NAACCR Webinar Series
Q&A Session
Collecting Cancer Data: Lung
Thursday, December 03, 2009
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Q: According to rule M1 note 2 one tumor in each lung (lung multiple primary rules) should be a single primary.
A: Rule M1 is only applied if tumors are in both lungs and at least one lung has more than one tumor. M6 applies if there is a single tumor in each lung.
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Q: For the lung case you just discussed, mass in the right lung and a mass in the left lung, the answer seems to conflict with the lung general instructions which state when there is a tumor in both lungs and a biopsy is done to just one tumor, it is one primary.
A: That general instruction is in reference to the situation where there are multiple tumors in 1 lung and single or multiple tumors in the other lung. In that situation it is considered a single primary. The example presented was a single tumor in each lung.
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Q: Please include the previous lung example of the RUL and LLL in the Q&A that is sent out after the Webinar. Thank you.
A: Very good suggestion. The example follows.
SCENARIO
• A patient underwent a chest x-ray that showed an abnormal mass in the right lung and another in the left lung. The patient then had a CT scan of the chest which revealed a 2cm mass in the right upper lobe and a 1.5cm mass in the left lower lobe.
– No other information on CT, they are just called “masses”.
• The mass in right upper lobe is biopsied and reveals squamous cell carcinoma.
• No biopsy of the left lower lobe is done.
ANSWER
• Because the right upper lobe mass was malignant, we would consider the “mass” in the left lower lobe to be malignant as well. According to rule M6 these would be two primaries.
– If a biopsy had not been done and all we had was imaging describing both only as “masses”, this case would not be accessioned.
• The right upper lobe mass would be assigned a histology of 8070/3 (squamous cell carcinoma) and the “mass” would be assigned a histology of 8000 (malignancy, NOS)
– SEER Inquiry Team
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Q: Please clarify your example of 2 lung tumors considered 2 primaries. The second scenario just recently was 1 primary. Please explain better - hard to understand.
A: A single tumor in each lung is multiple primaries (rule M6). When only one tumor is biopsied but the patient has two or more tumors in one lung and may have one or more tumors in the contralateral lung, it is a single primary (rule M1).
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Q: What if the MD states that the tumor in the left lower lobe is metastasis from right lobe mass & stages/treats patient as stage IV lung cancer?
A: A statement from the physician saying that one tumor is metastasis from the other would be sufficient to make this one primary (rule M6 would not apply).
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Q: Patient has one lung nodule in RUL and one lung nodule in RLL. The physician is treating as two primaries. Both lung nodules have the same histology code. Is this one or two primaries?
A: Based on the limited information here, this is a single primary using the MP/H rules for lung. ______
Q: In the scenario on slide # 18, what primary site would be coded and please address laterality?
A: Primary site is C34.9, and laterality is code 4. Laterality was confirmed from an I&R question and answer.
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Q: Please repeat the H code for 8480 in scenario 1 from quiz 1; it's left off slide.
A: Adenocarcinoma mucinous type with focal bronchiolo alveolar features. Ignore the focal bronchiolo alveolar. That leaves you with mucinous adenocarcinoma (8480).Rule H5 would be used to assign this histology.
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Q: Was the study just mentioned regarding registrar knowledge of the lung the "Standford Study"
A: it was the 2008 reliability study conducted by SEER.
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Q: Is the "elastic layer" clearly documented in the path report? I'm not sure I have ever seen that before.
A: The following information is on page 264 of the AJCC Cancer Staging Manual, 7th Edition: “On the basis of a review of published literature, the IASLC Staging Committee recommends that elastic stains can be used in cases where it is difficult to identify invasion of the elastic layer by hematoxylin and eosin (H&E) stains.” It may be that you will begin to see information about the elastic layer of the visceral pleura in path reports.
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Q: What is the elastic layer, not heard that term before?
A: The elastic layer of the pleura is made up of elastic fibers. Visceral pleural invasion is defined as invasion of the surface of the outside of the visceral pleural or invasion beyond the elastic layer. The elastic layer may be identified on hematoxylin and eosin (H&E) stains or by elastic stains.
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Q: Which code did you say to use if the tumor extension is intrapericardial?
A: Assign code 700 when there is involvement of the main pulmonary artery and the intrapericardial segments of the right and left pulmonary artery and the right and left inferior and superior pulmonary veins.
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Q: Should CS Tumor Size/Ext Eval always be coded 1 if there was a needle biopsy, or would code 0 be used if you determined the extension from imaging even if needle biopsy was done?
A: If the imaging information derives a higher T category than the needle biopsy information, then the code for CS Tumor Size/ Ext Eval should be 0.
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Q: When would you assign code 23, separate tumor nodule(s) in contralateral lung, for CS Mets at DX if it's considered a second primary per MP/H rules? It is rare that both nodules would be biopsied.
A: You would use MP/H rules first to determine if there is a single primary or multiple primaries. If considered a single primary, assign code 23 for CS Mets at DX because of the separate tumor nodule in the contralateral (opposite) lung. If multiple primaries, then each case is abstracted separately.The tumor in the contralateral lung would not be counted as metastasis.
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Q: Which CS Mets at DX code is assigned for pleural effusion, NOS?
A: That depends on the location of the pleural effusion. Assign code 15 for CS Mets at DX if pleural effusion, NOS, is ipsilateral; code 16 if contralateral; code 17 if bilateral; code 18 if not known if ipsilateral or contralateral.
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Q: Can code 24 be assigned in CS Mets at DX for the following situation: main tumor in upper lobe left lung and also a pleural based mass in lower left lung?
A: If the mass in the lower lobe is in the pleura, then assign code 24 (discontinuous pleural tumor foci) in CS Mets at DX. However, often “ pleural based” means a peripheral location in the lung or near the pleura, not in it. In that case, consider the “pleural based” mass in the lower left lung a separate tumor nodule in the same lung. Separate tumor nodules in the same lung determined to be a single primary are coded in CS SSF1.
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Q: When coding CS SSF1 do you include a single tumor nodule or must it be tumor nodules (multiple) only?
A: If there is only 1 primary lung tumor, assign code 000 for CS SSF1.
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Q: I thought you couldn't consider the term adenopathy as involvement except in the mediastinum or hilum; i.e., scenario 2?
A: Yes, you are correct. Note 2 that precedes the codes for CS Lymph Nodes states: “If at mediastinoscopy/x-ray, the description is "mass", "adenopathy", or "enlargement" of any of the lymph nodes named as regional in codes 100 and 200, assume that at least regional lymph nodes are involved. If there is any mention of bilateral or contralateral mass, adenopathy or lymph node involvement, use code 600.
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Q: It is stated in the second sentence in note 2 that precedes the CS Lymph Nodes codes that if there is any mention of bilateral or contralateral mass, adenopathy, or lymph node involvement, use code 600. Is that just for lymph nodes in codes 100 and 200, not for supraclavicular?
A: Yes. The terms above should only be used to indicate involvement for lymph nodes named in CS Lymph Nodes codes 100 and 200.
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Q: Could you provide more explanation on when to use codes 500 or 800 for CS Lymph Nodes. Please give an example of when to use code 800.
A: Use code 500 for CS Lymph Nodes when it is not known whether the involved lymph nodes are ipsilateral bronchial, ipsilateral mediastinal, or bilateral/contralateral AND you know that the involvement is regional lymph nodes or stated as N1, NOS. Code 800 is used when there is no documentation whether the nodes are regional or distant. Code 800 is rarely used because distant nodes would probably not be included in a standard lung resection as part of an en bloc removal of lymph nodes.
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Q: Please clarify the answer for question number 5 in scenario 2. Supraclavicular adenopathy is documented. Based on note 2 why is the answer not 600 (ipsilateral or contralateral supraclavicular nodes)?
A: Note 2 specifically states adenopathy indicates involvement for those lymph node regions documented in codes 100 & 200. Supraclavicular does not fall into either of those codes.
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Q: Quiz 2, Scenario 3. This patient has malignant pleural effusion. Code 400 for CS ext is without pleural effusion. What would the code be?
A: We had that same question and referred to experts. The CSv2 mapping team is making a decision on that. For now, I feel that 400 is the best answer.
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Q: In exercise 6 are we sure we have atelectasis in the entire lung?
A: There is complete lung collapse per radiology report #1
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Q: In exercise 6 should CS SSF 3-25 be 988 rather than 998?
A: You are absolutely correct. Thanks for pointing that out.
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