4.1 Staging Classification

4.1.1 Conventional two-stage system
SCLC is traditionally staged as limited or extensive disease, according to Veterans Administration Lung Group system. Definition of limited disease is based on the possibility of encompassing all the detectable tumor within a 'tolerable' radiotherapy port. A definition of what a tolerable radiotherapy port is is still lacking. The prognosis and the choice of therapeutical modalities of SCLC patients depends on the disease extension.

4.1.2 Limited disease
Limited disease should include patients with disease restricted to one hemithorax with regional lymph node metastasis (including ipsilateral and contralateral hilar, mediastinal and supraclavicular nodes) and with malignant pleural effusions. Left laryngeal nerve involvement and superior vena cava obstruction are considered as limited disease. Recently, patients with contralateral mediastinal and/or supraclavicular metastasis and/or ipsilateral pleural metastasis have been included in this setting being their prognosis better than that of patients with distant metastatic sites.

4.1.3 Extensive disease
Extensive disease represents any tumor beyond these bounds.

4.1.4 Other classifications
The usefulness of the TNM classification is superior to the conventional classification system only in very limited disease.

4.1.5 TNM classification (UICC/AJC, 1992)

TX:	Primary tumor can not be assessed, or tumor proven by the presence of malignant cells in sputum or bronchial washings but not visualized by imaging or bronchoscopy
T0:	No evidence of primary tumor
Tis:	Carcinoma in situ
T1:	Tumor 3 cm or less in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e., not in the main bronchus)
T2:	Tumor with any of the following features of size or extent: More than 3 cm in greatest dimension Involving main bronchus, 2 cm or more distal to the carina Invading the visceral pleura Associated with atelectasis or obstructive pneumonitis that extends to the hilar region but does not involve the entire lung
T3:	Tumor of any size that directly invades any of the following: Chest wall (including superior sulcus tumor), diaphragm, mediastinal pleura, or parietal pericardium or tumor in the main bronchus less than 2 cm distal to the carina or associated atelectasis or obstructive pneumonitis of the entire lung
T4:	Tumor of any size that invades any of the following: mediastinum, heart, great vessels, trachea, esophagus, vertebral body, carina or tumor with malignant pleural effusion
NX:	Regional lymph nodes cannot be assessed
N0:	No regional lymph node metastasis
N1:	Metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes, including direct extension
N2:	Metastasis in ipsilateral mediastinal or subcarinal lymph node(s)
N3:	Metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph node(s)
MX:	Presence of distant metastases cannot be assessed
M0:	No distant metastases
M1:	Distant metastases

4.1.6 Stage grouping (UICC/AJC, 1992)

Occult carcinoma	TX	N0	M0
Stage 0	Tis	N0	M0
Stage I	T1 T2	N0 N0	M0 M0
Stage II	T1 T2	N1 N1	M0 M0
Stage IIIA	T1 T2 T3	N2 N2 N0,N1,N2	M0 M0 M0
Stage IIIB	Any T T4	N3 Any N	M0 M0
Stage IV	Any T	Any N	M1

4.2 Staging and restaging procedures

4.2.1 Aim of staging
The staging procedures for SCLC are aimed at the evaluation of the extension of disease and at the definition of the treatment strategy. Maximization of staging procedures is of benefit in the identification of good prognosis patients amenable to locoregional treatment.

4.2.2 Staging procedure
The recommended staging procedures include:

Chest X-ray

Ultrasound or CT upper abdomen

Radionuclide bone scan

CT or MRI brain

References

4.I
Campling B, Quirt I, DeBoer G et al. Is bone marrow examination in small cell lung cancer really necessary? Ann Int Med 1986; 105: 508-512.