The Anatomy of

Collaborative Staging:
Lung

Presentation developed by
April Fritz, RHIT, CTR
april.fritz@nih.gov
SEER Program
National Cancer Institute
 Lung Cancer

 Estimated 12.7% of all 2004 cancer cases

 Collaborative Stage fields
• 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 2

 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)
(malignant cells in bronchopulmonary
secretions; no tumor seen)
997 Diffuse (entire lobe) (M1)
998 Diffuse (entire lung) (M1)

CS Lung Coding 2004 3

 Lung -- CS Extension -- Notes

1. Direct extension to other structures is M1.

Sternum, skeletal muscle, skin of chest, contra-
lateral 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 4
 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 5

 Lung -- CS Extension -- 00-11, 23-30

B Code 00 Very rare

Code 10 Confined to
C lung; needs size
E F Code 11 Superficial
bronchus only (D)
D
Code 23 Starts in hilus
(E); needs size
A 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 6
 Lung -- CS Extension -- 20-21, 45
C

A
>2 cm
B

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 7
 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 8
 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 9
 Lung -- CS Extension -- 56-61
Extension Codes
Superior Direct extension to:
sulcus Trachea 56 Parietal pericardium
Clavicle (A)
B
E 59 Phrenic nerve (not
shown)
C A
D
60 Brachial plexus
Ribs from superior sulcus
D (B); Pancoast tumor
Pleura
60 Chest wall (C)
Pleural 60 Diaphragm (D)
space 60 Parietal pleura (E)
Pericardium Diaphragm 61 Upper brachial
plexus (not shown,
similar to B)
CS Lung Coding 2004 10
Lung -- CS Extension -- 70, 71, 73, 75
Direct invasion of any of
the following:
70 Mediastinum (A)
C 71 Heart, visceral
D
pericardium (B)
E 70 Trachea (C)
D
70 Great vessels (D)
70 Carina (E)

B
Not shown:
70 Esophagus
(behind trachea)
A 70 Nerves
73 Adjacent rib
75 Vertebral body
(posterior to lung)
CS Lung Coding 2004 11
 Lung -- CS Extension -- Great Vessels

70 Superior vena cava

70 Main pulmonary artery
70 R and L pulmonary artery trunks*
70 R and L superior pulmonary veins*
70 R and L inferior pulmonary veins*
74 Aorta
77 Inferior vena cava

* intrapericardial segments

CS Lung Coding 2004 12

 Lung -- CS Extension -- 65, 72

B Pleura
Pleural effusion
(malignant or NOS)
Pleural space
Extension Codes
65 Separate tumor nodules in same lobe (A)
72 Any tumor with malignant pleural effusion (B)
76 Discontinuous pleural tumor foci (C)
79 Pericardial effusion (not shown)
CS Lung Coding 2004 13
 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 14

 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 15

 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 16

 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).

CS Lung Coding 2004 17

 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).

CS Lung Coding 2004 18

 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.

CS Lung Coding 2004 19

 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 20
 Lung -- CS Lymph Nodes
Lymph Nodes
60 10 Same side
Hilar, bronchial,
peribronchial,
20
60 intrapulmonary
(LN stations 10-14)
20 Same side
10 Subcarinal,
mediastinal, others
(LN stations 1-9)
6
50 Regional LN, NOS
0
60 Contralateral
20 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.
CS Lung Coding 2004 21
 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 22

 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 23

 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 24

 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 25

 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 26

 Lung -- CS Mets at Dx
C
Primary A separate
tumor contralateral
tumor nodule

B
separate
CS Mets at Dx Codes
ipsilateral 10 Distant lymph nodes (A)
tumor
nodule Separate tumor nodules
in a different lobe:
D
liver 35 Ipsilateral (B);
metastasis 39 Contralateral (C)
40 Distant metastasis (D)
Not shown:
37 Extension to sternum, skeletal muscle, skin of chest
39 Extension to contralat lung, mainstem bronch.
50 (10 + 40)
CS Lung Coding 2004 27
 Lung -- Site-Specific Factors

NONE!

CS Lung Coding 2004 28