Standard 5.8 Lung NODES Webinar FAQ

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.

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.

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.

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.

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.

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%.

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.

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”).

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.

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.

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

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.

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

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.

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.

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.

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%.

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.

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.

Standard 5.8 case identification guidelines are available here.

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%.

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.

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%.

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

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.

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.

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.

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”).

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)

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

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

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

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.

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

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

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

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

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

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.

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

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.

Yes, full and meaningful participation will count as corrective action for standard 5.8.

Please see the below document titled "5.8 Survey Schedule and Credit."

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

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.

Credit for standards will be given, so long as the program meaningfully participates (including submitting data for all submissions, participating in webinars and cohort calls, etc.), even if the 20% increase was not achieved.

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.

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

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

Yes, please reference the case Identification guidelines for Standards 5.8.