Pleural Effusion

Description

Pleural effusion is the accumulation of fluid between the parietal pleura (the pleura covering the chest wall and diaphragm) and the visceral pleura (the pleura covering the lungs). Pleural effusion is the accumulation of fluid between the two layers of pleura: visceral (covering the lungs) and parietal (lining the chest wall and covering the diaphragm). Pleural effusion is a symptom of mesothelioma that increases the Summary Stage from local or regional direct extension to distant involvement.

Rationale

Pleural Effusion can be collected by the surveillance community for pleura cancers. Prior to 2018, Pleura SSF #1 was used for Pleural Effusion.

Additional Info

**Source documents:** imaging, pathology, and cytology reports **Other names include**: pleural fluid, thoracentesis

Notes

**Note:** **Definition of pleural effusion** * One of the most common symptoms of mesothelioma is a pleural effusion, or an accumulation of fluid between the parietal pleura (the pleura covering the chest wall and diaphragm) and the visceral pleura (the pleura covering the lungs). * Record the absence or presence of pleural effusion and specifically, if present, whether the pleural effusion is non-malignant, malignant, atypical or NOS.

Coding Guidelines

**1)** Record the absence or presence of pleural effusion * If pleural effusion is present and examined microscopically, record whether the pleural effusion is non-malignant, malignant, or not specified. **2) Code 0** when there is no evidence of pleural effusion **3) Code 1** when * **a.** Pleural effusion microscopically confirmed to be non-malignant * **b.** Pleural effusion is stated to be negative for malignant cells * **c.** Pleural effusion is seen on imaging, but pleural fluid cytology is negative for malignant cells **4) Code 2** when * **a.** Pleural effusion microscopically confirmed to be malignant * **b.** Pleural effusion is stated to be positive for malignant cells * **c.** Pleural fluid cytology described as suspicious or suspicious for mesothelioma * **d.** Physician states pleural effusion is positive in the absence of positive cytology   **5) Code 3** when * **a.** Pleural fluid cytology is described as atypical or atypical mesothelial cells but not specifically as non-malignant or malignant **6) Code 4** when * **a.** Pleural effusion is reported on imaging, but there is no cytology * **b.** Pleural effusion is reported on imaging, but there is no physician’s statement on whether it is positive **7) Code 9** when * **a.** Not documented in the medical report * **b.** Presence or absence of pleural effusion not evaluated (assessed) * **c.** Unknown if Pleural Effusion evaluated (assessed)

Default

8

NAACCR Item

NAACCR #3913

Metadata

SSDI
Code Description
0 Pleural effusion not identified/not present
1 Pleural effusion present, non-malignant (negative)
2 Pleural effusion present, malignant (positive) Physician states pleural effusion is malignant in the absence of positive cytology
3 Pleural effusion, atypical/atypical mesothelial cells
4 Pleural effusion, NOS
8 Not applicable: Information not collected for this case (If this item is required by your standard setter, use of code 8 will result in an edit error.)
9 Not documented in medical record Pleural effusion not assessed or unknown if assessed