Non-Small Cell Lungcancer : staging
Publicationdate: 20-8-2007
Lungcancer is the leading cause of cancer-related mortality in both men and women.
Lungcancer is classified into two categories, small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC).
SCLC usually has metastasized by the time of presentation.
It is therefore not curable and will not be discussed in this review.
NSCLC is a group of primary lung neoplasms with the same staging system and therapy and it can be cured with resection if it is in an early stage.
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Therefore the most important question in a patient with NSCLC is whether the tumor is resectable.
In this review we will discuss:
TNM-classification of NSCLC.
T-staging with CT.
N- and M-staging with CT and PET-CT.
这段是开场白，文字易懂，我就不翻译了，这段话的关键词是分期的最关键作用就是肿瘤是否可切除，因为这个关乎治疗是否彻底。
医药家园
医药家园 博客
TNM-classification
TNM分期（感觉有些新同僚不是太注意分期，只是简单的说明一下早期还是晚期，其实把分析看得越细致，我们在处理的时候可能会获益更多。）
NSCLC includes adenocarcinoma (35-40%), squamous cell carcinoma (25-30%) and large cell carcinoma (10-15%).
非小细胞肺癌包括35-40%的腺癌，25-30%的鳞状细胞癌和10-15%大细胞癌。
NSCLC is staged according to the TNM-staging system.
TNM subsets are grouped into certain stages, because these patients share similar prognostic and therapeutic options.
TNM分期法把该病分成几期，主要是为了将预后和治疗方法相似的病人归类。
For instance all stage IIIA patients have a 5 year-survival of 10%.
例如：IIIa期病人的5年生存率只有10%。
In the table on the left resectable stages are indicated in green and unresectable stages are indicated in red. 表里，红的是不可切除，绿的为可切除。
Stage IIIA is possibly resectable, usually after combined-modality therapy consisting of platinum-based chemotherapy and radiation.
IIIa期是可切除的，通常在综合治疗后：包括铂类化疗和放疗。（实际上，在国内，是否可切除在于哪个科先诊断，但是我们需要病人的时候是否优先考虑病人的利益呢？那就看同仁的心了。）
Stage IIIB, i.e. any patient who has T4 or N3 disease is virtually unresectable, but in some countries there are subgroups of patients that will get a resection.
Evidently all patients with distant metastases (stage IV) are inoperable.
IIIb期，T4，N3被认为几乎不能手术切除，除了某些国家采取，很明显，IV不应该手术。
其实看文章挺累的，先来张图，或者我们才会感觉到自己知识的魅力，文字大家都懂，但是黑漆漆的CT只有我们医生才读的出来。
The goal of imaging is to decide whether the tumor is resectable and whether it should be a lobectomy or a pneumonectomy.
成像的目的是决定行肺叶切除还是肺切除。
On the left a patient with a tumor near the fissure.
肿瘤靠近肺裂。
On coronal reconstructions it was demonstrated that there was no transfissural growth.冠状面重建发现没有裂的生长（这句话比较别扭，不好翻译）
Lobectomy therefore is a possibilty.
所以可行叶切除。
再来个图。今天晚上好冷啊，不过北极熊还是吃自己的幼崽，原因就是大气越来越暖，扯远了。
Lobectomy is not possible if there is:
Tranfissural growth.
Pulmonary vascular invasion.
这么冷的天气，版主怎么也因为苦劳给我一分吧，呵呵。
Invasion of main bronchus.侵犯主支气管。
Involvement of upper and lower lobe bronchi.包括上下叶支气管。
Thin collimation and MPR are necessary in order to clearly demonstrate the relation of a tumor with the fissure.
薄层扫描和多平面重组(multiplanar reconstruction MPR)可以明确肿块与肺裂之间的关系。
On the left a case with transfissural growth on both coronal and sagittal reconstructions.
上图可见冠面和矢状面都都有肿瘤生长。（如果肺裂不会看，可以看左图的左侧，主动脉弓上缘可见一水平线，那个就是肺裂。）
Lobectomy is not possible.
有肺裂侵犯被列为叶切除术禁忌。
T-Staging
T分期了。
见下图
T-staging is best done with CT to determine the local extent and to look for satellite nodules.
CT是T分期最好的工具，可以明确局部侵犯和卫星结节。
There are advantages if CT precedes bronchoscopy and the information from CT is used by the bronchoscopist.
支气管镜前行CT也是必要的。
CT however has important limitations in overall staging.
总体分期CT有很大的限制。
Preoperative predictions with CT differ from operative staging in 45% of cases.
Patients are being both over- and understaged.
手术分期后只有45%跟术前CT分期吻合。病人分期可能被高估或者低估。
CT staging remains unsatisfactory for detecting hilar (N1) and mediastinal (N2 and N3) lymph node metastases, and for chest wall involvement (T3) or mediastinal invasion (T4), in which sensitivity and specificity can be less than 65%.
CT分期不能满意检测肺门（N1）和纵隔（N2和N3）淋巴结转移，并胸壁（T3）侵犯或纵隔侵犯（T4），其敏感性和特异性，低于65％。
MR is more useful than CT in the following cases:
以下MR就更有用了。
mediastinal ingrowth 纵膈内生长
pancoast tumor 肺上钩癌
vertebral ingrowth 侵犯椎体
PET has a limited role in T-staging because of its lack of resolution.
PET however is of great value in N- and M-staging.
累了，明天再继续吧。
开始分期了
T1 – tumor
Diameter of 3 cm or smaller and surrounded by lung or visceral pleura or
endobronchial tumor distal to the lobar bronchus
直径小于等于3厘米，或者被肺组织、胸膜包围，肿瘤未侵犯叶支气管近端（未侵犯主支气管）
On the left a typical T1 tumor.
T2 – tumor
Greater than 3 cm
肿瘤直径大于3cm
Invasion of the visceral pleura 侵犯脏层胸膜
Atelectasis or obstructive pneumopathy involving less than the whole lung非累计全肺的肺不张或肺阻塞。
Tumor involving the main bronchus ，2 cm or more distal to the carina.
侵犯主支气管，但距离隆突2cm以上。
On the left a typical T2 tumor with obstructive infiltrate of the left lower lobe.
The tumor is located in the main bronchus, but the distance is more than 2 cm from the carina.
T3 – tumor
Tumor with atelectasis or obstructive pneumonitis of the entire lung 与肿瘤相关的阻塞性肺病或者肺不张。
Tumor in the main bronchus within 2 cm of the carina but not invading it
Tumor of any size with invasion of non-vital structures such as the chest wall, mediastinal pleura, diaphragm, pericardium.
距离隆突小于2cm，肿瘤侵犯以下非关键组织，胸壁，壁层胸膜，膈肌，心包。
Chest pain usually indicates chest wall invasion (i.e.T3).胸痛通常提示肿瘤侵犯胸壁（当然胸膜牵拉或者胸膜不光滑也会胸痛，但是却经常与呼吸相关。）
A Pancoast tumor is a tumor that involves the superior sulcus and the chest wall is almost always involved in these patients (i.e. T3).肺上钩瘤也位列其中。
Local chest wall invasion can be treated with en-bloc resection. 局部胸壁侵犯可以行局部切除。
On the left a typical T3 tumor.侵犯胸壁的肺上沟瘤。
T4 – tumor
Invasion of vital mediastinal structures ((heart, trachea, esophagus, great vessels). 侵犯纵膈重要器官（心脏，气管，食道，大血管）
Invasion of vertebral body 椎体
Malignant pleural or pericardial effusion (cytologically proven) 恶性胸腔积液和心包积液
Satellite tumor within the same lung as the primary tumor (biopsy proven).同一肺内的卫星病灶。
On the left an endobronchial tumor of the left main bronchus within 2 cm of the carina.
This means that it is at least a T3 tumor.
There is also invasion of the mediastinum (blue arrow) and invasion of the pulmonary artery (small yellow arrow), indicating that this is a T4-tumor.
下图分析，距离隆突小于2cm，也就是说最少T3，同时侵犯纵膈（蓝箭头），侵犯肺动脉（黄箭头），证明这个是T4.
其实挺累的，做医生也是很无聊的，读无聊的书作无聊的人，可能人生有时候比较无奈，苦中一点甜，总感觉比别人懂多一点点或者今天收获一点点，心里还是有点滋味的。
牢骚发完，继续努力。
In many cases T4-tumors do not pose a diagnostic dilemma.
On the left we see a large mass that invades the mediastinum.图上可见一侵犯纵膈的大肿块
There is complete obliteration of the superior vena cava with collaterals in the para-aortic and paraspinal regions.上腔静脉完全闭塞，包括腹主动脉旁区和椎体旁区。
The aortic arch is partially surrounded by tumor. 主动脉弓被部分包绕
T4 – tumor (2)
On the left another straight forward case.
The tumor invades the mediastinum and surrounds and narrows the right pulmonary artery.肿瘤侵犯纵膈和包绕肺动脉，同时肺动脉可见狭窄。
T4 – tumor (3)- mediastinal invasion
In many cases it is not certain whether there is mediastinal invasion.未必侵犯纵膈的情况：
These are patients with a mass that is not clearly invading the mediastinum but that do not have an intervening fat-plane (Figure).这句话翻译可能为：不清楚是否侵犯纵膈，但是脂肪间隙不清楚。an intervening fat-plane 这个词不知道什么意思。
In the case on the left there is an intimate relationship of the tumor with the right brachiocephalic vein.图上可见肿块与上肢静脉距离非常近。
This should be dagnosed as ‘indeterminate mediastinal invasion’.这就是不可确定纵膈侵犯
This patient should be given the benefit of the doubt and get an operation, since that is the only chance for definitive cure.手术是唯一明确方法。
At surgery the tumor fell away from the mediastinum and was subsequently succesfully resected.书中发现肿块远离纵膈和成功被切除。
On the left an odd case, that was recently published in the NEJM, to illustrate the difficulty of determining mediastinal invasion (11).这个一个难以确定是否侵犯纵膈的个案。
A CT showed a mass in the right upper lobe, closely associated with the paratracheal soft tissues, indicating possible mediastinal invasion.
可见肿块与气管接近，那就有可能侵犯纵膈。
A needle biopsy of the mass resulted in a pneumothorax. 活检后导致了气胸
Repeat CT imaging with the patient in a right decubitus position revealed that the mass had moved with the lung and had separated completely from the trachea and mediastinum.气胸后肿块位移。
Evidently this is not a T4-tumor, but a T2-tumor. 最后明确T2.
The patient underwent resection of the right upper lobe.
就像不是去发现青霉素却找到青霉素一样，峰回路转，柳暗花明。
这里没有直译，只是把关键的东西翻译出来，需要看原文的请到网站http://www.radiologyassistant.nl/en/42459cff38f02
精彩1！谢谢！
怎么还是老的分法
复习一下