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T4 or MI?

      A 77-year-old veteran with little prior medical care and history of extensive tobacco use presented with 30-lb weight loss, cough, and failure to thrive. On examination, he was a frail, cachectic African American male with poor air movement and decreased breath sounds on the right lung. Abdominal examination was normal without tenderness or hepatomegaly. A chest radiograph revealed a large right lower lobe mass. Computed and positron emission tomography scans (FIGURE 1, FIGURE 2) revealed a large right lower lobe mass with central necrosis and direct invasion of the mass into the diaphragm and 3 cm into the dome of the liver. Both the right lung and liver displayed intense confluent peripheral fluorodeoxyglucose uptake. Fine needle biopsy of the right lower lobe mass revealed fine keratinizing squamous cell carcinoma. Because of poor performance status and evidence of other metastatic disease on the positron emission tomography scan, the patient was referred to hospice. However, had he been a candidate for therapy and without evidence of distant metastasis, the question was raised on appropriate staging. Does the right lung mass with direct invasion into the liver represent a T4 or M1 tumor? Direct invasion of the liver is not included in the current tumor, node, metastasis staging system.