1. Lung “Coding Bootcamp” Nicole Catlett, CTR 2014 Kentucky Cancer Registry Fall Workshop

2. 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 7 th 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/ 3

4. 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

5. Visceral pleura (Parietal)

6. “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.

7. 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

8. 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.

10. 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)

11. Source: 7 th Edition AJCC Staging Atlas

12. 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

13. 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 T1 Lung Cancer Source: UICC TNM-Interactive, Wiley-Liss, 1998/A.Fritz Overview of Five Major Sites slide 51, April 2014

14. 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

15. 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 or obstructive pneumonitis extending to hilar region but not involving entire lung T2 Lung Cancer Source: UICC TNM-Interactive, Wiley-Liss, 1998/A.Fritz Overview of Five Major Sites slide 51, April 2014

16. 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

17. Any of the following: Direct invasion of A Chest wall B Diaphragm C Mediastinal pleura D Parietal Pericardium Source: UICC TNM-Interactive, Wiley-Liss, 1998/A.Fritz Overview of Five Major Sites slide 53, April 2014 T3 Lung Cancer Ribs Pleura

18. 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

19. 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

20. Separate tumor nodules in a different ipsilateral lobe T4 Lung Cancer Source: UICC TNM-Interactive, Wiley-Liss, 1998/A.Fritz Overview of Five Major Sites slide 55, April 2014

21. T3 Multiple tumors in same lobe Primary tumor Source: UICC TNM-Interactive, Wiley-Liss, 1998/A.Fritz Overview of Five Major Sites slide 55, April 2014 T4 Multiple tumors in different lobe T3 vs T4

22. 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

23. 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.

24. 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

25. 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)

26. 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

27. 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

28. COMBINED CODING EXT/SSF2 TABLE FOR SURGICALLY RESECTED LUNG CASES CSEXT 100SSF2 000PL0 T1 based on extension CSEXT 410 SSF2 000PL0 T1 based on extension CSEXT 420SSF2 010 OR 020PL1 OR PL2 T2 based on extension CSEXT 430SSF2 040PL1 T2 based on extension CSEXT 600SSF2 030PL3T3 based on extension

29. Time for Practice Exercises

30.  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__

31. EXERCISE #2 Match the following with the best CS EXTENSION CODE _D_ Tumor confined to lung on path reportA. 600 _A_ Tumor invades parietal pleura on imagingB. 410 _B_ Tumor extends into elastic layer but not through on path reportC. 420 _C/F_ Tumor involves visceral pleura on path reportD. 100 _E_ Tumor invades pleura, NOS per consult note with no other info availableE. 430 _F/C_ Tumor extends to the visceral pleural surface on path reportF. 420

32. EXERCISE #3 Match the following with the correct clinical AJCC T category _D_ Tumor 8 cm in size directly invading the mediastinumA. T1b _A_ Tumor 2.9 cm in size confined to lungB. T3 _F_ Tumor 1.9 cm pleural based mass seen on imagingC. T2a _B_ Tumor 7 cm in size invading parietal pleuraD. T4 _C/G_ Tumor 2.1 cm in size invading the visceral pleuraE. T2b _E_ Tumor 5.6 cm in size confined to lungF. T1a _G/C_ Tumor 3.0 cm in size extending to visceral pleural surfaceG. T2a

33. PL0 T1 PL3 T3 PL1 T2 PL0 T1 PL2 T2

34. Answers: 420 000 020 cT2aN0M0 Stage IB pT2aN0 Stage IB

35. Answers: 100 000 998 cT1bN2M0 Stage IIIA pTxNx Stage Unknown

36. Answers: 420 000 010 pT2aN0 Stage IB

37. Answers: 100 000 cT1aN0M0 Stage IA pT1aN0 Stage IA

38. Answers: 600 000 030 pT3NX Stage IIB

39. Practice Exercises & Case Answer Key  Will be posted on KCR’s website after the workshop!

40. Thank You!!

41. CONTACT INFO  Nicole Catlett, CTR KCR Regional Coordinator nicole@kcr.uky.edu