Nicole Catlett, CTR
2014 KCR FALL WORKSHOP “LUNG CODING BOOTCAMP” CASE EXERCISES
EXERCISE #1
Code the Topography:
___ R lung apical mass
c34.____
___ R hilar mass with no other pulmonary nodules seen
c34.____
___ Left lung base mass
c34.____
___ Upper lobe of left lung
c34.____
___ RML
c34.____
___ Left main bronchus mass
c34.____
___Tumor overlaps lower & upper lobe of L lung, no statement of which lobe tumor arose in c34.____
___ Multiple tumors in both lungs, primary tumor unknown
c34.____
EXERCISE #2
Match the following with the best CS EXTENSION CODE:
___Tumor confined to lung on path report
A. 600
___Tumor invades parietal pleura on imaging
B. 410
___Tumor extends into elastic layer but not through on path report
C. 420
___Tumor involves visceral pleura on path report
D. 100
___Tumor invades pleura, NOS per consult note with no other info available
E. 430
___Tumor extends to the visceral pleural surface on path report
F. 420
EXERCISE #3
Match the following with the correct clinical AJCC T category:
____Tumor 8 cm in size directly invading the mediastinum
A. T1b
____Tumor 2.9 cm in size confined to lung
B. T3
____Tumor 1.9 cm pleural based mass seen on imaging
C. T2a
____Tumor 7 cm in size invading parietal pleura
D. T4
____Tumor 2.1 cm in size invading the visceral pleura
E. T2b
____Tumor 5.6 cm in size confined to lung
F. T1a
____Tumor 3.0 cm in size extending to visceral pleural surface
G. T2a
Page 1 of 6
Nicole Catlett, CTR
2014 KCR FALL WORKSHOP “LUNG CODING BOOTCAMP” CASE EXERCISES
EXERCISE #4
Use the following diagram
Parietal pleura/Chest Wall
Surface of Visceral Pleura
Elastic Layer of Visceral Pleura
Lung Parenchyma
The 5 diagrams above are demonstrating tumor invasion, label each with the correct descriptions (PL
& T) based on extension only:
PL0
PL1
PL2
T1
T2
T3
PL3
Page 2 of 6
Nicole Catlett, CTR
2014 KCR FALL WORKSHOP “LUNG CODING BOOTCAMP” CASE EXERCISES
CODING EXERCISES
CASE #1
H&P = 50 yo wf presented to ER with chest pain & SOA; +tobacco use 1 ppd x 30 yrs; No personal HX of
cancer w/ +FHX of colon cancer in father.
IMAGING = CT C/A/P showed RUL mass extending to the pleural surface measuring 2.9 cm x 2.8 cm. No
pleural effusion or pericardial effusion noted. There are no enlarged R hilar or mediastinal LNs
identified.
BIOPSY = CT guided needle biopsy was positive for poorly differentiated Squamous Cell Carcinoma.
SURGERY = RUL lobectomy w/ path revealing a 2.9 cm SCC extending to the visceral pleural surface.
Benign peribronchial LNs 4 total, R hilar LNs 3 total, LN total = 7, all negative.
CS EXTENSION ______
SSF1 ______
SSF2 ______
cT___ cN ____ cM____ cStage _____
pT___ pN ____
pStage_____
CASE#2
H&P = 68 yo male presents for XRT consult for newly diagnosed Adenocarcinoma of his LLL. Imaging
reports reviewed & summary: LLL mass 2.3 cm abutting the pleura with associated L hilar and L
paratracheal LAD, all of which are hypermetabolic on PET. A needle BX was performed of the LLL mass
which was positive for adenocarcinoma of lung. Patient refused surgery & chemo and was sent for XRT
consult. XRT began and patient declined during week three so XRT discontinued and patient referred to
Hospice.
CS Extension _____
SSF1 _____
SSF2 _____
cT___ cN ___ cM ___ cStage _____
pT___ pN____
pStage _____
Page 3 of 6
Nicole Catlett, CTR
2014 KCR FALL WORKSHOP “LUNG CODING BOOTCAMP” CASE EXERCISES
CASE#3
Diagnosis
1) Lung, left upper lobe, wedge resection:
- Invasive adenocarcinoma, well differentiated, 1.5 cm.
- Tumor invades the visceral pleura (elastic stains reviewed).
- Tumor is present 5 mm from the staple resection margin.
2) Lung, left upper lobe, completion lobectomy:
- Lung parenchyma with patchy congestion and anthracotic pigment.
- Vascular and bronchial margins are 3 cm from the wedge resection margin.
- Negative for adenocarcinoma.
-----------------------------------------------------------------------Surgical Pathology Cancer Case Summary
Specimen:
Lobe of lung
Procedure:
Wedge resection and completion lobectomy
Specimen Laterality: Left
Tumor Site(s):
Left upper lobe
Tumor Size, Greatest dimension: 1.5 cm
Tumor Focality:
Unifocal
Histologic Type:
Adenocarcinoma
Histologic Grade: Grade 1: Well differentiated
Visceral Pleura Invasion: Present
Tumor Extension:
Not identified
Bronchial Margin:
Uninvolved by invasive carcinoma and carcinoma in-situ
Vascular Margin:
Uninvolved by invasive carcinoma
Parenchymal Margin: Uninvolved by invasive carcinoma
Parietal Pleural Margin: N/A
Chest Wall Margin:
N/A
If all margins uninvolved by invasive carcinoma:
Distance of invasive carcinoma from closest margin: 3 cm
Specify margin: Bronchial and vascular margins
Lymph-Vascular Invasion: Not identified
Primary Tumor (pT): pT2a: Tumor 5 cm or less in greatest dimension with invasion of the visceral pl.
Regional Lymph Nodes (pN): pN0: No regional lymph node metastases
Specify: Number examined: 5
Number involved:
0
CS Extension____
SSF1____
SSF2____
pT____ pN___ pStage _____
Page 4 of 6
Nicole Catlett, CTR
2014 KCR FALL WORKSHOP “LUNG CODING BOOTCAMP” CASE EXERCISES
CASE#4
H&P = patient presents for surgical resection for newly diagnosed lung cancer. Review of imaging
demonstrates a RUL lung nodule measuring 1.8 cm in size w/ no LAD seen and no pleural or pericardial
effusion. This is suspicious for malignancy per report impression.
Surgical Pathology Cancer Case Summary
Specimen:
Lung.
Procedure:
Lobectomy.
Specimen Integrity: Pleural surface focally disrupted.
Specimen Laterality: right
Tumor Site(s):
Right upper lobe, subpleural location.
Tumor Size, Greatest dimension: 2 cm
Tumor Focality:
Unifocal.
Histologic Type:
Squamous cell carcinoma.
Histologic Grade: Grade 2: Moderately differentiated
Visceral Pleura Invasion: Not present in nondisrupted sections of lung, see COMMENT.
Tumor Extension:
Tumor appears confined to the lung, with no involvement of the main bronchus,
and no invasion of the pleura, in the areas where the overlying pleura is intact.
Regional Lymph Nodes (pN): pN0: No regional lymph node involvement.
Specify: Number examined: Fragmented hilar lymph node, number
indeterminate, and 1 mediastinal lymph node.
Number involved:
0
COMMENT: The tumor is present in a subpleural location. An elastin stain performed on block 1E,
where the pleural surface is intact, demonstrates no invasion of the visceral pleura. Because of the
specimen's disruption, the relationship of the tumor to the pleura is indefinite.
CS Extension ______
SSF1_____
SSF2_____
cT ___ cN ____ cM ____ cStage _____
pT ___ pN ____
pStage_____
Page 5 of 6
Nicole Catlett, CTR
2014 KCR FALL WORKSHOP “LUNG CODING BOOTCAMP” CASE EXERCISES
CASE#5
The Synoptic report utilizes the CAP protocol from October 2013 for carcinoma of lung.
Specimen: Lobe of lung.
Procedure: Lobectomy.
Specimen Integrity: Intact.
Specimen Laterality: Right.
Tumor Site: Upper lobe.
Tumor Size: 5.5 cm.
Tumor Focality: Unifocal.
Histologic Type: Squamous cell carcinoma.
Visceral Pleural Invasion: Present.
Tumor Extension: Parietal pleura.
Margins: Margins uninvolved by invasive carcinoma.
Distance of invasive carcinoma from closest margin: 1.5 mm from chest wall margin.
Bronchial margin: Uninvolved by invasive carcinoma.
Vascular margin: Uninvolved by invasive carcinoma.
Parenchymal margin: Uninvolved by invasive carcinoma.
Lymph-Vascular Invasion: Not identified.
Number of lymph nodes examined: At least 7.
Comment: The exact number of nodes cannot be determined because specimens 2, 3 and 4
were received as multiple lymph node fragments.
Distance metastases: Not applicable.
Ancillary studies: Elastic Van Gieson stain performed on sections of pleura from specimen 1.
CS Extension _____
SSF1 ______
SSF2 ______
pT ___ pN___
pStage _____
Page 6 of 6