lung “coding bootcamp” nicole catlett, ctr 2014 kentucky cancer registry fall workshop

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

3

Sites +

Codes…

Lung Cancer Module. U. S. National Institutes of Health, National Cancer Institute, 02/03/12, <http://training.seer.cancer.gov/>.

http://training.seer.cancer.gov/

TOPOGRAPHY CODES ICD-O-3

c34.0 Main Bronchus (Hilar mass considered the primary)c34.1 Upper Lobe (apex)c34.2 Middle Lobe (right lung only)c34.3 Lower Lobe (base)c34.8 Overlapping lesion of lung (used when one tumor in multiple lobes and it can’t be determined which lobe the tumor arose from)c34.9 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 oflayers of visceral pleuraand relationship toadjacent structures withPL codes. Created byA.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 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)

Source: 7th Edition AJCC Staging Atlas

AJCC TNM STAGINGTX 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 bronchoscopyT0 No evidence of primary tumorTis Carcinoma in-situT1 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 bronchusT1a Tumor 2 cm or lessT1b Tumor more than 2 cm but 3 cm or less

Tumor 3 cm or less in size, surrounded by lung or visceral pleura; no invasionmore proximal than the lobar bronchusT1a ≤ 2 cmT1b > 2 to 3 cm

T1 Lung Cancer

Source: UICC TNM-Interactive, Wiley-Liss, 1998/A.Fritz Overview of Five Major Sites slide 51, April 2014

AJCC TNM STAGINGT2 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 lungT2a Tumor more than 3 cm but 5 cm or lessT2b 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)

*In main bronchus ≥ 2 cm from carina

*Associated atelectasis orobstructive pneumonitis extending to hilar regionbut not involving entire lung

T2 Lung Cancer


AJCC TNM STAGINGT3 • 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

Any of the following:

Direct invasion of A Chest wallB Diaphragm C Mediastinal pleuraD Parietal Pericardium


T3 Lung Cancer

Ribs

Pleura

AJCC TNM STAGINGT4 • 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

Direct invasion of any of the following:A MediastinumB HeartC TracheaD Great VesselsE CarinaNot Shown:Esophagus (behind trachea)Adjacent ribVertebral body (posterior to lung)

continued on next slide


T4 Lung Cancer

Separate tumor nodules in a different ipsilateral lobe

T4 Lung Cancer


T3Multiple tumors in same lobe

Primary tumor


T4Multiple tumors in different lobe

T3 vs T4

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 layer430 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

When a tumor is classified as “VPI not identified. Confirmed by elastic stain” this could represent three scenarios:

1. the tumor does not even extend to the elastic tissue

2. the tumor abuts the elastic tissue

3. 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)


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)


CS EXTENSION & SSF2 CODING EXAMPLES

PATH REPORT EXAMPLES

Visceral pleural invasion: Identified


Visceral pleural invasion: Identified (confirmed by elastin stain)


Tumor extends to visceral pleural surface


Parietal pleural invasion identified


COMBINED CODING EXT/SSF2 TABLE FOR SURGICALLY RESECTED LUNG CASESCSEXT 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



Time forPractice 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 c34._8__

___ Multiple tumors in both lungs, primary tumor unknown 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

The 5 diagrams above are demonstrating tumor invasion, label each with the correct descriptions (PL & T) based on extension only

PL0 PL1 PL2 PL3

T1 T2 T3

PL0T1

PL3T3

PL1T2

PL0T1

PL2T2

Answers:420 000020cT2aN0M0 Stage IBpT2aN0 Stage IB

Answers:100000998cT1bN2M0 Stage IIIApTxNx Stage Unknown

Answers:420000010pT2aN0 Stage IB

Answers:100000000cT1aN0M0 Stage IApT1aN0 Stage IA

Answers:600000030pT3NX Stage IIB

Practice Exercises & Case Answer Key

Will be posted on KCR’s website after the workshop!

ThankYou!!

CONTACT INFO

Nicole Catlett, CTR

KCR Regional Coordinator

[email protected]

lung “coding bootcamp” nicole catlett, ctr 2014 kentucky cancer registry fall workshop

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