Advanced Abstracting Issues for the Lung Cancer Diagnosis

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Advanced Abstracting Issues for the Lung Cancer
Diagnosis

• Judy Andrews, CTR
• Metropolitan Regional Coordinator
• Georgia Center for Cancer Statistics
• GATRA Fall Meeting 2004

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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

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Anatomy

• Related adjectives Lung pneumo-, pulmono-,
  broncho-, bronchiolo-, alveolar, hilar
• Breathing -pnea (difficulty with
  breathingdyspnea)
• Paired organ
• Subsites
• Right lobe 3 lobes
• Left Lobe 2 lobes

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Lung Anatomy
Carina
Upper Lobe
Oblique Fissure
Middle Lobe
Lower Lobe
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Lung Anatomy Key Words

• Apex
• Hilum
• Carina
• Lingula
• Cardiac Notch
• Pleural Cavity
• Chest Wall
• Mediastinum
• Base

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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

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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

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Regional Lymph Nodes for the Lung

• 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

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Regional Lymph Nodes for the Lung

• Extrathoracic
• Scalene
• Supraclavicular or transverse cervical

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Common Metastatic Sites for the Lung

• Lymphatic Spread
• Cervical Lymph Nodes
• Contralateral Lung
• Contralateral Mediastinum
• Hematogenic Spread
• Brain
• Bone
• Liver
• Adrenal glands
• Contralateral Lung

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Extent of Disease Evaluation for the Lung

• Diagnostic Studies Physical Exam
• Signs and Symptoms
• Palpable lymph nodes or organs
• Pancoast Tumor
• Horners Syndrome

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Extent of Disease Evaluation for the Lung

• Diagnostic Studies Imaging
• Chest X-ray
• CAT Scan
• MRI Scan
• PET Scan
• Bone Scan

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Extent of Disease Evaluation for the Lung

• Diagnostic Studies Endoscopies
• Bronchoscopy
• Mediastinoscopy
• Thoracoscopy

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Extent of Disease Evaluation for the Lung

• Diagnostic Studies Pathological
• Closed Chest Needle Biopsy
• Cytology (Thoracentesis)
• Sputum Cytology
• Bronchial Washings
• Bone Marrow Biopsy

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Extent of Disease Evaluation for the Lung

• 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)

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Staging Systems for Lung

• SEER Extent of Disease 3rd Edition
• (Diagnosis year 1988-2003)
• SEER Summary Staging 2000
• (Diagnosis year 2001-2003)
• American Joint Committee on Cancer (AJCC)
• TNM 6th Edition
• (Diagnosis year 2003 forward)
• Collaborative Staging
• (Diagnosis year 2004 forward)

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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

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Collaborative Stage

• General Guidelines
• Timing Rule
• Site-specific guidelines
• Highest applicable number for each field
• Greatest extent of disease

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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

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Collaborative Stage for Bronchus and Lung

• CS Tumor Size
• 000 No mass/tumor found
• 001-998 001-998 millimeters (exact size)
• 989 989 millimeters or larger
• 990 Microscopic focus or foci only, no
  size of focus given
• 991 Described as less than 1 cm
• 992-995 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

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Collaborative Stage for Bronchus and Lung

• CS Extension
• Primary Tumor extension
• DO NOT CODE DISCONTINOUS METASTASES IN THIS FIELD
• Priority order for extension
• Notes 1-7 Read carefully

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Collaborative Stage for Bronchus and Lung

• CS TS/EXT EVAL
• Evaluates source for CS Tumor Size and
• CS Extension
• Describes clinical or pathological staging
• of the tumor

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Collaborative Stage for Bronchus and Lung

• 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

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Collaborative Stage for Bronchus and Lung

• 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

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Collaborative Stage for Bronchus and Lung

• 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

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Collaborative Stage for Bronchus and Lung

• Regional Nodes Positive
• 00 All nodes examined negative
• 01-89 1-89 nodes positive
• 90 or more nodes positive
• 95 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
• 01-89 1-89 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

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Collaborative Stage for Bronchus and Lung

• 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.

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Collaborative Stage for Bronchus and Lung

• 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

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Collaborative Stage for Bronchus and Lung

• 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

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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

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Treatment for Bronchus and Lung

• Surgery Codes
• Primary Site
• Scope of Regional Lymph Node
• Surgical Procedure of Other Site

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Treatment for Bronchus and Lung

• Surgery Codes continued
• Primary Site
• Scope of Regional Lymph Node
• Surgical Procedure of Other Site

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Treatment for Bronchus and Lung

• Surgery Codes continued
• Primary Site
• Scope of Regional Lymph Node
• Surgical Procedure of Other Site

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Treatment for Bronchus and Lung

• Radiation
• Treatment Volume
• Treatment Modality
• Regional Dose
• Boost Modality
• Boost Dose
• Prophylactic Cranial Radiation (PCI)

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Treatment for Bronchus and Lung

• Chemotherapy
• Non-Small Cell Carcinoma
• Small Cell Carcinoma
• Hormones
• Immunotherapy
• Other
• Endoscopic Photodynamic Therapy

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Keys to Abstracting

• Organization
• Dates
• Procedure Documentation
• Resources
• Diagnosis year
• Text
• Pertinent
• Acronyms