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Cancer Programs

Standard 5.8 Lung NODES Webinar FAQ

Standard Clinical

Is this NSCLC only?

This standard applies to all primary pulmonary resections performed with curative intent for non-small cell lung cancer (NSCLC), small cell lung cancer (SCLC), or carcinoid tumors of the lung.

Are there plans for implementation of Lung Operative Note synoptic reports?

For now, the focus is on Standards 5.3–5.8 and ensuring that CoC sites have the resources they need to be compliant with the existing standards. However, beginning in 2026, the CoC will be working towards implementing expanded requirements for synoptic operative reporting with the goal of transitioning to full synoptic operative reports. Additional cancer features in synoptic format will likely be required, along with currently required elements/responses. In the coming years new operative standards will be implemented for disease sites not already represented in the CoC standards for accreditation.

Is a biopsy confirmation of Adenocarcinoma required for case inclusion into the standard?

As in question 1, the standard would apply if there is a cancer Dx (NSCLC, SCLC, Carcinoid). For NSCLC this could be adenocarcinoma, squamous carcinoma, large cell, poorly differentiated, etc. Metastatic carcinomas (e.g. colon adeno) would be excluded.

Does the operative report and/or the surgery consult need to state "Curative Intent"?

Intent should be assigned postoperatively by the operating surgeon on the basis of preoperative evaluation and intraoperative management, and is to be clearly documented in the operative report for any "curative intent" operation covered by this standard.

Asking as a pathologist, what is considered curative intent so as to know what cases are excluded from the standard?

Standards 5.3 through 5.8 apply to all operations conducted with curative intent. Intent should be assigned postoperatively by the operating surgeon on the basis of preoperative evaluation and intraoperative management, and is to be clearly documented in the operative report for any operation covered by these standards. Curative operations generally include complete resection of the primary tumor and nodal evaluation for therapeutic or staging purposes.

CoC podcast mentioned prior EBUS can be added to pathology report to help with nodal assessment. other CoC webinars etc. said this was not allowed.

As endobronchial ultrasound (EBUS) does not remove nodes, those nodes do not count toward the requirements of Standard 5.8. Nodes biopsied during EBUS should be removed at surgery as additional confirmation of benign versus malignant pathology. Nodes from mediastinoscopy must be included on the same pathology report as the lung resection to count toward the requirements of Standard 5.8. If nodes are sampled at the time of mediastinoscopy performed at a separate operation on a separate day prior to surgery, then those nodes would satisfy the requirement only if documented within the pathology report from the curative intent operation. It is recommended that when pathologists complete the CAP synoptic pathology report for the lung resection, they should also include mediastinal nodal histology results from any other setting. Nodal station must be identified. EBUS cytology alone does not comply with the standard. In general, the surgeon should always strive to obtain lymph nodes from at least one hilar station and at least three distinct mediastinal stations. However, we recognize that there may be infrequent clinical situations in which the standard is not able to be achieved, which is why the threshold compliance rate in 80%.

If the 2R and 4R packet is sent together, does this count as one N2 or two N2?

The packet should be separated and labeled appropriately if the surgeon believes the nodes have been harvested from two separate lymph node stations (i.e., separate the 2R portion from the 4R portion if possible, and label accordingly). If the surgeon ultimately obtains mediastinal lymph nodes from at least 2 other stations (7, 8R, or 9R) then the point is moot given the goal of harvesting at least 3 different mediastinal nodal stations has been accomplished. The surgeon must take responsibility for appropriately and specifically labeling lymph nodes.

If you send a fat pad from a station and label it but no nodes are found, does this count or not count as an N2 node?

This will not satisfy the requirement for harvesting an N2 lymph node but is a realistic occurrence during these operations (one cannot always know for sure if a lymph node exists within a particular fat pad). Occasionally, lymph nodes will not be present or safely accessible during the conduct of an operation. The threshold compliance rate is less than 100% to take this infrequent occurrence into consideration. Surgeons should ideally document where they looked to harvest nodes, even if none were found in a particular station, to provide clarity to the extent of thoroughness during the surgery (e.g., “no lymph nodes were visible within the level 9L inferior pulmonary ligament station despite thorough dissection”).

What do you do when the surgeon says LNs were resected/not found and pathology did not find LNs. Is that compliant?

No, The measure of compliance for Standard 5.8 pathology reports for curative pulmonary resection documents the nodal stations examined by the pathologist documented in synoptic format. What is the recommendation for situations where the surgeon is unable to remove nodes? The threshold of compliance is 80% to account for the inevitable and infrequent clinical situations in which the standard is not able to be achieved. Surgeons should always document when/why they could not obtain more lymph nodes.

CAP does not require a synoptic report for lung resection patients who received neoadjuvant chemotherapy and have complete response. Is ACoS asking for more than what is required by CAP for these patients?

No, this standard applies to pulmonary resections performed with curative intent and excludes primary resection specimens with no residual cancer (e.g. following neoadjuvant therapy). Surgeons should still seek thorough lymphadenectomy in these cases even though they drop off due to a technicality.

Will patients with complete response to neoadjuvant therapy be excluded?

The standard and the related QI project exclude primary resection specimens with no residual cancer (e.g. following neoadjuvant therapy).

What is the rationale for the standard? How was Standard 5.8 determined?

Please refer to the Operative Standards Toolkit (Operative Standards Toolkit | ACS (facs.org) and specifically the section on Standard 5.8. The Society of Thoracic Surgeons Webinar on CoC Standard 5.8, “Understanding and Implementing the New CoC Lung Cancer Standards (April 28, 2022),” provides the background and rationale for the standard.

Are cases where cancer is not known at the time of surgery included in this standard?

According to the FAQ for the CoC Operative Standards, if the cancer is unknown prior to surgery, then the case is not included in the scope of these standards

Per our thoracic surgeons' directions, we are classifying wedge resections as not curative. Thus they are being excluded from this standard. Are there situations where they SHOULD be included?

A wedge resection which is intended as the only therapy for an early stage lung cancer would need to be included and lymph node dissection would be best proactive as established by two recent RCT's. If the wedge is for diagnostic only, then those cases would be excluded.

Will you eventually require synoptic op template for lung resections

For now, the focus is on Standards 5.3–5.8 and ensuring that CoC sites have the resources they need to be compliant with the existing standards. However, beginning in 2026, the CoC will be working towards implementing expanded requirements for synoptic operative reporting with the goal of transitioning to full synoptic operative reports. Additional cancer features in synoptic format will likely be required, along with currently required elements/responses. In the coming years new operative standards will be implemented for disease sites not already represented in the CoC standards for accreditation.

Have there been any thoughts around making this a Operative Report synoptic

For now, the focus is on Standards 5.3–5.8 and ensuring that CoC sites have the resources they need to be compliant with the existing standards. However, beginning in 2026, the CoC will be working towards implementing expanded requirements for synoptic operative reporting with the goal of transitioning to full synoptic operative reports. Additional cancer features in synoptic format will likely be required, along with currently required elements/responses. In the coming years new operative standards will be implemented for disease sites not already represented in the CoC standards for accreditation.

If a mediastinoscopy/EBUS is performed prior to the curative resection, can these procedures qualify for Standard 5.8, and do they have to be included within the curative resection pathology report or can they remain in a separate report to qualify?

As endobronchial ultrasound (EBUS) does not remove nodes, those nodes do not count toward the requirements of Standard 5.8. Nodes biopsied during EBUS should be removed at surgery as additional confirmation of benign versus malignant pathology. Nodes from mediastinoscopy must be included on the same pathology report as the lung resection to count toward the requirements of Standard 5.8. If nodes are sampled at the time of mediastinoscopy performed at a separate operation on a separate day prior to surgery, then those nodes would satisfy the requirement only if documented within the pathology report from the curative intent operation. It is recommended that when pathologists complete the CAP synoptic pathology report for the lung resection, they should also include mediastinal nodal histology results from any other setting. Nodal station must be identified. EBUS cytology alone does not comply with the standard. In general, the surgeon should always strive to obtain lymph nodes from at least one hilar station and at least three distinct mediastinal stations. However, we recognize that there may be infrequent clinical situations in which the standard is not able to be achieved, which is why the threshold compliance rate is less than 100%.

Can someone comment on the impact of neoadjuvant chemoimmunotherapy and nodal, operative dissection? We are discussing these patients in a multidisciplinary forum pre and post treatment. The degree of nodal and perivascular fibrosis is significant. In addition, in larger health systems, will smaller, noncompliant programs have an adverse impact on larger, more experienced and compliant programs within the same health system.

We will be collecting data about neoadjuvant therapy in the project to better understand this. In reality, nodal assessment is probably MORE important in these cases. However, these are quite a bit more challenging technically. In order to be compliant with the standard, at least 80% of cases reviewed will have had to meet the standard. This should also be less common in low volume programs so the small denominator would not apply.

Is it standard of care to dissect LNs when you have a clinical stage 0 (cT1is, cN0, cM0) patient, and would these patients apply to this standard?

Standard 5.8 applies to all primary pulmonary resections performed with curative intent for non-small cell lung cancer (NSCLC), small cell lung cancer (SCLC), or carcinoid tumors of the lung. This standard applies to all operative approaches.

Are any histologies excluded from standard 5.8?
If a mediastinoscopy/EBUS is performed prior to the curative resection, can these procedures qualify for Standard 5.8, and do they have to be included within the curative resection pathology report or can they remain in a separate report to qualify?


As endobronchial ultrasound (EBUS) does not remove nodes, those nodes do not count toward the requirements of Standard 5.8. Nodes biopsied during EBUS should be removed at surgery as additional confirmation of benign versus malignant pathology. Nodes from mediastinoscopy must be included on the same pathology report as the lung resection to count toward the requirements of Standard 5.8. If nodes are sampled at the time of mediastinoscopy performed at a separate operation on a separate day prior to surgery, then those nodes would satisfy the requirement only if documented within the pathology report from the curative intent operation. It is recommended that when pathologists complete the CAP synoptic pathology report for the lung resection, they should also include mediastinal nodal histology results from any other setting. Nodal station must be identified. EBUS cytology alone does not comply with the standard. In general, the surgeon should always strive to obtain lymph nodes from at least one hilar station and at least three distinct mediastinal stations. However, we recognize that there may be infrequent clinical situations in which the standard is not able to be achieved, which is why the threshold compliance rate is less than 100%.

What is the Rationale for the Standard? How was Standard 5.8 determined?

Please refer to the Operative Standards Toolkit (Operative Standards Toolkit | ACS (facs.org) and specifically the section on Standard 5.8. The Society of Thoracic Surgeons Webinar on CoC Standard 5.8, “Understanding and Implementing the New CoC Lung Cancer Standards (April 28, 2022),” provides the background and rationale for the standard.

If a mediastinoscopy/EBUS is performed prior to the curative resection, can these procedures qualify for Standard 5.8, and do they have to be included within the curative resection pathology report or can they remain in a separate report to qualify?


As endobronchial ultrasound (EBUS) does not remove nodes, those nodes do not count toward the requirements of Standard 5.8. Nodes biopsied during EBUS should be removed at surgery as additional confirmation of benign versus malignant pathology. Nodes from mediastinoscopy must be included on the same pathology report as the lung resection to count toward the requirements of Standard 5.8. If nodes are sampled at the time of mediastinoscopy performed at a separate operation on a separate day prior to surgery, then those nodes would satisfy the requirement only if documented within the pathology report from the curative intent operation. It is recommended that when pathologists complete the CAP synoptic pathology report for the lung resection, they should also include mediastinal nodal histology results from any other setting. Nodal station must be identified. EBUS cytology alone does not comply with the standard. In general, the surgeon should always strive to obtain lymph nodes from at least one hilar station and at least three distinct mediastinal stations. However, we recognize that there may be infrequent clinical situations in which the standard is not able to be achieved, which is why the threshold compliance rate is less than 100%.

Pathology documentation in the synoptic summary can be difficult to interpret when the number of lymph nodes removed from each station, are not documented. Apparently CAP protocol checklist does not require this. How can this be handled?

The unit of assessment for Standard 5.8 is the station, rather than the number of nodes sampled at each station. A discrete node count for each station is not required as the standard treats node sampling as either 'done' or 'not done' for each station. A total of 3 mediastinal and 1 hilar stations need to be sampled for a case to be considered compliant

I am a pathologist. For all resected primary lung cancer specimens (including lobectomy and wedge resection), we use synoptic report to document the lymph nodes, even if we do not know if the procedure is curative. Would this be a problem?

No, Standard 5.8 applies to all primary pulmonary resections performed with curative intent for non-small cell lung cancer (NSCLC), small cell lung cancer (SCLC), or carcinoid tumors of the lung. This standard applies to all operative approaches. There is not penalty for using synoptic reporting outside of the CoC Operative Standards.

Any updates on the EPIC Synoptic CoC AcoS collaboration?

Epic currently licenses the required elements and responses for CoC Standards 5.3-5.6. Epic also works with the College of American Pathology for their requirements.

For a patient who undergoes a mediastinoscopy prior to their curative surgery, and nodes are removed at that time – I understand we can use those nodes as part of the removed nodes, if they are in the final path report- is this correct?  Is an ‘addendum’ to the path report acceptable?

Nodes from mediastinoscopy must be included on the same pathology report as the lung resection to count toward the requirements of Standard 5.8. If nodes are sampled at the time of mediastinoscopy performed at a separate operation on a separate day prior to surgery, then those nodes would satisfy the requirement only if documented within the pathology report from the curative intent operation. Likewise, amended or addended pathology reports can meet the requirements of Standards 5.7 and 5.8; however, reports should only be corrected when the change will affect clinical care.

If unable to locate a node in a specific station, is it acceptable to annotate ‘node not present’ and move on, and still be considered ‘compliant’?

Occasionally, lymph nodes will not be present or safely accessible during the conduct of an operation. The threshold compliance rate is less than 100% to take this infrequent occurrence into consideration. Surgeons should ideally document where they looked to harvest nodes, even if none were found in a particular station, to provide clarity to the extent of thoroughness during the surgery (e.g., “no lymph nodes were visible within the level 9L inferior pulmonary ligament station despite thorough dissection”).

Data

What is the reporting period for the baseline data?

For Baseline, you will be asked to submit 20 randomly selected cases from 2023 or earlier (meaning if you did not have 20 cases in 2023, you may submit cases from 2022, 2021, etc until you reach 20)

2022 will be the most recent year of data abstracted. How will we collect data?

This data should be looked at in near real time via a chart audit.

What does data entry look like? (frequency of collection, number of items, etc.)

Baseline data and 3 subsequent collection periods will occur in 2024. A sample data collection form can be found on the project website.

What's the recommendation for programs with lower volumes of lung resections >20 per year?

Submit 100% of cases for every data submission, You may be asked to respond to additional questions about your sample.

In the other projects even if we you are doing very well it was encouraged to still participate. Is this true with this one?

Yes, if you are doing well with 5.8 we encourage participation as an opportunity to coach other programs, share lessons learned and best practices, etc.

What if we don't know if we will have at least 1 patient? The 1 patient could come at the end of the year 2024.

You must have at least 1 case in previous years to submit baseline data and participate

Our program hasn't performed these procedures since 2021, so we have no data for 2022 or 2023. We will onboard a surgeon in April 2024 to continue these surgeries. Can we participate?

Yes, you would need to submit baseline data/cases from 2021.

Accreditation

This project is IRB approved. Can we earn credit for CoC Standard 9.1 [Clinical Research accruals]?

Not all projects submitted to IRB are considered research, and this project is deemed "non-human subject research" and thus, this does not qualify for 9.1 credit

Our patients receive these surgeries at our non- CoC accredited sister hospital. Both hospitals share the same pathology lab, medical staff, etc. Can we still participate?

If you do not perform this surgery at your facility, then this project would not be applicable for your program.

We have multiple facilities in our INCP, and not all have lung resections each calendar year. Would that preclude us from participating as a network?

You can participate in this project as a site specific QI project. The other QI project must involve all "child" facilities within the INCP

If we participate for both years, can this QI project be used for standard 7.3 for both 2024 and 2025?

As of now, this is a one year project, with a second year pending. At this point in time, credit is only approved for standard 7.3 for calendar year 2024. The project team will seek approval for 7.3 for 2025 in the coming year.

We will be participating in a different QI project in 2024. Can we use this project as a goal instead?

No, it is not allowable to use a standard as a goal.

If after the first year of participation we are compliant with standard 5.8, can we still participate in the second year and earn credit?

Yes, you may participate in year one and year two; or you may choose to only participate in one year. Please note, no credit has been awarded for year 2 as of now.

If our program was non-compliant on our most recent site review, will participation in this project serve as corrective action?

Yes, full and meaningful participation will count as corrective action for standard 5.8. Meaningful participation includes submitting data for all submissions, participating in webinars and cohort calls and a status update to the cancer committee with documentation in meeting minutes at least twice a year.

If you participate in this QI project, will Standard 5.8 chart review be waived during the site visit or will you still need to ensure facility compliance?

Please see the document below

5.8 Lung NODES QI credit 

If you have been compliant in this standard historically can you still participate for credit? (i.e. if you have not had any non-compliant cases for 5.8 previously)

Yes, we welcome participation even if your program has been compliant in past years.

Do all facilities in an INCP need to participate?

All programs that conduct pulmonary resections should participate. If not all programs in the INCP conduct pulmonary resections, they will not participate, and this project will be considered a "site-specific" project. The INCP will need to conduct another QI project inclusive of all programs in the network.

Will my facility still earn credit if we are unable to reach the QI goal?

Credit for standards will be given, so long as the program meaningfully participates (Meaningful participation includes submitting data for all submission, participating in webinars and cohort calls and a status update to the cancer committee with documentation in meeting minutes at least twice a year), even if the 20% increase was not achieved.

Can I participate in both National Projects this year?

Yes, you may participate in both national projects. If successfully completed you would get credit for Standard 5.8 (Lung NODES), 8.1 (Breaking Barriers) and 7.3; you will only be awarded credit once for 7.3 for the calendar year, despite participating in two QI projects.

General

Will links be sent for each facility to enroll and submit data for Integrated Network Cancer Programs?

The link can be accessed via the Lung NODES webpage here. You can complete this link as many times as needed.

Will all QI team members be required to attend the cohort meetings?

At least one QI team member is required to attend the cohort meetings, unless clinical care or administrative responsibilities interferes.

Will there be a PDF sheet that identifies eligible case criteria, for example dx codes?