1. TNM Staging of Lung Cancer 7 th Edition and v02.05 SSFs Presentation developed by April Fritz, RHIT, CTR Reno, Nevada april@afritz.org

2. Lung Staging TNM 7 th Edition 2 Celebrities Who Had Lung Cancer

3. Lung Staging TNM 7 th Edition 3 The Crowded Thorax Larynx Thyroid Trachea Thymus Pleura Sternum (cut away) Aorta Intercostal muscles Ribs Diaphragm Heart Lungs

4. Lung Staging TNM 7 th Edition 4 Upper lobe Middle lobe Lower lobe C34.1 C34.2 C34.1 Carina C34.3 Trachea C33.9 Lung Anatomy showing ICD-O-3 codes

5. Lung Staging TNM 7 th Edition 5 Important Anatomical Landmarks Graphics source: Mediclip, Williams and Wilkins. Right LungLeft Lung Hilum Lingula Apex Lower lobe Upper lobe Middle lobe

6. Lung Staging TNM 7 th Edition 6 Trachea Mainstem bronchus Lobar bronchus Segmental bronchus Bronchiole Alveolar duct Alveolus Adapted from R S Snell: Clinical Anatomy for Medical Students, 5th ed. 1995. Respiratory Tract

7. Lung Staging TNM 7 th Edition 7 Alveoli Source: http://www.webschoolsolutions.com/patts/systems/lungs.htm#anatomy

8. Lung Staging TNM 7 th Edition 8 The Mediastinum Image source: mywebpages.comcast.net/ wnor/thoraxlesson3.htm Clavicle Superior mediastinum Inferior mediastinum Anterior mediastinum Middle mediastinum Posterior mediastinum

9. Lung Staging TNM 7 th Edition 9 Bronchioloalveolar Carcinoma – New Terminology From IASLC 2011: terms BAC and mixed subtype adenocarcinoma no longer used. 1.≤ 3 cm, NO stromal, lymphatic, vascular or pleural invasion, no necrosis, no growth patterns other than lepidic  Adenocarcinoma in situ, either serous (8140/2) or mucinous (8253/2; rare) 2.≤ 3 cm, with ≤ 5 mm area of stromal invasion or growth pattern(s) other than lepidic  Minimally Invasive Adenocarcinoma (MIA): Non-mucinous 8250/2; Mucinous 8257/3 use 8253/3 until 2018 Source: 2015 WHO Classification of Tumors of the Lung

10. Lung Staging TNM 7 th Edition 10 Bronchioloalveolar Carcinoma – New Terminology 3.> 3 cm OR with lymphatic, vascular or pleural invasion OR necrosis OR > 5 mm area of stromal invasion OR growth pattern(s) other than lepidic  Serous: invasive adenocarcinoma, lepidic predominant (8250/3) Mucinous: invasive mucinous adenocarcinoma (8253/3) Source: 2015 WHO Classification of Tumors of the Lung

11. Lung Staging TNM 7 th Edition 11 Invasive Adenocarcinoma Subtypes and variants  Lepidic (formerly most mixed subtype tumors with non- mucinous BAC) – 8250/3  Acinar – 8551/3  Papillary – 8260/3  Solid – 8230/3  Micropapillary added as a new histologic subtype – 8265/3  Invasive mucinous adenocarcinoma (formerly mucinous BAC) – 8253/3  Colloid – 8480/3  Fetal – 8333/3  Enteric adenocarcinoma – 8144/3

12. Lung Staging TNM 7 th Edition 12 Summary of Lung T Classification TX Positive cytology only T1 ≤ 3 cm  T1a ≤ 2 cm  T1b > 2–<3 cm T2 Main bronchus 2 cm from carina, invades visceral pleura, partial atelectasis  T2a > 3 cm to 5 cm  T2b > 5 cm to 7 cm T3 > 7 cm; parietal pleura, chest wall, diaphragm, pericardium, mediastinal pleura, main bronchus < 2 cm from carina, total atelectasis, separate nodule(s) in same lobe T4 Mediastinum, heart, great vessels, carina, trachea, esophagus, vertebral body; separate tumor nodule(s) in a different ipsilateral lobe

13. Lung Staging TNM 7 th Edition 13 T1 Lung Cancer Tumor 3 cm or less in size, surrounded by lung or visceral pleura; no invasion more proximal than a lobar bronchus T1a≤ 2 cm T1b> 2 to 3 cm Source: UICC TNM-interactive, Wiley-Liss, 1998

14. Lung Staging TNM 7 th Edition 14 T2 Lung Cancer Source: UICC TNM-interactive, Wiley-Liss, 1998 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 with atelectasis or obstructive pneumonitis extending to hilar region but not involving entire lung

15. Lung Staging TNM 7 th Edition 15 Atelectasis/Obstructive Pneumonitis Source: www.upstate.edu/radiology/ olla/lung_cancer.htm T2 Obstructive Pneumonitis Do not code bronchopneumonia T3 Atelectasis of Right Lung Source: Medi-clip: Grant’s Atlas Images I, Thorax and Abdomen. Williams and Wilkins, 1998.

16. Lung Staging TNM 7 th Edition 16 T3 Lung Cancer (1) Any of the following: Tumor > 7 cm Any of following: In main bronchus < 2 cm from carina without involving carina Atelectasis or obstructive pneumonitis of entire lung Separate tumor nodule(s) in same lobe continued Source: UICC TNM-interactive, Wiley-Liss, 1998

17. Lung Staging TNM 7 th Edition 17 T3 Lung Cancer (2) Any of the following: Direct invasion of A.Chest wall B.Diaphragm C.Mediastinal pleura D. Parietal pericardium —Phrenic nerve

18. Lung Staging TNM 7 th Edition 18 Pancoast Tumor T3Pancoast tumor (superior sulcus tumor) T4Superior sulcus tumor with encasement of subclavian vessels or involvement of superior branches of brachial plexus above C8 C8 Image source: http://www.mayoclinic.org/ brachial-plexus/details.html

19. Lung Staging TNM 7 th Edition 19 T4 Lung Cancer (1) Direct invasion of any of the following: Mediastinum Heart Trachea Great vessels Carina Not shown: Esophagus (behind trachea) Adjacent rib Vertebral body (posterior to lung) continued A B C D E

20. Lung Staging TNM 7 th Edition 20 T3 vs T4 T3 Multiple tumors in same lobe Source: UICC TNM-interactive, Wiley-Liss, 1998 T4 Multiple tumors in different lobe

21. Lung Staging TNM 7 th Edition 21 Superior vena cava Main pulmonary artery R and L pulmonary artery trunks* R and L superior pulmonary veins* R and L inferior pulmonary veins* Aorta Inferior vena cava * intrapericardial segments Great Vessels (T4) Superior vena cava Heart Great vessels

22. Lung Staging TNM 7 th Edition 22 Direct Extension per TNM Manual TNM Phrenic nerve invasionT3 Discontinuous pleural fociT4 Vocal cord paralysisT4* SVC obstructionT4* Tracheal/esophageal compression T4* * unless primary is peripheral, then code in N Details coming

23. Lung Staging TNM 7 th Edition 23 Summary of Lung N and M N1 Ipsilateral peribronchial, ipsilateral hilar N2 Ipsilateral mediastinal, subcarinal N3 Contralateral mediastinal or hilar, scalene or supraclavicular M1 Distant metastasis  M1a Separate tumour nodule(s) in a contralateral lobe; pleural nodules or malignant pleural or pericardial effusion  M1bDistant metastasis

24. Lung Staging TNM 7 th Edition 24 N3 N2 N1 N3 N2 Adapted from R S Snell: Clinical Anatomy for Medical Students, 5th ed. 1995. Lung Cancer Lymph Nodes Lymph Nodes N1Same side Intrapulmonary Peribronchial Hilar By direct extension N2Same side Mediastinal Subcarinal N3Contralateral Mediastinal Hilar Any scalene Any supraclavicular

25. Lung Staging TNM 7 th Edition 25 Lymph Node Stations Not the same as N categories Stations are based on surgical landmarks Source: UICC TNM-interactive, Wiley-Liss, 1998

26. Lung Staging TNM 7 th Edition 26 Lymph Nodes – N1 and N2 Ipsilateral bronchial HilarPeribronchial Image source: AJCC Cancer Staging Atlas, Springer-Verlag, 2006. Hilar Adenopathy Image source: www.uveitis.org/images/sarcoid7.jpg

27. Lung Staging TNM 7 th Edition 27 Lymph Nodes – N2 Image source: AJCC Cancer Staging Atlas, Springer-Verlag, 2006. SubcarinalIpsilateral mediastinal Source: Workbook for Staging of Cancer, 2nd ed., pages 110-111 N2 Ipsilateral mediastinal Mediastinal lymph node stations

28. Lung Staging TNM 7 th Edition 28 Lymph Nodes – N3; Distant Mets – M1a N3 M1a Lymph Nodes N3 Bilateral or contralateral mediastinal, scalene, supraclavicular Distant Mets M1a Distant lymph nodes including cervical nodes Image source: AJCC Cancer Staging Atlas, Springer-Verlag, 2006.

29. Lung Staging TNM 7 th Edition 29 M1 Lung Cancer M1aSeparate tumor nodules in contralateral lobe Pleural nodules Malignant pleural or pericardial effusion M1bDistant metastasis Pleural effusion

30. Lung Staging TNM 7 th Edition 30 Pleural Effusion TNM Guideline Assume to be malignant (M1a) UNLESS * Negative cytology on multiple exams AND * Non-bloody, not an exudate AND * Clinical judgement correlates with benign diagnosis

31. Lung Staging TNM 7 th Edition 31 Clinical Staging Criteria: Lung Limited to evidence acquired before treatment  Physical examination  Imaging studies  Laboratory tests  Staging procedures AJCC Cancer Staging Manual 7 th Edition, page 255

32. Lung Staging TNM 7 th Edition 32 Clinical Staging Criteria: Lung Imaging studies  computed and positron emission tomography) Staging procedures  Bronchoscopy or esophagoscopy with ultrasound directed biopsies (EBUS, EUS)  Mediastinoscopy  Mediastinotomy  Thoracentesis  Thoracoscopy (VATS)  Exploratory thoracotomy AJCC Cancer Staging Manual 7 th Edition, page 255

33. Lung Staging TNM 7 th Edition 33 Pathologic Staging Criteria: Lung AJCC Cancer Staging Manual 7 th Edition, page 256 All evidence acquired before treatment AND Supplemented or modified by the additional evidence acquired during and after surgery, particularly from pathologic examination.

34. Lung Staging TNM 7 th Edition 34 Pathologic Stage Provides precise data used for estimating prognosis and calculating end results  pT requires Resection of the primary tumor sufficient to evaluate the highest pT category OR Biopsy that proves highest pT category

35. Lung Staging TNM 7 th Edition 35 Pathologic Stage Cont’d When T is evaluated clinically, N must be cN  Unresectable lung tumor with positive biopsy of contralateral scalene LN = cN p 4 AJCC 7 ED* Do not record post-treatment stage pN ideally entails removal of a sufficient number of lymph nodes to evaluate the highest pN category If pathologic assessment of lymph nodes reveals negative nodes but the number of lymph node stations examined are fewer than suggested above, classify the N category as pN0

36. Lung Staging TNM 7 th Edition 36 Stage Groups Occult TXN0 M0 0TisN0 M0 IAT1a-bN0 M0 IBT2aN0 M0 IIAT1a-b, T2aN1 M0 T2bN0 M0 IIBT2bN1 M0 T3N0 M0 IIIAT1-2N2 M0 T3 N1-2 M0 T4 N0-1 M0 IIIBAny TN3 M0 T4 N2-3 M0 IVAny T Any N M1a-b

37. Lung Staging TNM 7 th Edition 37 SSF 1 – Separate Tumor Nodules/ Ipsilateral Lung Required by COC, SEER, NPCR Location of separate tumor nodules affects T Codes 000No separate nodules noted 010Separate nodules in ipsilat lung, same lobe 020Separate nodules in ipsilat lung, different lobe 030Separate nodules, ipsilat lung, same and different lobe 040Separate nodules, ipsilat lung, unknown if same or different lobe 988Not applicable: Information not collected 999Unknown if separate tumor nodules; Not documented in patient record

38. Lung Staging TNM 7 th Edition 38 SSF 2 – Visceral Pleural Invasion/ Elastic Layer Required by COC, SEER For tumor < 3 cm (T1), invasion of visceral pleura upstages T  PL1-PL2  T2  PL3  T3 Source: virtualmedicalcentre.com/uploads/VMC/ DiseaseImages/598_Normal_L_Pleura.jpg Surface of visceral pleura (PL 2) Pleural space Visceral pleura (PL 1) beyond elastic layer Lung Parietal pleura (PL 3)

39. Lung Staging TNM 7 th Edition 39 Visceral Pleural Invasion PL0—Within subpleural lung parenchyma or invading superficially into pleural connective tissue beneath elastic layer. Not a T descriptor; T category should be assigned on other features. PL1—Invades beyond elastic layer PL2—Invades to pleural surface PL1/PL2 indicate VPI; T2 descriptor PL3—Tumor invades into any part of parietal pleura T3 descriptor Reprinted from Journal of Thoracic Oncology. Copyright © 2008 Aletta Ann Frazier, MD.

40. Lung Staging TNM 7 th Edition 40 SSF 2 – Visceral Pleural Invasion/ Elastic Layer Required by COC, SEER Codes 000No evidence of visceral pleural invasion; not through elastic layer (PL 0) 010Beyond visceral elastic pleura, limited to pulmonary pleura; through elastic layer (PL 1) 020To surface of pulmonary pleura; Extends to surface of visceral pleura (PL 2) 030Extends to parietal pleura (PL 3) 040Invasion of pleura, NOS 988Not applicable: Information not collected 998No histology of pleura 999Unknown if visceral pleural invasion is present; Not documented in patient record

41. Lung Staging TNM 7 th Edition 41 CODING TNM FACTOIDS

42. Lung Staging TNM 7 th Edition 42 cTNM – Blanks, X, or Number Meets c classification criteria Use x or numbers M must be 0 or 1 Does not meet c classification criteria  T, N, and M all blank  Group stage 99  Example: incidental/surprise diagnosis  Chest x-ray your facility; no further information

43. Lung Staging TNM 7 th Edition 43 pTNM – Blanks, X, or Number Meets p classification criteria  T and N either X or numbers  M0 or M1 Does not meet p classification criteria  T, N, and M blank  Group stage 99  Example: No resection of primary

44. Lung Staging TNM 7 th Edition 44 Source of Information? Louanne Currance Louanne spoke with Donna Gress to clarify when T, N, or M should be blank

45. Lung Staging TNM 7 th Edition 45 T4 Cont’d Is it possible to code pT without gross tumor removal? What do you think? Example (verbal)

46. Lung Staging TNM 7 th Edition 46 Guess What – Information in Text T2 invasion hilar fat (unless higher by size) T2a  Invasion across fissure  Direct invasion adjacent lobe (unless higher by size)

47. Lung Staging TNM 7 th Edition 47 T3 Invasion mediastinal pleura (no matter what tumor size) Pericardial invasion  Note T3 does not include malignant pericardial infusion Invasion of sternum Phrenic nerve invasion

48. Lung Staging TNM 7 th Edition 48 T4 Vocal cord paralysis can be:  Invasion of vocal cords T4 OR  LN involvement N2 (find out why) Pancoast tumor  Involvement of brachial plexus  Invasion vertebra or spinal canal Direct extension to mediastinal fat

49. Lung Staging TNM 7 th Edition 49 Must Know Direct extension to LN coded as LN metastases  Example: 2.8 cm tumor confined to lung with invasion of intrapulmonary node – code T1 N1 T based on size of tumor – N based on invasion of node

50. Lung Staging TNM 7 th Edition 50 Requirements for pN First “drainage” station depends on lobe Is one node enough for pN?  Cannot use molecular markers such as EGFR and K-ras  Only sentinel node – specific circumstances  Lymphoma with one clinically positive node  Most chapters require 4 nodes  Lung – no evidence-based studies to confirm number of nodes

51. Lung Staging TNM 7 th Edition 51 How Many LN for pN Still investigational p 255 AJCC 7 ED Evidence to support  6 or more hilar AND mediastinal nodes  At least 3 nodes from N1 category  At least 3 mediastinal nodes (includes sub- carinal nodes)

52. Lung Staging TNM 7 th Edition 52 Lymph Node Stations – N Value N2  Ipsilateral surgical stations 1-9  Rt lung: Stations 2, 4, 7, 10, and 11  Lt lung: Stations 5, 6, 7, 10, and 11  LL tumors should include Station 9 N3  Ipsilateral surgical stations 10-14 Stations 12-14 lobectomy or pneumonectomy

53. Lung Staging TNM 7 th Edition 53 M1a Discontinuous tumor foci parietal pleura  Ipsilateral  NOT direct extension Discontinuous tumor foci visceral pleura  Ipsilateral  NOT direct extension Malignant pericardial effusion Discontinuous tumor nodules pericardium

54. Lung Staging TNM 7 th Edition 54 M1b Discontinuous tumors chest wall  Not direct extension Discontinuous tumors diaphragm  Not direct extension

55. Lung Staging TNM 7 th Edition 55 Questions?