1. The Anatomy of Collaborative Staging: Lung
Presentation developed by
April Fritz, RHIT, CTR
SEER Program
National Cancer Institute

2. 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
Birds eye view of the lung schema. No SSF are used

3. Lung -- Tumor Size Site-specific (not standard) table Special codes
Standard definitions
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)
Tumor size table is a non-standard table. Incorporating the special codes to record those “occult, diffuse tumors.

4. 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.
Page 404 in CS manual.
Note 1:   Direct extension to or other involvement of structures considered M1 in AJCC staging is coded in the data item CS Mets at DX. This includes: sternum; skeletal muscle; skin of chest; contralateral lung or mainstem bronchus; separate tumor nodule(s) in different lobe, same lung, or in contralateral lung.
Note 2:   Distance from Carina. Assume tumor is greater than or equal to 2 cm from carina if lobectomy, segmental resection, or wedge resection is done.
Note 3:   Opposite Lung. If no mention is made of the opposite lung on a chest x-ray, assume it is not involved.
Note 4:   Bronchopneumonia. "Bronchopneumonia" is not the same thing as "obstructive pneumonitis" and should not be coded as such.
Note 5:   Pulmonary Artery/Vein. An involved pulmonary artery/vein in the mediastinum is coded to 70 (involvement of major blood vessel). However, if the involvement of the artery/vein appears to be only within lung tissue and not in the mediastinum, it would not be coded to 70.

5. 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
Note 6:   Pleural Effusion.
A. Note from SEER manual: Ignore pleural effusion that is negative for tumor. Assume that a pleural effusion is
negative if a resection is done.
B. Note from AJCC manual: Most pleural effusions associated with lung cancers are due to tumor. However, there
are a few patients in whom multiple cytoopathologic examinations of pleural fluid are negative for tumor.
In these cases, fluid is non-bloody and is not an exudate. When these elements and clinical judgement dictate
that the effusion is not related to the tumor, the effusion should be excluded as a staging element and the patient
should be staged T1, T2, or T3.
Note 7:   Vocal cord paralysis (resulting from involvement of recurrent branch of the vagus nerve), superior vena cava obstruction, or compression of the trachea or the esophagus may be related to direct extension of the primary tumor or to lymph node involvement. The treatment options and prognosis associated with these manifestations of disease extent fall within the T4-Stage IIIB category; therefore, generally use code 70 for these manifestations. HOWEVER, if the primary tumor is peripheral and clearly unrelated to vocal cord paralysis, vena cava obstruction, or compression of the trachea or the esophagus, code these manifestations as mediastinal lymph node involvement (code 20) in CS Lymph Nodes unless there is a statement of involvement by direct extension from the primary tumor.
Code an extension where it appears.
Computer algorithm will correctly assign the stage

6. Lung -- CS Extension -- 00-11, 23-30A B C F E D
Code 00 Very rare
Code 10 Confined to lung; needs size
Code 11 Superficial bronchus only (D)
Code 23 Starts in hilus (E); needs size
Code 25 Starts in carina (F); needs size
Code 30 Localized, NOS
Review of CS Extension and Codes
CS Extension Code 10
Tumor surrounded by lung (A) or
visceral pleura (B); no invasion more
proximal than a lobar bronchus (C)

7. Lung -- CS Extension -- 20-21, 45B C A
>2 cm
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)

8. 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

9. Lung -- CS Extension -- 50-55B A
2 cm
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)

10. Lung -- CS Extension -- 56-61
Extension Codes
Direct extension to:
56 Parietal pericardium
(A)
59 Phrenic nerve (not
shown)
60 Brachial plexus
from superior sulcus
(B); Pancoast tumor
60 Chest wall (C)
60 Diaphragm (D)
60 Parietal pleura (E)
61 Upper brachial
plexus (not shown,
similar to B)
Superior
sulcus
Clavicle
Trachea
Ribs
Pleura
Pleural
space
Pericardium
Diaphragm C B D A E

11. Lung -- CS Extension -- 70, 71, 73, 75 Direct invasion of any of
the following:
70 Mediastinum (A)
71 Heart, visceral
pericardium (B)
70 Trachea (C)
70 Great vessels (D)
70 Carina (E) A B C D E
Not shown:
70 Esophagus
(behind trachea)
70 Nerves
73 Adjacent rib
75 Vertebral body
(posterior to lung)

12. 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

13. Lung -- CS Extension -- 65, 72 C A B Pleura Pleural effusion
Pleural space
Pleural effusion
(malignant or NOS) B A C
Codes are out of sequence to give you the correct anatomical display
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)

14. Discontinuous Nodules
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
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

15. 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

16. 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
Non-standard mapping for TS/Ext Eval
Code 1 maps to pathologic (AJCC)
Includes endoscopic biopsies, FNA, surgical observation

17. 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 mediastinal extension TS/Ext Eval endoscopic, FNA.
Extension determines the mapping (pT4).

18. 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 confined to one lung TS/Ext Eval surgical resection,
no pre-op treatment
Tumor size from path report determines the
mapping (pT1).

19. 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 pleural effusion (NOS) TS/Ext Eval clinical (CT scan)
Clinical findings document farther extension
than tissue findings.

20. 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 Lymph Nodes (page 407
Note 1:   Code only regional nodes and nodes, NOS, in this field. Distant nodes are coded in the field Mets at DX.
Note 2:   If at mediastinoscopy/x-ray, the description is "mass", "adenopathy", or "enlargement" of any of the lymph nodes named in Regional Lymph Nodes, assume that at least regional lymph nodes are involved.
Note 3:   The words "no evidence of spread" or "remaining examination negative" are sufficient information to consider regional lymph nodes negative in the absence of any statement about nodes.
Note 4:   Vocal cord paralysis (resulting from involvement of recurrent branch of the vagus nerve), superior vena cava obstruction, or compression of the trachea or the esophagus may be related to direct extension of the primary tumor or to lymph node involvement. The treatment options and prognosis associated with these manifestations of disease extent fall within the T4-Stage IIIB category; therefore, generally use code 70 for these manifestations. HOWEVER, if the primary tumor is peripheral and clearly unrelated to vocal cord paralysis, vena cava obstruction, or compression of the trachea or the esophagus, code these manifestations as mediastinal lymph node involvement (code 20) in CS Lymph Nodes unless there is a statement of involvement by direct extension from the primary tumor.

21. Lung -- CS Lymph Nodes Lymph Nodes 10 Same side
Hilar, bronchial, peribronchial, intrapulmonary
(LN stations 10-14)
20 Same side
Subcarinal,
mediastinal, others
(LN stations 1-9)
50 Regional LN, NOS
60 Contralateral
Mediastinal, hilar
any scalene, any
supraclavicular
80 Lymph nodes, NOS
99 Unknown,
undocumented 60 20 10
Adapted from R S Snell: Clinical Anatomy for Medical Students, 5th ed

22. 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

23. 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
Non-standard mapping for TS/Ext Eval
Code 1 maps to pathologic (AJCC)
Includes endoscopic biopsies, FNA, surgical observation

24. 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.

25. 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).

26. 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

27. Lung -- CS Mets at Dx C A B CS Mets at Dx Codes D
separate
ipsilateral tumor
nodule
Primary
tumor
separate contralateral tumor nodule
liver
metastasis C B D A
CS Mets at Dx Codes
10 Distant lymph nodes (A)
Separate tumor nodules
in a different lobe:
35 Ipsilateral (B);
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 ( )

28. Lung -- Site-Specific Factors
NONE!