Slide 1 Collaborative Stage Site-Specific Instructions - LUNG In this presentation, we are going to review the AJCC Cancer Staging criteria for the lung primary site. Slide 2 Reading Assignments As each data item is being discussed, you should stop and read the information in CSv2 Part II for the lung and CSv2 Part I, Section 2 for that data item including the associated notes, codes and definitions. 2 It is important that you follow along and make notes in your manual. In addition to reading the slides and the instructor s notes, it is important that you stop and read the related sections in your manual as not every point will be discussed in detail. As we go through each data item, don t forget the general rules. They still apply. These will not be discussed in detail. Only those things that are specific to the lung schema will be discussed. Also, don t forget about the information you learned in the AJCC presentation, such as the discussions on hilar versus hilum, clinical findings that are often missed, and pleural effusions. These concepts apply to CS as well.
Slide 3 CS Lung Schema CS TS/Ext Eval CS Lymph Nodes Eval CS Reg LN Pos CS Reg LN Exam CS Mets Eval Refer to the General Rules Refer to the CS Breast presentation 3 As we discuss each site specific schema, many of the concepts are the same throughout and do not need to be repeated. The data items listed on this slide will not be discussed again. These data items follow the general rules and do not differ from the discussion provided in the CS Breast presentation. For the Eval fields, refer to the clinical and pathologic staging criteria in the AJCC manual and in the AJCC Lung presentation for the procedures that qualify for each eval code. Also, for those data items that are discussed, many of the concepts for the general rules will not be repeated. The presentation will focus on those areas specific for the lung.
Slide 4 CS Tumor Size Records the largest dimension or diameter of the primary tumor Needed to assign the AJCC T category in certain cases Special Codes for the Lung: 996 Occult carcinoma. No visible tumor, but malignant cells in sputum (CS Extension Code 980) 997 Diffuse tumor involving entire lobe 998 Diffuse tumor involving entire lung. Diffuse, NOS Do not code size of hilar mass unless the primary tumor is stated to be in the hilum 4 For the most part, the tumor size for the lung follows the general rules for this data item. There are a few codes that have a description that applies specifically to the lung. For example, if they do a sputum cytology that contained malignant cells, but the radiology was negative for tumor, then assign the tumor size as 996. These occult tumors will also have a CS Extension code of 980. These special codes have priority over the other codes. And, following through from our discussion on hilar versus hilum in the AJCC presentation, the description of hilar can be describing either the primary tumor or lymph node involvement. Only code the size of the hilar mass if it stated to be the primary tumor and not the lymph node mass. The tumor size is needed to derive the AJCC T category in certain instances. Avoid coding unknown if at all possible.
Slide 5 CS EXTENSION - LUNG Contiguous (direct) extension of the primary tumor Within the organ of origin or Directly into neighboring organs Code the farthest documented extension of the primary tumor. Do not include discontinuous (separate) metastases to distant sites. These are coded in CS Mets at Dx 5 In the CS Extension, we are going to document how far the primary tumor has directly extended into the surrounding tissues, organs, or other structures. If there is a separate site of tumor, it is not a factor in this data item. Use the CS Mets at DX field.
Slide 6 CS EXTENSION NOTE 1 Direct extension to or involvement of these structures is coded in the data item CS Mets at DX. CS Mets Code 23 D.E. to Contralateral Lung D.E. to Contralateral MSB Separate Tumor Nodule(s) in Contralateral lung CS Mets Code 37 Sternum Skeletal Muscle Skin of Chest CS Mets Code 40 Rib 6 Use CS Extension Code 730 when there is direct extension from the primary tumor into an adjacent rib. There are a few exceptions. There are a few neighboring structures that are NOT included in the CS Extension data item. They are listed here on the slide and in Note 1. If there is direct extension into these structures, then it is coded in the CS Mets at Dx data item. Look at the CS Extension code 730. To use code 730, there has to be direct extension from the primary tumor into an adjacent rib (which means it has to be on the same side as the involved lung). If it is a completely separate tumor in the rib, then it is coded in CS Mets at Dx, code 40.
Slide 7 CS Extension Local (T1 or T2) B E A F D C (D) Code 110 Superficial bronchus only, any TS (E) Code 230 Confined to hilus; need TS (F) Code 250 Confined to carina; need TS Code 300 Localized, NOS 7 CS Extension Code 100 Confined to Lung, need TS (A) Tumor surrounded by lung (B) Or by visceral pleura; (C) No invasion more proximal than a lobar bronchus The next few slides show a comparison of what AJCC T category will be derived based on what you entered in the CS Tumor Size and CS Extension data items. Note that it takes both fields to derive the T for many codes, so avoiding unknowns in both of these is very important. A tumor size of more than or less than 3cm is the deciding factor as to whether these are a T1 or a T2. To use a code 100 (tumors A-C), it has to be completely surrounded by lung tissue or the visceral pleura. It can extend into a lobar bronchus but no farther. Most cases surrounded by normal tissue are coded to 100. Do not code superficial tumors as code 100. Superficial lung tumors of any size are coded to 110 (D). Superficial tumors are located near the surface of the lung and minimally invasive, and the invasion is limited to the bronchial wall. The tumor in the hilum (E) in this picture looks like it is in the middle of the upper lobe, but if you will remember the side view of the lung, this is actually that area where the bronchus enters the lung. Often we think of hilum being near the top or the apex of the lung, but that is not always the case. If the tumor is confined to the hilum, use cod 230. If the tumor is confined to the carina, use code 250 (F). And, even though code 300 is a higher code for local, use this code only if there is not enough information to assign the more specific codes of 100-250.
Slide 8 CS EXTENSION NOTE 2 Distance from Carina For tumors involving the ipsilateral main stem bronchus 8 Local Code 200 (T2) Extension to MSB from other parts of the lung and stated to be >= 2cm away If MSB involved and resection was done - assume > 2cm away Code 210 (T2) Distance not stated Surgery not done Regional Code 500 (T3) Extension to MSB from other parts of the lung and stated to be < 2cm away Code 700 (T4) Tumor extends all the way to the carina Note 2 addresses tumors that involve the ipsilateral main stem bronchus (contralateral involvement is coded in CS Mets at Dx). The tumor could have either arisen in the MSB or started somewhere else in the lung and extended to involved the MSB. If the tumor involves the main stem bronchus, we need to determine: Did it arise in the main stem bronchus? If not, did it extend to involve the MSB and if so, how far from the carina is it? The deciding factor for distance is 2cm. Is it less than or equal to 2 cm away or more than 2cm away? Use code 200 if the tumor: extended from other parts of the lung to involve the MSB and it was stated to be >= 2cm away. is confined to the MSB but is 2cm or more AWAY from the carina. involved the MSB and a resection was done. We can assume that the tumor must have been greater than 2cm away if they did surgery (lobectomy, segmental resection, or wedge resection). If the tumor is involving the main stem bronchus but the distance from the carina is not stated, then use code 210. For these cases, surgery would not have been done. If the tumor arose in the MSB or it extended into the MSB and it was stated to be LESS than 2cm away, this is considered more extensive and is coded to code 500. If the tumor extends all the way to involve the carina for other parts of the lung or MSB, use code 700.
Slide 9 CS Extension Code 400 (T2) H G 9 (G) Tumor associated with atelectasis or (H) Obstructive pneumonitis that extends to the hilar region but does not involve entire lung; no pleural effusion Review the discussion in the AJCC lung presentation on atelectasis and obstructive pneumonitis. Use code 400 for tumors that are associated with atelectasis (G) or obstructive pneumonitis (H) that extends to the hilar region. This may also be called partial atelectasis or obstructive pneumonitis.
Slide 10 CS Extension Code 410-440 (T2) I (I) Codes 410-430 Invades visceral pleura 10 If the tumor extends to involve the visceral pleura (I) the codes that apply are codes 410-430. The exact code depends on whether or not the elastic layer is involved. Review the related paragraph in the AJCC manual in the lung chapter. If this involvement is not mentioned, then use code 430. Code 440 is used when the most extensive tumor involvement is of the pulmonary ligament.
Slide 11 CS Extension Code 550 (T3) Code 550 - Atelectasis or obstructive pneumonitis of ENTIRE lung 11 If the atelectasis or obstructive pneumonitis involves the ENTIRE lung, then assign code 550. Also in the 500 range are the following: Code 560 - Parietal pericardium or pericardium, NOS. This is not the same as a pericardial effusion. This is direct involvement of the actual parietal pericardium. Code 590 - Invasion of phrenic nerve
Slide 12 CS Extension Codes 600-610 (T3 or T4 ) Code 600: INFERIOR brachial plexus Chest Wall Diaphragm Pancoast tumor Parietal pleura Code 610: Superior sulcus tumor WITH Encasement of subclavian vessels OR Unequivocal SUPERIOR brachial plexus 12 Review the discussion on Pancoast tumors in the AJCC Manual and Lung presentation. Code 600 includes involvement of the following structures: Brachial plexus, INFERIOR branches or NOS, from superior sulcus Chest (thoracic) wall Diaphragm Pancoast tumor (superior sulcus syndrome), NOS Parietal pleura. Again, this is not the same as a pleural effusion. This is direct extension to the actual parietal pleura. Code 610 includes the following: Superior sulcus tumor WITH encasement of subclavian vessels OR WITH unequivocal involvement of SUPERIOR branches of brachial plexus (C8 or above)
Slide 13 CS Extension Code 700 Pulmonary artery/vein involvement by direct extension of the primary tumor - If involvement of artery/veins in the mediastinum, code to 700 - If involvement appears to only be within the lung tissue, ignore, and do not code to 700. 13 CS EXTENSION Note 5 Code 700 has several different types of involvement included in it, including most major blood vessels. It is natural that a tumor, even in the lung tissue will likely involve some of the blood vessels with the lung tissue the lung is very vascular. What we are looking for is when the tumor grows beyond the lung tissue into the major blood vessels (such as those listed on the next slide). If so, then code to 700. If not, then code based on the all other elements of the tumor involvement.
Slide 14 CS Extension - Major Blood Vessels (T4) 14 700 Superior vena cava 700 Main pulmonary artery 700 R and L pulmonary artery trunks* 700 R and L superior pulmonary veins* 700 R and L inferior pulmonary veins* 740 Aorta 770 Inferior vena cava * intrapericardial segments This slide provides an expanded list of what is considered major blood vessels. Most of them are coded to code 700 except for the aorta and inferior vena cava.
Slide 15 CS EXTENSION - Code 700 versus CS LYMPH NODES - Code 200 Vocal cord paralysis Superior vena cava obstruction Compression of trachea or esophagus These conditions may be related to direct extension of the primary tumor (CS Ext code 700) or to lymph node involvement (CS LN code 200). 15 CS EXTENSION Note 6, CS LYMPH NODES Note 4 Review the discussion on vocal cord paralysis in the AJCC manual and in the lung presentation. Code 700 also includes vocal cord paralysis, superior vena cava obstruction, or compression of the trachea or the esophagus. These conditions may be related to direct extension of the primary tumor or to lymph node involvement. If due to direct extension of the primary tumor, code in the CS Extension data item.
Slide 16 Use CS Extension Code 700 (T4) If conditions are due from extension of the primary tumor within the lung Usually, the primary tumor is centrally located In general, code 700 is used for these manifestations 16 As a general guideline, if the tumor is located centrally within the lung itself, and you have any of the conditions listed on the previous slide, you should assign a CS Extension code of 700. If the medical record indicates otherwise, code as indicated. The red hashmark area is the SVC obstruction, etc.
Slide 17 Use CS Lymph Nodes Code 200 (N2) If these conditions are clearly not related to direct extension of the primary tumor Usually, the primary tumor is located in the periphery of the lung Therefore, considered mediastinal lymph node involvement 17 If the primary tumor is peripheral and clearly unrelated to the conditions listed on the previous slide, code as mediastinal lymph node involvement (code 200) in CS Lymph Nodes unless there is a statement of involvement by direct extension from the primary tumor.
Slide 18 Lung -- CS Lymph Nodes 60 10 20 20 60 60 Lymph Nodes 100 Same side Hilar, bronchial, peribronchial, intrapulmonary 200 Same side Subcarinal, mediastinal, others 500 Regional LN, NOS 600 Contralateral Mediastinal, hilar any scalene, any supraclavicular 800 Lymph nodes, NOS 999 Unknown, undocumented Adapted from R S Snell: Clinical Anatomy for Medical Students, 5th ed. 1995. 18 Note 1. The regional nodes for the lung are listed in codes 100-600. All other nodes are coded in the Mets at Dx field. Codes 100 and 200 refer to ipsilateral. Code 600 refers to contralateral or bilateral. Code 600 also includes ipsilateral and contralateral scalene and supraclavicular.
Slide 19 CS LYMPH NODES NOTES 2-3 2. Assume the lymph nodes are involved if the words mass, adenopathy, or enlargement are used to describe any of the lymph nodes named in codes 100 and 200. If ipsilateral, use codes 100 or 200. If bilateral or contralateral, use code 600. 3. No Evidence of Spread or Remaining Examination Negative is sufficient information to consider regional lymph nodes negative (in the absence of any statement about nodes). 19 2. For LUNG, assume the lymph nodes are involved if the words mass, adenopathy, or enlargement are used to describe any of the lymph nodes named in codes 100 and 200. If the description is of ipsilateral nodes, use codes 100 or 200. If bilateral or contralateral, use code 600. 3. Lung is considered an inaccessible site because the site and the regional lymph nodes cannot be easily palpated. You should record the regional lymph nodes as negative rather than unknown when there is no mention of regional lymph node involvement in the physical examination, pre-treatment diagnostic testing or surgical exploration. No Evidence of Spread or Remaining Examination Negative is sufficient information to consider regional lymph nodes negative (in the absence of any statement about nodes).
Slide 20 CS Lymph Nodes Issues If both clinical and pathological assessments of nodes are available, which should be coded? Code the farthest extension Example: RUL wedge resection, one interlobar lymph node involved (code 100). Pre-op CT scan shows right mediastinal node enlarged. Patient referred for RT. Code as 200 mediastinal node(s) involved with Eval code 0 (clinical). 20 Remember that clinical information can be used in assigning the CS data items. The exception is if the pathology examines the same nodes as described clinically and were proven to be negative. For example, if the mediastinal node had also been biopsied and was negative, then only the interlobar nodes should be considered as involved. The CS Extension code will be 100 and the eval code will be 1.
Slide 21 CS METS at DX Use Code 00 (not code 99), when there is no information regarding metastasis, but the patient receives the standard treatment for localized or early stage disease Use Code 23 if the contralateral lung is involved AND it is documented as a metastasis Two separate primaries were ruled out Use code 40 if the only indication of distant metastasis is a physician statement in the medical record 21 Cervical Lymph Nodes are Distant!
Slide 22 CS Mets at Dx Codes 15-20 Most pleural effusions are due to tumor Any mention of pleural effusion is coded Codes 15-18: Pleural effusion Code 20: Pericardial effusion Credit line: Lung. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer Staging Atlas. New York: Springer, 2006: 167-176. American Joint Committee on Cancer. 22 Review the discussion on pleural effusion in the AJCC manual and in the lung presentation. Pleural effusions and pericardial effusions are coded in the CS Mets at Dx data item. The exact code for the pleural effusion involvement depends on whether it is ipsilateral (code 15), contralateral (code 16), both (code 17) or unknown (code 18). Pericardial effusions are assigned code 20.
Slide 23 CS Mets at Dx Code 24 Discontinuous pleural tumor foci (I) I Pleura (2 layers) Used with permission: April Fritz, A.Fritz and Associates, LLC Pleural effusion (malignant or NOS) Pleural space 23 This graph provides an example of a discontinuous pleural tumor foci that would be assigned code 24.
Slide 24 SSF 1: Separate Tumor Nodules Code 000: None (no mention on imaging or path) Code 010: Identified in SAME lobe ipsilateral lung Code 020: Identified in DIFFERENT lobe ipsilateral lung Code 030: Identified in ipsilateral lung Same and different lobe Code 010 Code 020 Code 040: Identified in ipsilateral lung Unknown if same or different lobe Code 999: Unknown There are only 2 SSF s for the lung. The first SSF records the status of separate tumor nodules in the SAME lung. The information to support the presence of multiple tumors can come from either the clinical workup (imaging) or the pathologic resection. Again, the MP/H rules will have been used to determine that these are the same primary. Any tumor nodules in the OPPOSITE lung will be recorded in CS Mets at Dx. This information was previously recorded in CS Extension. The codes were expanded and moved to SSF1. This information will be needed to derive the stage.
Slide 25 SSF 2: Visceral Pleural Invasion (VPI)/Elastic Layer Relevant for peripheral lesions Presence of VPI increases the T category and stage Determined on pathologic examination Codes based on four categories of VPI (PL0-PL3) 25 Review the related information on the elastic layer in the AJCC manual. VPI is relevant for peripheral lung tumors. The presence of visceral pleural invasion by tumors smaller than 3 cm increases the T category and stage. Involvement of the elastic layer can only be determined on pathologic examination. Therefore, this information is based on the results stated on the pathology report. If there was no examination of the pleura, use code 998. The information in the pathology report may be a text description, such as tumor surrounded by lung parenchyma. Or, one of the four categories (PL0-PL3) of visceral pleural invasion may be stated. You should be looking for either of these in the pathology report. Four categories are defined for visceral pleural invasion: PL0 Tumor surrounded by lung parenchyma or invades superficially into pleural connective tissue beneath elastic layer but does not completely traverse elastic layer of pleura (not classified as pleural invasion for staging purposes) PL1 Tumor invades beyond elastic layer (classified as T2) PL2 Tumor extends to surface of the visceral pleura (classified as T2) PL3 Invasion of parietal pleura (classified as T3)
Slide 26 Microscopic Anatomy of Visceral Pleura Moving from the visceral pleural surface to the lung parenchyma: 1. a single layer of mesothelial cells 2. a submesothelial connective tissue layer, 3. elastic fibers that usually form a single prominent layer (may also form a second discontinuous layer) 4. a connective tissue layer 26 This slide provides additional information regarding the anatomy of the visceral pleura. The layers moving from the visceral pleural surface to the lung parenchyma are listed in order.
Slide 27 Resources AJCC Cancer Staging Manual, Seventh Edition CDC NPCR Education and Training Series Collaborative Staging Manual and Coding Instructions ICD-O-3 SEER Training Website TNM Atlas, 3rd ed. 2nd rev., by B. Spiessl et al. Springer Verlag 1992 The graphics, coding instructions, and other supportive information were provided by the following resources. Slide 28 This Concludes This Presentation Please return to the course content to complete additional case scenarios to reinforce the coding instructions.