Lung Coding Bootcamp (updated 9-15-14)

Report
Lung
“Coding Bootcamp”
Nicole Catlett, CTR
2014 Kentucky Cancer Registry Fall Workshop
OBJECTIVES

Review Lung Topography

Review Lung Anatomy including visceral pleural layers & CS extension codes
including CS algorithm error

Knowledge of Elastic staining and reporting of pleural number (PL#)
category/coding in CS SSF2 field

Review 7th Edition AJCC T categories for Lung

Review path report examples

Understand the relationship between CS extension code & SSF2 code in
surgically resected lung cases with visceral/parietal pleural invasion
(combined chart created for reference)

Practice Exercises & Case Exercises
Sites +
Codes…
Lung Cancer Module. U. S. National Institutes of Health, National Cancer Institute, 02/03/12, <http://training.seer.cancer.gov/>.
3
TOPOGRAPHY CODES
ICD-O-3
c34.0
c34.1
c34.2
c34.3
c34.8
c34.9
Main Bronchus (Hilar mass considered
the primary)
Upper Lobe (apex)
Middle Lobe (right lung only)
Lower Lobe (base)
Overlapping lesion of lung (used when
one tumor in multiple lobes and it
can’t be determined which lobe the
tumor arose from)
Lung, NOS
Visceral pleura
(Parietal)
“PLEURAL-BASED”
**This issue has gone to AJCC several times. According to AJCC, "pleural
based" means location, not involvement. So, if that is the only extension
information you have, do not code involvement of the pleura.
So....this should NOT be used to specify invasion of the pleura. There are
a couple of reasons for this:

1. It is a descriptive term that is also used in non-neoplastic diseases
(e.g. pulmonary infarcts, pleural plaques).

2. Pleural invasion is defined as a pathologic finding where the tumor
crosses the visceral pleural elastica.
LAYERS OF VISCERAL PLEURA
Figure I-2-9. Layers of
Visceral Pleura.
Schematic drawing of
layers of visceral pleura
and relationship to
adjacent structures with
PL codes. Created by
A.Fritz, CTR. (CS manual
part I, section II, site
specific instructions, lung)
Elastin stain may be performed to
determine if the tumor invades
and/or extends through the elastic
layer
Summary of Elastin Stain

The elastic layer may be identified on hematoxylin and eosin (H&E) stains or
by special stains looking for the elastic fibers (EVG elastic Verhoeff-van
Gieson).

An elastic stain is not needed in most cases to assess the pleura for invasion,
only in those cases where the distinction between PL0 and PL1 is unclear on
H&E sections.

Elastic stains may also be helpful in cases where the visceral and parietal
pleura are adherent, making it difficult to identify the boundary between the
visceral pleural surface and the parietal pleura.

When elastic stains are performed it will be noted on the path report
somewhere.
SSF2 Pleural/elastic layer invasion
Four categories are defined for visceral pleural invasion:
PL0
PL1
PL2
PL3
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)
Tumor invades beyond elastic layer (classified as T2)
Tumor extends to surface of the visceral pleura (classified as T2)
Invasion of parietal pleura (classified as T3)
Source: 7th Edition AJCC Staging Atlas
AJCC TNM STAGING
TX
Primary tumor cannot 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, surrounded by lung or
visceral pleura, without bronchoscopic
evidence of invasion more proximal than the
lobar bronchus (i.e., not in the main bronchus
T1a Tumor 2 cm or less
T1b Tumor more than 2 cm but 3 cm or less
T1 Lung Cancer
Tumor 3 cm or less
in size, surrounded
by lung or visceral
pleura; no invasion
more proximal than
the lobar bronchus
T1a ≤ 2 cm
T1b > 2 to 3 cm
Source: UICC TNM-Interactive, Wiley-Liss, 1998/A.Fritz Overview of Five
Major Sites slide 51, April 2014
AJCC TNM STAGING
T2
Tumor more than 3 cm but 7 cm or less OR
tumor involves main bronchus, 2 cm or more
distal to the carina; invades visceral pleura
(PL1 or PL2); associated with atelectasis or
obstructive pneumonitis that extends to the
hilar region but does not involve entire lung
T2a Tumor more than 3 cm but 5 cm or less
T2b Tumor more than 5 cm but 7 cm or less
Tumor > 3 to 7 cm in size
*T2a > 3 to 5 cm
*T2b > 5 to 7 cm
Any of following:
*Invading visceral pleura
(PL1, PL2)
T2 Lung Cancer
*In main bronchus ≥ 2 cm
from carina
*Associated atelectasis
or
obstructive pneumonitis
extending to hilar region
but not involving entire
lung
Source: UICC TNM-Interactive, Wiley-Liss, 1998/A.Fritz Overview of Five
Major Sites slide 51, April 2014
AJCC TNM STAGING
T3
• Tumor more than 7 cm
• Tumor directly invades parietal pleura (PL3), chest
wall (including superior sulcus tumors),
diaphragm, phrenic nerve, mediastinal pleura,
parietal pericardium
• Tumor in the main bronchus- less than 2 cm distal
to the carina but without involvement of the
carina
• Associated atelectasis or obstructive pneumonitis
of the entire lung
• Separate tumor nodule(s) in the same lobe
T3 Lung Cancer
Any of the following:
Direct invasion of
A
B
C
D
Chest wall
Diaphragm
Mediastinal pleura
Parietal Pericardium
Ribs
Pleura
Source: UICC TNM-Interactive, Wiley-Liss, 1998/A.Fritz Overview of Five Major Sites slide 53, April 2014
AJCC TNM STAGING
T4
• Tumor of any size that invades the mediastinum,
heart, great vessels, trachea, recurrent laryngeal
nerve, esophagus, vertebral body or carina
• Separate tumor nodule(s) in a different ipsilateral
lobe
T4 Lung Cancer
Direct invasion of any of the following:
A Mediastinum
B Heart
C Trachea
D Great Vessels
E Carina
Not Shown:
Esophagus (behind trachea)
Adjacent rib
Vertebral body (posterior to lung)
continued on next slide
Source: UICC TNM-Interactive, Wiley-Liss, 1998/A.Fritz Overview of Five Major Sites slide 54, April 2014
T4 Lung Cancer
Separate tumor nodules in a different ipsilateral lobe
Source: UICC TNM-Interactive, Wiley-Liss, 1998/A.Fritz Overview of Five Major Sites slide 55, April 2014
T3 vs T4
T3
Multiple
tumors in
same lobe
T4
Multiple
tumors in
different
lobe
Primary tumor
Source: UICC TNM-Interactive, Wiley-Liss, 1998/A.Fritz Overview of Five Major Sites slide 55, April 2014
CS EXTENSION CODES
100 Confined to lung
410 Extension to but not into pleura, including invasion of elastic
layer BUT not through the elastic layer
420 Invasion of pleura, including invasion through the elastic layer
430 Invasion of pleura, NOS (clinical cases)
600 Extension to parietal pleura
CS Extension code 410 algorithm error

There is an error with the 'Size Extension SSF1 AJCC 7 Table‘ in Collaborative
Staging. It has 410 (PL0) grouped with the T2 extension codes in the
derivation table. This most likely will not be fixed.

What does this mean?
Avoid using extension code 410 as it will derive T2 when the tumor size < 3cm
when it should derive a T1.
EXAMPLE: 2.3 cm TS, ext 410 coded per path report; pT1b on path; CS derived
stage = pT2a = which upstages from IA to IB.

Recommend reviewing lung cases coded to CS Ext 410 and either recoding to
100 (confined) OR 420 (invasion of pleura).

If the TS derives a T2 category the extension code 410 if appropriate could
remain.
2011 KY Surgically Resected Lung
Cases

5016 total lung cases

1090 lung cases had a surgical resection (codes 20-70)

21.7% of lung cases surgically resected
VPI not identified by elastin stain

1.
2.
3.

When a tumor is classified as “VPI not identified. Confirmed by
elastic stain” this could represent three scenarios:
the tumor does not even extend to the elastic tissue
the tumor abuts the elastic tissue
the tumor invades into but not through the prominent elastic
layer (this is the rarest of the three scenarios).
All of these can be safely coded as CS EXT 100 (confined to
lung). The last could be coded as CS EXT 410 (into elastic layer
but not through-PL0), but should only be coded as such if the
scenario is explicitly stated in the pathology report
(Reference: CAnswerForum thread posted 8/29/2014)
CS EXTENSION & SSF2 CODING EXAMPLES
PATH REPORT EXAMPLES

Visceral pleural invasion: Not identified
CSEXT 100 / SSF2 000 (PL0) = T1 based on extension only

Visceral pleural invasion: Not identified (by elastic stain)
CSEXT 100 / SSF2 000 (PL0) = T1 based on extension only

Visceral pleural invasion: none; elastin stain positive for invasion of the
elastic layer but not through the elastic layer (PL0) **(Code only if stated
on path BUT avoid if TS is <3cm due to CS algorithm error)
CSEXT 410 / SSF2 000 (PL0) = T1 based on extension only
CS EXTENSION & SSF2 CODING EXAMPLES
PATH REPORT EXAMPLES

Visceral pleural invasion: Identified
CSEXT 420 / SSF2 010 (PL1) = T2 based on extension only

Visceral pleural invasion: Identified (confirmed by elastin stain)
CSEXT 420 / SSF2 010 (PL1) = T2 based on extension only

Tumor extends to visceral pleural surface
CSEXT 420 / SSF2 020 (PL2) = T2 based on extension only

Parietal pleural invasion identified
CSEXT 600 / SSF2 030 (PL3) = T3 based on extension only
COMBINED CODING EXT/SSF2 TABLE FOR
SURGICALLY RESECTED LUNG CASES
CSEXT 100
SSF2 000
PL0
T1 based on
extension
CSEXT 410
SSF2 000
PL0
T1 based on
extension
CSEXT 420
SSF2 010 OR 020
PL1 OR PL2
T2 based on
extension
CSEXT 430
SSF2 040
PL1
T2 based on
extension
CSEXT 600
SSF2 030
PL3
T3 based on
extension
Time for
Practice Exercises

EXERCISE #1

Code the Topography:

___ R lung apical mass
c34._1__

___ R hilar mass with no other pulmonary nodules seen
c34._0__

___ Left lung base mass
c34._3__

___ Upper lobe of left lung
c34._1__

___ RML
c34._2__

___ Left main bronchus mass
c34._0__

___Tumor overlaps lower & upper lobe of L lung, no statement of
which lobe tumor arose in

___ Multiple tumors in both lungs, primary tumor unknown
c34._8__
c34._9__
EXERCISE #2
Match the following with the best CS EXTENSION CODE
_D_ Tumor confined to lung on path report
A. 600
_A_ Tumor invades parietal pleura on imaging
B. 410
_B_ Tumor extends into elastic layer but not through on path report
C. 420
_C/F_ Tumor involves visceral pleura on path report
D. 100
_E_ Tumor invades pleura, NOS per consult note with no other info available
E. 430
_F/C_ Tumor extends to the visceral pleural surface on path report
F. 420
EXERCISE #3
Match the following with the correct clinical AJCC T category
_D_ Tumor 8 cm in size directly invading the mediastinum
A. T1b
_A_ Tumor 2.9 cm in size confined to lung
B. T3
_F_ Tumor 1.9 cm pleural based mass seen on imaging
C. T2a
_B_ Tumor 7 cm in size invading parietal pleura
D. T4
_C/G_ Tumor 2.1 cm in size invading the visceral pleura
E. T2b
_E_ Tumor 5.6 cm in size confined to lung
F. T1a
_G/C_ Tumor 3.0 cm in size extending to visceral pleural surface
G. T2a
EXERCISE #4
Use the following diagram
Parietal pleura/Chest Wall
Surface of Visceral Pleura
Elastic Layer of Visceral Pleura
Lung Parenchyma
PL0
T1
PL3
T3
PL1
T2
PL0
T1
PL2
T2
The 5 diagrams above are demonstrating tumor invasion, label each with the correct descriptions (PL &
T) based on extension only
PL0
PL1
PL2
T1
T2
T3
PL3
Answers:
420
000
020
cT2aN0M0 Stage IB
pT2aN0 Stage IB
Answers:
100
000
998
cT1bN2M0 Stage IIIA
pTxNx Stage Unknown
Answers:
420
000
010
pT2aN0 Stage IB
Answers:
100
000
000
cT1aN0M0 Stage IA
pT1aN0 Stage IA
Answers:
600
000
030
pT3NX Stage IIB
Practice Exercises & Case Answer
Key
Will
be posted on KCR’s
website after the workshop!
Thank
You!!
CONTACT INFO
 Nicole
Catlett, CTR
KCR Regional Coordinator
[email protected]

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