Download Lung -- CS Lymph Nodes

The Anatomy of
Collaborative Staging:
Lung
Presentation developed by
April Fritz, RHIT, CTR
[email protected]
SEER Program
National Cancer Institute
Lung Cancer
 Estimated 12.7% of all 2004 cancer cases
 Collaborative Stage fields
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Tumor Size--special codes
Extension
TS/Ext Eval--non-standard mapping
Lymph Nodes
LN Eval--non-standard mapping
LN Pos--standard
LN Exam--standard
Mets at Dx
Mets Eval--standard
Site-specific factors 1-6--not used
CS Lung Coding 2004
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Lung -- Tumor Size
 Site-specific (not standard) table
 Special codes
000-990
Standard definitions
991-995
Less than _ cm
 Use if precise size not available
996
Occult carcinoma (TX)
997
998
CS Lung Coding 2004
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(malignant cells in bronchopulmonary
secretions; no tumor seen)
Diffuse (entire lobe) (M1)
Diffuse (entire lung) (M1)
Lung -- CS Extension -- Notes
1. Direct extension to other structures is M1.
Sternum, skeletal muscle, skin of chest, contralateral lung or mainstem bronchus, separate
tumor nodules in different lobe
2. If resection done, assume tumor is > 2 cm
from carina.
3. Assume opposite lung is not involved
unless mentioned on x-ray/imaging.
4. Do not include bronchopneumonia with
atelectasis in code 40 or 55.
5. Involved pulmonary artery/vein must be
inside pericardium to be coded as 70.
CS Lung Coding 2004
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Lung -- CS Extension -- Notes
6. Pleural effusion
a. ignore negative pleural effusion (not 72)
b. assume negative if resection performed
c. ignore if clinical judgement says effusion
is not related to tumor
7. Vocal cord paralysis--SVC obstruction-compression of trachea/esophagus
a. use Extension code 70 unless tumor is
peripheral
b. use LN code 20 if tumor is peripheral
 Code an extension where it appears.
• Computer algorithm will correctly assign the stage
CS Lung Coding 2004
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Lung -- CS Extension -- 00-11, 23-30
B
Code 00 Very rare
C
E
F
D
A
Code 10 Confined to
lung; needs size
Code 11 Superficial
bronchus only (D)
Code 23 Starts in hilus
(E); needs size
Code 25 Starts in
carina (F); needs size
CS Extension Code 10
Code 30 Localized, NOS
Tumor surrounded by lung (A) or
visceral pleura (B); no invasion more
proximal than a lobar bronchus (C)
CS Lung Coding 2004
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Lung -- CS Extension -- 20-21, 45
C
A
B
>2 cm
CS Extension Codes
20 In main bronchus > 2 cm from carina (A)
21 Involving mainstem bronchus, distance not stated (B)
45 Invading visceral pleura (C)
CS Lung Coding 2004
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Lung -- CS Extension -- 40
B
A
Extension Code 40
Tumor associated with atelectasis (A) or
obstructive pneumonitis (B) that extends to the hilar region
but does not involve entire lung; no pleural effusion
CS Lung Coding 2004
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Lung -- CS Extension -- 50-55
2 cm
B
A
Extension Codes
50 Tumor in main bronchus < 2 cm from carina without
involving carina (A); also 52 and 53
55 Atelectasis or obstructive pneumonitis of entire lung (B)
CS Lung Coding 2004
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Lung -- CS Extension -- 56-61
Superior
sulcus
Clavicle
Trachea
B
E
A
D
C
Ribs
D
Pleura
Pleural
space
Pericardium
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Diaphragm
Extension Codes
Direct extension to:
56 Parietal pericardium
(A)
59 Phrenic nerve (not
shown)
60 Brachial plexus
from superior sulcus
(B); Pancoast tumor
60 Chest wall (C)
60 Diaphragm (D)
60 Parietal pleura (E)
61 Upper brachial
plexus (not shown,
similar to B)
Lung -- CS Extension -- 70, 71, 73, 75
C
E
D
B
D
Direct invasion of any of
the following:
70 Mediastinum (A)
71 Heart, visceral
pericardium (B)
70 Trachea (C)
70 Great vessels (D)
70 Carina (E)
Not shown:
70 Esophagus
(behind trachea)
A
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70 Nerves
73 Adjacent rib
75 Vertebral body
(posterior to lung)
Lung -- CS Extension -- Great Vessels
70
70
70
70
70
74
77
Superior vena cava
Main pulmonary artery
R and L pulmonary artery trunks*
R and L superior pulmonary veins*
R and L inferior pulmonary veins*
Aorta
Inferior vena cava
* intrapericardial segments
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Lung -- CS Extension -- 65, 72
C
A
B
Pleura
Pleural effusion
(malignant or NOS)
Pleural space
65
72
76
79
Extension Codes
Separate tumor nodules in same lobe (A)
Any tumor with malignant pleural effusion (B)
Discontinuous pleural tumor foci (C)
Pericardial effusion (not shown)
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Lung -- CS Extension
Discontinuous Nodules
 Discontinuous tumor foci in ipsilateral
parietal and visceral pleura from direct
pleural invasion by primary tumor:
Extension code 76
 Discontinuous tumors outside the
parietal pleura in chest wall or
diaphragm: Mets at Dx code 40
CS Lung Coding 2004
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Lung -- CS Extension
Remaining Extension Codes
80 Further contiguous extension
(other than structures specified in Mets at Dx)
95 No evidence of primary tumor (T0)
98 Occult carcinoma (malignant cells in sputum
or bronchial washings but lesion not seen)
99 Unknown extension; not assessed;
not documented
CS Lung Coding 2004
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Lung -- CS TS/Ext Eval
 Non-standard mapping for TS/Ext Eval
• Code 1 maps to pathologic
 Includes endoscopic biopsies, FNA, surgical
observation
 Linked to CS Extension and Tumor Size
 Document farthest extension clinically or
pathologically
• May not be highest eval code
• Document information most useful for staging
 Tumor size where appropriate
 Extension where appropriate
CS Lung Coding 2004
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Lung -- Coding CS TS/Ext Eval
 Example 1
• Lung cancer, CXR shows 4 cm mass in medial RUL.
Mediastinoscopy and FNA bx shows direct tumor
extension through pleura into anterior
mediastinum.
Patient referred for radiation therapy.
Codes: Tumor size 040 clinical (CXR)
Extension
70 mediastinal extension
TS/Ext Eval 1 endoscopic, FNA.
Extension determines the mapping (pT4).
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Lung -- Coding CS TS/Ext Eval
 Example 2
• Lung mass, CXR shows 3.5 cm mass in RML. FNA
shows squamous carcinoma. Resected specimen
shows that tumor is surrounded by normal tissue
but tumor size is actually 2.8 cm.
Codes: Tumor size 028 path specimen
Extension
10 confined to one lung
TS/Ext Eval 3 surgical resection,
no pre-op treatment
Tumor size from path report determines the
mapping (pT1).
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Lung -- Coding CS TS/Ext Eval
 Example 3
• Lung 5 cm RLL mass on CXR. CT scan shows pleural
effusion on right. FNA of mass shows small cell
carcinoma.
Codes: Tumor size 050 path specimen
Extension
72 pleural effusion (NOS)
TS/Ext Eval 0 clinical (CT scan)
Clinical findings document farther extension
than tissue findings.
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Lung -- CS Lymph Nodes -- Notes
1. Code only regional nodes in this field.
2. ‘Mass,’ ‘adenopathy’ or ‘enlargement’ of
any nodes in code 20 are assumed to be
involved.
3. Assume nodes are negative if stated as ‘No
evidence of spread’ or ‘remaining exam
negative’ and no other comment about
nodes.
4. Vocal cord paralysis--SVC obstruction-compression of trachea/esophagus
a. use Extension code 70 unless tumor is peripheral
b. use LN code 20 if tumor is peripheral and no
statement of direct extension from a primary
tumor
CS Lung Coding 2004
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Lung -- CS Lymph Nodes
Lymph Nodes
60
20
60
10
6
0
20
10 Same side
Hilar, bronchial,
peribronchial,
intrapulmonary
(LN stations 10-14)
20 Same side
Subcarinal,
mediastinal, others
(LN stations 1-9)
50 Regional LN, NOS
60 Contralateral
Mediastinal, hilar
any scalene, any
supraclavicular
80 Lymph nodes, NOS
99 Unknown,
undocumented
Adapted from R S Snell: Clinical Anatomy for Medical Students, 5th ed. 1995.
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Lung -- CS Lymph Nodes
Lymph Node Stations
Based on surgical
landmarks
Not the same as
LN codes
Station
CS LN
1-9 ipsilat
20
1-9 contralat
60
10-14 ipsilat
10
10-14 contralat 60
Source: Workbook for Staging of Cancer, 2nd ed., pages 110-111
CS Lung Coding 2004
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Lung -- CS Reg Nodes Eval
 Non-standard mapping for Reg Nodes Eval
• Code 1 maps to pathologic
 Includes endoscopic biopsies, FNA, surgical
observation
 Document farthest extension clinically or
pathologically
• May not be highest eval code
• Document information most useful for staging
CS Lung Coding 2004
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Lung -- Coding Reg Nodes Eval
 Example 1
• Lung cancer, CXR shows 4 cm mass in right hilum.
Mediastinoscopy and FNA bx of left hilar nodes
shows poorly differentiated adenocarcinoma.
Patient referred for radiation therapy.
Codes: CS Lymph Nodes 60 Contralateral hilar
Reg Nodes Eval
1 FNA lymph nodes
Farthest involved lymph nodes confirmed by FNA
(pN3). No need for complete resection of nodes.
CS Lung Coding 2004
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Lung -- Coding Reg Nodes Eval
 Example 2
• Lung mass, CXR shows left hilar mass, likely
involved LN. FNA shows squamous carcinoma.
Physical examination indicates hard left
supraclavicular lymph node. Pt referred to medical
oncologist.
Codes: CS Lymph Nodes 60 Ipsilat. supraclav LN
Reg Nodes Eval
0 Clinical
Although hilar nodes (code 10) are proven by bx,
clinical exam documents farther extension (cN3).
CS Lung Coding 2004
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Lung -- CS Mets at Dx -- Notes
1. For Mets at Dx, M0 or M1 is decided on
the basis of Tumor Size.
 If Tumor Size is 998 (diffuse), Mets at Dx is M1
 For any other Tumor Size, Mets at Dx is M0
CS Lung Coding 2004
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Lung -- CS Mets at Dx
A
Primary
tumor
B
C
separate
contralateral
tumor nodule
CS Mets at Dx Codes
separate
ipsilateral
tumor
nodule
10 Distant lymph nodes (A)
Separate tumor nodules
in a different lobe:
D
35 Ipsilateral (B);
39 Contralateral (C)
40 Distant metastasis (D)
liver
metastasis
Not shown:
37 Extension to sternum, skeletal muscle, skin of chest
39 Extension to contralat lung, mainstem bronch.
50 (10 + 40)
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Lung -- Site-Specific Factors
NONE!
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