Nonsmall Cell Lung Cancer Staging

Metastatic spread of NSCLC is very common, with bone, adrenal, and brain being the most common sites.14 Brain metastases occur in approximately 33% of patients. Solitary metastases are noted in approximately 30% of cases. NSCLC stages are typically designated I to IV, including subsets IIA, IIB, IIIA, and IIIB. Staging is determined using standard tumor, node, and metastasis (T, N, M) criteria. The extent of staging tests performed depends on a number of factors, including the presenting symptoms, the extent of disease, and the exact tumor type. A thorough medical history and physical examination are the most important steps in the staging and subsequent work-up of a patient with suspected lung cancer. Clinical symptoms suggestive of brain metastasis include headache, seizures, or focal neurologic deficits. If a thorough medical history and physical examination demonstrate no evidence of extrapulmonary metastases, and a chest computed tomography (CT) scan sug gests a localized disease process, patients are considered clinical stage I or II. Such patients do not necessarily require a full metastatic work-up. Patients with clinical evidence of either nodal or distant metastases (stages III or IV) require a full metastatic work-up, including a body CT scan, a bone scan, and typically a brain CT scan or magnetic resonance imaging (MRI) study. More recently, positron-emission tomography (PET) scans have been used to facilitate screening and assessment for disease, because this technique appears to have greater sensitivity for smaller disease burdens, and an entire body can be screened in a single study. All patients with metastases outside of the thorax are considered stage IV, including all patients harboring brain metastases regardless of the number of lesions identified.

Patients with stage IV lung cancer have very poor long-term survival or cure rates, with a 1-year actuarial survival of 10% to 20%.15 Recent chemotherapy trials have demonstrated 1-year survival rates of up to 40%, although these patients represent a reasonably select group of patients and may not be representative of the general population of stage IV patients. Regardless, most people with brain metastases have a poor long-term prognosis, and this factor must be carefully considered when determining treatment strategies for individual patients.

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