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
 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)
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.
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
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
Tumor surrounded by lung (A) or
Code 30 Localized, NOS
visceral pleura (B); no invasion more
proximal than a lobar bronchus (C)
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)
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
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)
 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
D sulcus
Pleura
(B); Pancoast tumor
Pleural 60 Chest wall (C)
space 60 Diaphragm (D)
Pericardium Diaphragm 60 Parietal pleura (E)
61 Upper brachial
plexus (not shown,
similar to B)
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)
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
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)
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
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
 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
 Lung -- Coding CS TS/Ext
• Example 1
Eval
–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).

 Lung -- Coding CS TS/Ext
• Example 2
Eval
–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
 Lung -- Coding CS TS/Ext
• Example 3
Eval
–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.
 Lung -- CS Lymph Nodes --
1.Code only regional nodes in this field.
Notes
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
Lung -- CS Lymph Nodes
Lymph Nodes
60 10 Same side
Hilar, bronchial,
20 peribronchial,
60 intrapulmonary
(LN stations 10-14)
20 Same side
10 Subcarinal,
mediastinal, others
6 (LN stations 1-9)
0 50 Regional LN, NOS
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.
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

 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
 Lung -- Coding Reg Nodes
• Example 1
Eval
–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

 Lung -- Coding Reg Nodes
• Example 2
Eval
–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
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
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)