Advanced Abstracting Issues for the Lung Cancer Diagnosis

Advanced Abstracting Issues for the Lung Cancer Diagnosis
Judy Andrews, CTR Metropolitan Regional Coordinator Georgia Center for Cancer Statistics GATRA Fall Meeting 2004

ICD‑O-3 CODES ICD‑0‑3 TERM C34.0 Main bronchus C34.1 Upper lobe, lung
C34.2 Middle lobe, lung C34.3 Lower lobe, lung C34.8 Overlapping lesion of lung C34.9 Lung, NOS The ICD-O-3 four-digit subsites of the lung are considered part of a single primary site.

Anatomy Related adjectives: Lung= pneumo-, pulmono-, broncho-, bronchiolo-, alveolar, hilar Breathing= -pnea (difficulty with breathing=dyspnea) Paired organ Subsites: Right lobe: 3 lobes Left Lobe: 2 lobes You often will see references to the lung with adjectives such as pulmonary, bronchial, or hilar. A common symptom of lung cancer may be difficulty with breathing, or dyspnea. The lungs are a paired organ and each lung is considered a separate site, unless bilateral involvement is stated to be metastatic from one side. The right lung has 3 lobes (upper, middle, lower). The left lung has 2 lobes (upper and lower).

Lung Anatomy Carina Upper Lobe Oblique Fissure Middle Lobe Lower Lobe
The lung anatomy showing ICD-O-3 codes. C34.8 would be coded for a lung primary that crosses two sites (i.e., C34.1 and C34.2, and the site of origin cannot be determined). Your handout provides a more detailed overview of the lungs, and the segmental bronchi and bronchioles. Middle Lobe Lower Lobe

Lung Anatomy: Key Words
Apex Hilum Carina Lingula Cardiac Notch Pleural Cavity Chest Wall Mediastinum Base The apex is the narrowest part of the lung, and is located at the rounded top of the lung above the hilum. The hilum (also called the hilus or root of lung) is located at the entry point in each lung for the bronchi, nerves, lymph vessels, arteries and veins which supply air and oxygen for the respiration process. A hilar mass is not coded to the hilum, unless it is stated to be in the hilus of the lung. The lingula is an area of the upper lung that projects downward into the lower lung. The pleural cavity is the potential space between the visceral pleura (covering of the lungs) and the parietal pleura (pleura adherent to rib cage, diaphragm, and pericardium). The pleura is also called mesothelium. Mediastinum is the area between the lungs which contain the heart, thymus, great vessels, and other structures.

ICD-O-3 Morphology Codes
Small cell lung cancers include ICD‑O-3 morphology codes M‑80413, M‑80423, M‑80433, M‑80443, and M80453 Common non‑small cell lung cancer histologies Squamous or epidermoid (807_3) Adenocarcinoma (814_3) Bronchioloalveolar (82503) Large cell carcinoma (80123) Other subtypes of adenocarcinoma are acinar, papillary,and mucinous Adenosquamous carcinoma (85603) Mesothelioma (905_3) Bronchogenic carcinoma IS NOT a specific cell type Be sure to consult your ICD‑O manual for the correct morphology codes.. Small cell carcinoma is also called oat cell, round cell, reserve cell, or small cell intermediate cell carcinoma. Small cell cancers are usually central lesions (in the bronchus or toward the center or hilum of the lung). Occasionally, mixed tumors containing small cells and non‑small cells are diagnosed. These should be treated as small cell cancers. Common non‑small cell lung cancer histologies include Squamous or epidermoid, which are least likely to recur after resection; it is frequently a central or bronchial lesion Adenocarcinoma is usually slow‑growing, but can metastasize widely; it is usually a peripheral lesion Mesothelioma is linked to asbestos exposure; it usually involves the pleura, not the lung Carcinoids, melanomas, sarcomas and lymphomas may also arise in the lung Bronchogenic carcinoma is not a speific cell type, it is a description of where the tumor arose. More information should be obtained before the morphology is coded. Bronchioloalveolar (82503)‑‑a subtype of adenocarcinoma with a characteristic presentation and behavior Large cell carcinoma (80123)‑‑also called giant cell or clear cell Other subtypes of adenocarcinoma are acinar, papillary, and mucinous Adenosquamous carcinoma (85603)‑‑a specific histologic variant containing both epithelial (squamous) and glandular (adeno‑) cells

Regional Lymph Nodes for the Lung
The regional lymph nodes for the lung are all above the diaphragm Intrathoracic nodes include mediastinal and intrapulmonary nodes Scalene and supraclavicular nodes are also considered regional nodes for staging The regional lymph nodes for the lung are all above the diaphragm and include mediastinal, intrapulmonary, scalene and supraclavicular nodes.

Intrathoracic Pulmonary 12 Peribronchial 11 Intrapulmonary 10 Hilar 13 Segmental Superior mediastinal 1 Superior Mediastinal 3 Pretracheal,retrotracheal 2 Paratracheal 4 Lower paratracheal, azygos Intrathoracic Aortic 5 Subaortic (aortic window) 6 Para-aortic (ascending aorta or phrenic) Inferior mediastinal 7 Carinal, subcarinal 8 Paraesophageal 9 Pulmonary ligament Refer to the diagram in your hand out to identify the location of these regional lymph nodes of the lung.

Extrathoracic Scalene Supraclavicular or transverse cervical The extrathoracic regional nodes for a lung primary are the scalene nodes which are along the scalenus muscles in the base of the neck. The individual scalene muscles are the scalenus anterior, posterior, medius and minimus. The supraclavicular or transverse cervical nodes are right above your collarbone at the base of the neck. They are clinically noted as Virchow’s node.

Common Metastatic Sites for the Lung
Lymphatic Spread Cervical Lymph Nodes Contralateral Lung Contralateral Mediastinum Hematogenic Spread Brain Bone Liver Adrenal glands Lung cancer may spread via the lymphatics or bloodstream. Common sites of metastasis include the cervical lymph nodes, the contralateral lung & lymph nodes, brain, bone, liver and adrenal glands.

Extent of Disease Evaluation for the Lung
Diagnostic Studies: Physical Exam Signs and Symptoms Palpable lymph nodes or organs Pancoast Tumor Horner’s Syndrome The history and physical may identify signs and symptoms of lung cancer which may include cough, difficulty breathing, shortness of breath, coughing up blood, hoarseness, or pain. The physical exam should note location of any masses or palpable lymph nodes, especially supraclavicular lymph nodes. Tumors of the apex of the lung can create specific symptoms due to the invasion of the brachial plexus nerves causing pain or atrophy in the arm. This is called a Pancoast tumor or syndrome. Tumor invasion of the cervical sympathetic nerves (Horner’s syndrome) can cause ptosis (a drooping of the eyelid) or flushing of the affected side of the face. A Superior sulcus tumor is a less invasive tumor of the apex of the lung. Enlarged organs such as the liver (hepatomegaly), or jaundice (yellowing of the skin and eyes due to bile duct blockage), may indicate metastases.

Diagnostic Studies: Imaging Chest X-ray CAT Scan MRI Scan PET Scan Bone Scan Chest x-rays, CAT scans, MRI scans, and PET scans may provide size and location of primary tumor, relationship of the mass to other tissues, such as impingement or extension to another tissue (such as the ribs, chest wall, or pleura); elevation of the diaphragm on one side (phrenic nerve paralysis); hilar or mediastinal involvement; enlargement or decrease in size of the lung(s); opacity, such as ata-lec-te-sis, pleural effusion or pneumonitis; masses in mediastinum and/or hilum of lung; involvement of distant sites such as bone, brain or liver.

Diagnostic Studies: Endoscopies Bronchoscopy Mediastinoscopy Thoracoscopy Studies used to diagnosis or stage lung cancer may include procedures such as a bronchoscopy or mediastinoscopy. A thin lighted tube is inserted through the mouth or nose, and through the windpipe into the breathing passages. The physician can view the passages and collect cells or small samples of tissue. In a mediastinoscopy the physician makes a small incision in the neck or chest, and a scope is inserted. The mediastinum or center of the chest can be examined for tumor extension and lymph nodes can be seen and removed for evaluation. A thoracoscopy requires surgery to open the chest. This is a major operation performed in the hospital.

Diagnostic Studies: Pathological Closed Chest Needle Biopsy Cytology (Thoracentesis) Sputum Cytology Bronchial Washings Bone Marrow Biopsy Key information to search for in the medical record: Cell type and grade, location within specimen, exact size of lesion, distance from carina, presence of other tumors in specimen. Location, size, and number of lymph nodes involved and whether they are ipsilateral or contralateral. Extension to adjacent tissues such as mainstem broncus, pleura, pericardium, muscle, ribs. The results of biopsies of possible metastatic sites such as bone, brain, or liver. A needle biopsy involves inserting a needle through the chest into the lung cancer tumor to remove a sample of tissue. A thoracentesis removes a sample of fluid that surrounds the lungs to check for cancer cells.

Diagnostic Studies: Tumor Markers Neuron Specific Enolase (NSE) Squamous Cell Carcinoma Antigen DNA Studies Adrenocorticotropic Hormone (ACTH) Carcinoembryonic Antigen (CEA) Calcitonin Tissue Polypeptide Antigen (TPA) Tumor markers are used to assess tumor burden and monitor for recurrence. They may be done for a baseline or for observation. Some of the tumor markers for lung cancer are listed. Refer to your handout for their specific use.

Staging Systems for Lung
SEER Extent of Disease 3rd Edition (Diagnosis year ) SEER Summary Staging 2000 (Diagnosis year ) American Joint Committee on Cancer (AJCC) TNM 6th Edition (Diagnosis year 2003 forward) Collaborative Staging (Diagnosis year 2004 forward) Over the years different staging manuals and coding instructions have evolved. SEER Extent of Disease 3rd edition, SEER Summary Staging 2002, and AJCC TNM 6th edition staging are systems that have been used most recently. Even though SSS 2000 won’t be collected as a field after 2003, it will be a derived field in Collaborative Staging. Most of you have begun, or will be soon, abstracting 2004 cases utilizing the collaborative staging system. COC approved hospitals will still be coding TNM staging, and all facilities will likely continue to have cases to abstract from prior years, so expetise with previous coding systems will continue to be required. When you are abstracting a case it is imperative that you utilize the appropriate staging instructions and codes according to the year of diagnosis. For example, if a case was diagnosed in 1999, then you would use the SEER Extent of Disease 1988 Coding Instructions, the SEER Summary Staging Guide 1977, and the AJCC Cancer Staging Manual 5th edition.

Staging Systems for Lung
SEER Summary Stage 2000 In Situ Localized Reg by Direct Ext Reg Ipsilateral LN only Reg by Direct & Ipsilateral Reg LN Reg, Nos Distant Site/Node Involv SEER EOD Size Extent Regional Lymph Nodes Reg LN Positive Reg LN Examined AJCC TNM 6th Edition cT,pT: Extent of primary tumor cN,pN: Absence or presence & Ext of regional lymph nodes cM,pM: Absence/presence of metastasis [Clinical (c) and pathologic (p)] Collaborative Stage CS Tumor Size CS Tumor Size/Ext Eval CS Lymph Nodes CS Lymph Nodes Eval CS Mets at Dx CS Mets Eval CS Site Specific Factors 1-6 Refer to your manual for general and site specific instructions for coding the different staging systems. This slide briefly summarizes coding fields for each of the staging systems. SEER EOD, SSS 2000, and AJCC 6th edition have some general rules in common. The timing rule is generally consistent among the 3 systems. SEER EOD and SSS 2000 use the same terms of involvement and priority of assessment. Tumor size for EOD must be coded prior to any preoperative treatment; however extension for SEER EOD and SSS 2000 may be obtained after presurgical treatment as long as the timing rule is met. TNM staging requires microscopic confirmation for classification. TNM assesses clinical and pathological anatomic extent of disease through diagnostic studies, plus pathologic examination of resected specimen and lymph nodes. Again, it is imperative that you utilize the appropriate staging rules that correspond to the patient’s year of diagnosis. We will be discussing Collaborative Staging for lung cancer in depth as some of the rules are very different.

Collaborative Stage General Guidelines Timing Rule
Site-specific guidelines Highest applicable number for each field Greatest extent of disease Use all information available through completion of surgery (ies) in the first course of treatment, or all information available within four months of the date of diagnosis in the absence of disease progression, whichever is longer. Read the general rules in the Collaborative Stage manual. Each time you abstract a lung primary you will need to read the site-specific guidelines carefully and apply them as appropriate. The highest applicable number for each field is coded, with the exception of codes for unknown, not applicable and NOS categories. They do not take priority over lower, more specific numbers. CS tumor size, CS extension, CS lymph nodes, and CS mets at diagnosis records the greatest extent of disease based on clinical and pathological assessment. The evaluation fields will delineate how these codes were derived.

Collaborative Stage for Bronchus and Lung
General Guidelines continued: CS Tumor Size/Ext CS Tumor Size/Ext Eval CS Regional LN CS Reg Nodes Eval CS Mets CS Mets Eval Regional LN Pos/Regional LN Exam Site Specific Factors If the patient has surgery and does not receive any neoadjuvant treatment, code the greatest extent of disease based on combination of clinical (i.e., scans) and operative and pathological assessment. For patients who receive neoadjuvant, or preoperative systemic treatment or radiation therapy, assess the greatest size/extent of disease prior to treatment. For example, if a patient received radiation prior to tumor resection, code the size and extent of the tumor before radiation. In the unlikely event that the operative assessment after treatment shows farther extension, code greatest size/extension. The CS TS/Ext Eval will identify this as being post treatment. CS Tumor Size/Ext Eval, CS Reg Nodes Eval, and CS Mets at Eval fields describe how the most extensive tumor was established and if the patient received preoperative treatment There is a new rule for coding CS Lymph nodes for inaccessible sites such as the lung in localized or early stage disease: regional lymph nodes may be coded as negative rather than unknown if there is no mention of lymph nodes, and the patient receives what would be usual treatment to the primary site and there is minimal disease, i.e., early stage. Regional lymph nodes positive and regional lymph node examined must be pathologically confirmed to be coded. Site Specific factors are included in every schema; however for lung the factors are not used, so they are coded 888, not applicable.

CS Tumor Size 000 No mass/tumor found millimeters (exact size) millimeters or larger 990 Microscopic focus or foci only, no size of focus given 991 Described as less than 1 cm Described as less than (2,3,4,5 cm) 996 Malignant cells in bronchopulmonary secretions, but no tumor is seen radiographically or during bronchoscopy 997 Diffuse (entire lobe) 998 Diffuse (entire lung) 999 Unknown; size not stated Not documented in patient record Refer to your handout for tumor size codes in the CS manual. Do not code size of hilar mass unless primary is stated to be in the hilum. Record the largest dimension or diameter of the primary in millimeters. Priority order for recording tumor size is from the pathology report, operative report, imaging/radiographic, and endoscopy reports. Size is generally determined before the initiation of any chemotherapy or radiation therapy. If there is a difference in the tumor size among imaging and radiographic techniques, record the largest size of tumor in the record. Code 996 is for a lung cancer that is diagnosed in bronchopulmonary secretions, but there is no tumor seen radiographically or during a bronchoscopy. Code 997 and 998 takes precedence over any mention of size.

CS Extension Primary Tumor extension DO NOT CODE DISCONTINOUS METASTASES IN THIS FIELD Priority order for extension Notes 1-7: Read carefully Refer to CS extension codes for the lung in your handout. Code the farthest documented direct extension of the primary lung tumor into neighboring organs/structure/tissues. Do not code discontinuous metastases to distant sites in the CS extension field. Priority order for recording extension: From path report, operative report (when there has been no systemic or radiation treatment), and from imaging/radiographic techniques. If more extensive tumor size or extent is identified on the operative or pathology report after preoperative treatment, code to the farthest extent. The extent of disease may be inferred from the T category as stated by the physician should the information in the medical record be ambiguous. Record the numerically lowest equivalent extension code for that T category. CS extension for lung has 7 site specific schema notes. Read them carefully and apply them as appropriate. Example: Lobectomy showed a 3 cm LLL lung cancer, CT scan showed pleural effusions. CS Ext code would be 10. Per note 6, assume that a pleural effusion is negative if a resection is done.

CS TS/EXT EVAL Evaluates source for “CS Tumor Size” and “CS Extension” Describes clinical or pathological staging of the tumor The field for CS Tumor Size/Extent Evaluation codes the diagnostic methods that were used to determine the farthest extent of disease of the primary tumor. For Lung the tumor size and extension are a factor in determining the derived T category in TNM, so it will be necessary to select the evaluation code that reflects the source for how the worse or higher category was determined. There is no hierarchy such as pathological, radiographic, etc. The intent is to describe the source for how the greatest extent or size of the primary was derived, whether by biopsy, surgery, or radiographic exams.

CS TS/EXT EVAL Code 0, 1, 9 No surgery Code 2 Autopsy (diagnosis suspected) Code 3 Surgery followed by other therapy Code 5 Determined prior to neoadjuvant therapy Code 6 Determined after neoadjuvant therapy Code 8 Autopsy (diagnosis unsuspected) Code 9 Unknown, Not assessed, Not stated Refer to your handout for the exact CS TS/EXT EVAL codes. Code the procedure which described the farthest extension or size of the primary tumor. Important new concept: Code the most applicable code, not the numerically highest. If there is a difference between the derived category for the tumor size and the CS extension, select the evaluation code that reflects how the worse or higher category was determined. The evaluation code describes the procedure that identifies the most extensive tumor whether that is tumor size or how far the tumor extends. Code 5* & 6*: If size of extension of the tumor prior to treatment was the basis for neoadjuvant treatment, use code 5. If the size or extension of the tumor was greater after presurgical treatment, use code 6. Metastasis are not coded in this field. Example: As in our previous example, the CS tumor size/extension evaluation would be coded 3 even though the CT scan showed pleural effusions (a higher extension code) because Note 6 states to assume that a pleural effusion is negative if a resection is done. If only a biopsy had been done, the extension code would have been 72 and the Eval field would have been 0 (not 1 since the CT scan showed the farthest extent).

CS Lymph Nodes Regional Nodes and Nodes, NOS only Highest Applicable Code Exception (NOS) New Rule for Inaccessible Site Lung Notes 1-4: Read carefully CS Lymph nodes assess the regional lymph nodes that are involved with cancer at the time of diagnosis. Code the farthest regional lymph node that is involved either clinically or pathologically. If the lymph nodes are pathologically examined and no radiation or chemotherapy has been given, code from the pathology report. If there has been presurgical treatment, code information prior to surgery. Any unidentified lymph node(s) included in the resected specimen are coded as regional lymph node(s), NOS. The code for NOS may be a higher code; however, it has the lowest priority for coding. Look closely for more specific information. The terms fixed, matted, mass in the hilum or mediastinum are considered involvement of lymph nodes. For a lung primary, the terms adenopathy or enlargement are also considered involvement (this is an exception to other sites). The new rule for inaccessible sites allows you to code lymph nodes as clinically negative if they are not mentioned on imaging or during exploratory surgery. Extent of disease may be inferred from the N category stated by the physician. Record the numerically lowest equivalent extension code. CS extension for lung has 4 site specific schema notes. Read them carefully and apply as appropriate.

CS Reg Nodes Eval Code 0, 1, 9 No LN(s) removal Code 2 Autopsy (diagnosis suspected) Code 3 LN(s) surgery followed by other therapy Code 5 LN(s) status determined prior to neoadjuvant therapy Code 6 LN(s) status determined after neoadjuvant therapy Code 8 Autopsy (diagnosis unsuspected) Code 9 Unknown, Not assessed, Not stated Refer to your handout for the exact codes for CS Reg Nodes Evaluation for a lung primary. The field for CS regional nodes evaluation selects the code that best explains how the information in the CS Reg LN field was determined. It does not include distant lymph node(s) which are coded in CS Mets at Dx. The intent is to describe the source from which the information about the farthest involved regional lymph node was derived, whether by biopsy, surgery, or radiographic exams. This may not necessarily be the numerically highest evaluation code. Code 5* & Code 6*: If the size, number or extension of regional LN involvement determined prior to treatment was the basis for neoadjuvant therapy, use code 5. If more extensive tumor is determined during the examination of LNs after neoadjuvant therapy, use code 6.

Regional Nodes Positive 00 All nodes examined negative nodes positive 90 or more nodes positive Positive aspiration of LN(s) was performed 97 Positive nodes documented, number unspecified 98 No nodes examined 99 Unknown if nodes positive, not applicable, not stated in record Regional Nodes Examined 00 No nodes examined nodes examined 90 or more nodes examined No Reg LN removed, Aspiration of Reg LN performed Reg LN removal documented as sampling, number unknown/not stated 97 Reg LN removal documented as dissection, number unknown/not stated 98 Reg LN surgically removed, number of LNs unknown/not stated, not documented as sampling or dissection; nodes examined, number unknown 99 Unknown, not applicable, not stated in record Only regional lymph nodes are coded in these fields. See the CS Standard table for the codes. These fields require pathological confirmation. The number of regional lymph nodes examined is cumulative from all procedures that remove lymph nodes, through the completion of surgeries in the first course of treatment. If lymph nodes were removed for examination and no lymph nodes found, code 00 for regional nodes examined. When a lymph node is aspirated and other lymph nodes are removed, use code 98 for number regional nodes examined.

CS Mets at Dx 00 No; none 10 Distant Lymph Nodes (s), including cervical nodes 35 Separate tumor nodules (s) in different lobe, same lung 37 Extension to sternum, skeletal muscle, skin of chest 39 Extension to contralateral lung, contralateral main stem bronchus, separate tumor nodule(s) in contralateral lung 40 Abdominal organs, distant metastasis except to distant lymph nodes (code 10), distant mets, NOS, carcinomatosis 50 Distant mets + distant node(s) (10) + any [35-40] 99 Unknown; distant metastasis cannot be assessed, not documented in patient record. Refer to your handout for CS codes for distant metastasis at diagnosis for the lung primary. Code the highest applicable code, whether determined clinical or pathological, or whether or not the patient had any preoperative systemic therapy. Exclude metastasis known to have developed after the extent of disease was established. Code 00 (none) rather than 99 (unknown) when the physician gives the standard treatment for a lung cancer for localized or early stage disease. Code 99 would be used when there is a reasonable doubt that the tumor is no longer localized and there is not documentation of metastasis. Extent of disease may be inferred from the M category stated by the physician. Record the numerically lowest equivalent extension code.

CS Mets Eval Code 0, 1, 9 No surgery Code 2 Autopsy (diagnosis suspected) Code 3 Surgery followed by other therapy Code 5 Determined prior to neoadjuvant therapy Code 6 Determined after neoadjuvant therapy Code 8 Autopsy (diagnosis unsuspected) Code 9 Unknown, Not assessed, Not stated See CS standard table for the exact codes for CS Mets Eval for the lung primary. Same general rules apply for CS Mets Evaluation as for CS Tumor Size/Ext Eval and CS Lymph Node(s) Eval. Code 0 for non invasive methods of examining tissues such as imaging studies. Code 1 includes endoscopy and observations at surgery and mets are not biopsied. Code 3 for any positive biopsy or resection of distant mets. Code 5 for the clinical status of mets at diagnosis if the patient received preoperative systemic or radiation therapy. Code 6 if the patient received preoperative treatment, and the biopsy of some mets are negative, but there is still evidence of clinical mets.

CS Site Specific Factors SSF 1 Code 888 SSF 2 Code 888 SSF 3 Code 888 SSF 4 Code 888 SSF 5 Code 888 SSF 6 Code 888 Site Specific factors are not applicable for a lung primary. They are all coded 888.

Treatment for Bronchus and Lung
Surgery Non-small cell carcinoma: Stage I and II (Localized) Small cell carcinoma: Not recommended Radiation Non-small cell carcinoma: Inoperable, Advanced Small cell carcinoma: Recommended Systemic Therapy Non-small cell carcinoma: Chemotherapy Small cell carcinoma: Combination chemotherapy Hormonal & Endocrine Not proven to be useful Although they occupy the same organ, the major types of lung cancers are essentially two completely different diseases, each of which has its own recommended therapies. Non-small cell lung cancers are potentially curable with surgery, but largely unresponsive to chemotherapy. Small cell lung cancers, on the other hand, do respond to chemotherapy and radiation, but are usually too far advanced at diagnosis for a surgical cure. Stage 1 or 2 non-small cell cancers have the best cure rate with surgical resection. An alternative for more advanced or medically inoperable non-small cell lung cancer is radiation. Radiation can be curative in lower stage, inoperable cases. Radiation is the immediate treatment for symptoms of superior vena cava syndrome. Patients with distant metastasis can also be treated palliatively with radiation. Small cell carcinoma is extremely virulent, with a rapid clinical course if left untreated. However, because of its rapid growth rate (it tends to be widely disseminated at time of diagnosis), it is also more responsive to chemotherapy and radiation than non-small carcinoma. Surgery is not recommended for small cell carcinoma.

Surgery Codes Primary Site Scope of Regional Lymph Node Surgical Procedure of Other Site The site specific codes for surgery for a lung primary are included in your handout. They can also be found in the GCCR Policy & Procedure Manual, Section 5, Appendix F, page 17 or in the FORDS Manual, Appendix B. Biopsies that remove all of the tumor and leave only microscopic margins are to be coded in the surgical procedure of primary site. If only a sample of tissue is taken in a biopsy for diagnostic purposes, and there was no attempt to excise the tumor, code 00. If the surgeon states that the tumor was removed, excised, etc., then code events or 15 if no specimen was sent to pathology, or if a specimen was sent to pathology. Code the total or final results. If a portion of the primary site was previously removed and later the remainder of the primary is removed, code the final result.

Surgery Codes continued Primary Site Scope of Regional Lymph Node Surgical Procedure of Other Site The scope of regional lymph node surgery is coded even if surgery was not performed to the lung. Code the removal, biopsy, or aspiration of regional lymph nodes. Codes 0 to 7 are hierarchical. Do not code distant lymph nodes in this field. See Section 4, page of the GCCR P & PM for coding this field, or the FORDS manual, page 138.

Surgery Codes continued Primary Site Scope of Regional Lymph Node Surgical Procedure of Other Site Surgical procedure of other site records the surgical removal of distant lymph nodes or other tissue(s)/organs(s) beyond the primary site. Codes are hierarchical, and incidental removal of tissue or organs is not coded (the removal should be to confirm extent of disease).

Radiation Treatment Volume Treatment Modality Regional Dose Boost Modality Boost Dose Prophylactic Cranial Radiation (PCI) Radiation treatment is used extensively in lung cancer. This presentation will only generally describe the fields used to code radiation therapy for lung primaries. Refer to the GCCR P & PM or the FORDS manual for specific codes and guidelines. GCCR collects RX Summ—Radiation which is a composite of two radiation data fields collected in American College of Surgeons Commission on Cancer approved hospital cancer registries. The fields are automatically derived when sent to the State. Treatment volume, modality, regional dose, boost modality and boost dose are some of the radiation fields collected by COC hospital registries. They typically will be found in the radiation oncologist’s summary letter for first course of treatment. If multiple radiation therapy modalities were used, code the dominant modality. Boost treatment may precede regional treatment. Consult your radiation oncologist as necessary. Prophylactic cranial radiation (PCI) to the whole brain may be administered for small cell cancer patients who have negative brain imaging. It may be useful in extending symptom free quality of life, if not increasing actual survival.

Chemotherapy Non-Small Cell Carcinoma Small Cell Carcinoma Hormones Immunotherapy Other Endoscopic Photodynamic Therapy Chemotherapy drugs commonly used for treating non-small cell lung cancer include carboplatin containing regimens, taxol, taxotere, cisplatin, doxorubicin and cytoxan. Chemotherapy is often given as a radiosensitizer for patients receiving radiation. All patients treated for small cell lung cancer should receive combination chemotherapy regardless of the extent of disease. Chemotherapy drugs commonly used for treating small cell lung cancer may include: VPP which is Etopside (VP-16) and cisplatin, with or without other agents such as vincristine, methotrexate, adriamycin. CAV which is cytoxan, adriamycian, and vincristine. There are other combinations of these agents in use. Hormones and Immunotherapy have not proven to be useful in the treatment of lung cancer so far. Other modalities including endoscopic photodynamic therapy (a treatment that involves a light-activated drug, photofrin, and light from a laser) are under clinical evaluation for non-small cell lung cancer. Code any of these therapies that were given as part of the first course of therapy.

Keys to Abstracting Organization Resources Text Dates
Procedure Documentation Resources Diagnosis year Text Pertinent Acronyms Before abstracting give a cursory review of the chart to determine sources for site, histology, extent. Review for date of diagnosis. Provide dates for history and physical, radiographic imaging reports, biopsies, operative reports, pathology reports. This will not only help in organizing the abstract to determine such factors as pre/post treatment extent and evaluation for collaborative staging fields, it is also tremendously helpful to editors who try to “piece together” conflicting information from different facilities. Estimating dates is preferred, just be sure to note in the text that the specific date is an estimate. Note the source document where you obtained the information. This again will be important when you are coding for the evaluation fields in CS. Once you have determined the diagnosis year, refer to the appropriate staging manual. When abstracting cases you must use the rules in accordance with the year of diagnosis. The text for abstracts has continued to improve. A few reminders: record pertinent information related to the cancer, abbreviate or use acronyms whenever possible, but be sure they are understandable. READ the Manuals!! Collaborative Stage is new for all of us, there are general as well as site specific rules. When abstracting prior year cases make sure you are familiar with the guidelines in effect at that time. Questions?

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