
prevertebral (3P).
Inferior Mediastinal nodes
4. Lower Paratracheal (including Azygos
Nodes): below upper margin of aortic arch
down to level of main bronchus.
Aortic nodes
Adapted from the American Thoracic Society mapping scheme
5. Subaortic (A-P window): nodes lateral to
ligamentum arteriosum. These nodes are not
located between the aorta and the pulmonary
trunk, but lateral to these vessels.
6. Para-aortic (ascending aorta or phrenic):
nodes lying anterior and lateral to the
ascending aorta and the aortic arch.
Subcarinal nodes
7. Subcarinal.
Inferior Mediastinal nodes
8. Paraesophageal (below carina).
9. Pulmonary Ligament: nodes lying within the
pulmonary ligaments.
Pulmonary nodes
10-14. N1-nodes: these are located outside of
the mediastinum.

The boundary between level 10 and level 4 is on the

right the lower border of the azygos vein and on the
left the upper border of the pulmonary artery (N1
vs. N2).

There is an important separation to be made be-

tween level 1 and level 2/3 nodes, because it is N3-
stage versus N2.
The lower border of level 1 is the clavicles bilaterally
and, in the midline, the upper border of the
manubrium.

The boundary between level 4R and 4L is the left

lateral border of the trachea, and not the anatomic
midline.

Paracardial, internal mammarian, diaphragmatic,

axillary and intercostal lymph nodes are not de-
scribed in the IALSC lymph node map.
Occasionally these can be present.
It is proposed to regard these non-regional nodes as
metastastic disease [2].

CT is unrealiable in staging lymph nodes in patients

with NSCLC regardless of the threshold size that is
chosen.
PET-CT is much more reliable in determining the N-
status.
False-positives occur in patients with sarcoid, tuber-
culosis and other infections.
Because of the high negative predictive value, PET
scanning should be performed in all patients consid-
ered for surgery.

N1 - Nodes
N1-nodes are ipsilateral nodes within the lung up to
hilar nodes.
N1 alters the prognosis but not the management.

T2 tumor (> 3cm) in the right lower lobe with ipsilateral hilar
node (N1)

N2 - Nodes
N2-nodes represent ipsilateral mediastinal or sub-
carinal lymphadenopathy.

There is only a subset of patients with N2 disease

that benefits from resection.

Those are the patients who -after a negative medi-

astinoscopy- are found to have microscopic
metastatic disease at the time of thoracotomy.

These patients have a better prognosis than those

N2-disease – Right sided tumor with ipsilateral mediastinal
nodes with evident N2-disease.

N3 - Nodes
N3-nodes represent contralateral mediastinal or
contralateral hilar lymphadenopathy or scalene or
supraclavicular nodes.

These are irresectable.

N3-stage disease.

The images show two patients with lung cancer on

the right and contralateral nodes.

If these lymph nodes contain tumor cells, this

means inoperable stage IIIB-disease.

Two patients with N3-disease.

N3 - Nodes
Enable Scroll
N3-nodes represent contralateral mediastinal or
contralateral hilar lymphadenopathy or any scalene
or supraclavicular nodes.

These are irresectable.

N3-nodes on contralateral side and in supraclavicular region.

Scroll through the images.

For a tumor in the right lung the N-stages are:

N1
Ipsilateral peribronchial and/or hilar lymph nodes
10R-14R

N2
Ipsilateral mediastinal and/or subcarinal lymph
nodes 2R, 3aR, 3p, 4R, 7, 8R, 9R

N3
Contralateral mediastinal and/or hilar, as well as any
supraclavicular lymph nodes 1, 2L, 3aL, 4L, 5, 6, 8L,
9L, 10L-14L

For a tumor in the left lung the N-stages are:

N1
Ipsilateral peribronchial and/or hilar lymph nodes
10L-14L

N2
Ipsilateral mediastinal and/or subcarinal lymph
nodes 2L, 3aL, 4L, 5, 6, 7, 8L, 9L

N3
Contralateral mediastinal and/or hilar, as well as any
supraclavicular lymph nodes 1, 2R, 3aR, 3pR, 4R,
8R, 9R, 10-14R

M-Staging

Almost every organ may be involved in metastatic

disease.
Common are adrenal, nodal, brain, bone and liver
involvement.
M-staging in the current edition is based on the
presence of metastases, their location and multiplic-
ity.

A distinction is made between regional metastatic

disease (M1a) and solitary (M1b) or multiple (M1c)
distant metastatic disease:

M0: No distant metastases

M1: Distant metastases
M1a: Regional metastatic disease defined
as malignant pleural or pericardial
effusion/nodules, as well as contralateral
or bilateral pulmonary nodules.
M1b: solitary extrathoracic metastasis
M1c: Multiple extrathoracic metastases,
either in a single organ or in multiple
organs

1. The Eighth Edition Lung Cancer Stage Classiï¬​cation.

Detterbeck et al
CHEST (2017); 151(1):193-203
2. Proposals for Revision of the TNM Stage Groupings in the Forthcoming (Eighth) Edition of the TNM Classification for
Lung Cancer
3. International Association for the Study of Lung Cancer (IASLC) Lymph Node Map: Radiologic Review with CT
Illustration.
by El-Sherief et al
RadioGraphics (2014); 34:1680-1691
4. The Revised TNM Staging System for Lung Cancer
by Ramon Rami-Porta et al
Ann Thorac Cardiovasc Surg 2009; 15: 4 - 9
5. New Guidelines for the Classification and Staging of Lung Cancer: TNM Descriptor and Classification Changes in the
8th Edition.
by Peter Goldstraw

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