new tnm

What’s New in TNM 7? [email protected] Spring 2010

What’s New in TNM7

April Fritz, RHIT, CTRReno, Nevada

AJCC and UICC definitions are almost identical

AJCC edition UICC edition

The TNM System

What’s New in TNM7 3

Why a New Edition?

Challenges to cancer staging• Anatomic staging not meeting needs of clinicians• Desire for ‘personalized’ medicine• Non-anatomic / prognostic / predictive

information part of planning and outcomes evaluation

Needs for integration of new factors• Biologic / molecular• Response to therapy• Nomograms

Coordination with electronic records


7th Edition Goals

Improve clinical utility Make changes evidence-based Enhance prediction of individual outcomes Treatment selection – predict response

• Maintain system that meets population needs Structure

• Maintain anatomic base (T, N, M)• Incorporate validated non-anatomic factors

• Ulceration for melanoma, Gleason for prostate, etc.• Allow collection of relevant investigational factors



What’s New in 7th Edition?

New chapters Some chapters revised

• Split into multiple chapters• Include histologies formerly excluded

Chapter 1 revised and expanded Prognostic Factors

• CS Site-Specific Factors New look

• Staging-At-A-Glance• Color coding

• T, N, and M elements color coded• Color illustrations

• Redesigned staging formsWhat’s New in TNM7 6

6th Edition to 7th Edition

1.5 inch3.3 lb

7/8 inch2.5 lb

ThicknessWeight

$64.95$59.95Cost

5748Number of chapters

130< 100Number of illustrations

646435Number of pages

AJCC Cancer Staging Manual

7th Edition

AJCC Cancer Staging Manual

6th edition


New Look: Staging At-A-Glance


Summary of Changes

Example: Kidney



New Look: Color Coding

T definitions – blue N definitions – yellow M definitions – green Stage groupings – red Color illustrations Examples from esophagus chapter

Survival graph from colorectal chapter


New Look: Redesigned Staging Forms


Chapter 1

Revised and expanded• Clearly defined rules

• Both text and tables– General rules– T, N, M elements– Stage groups– Classifications

• Some rules changes


Rules Changes

Tumor size rounding• Round to nearest whole millimeter• 1 – 4 down, 5 – 9 up

Node biopsy and sentinel node(s) • Clinical if diagnostic (pre-treatment)• Pathologic if therapeutic

New stage groups for CIS and pM1• Can be both clinical and pathologic • cT_ cN_ pM1 Stage Group IV• pTis cN0 cM0 Stage Group 0

Elimination of MX



New Rule: MX and pMX Deleted

MX (cMX)• Inappropriate – clinical assessment of mets

can be based on PE alone • Makes cases unstageable• If pathologist doesn’t know clinical M, MX

should NOT be recorded. pMX

• Does not exist pM0

• Does not exist (except at autopsy)


New Rule: MX and pMX Deleted

Remaining Categories cM0

• Clinically no distant metastasis• Physical exam is sufficient

cM1• Distant metastasis clinically

pM1• Distant metastasis proven microscopically

If a tissue equivalent to cM1 is biopsied and is negative, it becomes cM0, not pM0


Clinical Classification Rules Modified

Timing• Prior to any definitive treatment• OR within 4 months• Whichever is shorter

Clinical staging basis includes biopsies• Lymph node(s)• Sentinel node(s)• Metastatic site

Also called pre-treatment staging


Pathologic Staging Rules Modified

Timing• Through completion of first course of treatment

• No pre-op systemic or radiation therapy• No disease progression

• OR within 4 months• Whichever is longer



Post-Therapy Staging

Also called intercurrent staging (‘y’classification)• Allows assessment of response to therapy• Prognostic

yc – Clinical staging after neoadjuvant treatment

yp – Pathologic staging after neoadjuvant treatment• Surgery meets criteria for pathologic staging• Stage group notation for no residual cancer

• ypT0 ypN0 cM0


Stage Grouping

New terminology• Stage group

• Prognostic stage group if non-anatomic factors included• Anatomic stage if only T, N, M

If grouping requires non-anatomic factor• Use lowest category if factor not available

• Assume lowest or least value of non-anatomic factor• Prostate example

• If PSA or Gleason unknown, can still stage group with known T, N and M

“Any” includes X• ‘Any N’ includes NX


Prognostic Factors

a.k.a. CSv2 Site-Specific Factors Two types listed in each chapter

• Required for Staging• Supplement T, N, M

• Clinically Significant• Clinically relevant but not always available• Tumor markers and lab values• Prognostic/predictive• Special interest/research• Supplementary – related diseases, exposures, etc.

AJCC aware of data collection burden in cancer registry


Prognostic Factors – Examples

Breast• Her2 (IHC, FISH, CISH)• Bloom-Richardson score• Multigene signature score

Colon-Rectum• Radial margin• Tumor deposits• KRAS gene• Microsatellite instability

Lung• Pleural elastic layer

invasion

Esophagus-Stomach• Tumor location

Prostate• PSA• Gleason score• Number biopsy cores

positive/examined

Lymphomas• International prognostic indices

• B-cell lymphomas• Follicular lymphomas

• International Prognostic Score• Hodgkin lymphoma

Head and Neck• HPV (human papilloma virus)• Extracapsular extension• Involvement of low neck nodes



New Chapters

Mucosal melanoma of head and neck Appendix (carcinomas) Gastrointestinal stromal tumors (GIST) Neuroendocrine tumors (Carcinoids)

• Stomach, small intestine, large intestine, appendix, pancreas, lung

Merkel cell carcinoma Adrenal cortex Ocular adnexal lymphoma


Chapters Split/Revised

Intrahepatic bile ducts (separate from Liver)• Liver Hepatocellular carcinoma• IHB Cholangiocarcinoma

Extrahepatic bile ducts • Perihilar bile ducts• Distal bile ducts

Skin • Cutaneous Squamous Cell Carcinoma and Other

Cutaneous Carcinoma • Merkel cell• Malignant melanoma

Histology code range listed for each chapter


Few or Minor Modifications

Head and Neck Liver Anal canal Mesothelioma,

pleural Skin (carcinoma) Small intestine

Biliary• Gallbladder• Ampulla• Pancreas

Gynecological sites Urological sites

• Except prostate


Major Modifications

Esophagus Stomach Colon Lung Prostate Breast



Esophagus-Stomach Changes

Shift of C16.0, parts of C16.1 and C16.2 to esophagus

Esophagogastric junction (EGJ) tumors:• If midpoint (epicenter) within 5 cm of EGJ and

also extends into esophagus, classify and stage as esophagus

• Stage all others with midpoint in stomach > 5 cm from EGJ or those within 5 cm of the EGJ with noextension into esophagus as gastric carcinoma

Lymph node counts harmonized


Esophagus GE Junction

From Edge et al. Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, seventh edition (2009) published by Springer Science and Business Media LLC, www.springerlink.com.

Esophago-gastric Junction Gastroesophageal Junction


Esophagus – 7th Edition

Tis Carcinoma in situ /High-grade dysplasiaT1 Lamina propria or submucosa

T1a Lamina propria or muscularis mucosaeT1b Submucosa

T2 Muscularis propriaT3 AdventitiaT4 Adjacent structures

T4a Pleura, pericardium, diaphragm, or adjacentperitoneum

T4b Other adjacent structures, e.g. aorta,vertebral body, trachea

Changes from 6th Ed.


Esophagus – 7th Edition

N0 No regional lymph node metastasisN1 1 to 2 regional lymph nodesN2 3 to 6N3 > 6[N1 was site dependent]

M0 No distant MetastasisM1 Distant metastasis

[M1a,b were site dependent]

Anatomical/Prognostic Stage Groups based on histologic type, grade, location within esophagus and T, N, M




Stomach – 7th Edition

T1 Lamina propria, submucosaT1a Lamina propriaT1b Submucosa

T2 Muscularis propriaT3 Subserosa (was T2b)T4a Perforates serosa (was T3)T4b Adjacent structures

N1 1 to 2 nodes N2 3 to 6 nodes (was N1)N3a 7 - 15 nodes (was N2)N3b 16 or more (was N3)

Stage Groupings revised



Colon Changes

T• T4 subdivided based on differential prognosis

N• Potential importance of satellite tumor deposits• Defined by site-specific factor Tumor Deposits (TD)• TD but no lymph node metastasis classified as N1c• N1 and N2 subdivided

M• M1a for single metastatic site• M1b for multiple metastatic sites

Stage Groupings redefined Appendix now separate from colon

• Carcinoma, carcinoid


Colon-Rectum – 7th Edition

T1 – T3 Unchanged

T4 Tumor directly invades other organs or structuresand/or perforates visceral peritoneumT4a Perforates visceral peritoneum T4b Directly invades other organ or structures


Colon-Rectum – 7th Edition

N1 Metastasis in 1 to 3 regional lymph nodesN1a 1 nodeN1b 2 – 3 nodesN1c Satellites [tumor deposits] in subserosa,

without regional nodesN2 Metastasis in 4 or more regional lymph nodes

N2a 4 – 6 nodesN2b 7 or more nodes

M1 Distant metastasisM1a One organM1b > one organ or peritoneum



Appendix (Carcinoma) – 7th Edition

COLON – RECTUM T4 Tumor directly invades

other organs or structuresand/or perforates visceral peritoneumT4a Perforates visceral

peritoneum T4b Directly invades other

organ or structures

M1 Distant metastasisM1a One organM1b > one organ or

peritoneum

Changes from TNM 6

APPENDIX (carcinoma)Separate mucinous fromnonmucinous carcinomas

T4a Perforates visceral peritoneum / Mucinous peritoneal tumor within right lower quadrant

T4b Other organs or structures

M1a Intraperitoneal metastasis beyond RLQ

M1b Non-peritoneal metastasis

Changes from colon


Carcinoids andNeuroendocrine Tumors

Staging GI tract

• Carcinoid: separate staging by site• Need size and/or depth of invasion

• Small cell/large cell: stage as carcinoma Pancreas: stage as carcinoma Lung: stage as carcinoma Skin: separate classification for Merkel cell

carcinoma


Appendix – 7th EditionCARCINOID Based mainly on size All WD NET except goblet

cell carcinoid

T1 < 2 cmT2 > 2 – 4 cm; cecumT3 > 4 cm; ileumT4 Perforates peritoneum;

other organs, structures

N1 Regional

Stage I T1 N0Stage II T2, T3 N0Stage III T4 N0

Any T N1Stage IV Any T Any N M1

CARCINOMA Like colon, based on depth;

includes goblet cell carcinoid

T1 SubmucosaT2 Muscularis propriaT3 Subserosa, non-peritonealized

periappendiceal tissuesT4a Perforates visceral peritoneum/

Mucinous peritoneal tumourwithin right lower quadrant

T4b Other organs or structures

N1 < 3 regionalN2 > 3 regional

M1a Intraperitoneal metastasis beyond right lower quadrant

M1b Non-peritoneal metastasisWhat’s New in TNM7 36

Carcinoids (NET) – 7th EditionGastrointestinal

APPENDIXT1 < 2 cmT2 > 2 – 4 cm; cecumT3 > 4 cm; ileumT4 Perforates peritoneum;

other organs, structures

SMALL INTESTINET1 Lam propria/submucosa and

< 1 cmT2 Muscularis propria or > 1 cm T3 Jejunum, ileum: subserosa

Ampulla, duodenum: pancreas or retroperitoneum

T4 Perforates serosa; adjacent structures

STOMACHTis < 0.5 mm confined to mucosaT1 Lam propria/submucosa and

< 1 cmT2 Muscularis propria or > 1 cm T3 SubserosaT4 Perforates serosa; adjacent

structures

LARGE INTESTINET1 Lam propria/submucosa and

< 2cm T1a < 1 cm T1b 1 to 2 cm

T2 Muscularis propria or > 2 cm T3 Subserosa or pericolorectal

tissuesT4 Perforates serosa; adjacent

structures



Gastrointestinal Stromal Tumors (GIST) – New in 7th Edition

ALL SITEST1 < 2 cmT2 > 2 – 5 cm T3 > 5 – 10 cmT4 > 10 cm

ANATOMICAL/PROGNOSTIC STAGE GROUPS

SMALL INTESTINE MR*Stage I T1-2 N0 M0 Low Stage II T3 Low Stage IIIA T4 Low

T1 HighStage IIIB T2, 3, 4 High Stage IV Any T N1 M0 Any

Any T Any N M1 Any

Prognostic factors: site, size, mitotic rate

ANATOMICAL/PROGNOSTIC STAGE GROUPS

STOMACH MR*Stage IA T1-2 N0 M0 Low Stage IB T3 Low Stage II T4 Low

T1-2 HighStage IIIA T3 High

IIIB T4 High Stage IV Any T N1 M0 Any

Any T Any N M1 Any* Mitotic rate


Lung Changes

Classification should be used for• Non-small cell AND small cell carcinomas• Carcinoid tumors

T• New tumor sizes and subclassifications• Multiple tumors in same lobe now T3• Multiple tumors in same lung different lobe

now T4 N

• New international lymph node map M

• Malignant pleural effusion now M1a Stage Groupings revised


Lung – 7th Edition

T1 <3 cmT1a < 2 cmT1b > 2 to 3 cm

T2 Main bronchus >2 cm from carina, invades visceral pleura, partial atelectasisT2a >3 to 5 cmT2b >5 to 7 cm

T3 > 7 cmChest wall, diaphragm, pericardium, mediastinal pleura, main bronchus <2 cm from carinaTotal atelectasisSeparate nodule(s) in same lobe (was T4)


Lung – 7th Edition

T4 Mediastinum, heart, great vessels, carina, trachea, esophagus, vertebraSeparate tumour nodule(s) in different ipsilateral lobe (was M1)

N1 Ipsilateral peribronchial, ipsilateral hilar nodesN2 Ipsilateral mediastinal, subcarinal nodesN3 Contralateral mediastinal or hilar, scalene or

supraclavicular nodes

M1a Separate tumour nodule(s) in contralateral lobe Pleural nodules Malignant pleural or pericardial effusion (was T4)

M1b Distant metastasis



Breast Changes

T• Guidance on determining tumor size• Clarification of inflammatory carcinoma• Recommend grading with Nottingham/Bloom

Richardson N

• Classification of isolated tumor cells more stringent• Restricted use of (sn) modifier to 5 or fewer nodes

M• Created new cM0 (i+) category• Disseminated tumor cells detectable in bone

marrow• Circulating tumor cells• Incidental in other tissues < 0.2 mm


Breast – 7th Edition

T1 Tumor size in millimetersT1mic < 1 mmT1a > 1 to 5 mmT1b > 5 to 10 mmT1c > 10 to 20 mm

T2 > 20 to 50 mmT3 > 50 mmT4a Chest wall (excludes pectoralis muscle)T4b Skin ulceration, nodules, edema not meeting

definition of inflammatory carcinomaT4c Chest wall and skinT4d Inflammatory carcinoma

Definition: clinical-pathologic entity characterized by diffuse erythema and edema (peau d'orange) involving one third or more of the skin of the breast



N A few changes in definitionsITCs: < 0.2 mm size or < 200 cells in clusterN1, N2 limited to Levels I and II axillary nodesN3: Level III, infraclavicular, supraclavicular

Internal mammary nodesN1b Micromets or detected by sentinel lymph node

procedure, no axillary nodes positiveN1c Micromets or detected by SLNB and pos ax LNN2b Clinically detected, no axillary nodes positiveN3b Clinically detected and pos ax LN

OR micromets/SLNB and > 3 pos ax LN



cM0(i+) Molecularly/micro-detected tumor cells incirculating blood (CTCs), bone marrow or other non-regional nodal tissue < 0.2 mm in patientwithout symptoms or signs of metastases

M1 Distant detectable metastases as determinedby classic clinical and radiographic meansand/or histologically proven larger than 0.2 mm

M0 includes M0(i+) pM0 is not valid; any M0 should be clinical No MX



Prostate Changes

T• Microscopic bladder neck extension now T3a

(was T4) N

• No changes M

• No changes Stage Grouping

• T2a moved to Stage I; T2b, T2c remain in Stage II• Grade/differentiation no longer a factor• PSA value included in prognostic grouping• Gleason score included in prognostic grouping• If PSA or Gleason unknown, can still stage


Prostate – 7th EditionAJCC Anatomical/Prognostic Groups

Stage PSA Gleason ScoreI T1a-c N0 M0 < 10 < 6

T2a N0 M0 < 10 < 6T1-2a N0 M0 X X

IIA T1a-c N0 M0 < 20 < 7T1a-c N0 M0 > 10 to < 20 < 6T2a N0 M0 < 20 < 7T2b N0 M0 < 20 < 7T2b N0 M0 X X

IIB T2c N0 M0 Any AnyT1-2 N0 M0 > 20 AnyT1-2 N0 M0 Any > 8

III T3a-c N0 M0 Any AnyIV T4 N0 M0 Any Any

Any T N1 M0 Any AnyAny T Any N M1 Any Any


Extrahepatic Bile Ducts – 7th EditionPROXIMAL /PERIHILAR BILE DUCT TUMORS (New site) Right, left, common hepatic ductsT1 Ductal wall T2a Beyond ductal wall T2b Adjacent hepatic parenchyma T3 Unilateral portal vein or

hepatic artery branchesT4 Main portal vein or branches

bilaterally; …N1, N2 Specific lymph node chainsAnatomical Stage GroupsStage I T1 N0 M0Stage II T2a-b N0Stage IIIA T3 N0Stage IIIB T1-3 N1Stage IVA T4 N0-1Stage IVB Any T N2 or M1

DISTAL EXTRAHEPATIC BILE DUCTS From cystic duct insertion

into common hepatic ductT1 Ductal wallT2 Beyond ductal wallT3 Adjacent organsT4 Celiac axis, or superior

mesenteric arteryN1 Regional

Anatomical Stage GroupsStage IA T1 N0Stage IB T2 N0Stage IIA T3 N0Stage IIB T1-3 N1Stage III T4 Any NStage IV Any T Any N M1


Mucosal Melanoma of Head and Neck (Upper Aerodigestive) – 7th Edition

Mucosal melanomas are aggressive tumors T1 and T2, Stages I and II are

omitted

T3 Epithelium/ submucosa(mucosal disease)

T4a Deep soft tissue, bone,cartilage, overlying skin

T4b Brain, dura, skull base,lower cranial nerves,masticator space, carotidartery, prevertebral space, mediastinal structures,cartilage, skeletal muscle,or bone

ANATOMICAL STAGE GROUPSStage III T3 N0Stage IVA T4a N0

T3-T4a N1Stage IVB T4b Any NStage IVC Any T Any N M1



Skin – 7th EditionSplit into two chapters

CARCINOMA (non-Merkel cell)T1 <2 cm with < 2 risk factors* T2 >2 with > 2 risk factors*T3 Maxilla, mandible, orbit, or

temporal boneT4 Skull base, axial or

appendicular skeleton

N1 1 node < 3 cmN2a 1 node > 3 to 6 cmN2b Mult ipsilat nodes < 6 cmN2c Bilat/contralat nodes < 6 cmN3 Any node > 6 cm

M1 Distant metastasis

MERKEL CELL CARCINOMAT1 < 2 cm T2 > 2 to 5 cmT3 > 5 cmT4 Deep extradermal structures

(bone, muscle…)

N1a Microscopic metastasisN1b Macroscopic metastasisN2 In transit metastasis

M1a Skin, subcut, distant nodesM1b LungM1c Other sites

New stage groupings for Merkel* Risk factors for carcinomas: >2 mm thickness; Clark level IV; perineural invasion; ear or non-hair-bearing lip primary; PD or undiff


Adrenal Cortical Carcinoma – 7th Ed

New site—carcinomas only Adrenal cortex produces

steroid hormones

T1 < 5 cm, no extra-adrenal invasion

T2 > 5 cm, no extra-adrenal invasion

T3 Local invasionT4 Adjacent organs

N1 Regional

M1 Distant

ANATOMICAL STAGE GROUPS

Stage I T1 N0Stage II T2 N0Stage III T1-2 N1

T3 N0Stage IV T3 N1

T4 N0-1Any T Any N M1


Summary

New chapters and revisions to existing chapters

Some staging rules changed for 7th edition New look User-friendly features Use for cases diagnosed on or after

01/01/2010


The Details

AJCC Cancer Staging ManualEdge, S.B.; Byrd, D.R.; Compton, C.C.; Fritz, A.G.; Greene, F.L.; Trotti, A. (Eds.) 7th ed., 2010, 646 p. 130 illus. With CD-ROM., SoftcoverISBN: 978-0-387-88440-0

AJCC Cancer Staging HandbookFrom the AJCC Cancer Staging ManualEdge, S.B.; Byrd, D.R.; Compton, C.C.; Fritz, A.G.; Greene, F.L.; Trotti, A. (Eds.) 7th ed., 2010, Approx. 745 p. 130 illus., SoftcoverISBN: 978-0-387-88442-4



AJCC Cancer Staging Manual and Handbook

www.cancerstaging.net (Springer)• Manual $64.95• Handbook $44.95• Quantity discounts available from publisher

www.Amazon.com• Manual $50.66• Handbook $35.06

www.bn.com (Barnes and Noble)• Manual $58.45 member price• Handbook $40.50 member price


Acknowledgements

Dr. Leslie Sobin• Chair, UICC TNM Staging Project

Dr. Carolyn Compton• Chair, American Joint Committee on Cancer

Dr. Steven Edge• Editor in chief, AJCC Cancer Staging Manual and

Handbook Donna Gress, CTR

• Technical Specialist, AJCC

FOR GENERAL QUESTIONS• [email protected]

How to Clinically TNM Stage a Case 1ACTUR Conference April 2010

How to ClinicallyStage a Case in TNM 7th Edition

ACTUR ConferenceApril 26, 2010

April Fritz, RHIT, CTR

Clinical TNM Staging 2

Describing Extent of Disease

T Primary tumor and contiguoustumor growth

N Regional lymph node involvement

M Distant metastases


Staging Basis

Clinical (c)• Before any treatment

Pathologic (p)• After neoadjuvant therapy

Retreatment (r) Autopsy (a)


General Rules for Staging

Chapter 1 TNM Manual Used for all sites Exceptions or additions in site-specific

chapters




1. MICROSCOPIC CONFIRMATIONAll cases should be confirmed microscopically.• Clinically diagnosed cases should be reported

separately.• Cancers are classified by their ICD-O-3 primary

site code.



2. TIMING Clinical staging

All information obtained prior to initiation of any treatment or within 4 months of diagnosis, whichever is shorter, with no disease progression.• Treatment decision includes watchful waiting.

Pathologic stagingAll information obtained through completion of first course surgery or within 4 months of diagnosis, whichever is longer, with no neoadjuvant treatment or disease progression.



3. CASES WITH NEOADJUVANT TREATMENTCases treated with neoadjuvant therapy (pre-operative systemic or radiation therapy) may have a second staging after treatment.• Should have clinical staging as baseline• Post-treatment staging labeled yc or yp


Posttherapy Classification

yTNM Measures response to neoadjuvant treatment

• Patient had systemic and/or radiation treatment before surgery

• Case staged at conclusion of therapy• Clinical if no further treatment (ycTNM)• Pathologic if resection (ypTNM)

Provides prognostic information• Help determine extent of surgery or subsequent

non-surgical treatment




4. PROGRESSION OF DISEASEOnly information obtained prior to documented progression of disease is used for staging.

5. UNCERTAINTY ABOUT CATEGORY• If in doubt about correct T, N, or M value, use the

lower (less advanced) category.• If in doubt about stage grouping, choose the

lower stage.• If in doubt about prognostic factor, assign the

lower category.Clinical TNM Staging 10


6. MISSING PROGNOSTIC FACTORIf required non-anatomic factor is not available, stage group case assuming lowest value for factor.Example: T2a N0 M0 prostate cancer but Gleason score and PSA unknown. Assign Stage Group I (PSA X, Gleason X).


Additional Chapter 1 Notes

Carcinoma in situ• Mixed stage pTis cN0 cM0• Can be reported as clinical or pathologic stage

Multiple tumors• Simultaneous tumors of same histology in one

organ• Classify by highest T category• Add suffix of m for multiplicity or number of tumors, as

in T2(m) or T2(3)• Simultaneous bilateral tumors: classify separately• Thyroid, ovary, liver: multiplicity part of

definitions


Additional Chapter 1 Notes

Subsequent primaries• Stage as new cancer• Do not stage with ‘y’ prefix unless neoadjuvant

therapy to new primary Unknown primary site

• No evidence of primary tumor (T0)• Stage according to site suspected by clinician



Working Stage

Combination of c) and p) information Used ONLY at Tumor Conference or in

chart• Not recorded in registry• Doesn’t meet COC Standard 4.3

Also called mixed stage or combined stage

Example• 79 yo patient presented at Tumor Conf after

lumpectomy shows DCIS w/ microinvasion. Does pt need LN excision?

• pT1mic cN0 cM0


7th Edition Rules Changes

Node biopsy and sentinel node(s) • Clinical if diagnostic (pre-treatment)• Pathologic if therapeutic

New stage groups for CIS and pM1• Can be both clinical and pathologic • cT_ cN_ pM1 Stage Group IV• pTis cN0 cM0 Stage Group 0


T – Tumor

Assessment of the primary cancer and any organs involved by contiguous extension

Increasing Values 1-4• Size• Local extension• Multiplicity• Symptoms

T Category Patterns• Size of primary (oral cavity, breast)• Depth of invasion (colon, bladder)• Location and extension (larynx, lung)• Combination


Other T Categories

Tis – Carcinoma In Situ• Can be stage grouped as either clinical or

pathologic• Primary tumor must be removed and

microscopically proven to be non-invasive (pTis) T0 – No evidence of primary tumor

• Tumor in primary site cannot be found



N – Regional Lymph Nodes

Absence or presence of metastases in primary lymph node drainage area of cancer

N0• Regional lymph nodes have been clinically or

pathologically proven to be free of metastatic disease

N1 – N3• N1 Regional lymph node metastasis• Increasing involvement of regional lymph nodes

by • Number (stomach, colon)• Location (lung, female genital organs)• Size (renal pelvis/ureter)


M – Distant Metastasis

Absence or presence of distant metastases Categories

• M0 Absence of metastatic disease• M1 Presence of at least one area of distant

metastases M1 subcategory example: prostate

• M1a Non-regional lymph nodes• M1b Bone(s)• M1c Other site(s)


Using X (Unknown)

TX Primary tumor cannot be assessed NX Regional nodes cannot be assessed

TX or NX cannot be assigned to a stage unless• Any T or Any N M1

Use TX or NX only when absolutely necessary


0 vs. X

0 “I looked for it (T, N or M) and Icouldn’t find it.”

• No evidence of involvement (N0, M0)• Metastases found, but no evidence of primary

(T0)• Tissue removed at another facility, no report

available (pT0, pN0) X “I wasn’t able to look for it.”

• No tissue removed (cTX, pTX)• No imaging or PE (cNX)• Patient refused workup• Can’t confirm suspicion of involvement



No More MX or pM0

MX and pM0 eliminatedRemaining Categories cM0

• Clinically no distant metastasis• Physical exam and history are sufficient• Extensive imaging not needed

cM1• Distant metastasis clinically

pM1• Distant metastasis proven microscopically

If a tissue equivalent to cM1 is biopsied and is negative, it becomes cM0, not pM0


Staging Basis

Clinical stage: essential to select and evaluate therapy options• Patient stage BEFORE treatment starts• Basis for FIRST treatment choice

Pathologic stage: provides most precise data to estimate prognosis, plan subsequent therapy, and calculate end results


Clinical Stage A.k.a. Pretreatment staging

• Assigned prior to cancer-directed treatment Derived from clinical observations

• Physical examination and clinical history• Imaging

• Extensive imaging not necessary

• Lab markers• Endoscopy• Surgical observation • Surgeon’s clinical observations and judgment

Ends when first cancer-directed treatment starts or decision is made not to treat

Should not be changed based on subsequent information from treatment


Clinical Stage

Using pathology information for clinical staging basis• Biopsy of primary site without resection (cT)• No pathologic information obtained (cT)• Biopsy of single lymph node without pathologic

information about primary site (cN)• Sentinel node biopsy prior to neoadjuvant treatment for

breast cancer• If no removal of primary tumor, then lymph node biopsy

or sentinel node procedure is cN• Negative biopsy of metastatic site (cM0 not pM0)



Clinical Staging

Use when• No surgical treatment• Adjuvant treatment prior to surgery• Insufficient information to stage pathologically


Sites Usually Staged Clinically

Cervix Head and neck sites Malignant lymphomas


Sites Rarely Staged Clinically

Hollow organs• Colon and rectum• Esophagus• Stomach• Renal pelvis and ureter• Corpus uteri

Malignant melanoma Breast Ovary


Sites with Clinical Staging Issues

Prostate• Path staging requires radical prostatectomy

Bladder• Requires depth of invasion• Path staging requires total cystectomy

Testis• Requires info on vascular invasion



Sites Where Clinical Findings are Important

Breast• Inflammatory breast carcinoma, skin or chest

wall involvement Lung

• Superior vena cava syndrome, compression of esophagus or trachea

• Obstructive pneumonitis, atelectasis Larynx

• Vocal cord paralysis Prostate

• Clinically inapparent or apparent primary


How to Clinically Stage a Case

1. Determine primary site2. Review “Rules for Classification” in

appropriate chapter Review general rules if necessary

3. Review medical records for information from tests and reports listed in “Clinical Staging”

4. Classify T, N, and M from shaded boxes in “Definitions of TNM”

5. Determine stage group from orange “Anatomic Stage/Prognostic Groups” box


Clinical Staging Criteria: BreastAJCC Cancer Staging Manual 7th Edition, page 352

Clinical Staging. Clinical staging includes physical examination, with careful inspection and palpation of the skin, mammary gland, and lymph nodes (axillary, supraclavicular, and cervical), imaging, and pathologic examination of the breast or other tissues as appropriate to establish the diagnosis of breast carcinoma. The extent of tissue examined pathologically for clinical staging is not as great as that required for pathologic staging (see “Pathologic Staging” below). Imaging findings are considered elements of staging if they are

collected within 4 months of diagnosis in the absence of disease progression or through completion of surgery, whichever is longer.


Pathologic Staging Criteria: BreastAJCC Cancer Staging Manual 7th Edition, page 353

Pathologic Staging. Pathologic staging includes all dataused for clinical staging, plus data from surgical exploration and resection as well as pathologic examination (gross and microscopic) of the primary carcinoma, regional lymph nodes, and metastatic sites(if applicable), including not less than excision of the primary carcinoma with no macroscopic tumor in any margin of resection by pathologic examination. A cancer can be classified pT for pathologic stage grouping if there is only microscopic, but not macroscopic, involvement at the margin. If there is transected tumor in the margin of resection by macroscopic examination…



Breast Case 1

2.2 cm breast tumor identified on mammogram; physical examination negative

Core needle biopsy positive for duct carcinoma Patient undergoes lumpectomy and sentinel lymph

node biopsy 1 of 3 nodes positive; 1.6 cm carcinoma

What is the clinical T? What is the clinical N?


Breast Case 2

Patient sees MD for lump in axilla. MD also finds small (< 1 cm) mass in UOQ.

Sentinel LN biopsy positive for metastatic duct carcinoma in two nodes

Patient undergoes 3 months of chemotherapy then simple mastectomy and axillary dissection: no primary tumor and no additional axillary nodes positive.


cT1 (≤ 20 mm)cN1 (sn) (mets in 1-3 nodes)


Clinical Staging Criteria: LungAJCC Cancer Staging Manual 7th Edition, page 255

Clinical Staging. Clinical classification (cTNM) is based on the evidence acquired before treatment, including physical examination, imaging studies (e.g., computed and positron emission tomography), laboratory tests, and staging procedures such as bronchoscopy or esophagoscopy with ultrasound directed biopsies (EBUS, EUS), mediastinoscopy, mediastinotomy, thoracentesis, and thoracoscopy (VATS) as well as exploratory thoracotomy.


Pathologic Staging Criteria: LungAJCC Cancer Staging Manual 7th Edition, page 256

Pathologic Staging. Pathological classification uses the evidence acquired before treatment, supplemented or modified by the additional evidence acquired during and after surgery, particularly from pathologic examination. The pathologic stage provides additional precise data used for estimating prognosis and calculating end results.

• The pathologic assessment of the primary tumor (pT) entails resection of the primary tumor sufficient to evaluate the highest pT category.

• The complete pathologic assessment of the regional lymph nodes (pN) ideally entails removal of a sufficient number of lymph nodes to evaluate the highest pN category.

• If pathologic assessment of lymph nodes reveals negative nodes but the number of lymph node stations examined are fewer than suggested above, classify the N category as pN0.



Lung Case

64 year old smoker has chest x-ray showing 7.5 cm mass in RUL.

CT scan shows questionable adenopathy in right mediastinum

Mediastinoscopy and FNA of mediastinal node confirms metastatic small cell carcinoma

Patient referred to medical oncologist



Summary

Assign clinical staging before any treatment starts

Review Rules for Classification in TNM chapter

Know the difference between diagnostic and therapeutic procedures• Especially for lymph nodes

cM0 unless proof of M1 clinically or pathologically

Breast 371

(continued on next page)

CL INIC AL Extent of disease before

any treatment

PAT HOL OGICExtent of disease through

completion of definitive surgeryy clinical – staging completed after neoadjuvant therapy but before subsequent surgery

y pathologic – staging completed after neoadjuvant therapy AND subsequent surgery

TXT0TisTis (DCIS)Tis (LCIS)Tis (Paget’s)

T1T1miT1aT1bT1cT2T3T4

T4a

T4b

T4cT4d

PRIMARY TUMOR (T)Primary tumor cannot be assessedNo evidence of primary tumorCarcinoma in situDuctal carcinoma in situLobular carcinoma in situPaget’s disease of the nipple is NOT associated with invasive carcinoma and/or

carcinoma in situ (DCIS and/or LCIS) in the underlying breast parenchyma. Carcinomas in the breast parenchyma associated with Paget's disease are categorized based on the size and characteristics of the parenchymal disease, although the presence of Paget's disease should still be noted

Tumor £ 20 mm in greatest dimension Tumor £ 1 mm in greatest dimensionTumor >1 mm but £ 5 mm in greatest dimensionTumor >5 mm but £ 10 mm in greatest dimensionTumor >10 mm but £ 20 mm in greatest dimension

Tumor >20 mm but £ 50 mm in greatest dimensionTumor >50 mm in greatest dimensionTumor of any size with direct extension to the chest wall and/or to the skin

(ulceration or skin nodules)*Extension to the chest wall, not including only pectoralis muscle

adherence/invasionUlceration and/or ipsilateral satellite nodules and/or edema (including peau

d'orange) of the skin which do not meet the criteria for inflammatory carcinoma

Both T4a and T4bInflammatory carcinoma**

*Note: Invasion of the dermis alone does not qualify as T4.**Note: Inflammatory carcinoma is restricted to cases with typical skin changes involving a third or more of the skin of the breast. While the histologic presence of invasive carcinoma invading dermal lymphatics is supportive of the diagnosis, it is not required, nor is dermal lymphatic invasion without typical clinical findings sufficient for a diagnosis of inflammatory breast cancer.

TXT0TisTis (DCIS)Tis (LCIS)Tis (Paget’s)

T1T1miT1aT1bT1cT2T3T4

T4a

T4b

T4cT4d

NXpNX

N0pN0pN0(i-)pN0(i+)

pN0(mol-)

pN0(mol+)

REGIONAL LYMPH NODES (N)Regional lymph nodes cannot be assessed (e.g., previously removed)Regional lymph nodes cannot be assessed (e.g., previously removed, or not

removed for pathologic study)No regional lymph node metastasesNo regional lymph node metastasis identified histologicallyNo regional lymph node metastases histologically, negative IHCMalignant cells in regional lymph node(s) no greater than 0.2 mm (detected by

H&E or IHC including ITC)No regional lymph node metastases histologically, negative molecular findings

(RT-PCR)Positive molecular findings (RT-PCR), but no regional lymph node metastases

detected by histology or IHC

NXpNX*

N0pN0pN0(i-)pN0(i+)

pN0(mol-)

pN0(mol+)

S T A G E C A T E G O R Y D E F I N I T I O N S

BREAST STAGING FORM

left right bilateralLATERALITY:

TUMOR SIZE:

HOSPITAL NAME/ADDRESS PATIENT NAME/ INFORMATION

372 American Joint Committee on Cancer • 2010

(continued from previous page)

N1pN1

pN1mi

pN1a

pN1b

pN1c

N2

pN2

N2a

pN2a

N2b

pN2b

N3

pN3

N3apN3a

N3b

N3c

pN3b

Metastases to movable ipsilateral level I, II axillary lymph node(s)Micrometastases; or metastases in 1 to 3 axillary lymph nodes; and/or in

internal mammary nodes with metastases detected by sentinel lymph node biopsy but not clinically detected**

Micrometastases (greater than 0.2 mm and/or more than 200 cells, but none greater than 2.0 mm)

Metastases in 1 to 3 axillary lymph nodes, at least one metastasis greater than 2.0 mm

Metastases in internal mammary nodes with micrometastases or macrometastases detected by sentinel lymph node biopsy but not clinically detected**

Metastases in 1 to 3 axillary lymph nodes and in internal mammary lymph nodes with micrometastases or macrometastases detected by sentinel lymph node biopsy but not clinically detected**Metastases in ipsilateral level I, II axillary lymph nodes that are clinically fixed

or matted; or in clinically detected* ipsilateral internal mammary nodes in the absence of clinically evident axillary lymph node metastases

Metastases in 4 to 9 axillary lymph nodes; or in clinically detected*** internal mammary lymph nodes in the absence of axillary lymph node metastases

Metastases in ipsilateral axillary lymph nodes fixed to one another (matted) or to other structures

Metastases in 4 to 9 axillary lymph nodes (at least one tumor deposit greater than 2.0 mm)

Metastases only in clinically detected*** ipsilateral internal mammary nodes and in the absence of clinically evident axillary lymph node metastases

Metastases in clinically detected*** internal mammary lymph nodes in the absence of axillary lymph node metastases

Metastases in ipsilateral infraclavicular (level III axillary) lymph node(s) with or without level I, II axillary lymph node involvement; or in clinically detected* ipsilateral internal mammary lymph node(s) with clinically evident level I, II axillary lymph node metastases; or metastases in ipsilateral supraclavicular lymph node(s) with or without axillary or internal mammary lymph node involvement

Metastases in 10 or more axillary lymph nodes; or in infraclavicular (level III axillary) lymph nodes; or in clinically detected*** ipsilateral internal mammary lymph nodes in the presence of 1 or more positive level I, II axillary lymph nodes; or in more than 3 axillary lymph nodes and in internal mammary lymph nodes with micrometastases or macrometastases detected by sentinel lymph node biopsy but not clinically detected**; or in ipsilateral supraclavicular lymph nodes

Metastases in ipsilateral infraclavicular lymph node(s) Metastases in 10 or more axillary lymph nodes (at least one tumor deposit

greater than 2.0 mm); or metastases to the infraclavicular (level III axillary lymph) nodes

Metastases in ipsilateral internal mammary lymph node(s) and axillary lymph node(s)

Metastases in clinically detected*** ipsilateral internal mammary lymph nodes in the presence of 1 or more positive axillary lymph nodes; or in more than 3 axillary lymph nodes and in internal mammary lymph nodes with micrometastases or macrometastases detected by sentinel lymph node

N1pN1

pN1mi

pN1a

pN1b

pN1c

pN2

pN2a

pN2b

pN3

pN3a

pN3b

biopsy but not clinically detected**Metastases in ipsilateral supraclavicular lymph node(s)


BREAST STAGING FORM

Breast 373


Metastases in ipsilateral supraclavicular lymph nodes*Classification is based on axillary lymph node dissection with or without sentinel lymphnode biopsy. Classification based solely on sentinel lymph node biopsy without subse-quent axillary lymph node dissection is designated (sn) for “sentinel node,” for example, pN0(sn).

**Note: Not clinically detected is defined as not detected by imaging studies(excluding lymphoscintigraphy) or not detected by clinical examination.

***Note: Clinically detected is defined as detected by imaging studies (excluding lymphoscintigraphy) or by clinical examination and having characteristics highlysuspicious for malignancy or a presumed pathologic macrometastasis based onfine needle aspiration biopsy with cytologic examination. Confirmation of clinicallydetected metastatic disease by fine needle aspiration without excision biopsy isdesignated with an (f) suffix, for example, cN3a(f). Excisional biopsy of a lymph nodeor biopsy of a sentinel node, in the absence of assignment of a pT, is classified asa clinical N, for example, cN1. Information regarding the confirmation of the nodal statuswill be designated in sitespecific factors as clinical, fine needle aspiration, core biopsy,or sentinel lymph node biopsy. Pathologic classification (pN) is used for excision orsentinel lymph node biopsy only in conjunction with a pathologic T assignment.

Note: Isolated tumor cell clusters (ITC) are defined as small clusters of cells notgreater than 0.2 mm, or single tumor cells, or a cluster of fewer than 200 cells ina single histologic cross-section. ITCs may be detected by routine histology or byimmunohistochemical (IHC) methods. Nodes containing only ITCs are excluded from the total positive node count for purposes of N classification but should beincluded in the total number of nodes evaluated

M0

cM0(i+)

M1

DISTANT METASTASIS (M)No clinical or radiographic evidence of distant metastases (no pathologic M0;

use clinical M to complete stage group)No clinical or radiographic evidence of distant metastases, but deposits of

molecularly or microscopically detected tumor cells in circulating blood, bone marrow or other non-regional nodal tissue that are no larger than 0.2 mm in a patient without symptoms or signs of metastases

Distant detectable metastases as determined by classic clinical and radiographic means and/or histologically proven larger than 0.2 mm

M1

pN3c pN3c

BREAST STAGING FORM



Lung 267

CLINICAL Extent of disease before

any treatment

PATHOLOGICExtent of disease through

completion of definitive surgeryy clinical – staging completed after neoadjuvant therapy but before subsequent surgery

y pathologic – staging completed after neoadjuvant therapy AND subsequent surgery

TXT0TisT1

TXT0TisT1

T1aT1bT2

T1aT1bT2

T2aT2bT3

T2aT2bT3

T4

PRIMARY TUMOR (T)Primary tumor cannot be assessedNo evidence of primary tumorTis Carcinoma in situTumor £3 cm in greatest dimension, surrounded by lung or visceral pleura,

without bronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e., not in the main bronchus)*

Tumor £2 cm in greatest dimensionTumor > 2 cm but £3 cm in greatest dimensionTumor > 3 cm but £7 cm or tumor with any of the following features (T2 tumors

with these features are classified T2a if £ 5 cm)Involves main bronchus, ³2 cm distal to the carinaInvades visceral pleura (PL1 or PL2)Associated with atelectasis or obstructive pneumonitis that extends to the hilar region but does not involve the entire lung

Tumor > 3 cm but £5 cm in greatest dimensionTumor > 5 cm but £7 cm in greatest dimensionTumor > 7 cm or one that directly invades any of the following: parietal pleural

(PL3) chest wall (including superior sulcus tumors), diaphragm, phrenic nerve, mediastinal pleura, parietal pericardium; or tumor in the main bronchus (< 2 cm distal to the carina* but without involvement of the carina; or associated atelectasis or obstructive pneumonitis of the entire lung or separate tumor nodule(s) in the same lobe

Tumor of any size that invades any of the following: mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body, carina, separate tumor nodule(s) in a different ipsilateral lobe

* The uncommon superficial spreading tumor of any size with its invasive component limited to the bronchial wall, which may extend proximally to the main bronchus, is also classified as T1a.

T4

NXN0N1

N2N3

REGIONAL LYMPH NODES (N)Regional lymph nodes cannot be assessedNo regional lymph node metastasisMetastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and

intrapulmonary nodes, including involvement by direct extensionMetastasis in ipsilateral mediastinal and/or subcarinal lymph node(s)Metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or

contralateral scalene, or supraclavicular lymph node(s)

NXN0N1

N2N3

M0M1M1a

M1b

DISTANT METASTASIS (M)No distant metastasis (no pathologic M0; use clinical M to complete stage group)Distant metastasisSeparate tumor nodule(s) in a contralateral lobe; tumor with pleural nodules or

malignant pleural (or pericardial) effusion**Distant metastasis

**Most pleural (and pericardial) effusions with lung cancer are due to tumor. In a few patients, however, multiple cytopathologic examinations of pleural (pericardial) fluid are negative for tumor, and the fluid is nonbloody and is not an exudate. Where

M1M1a

M1b

S T A G E C A T E G O R Y D E F I N I T I O N S

L UNG S TAGING F ORM

left right bilateralLATERALITY:

TUMOR SIZE:


268 American Joint Committee on Cancer • 2010

(continued from previous page)

these elements and clinical judgement dictate that the effusion is not related to the tumor, the effusion should be excluded as a staging element and the patient should be classified as M0.

CLINICALGROUP T N M

Occult TX N0 M00 Tis N0 M0IA T1a N0 M0

T1b N0 M0IB T2a N0 M0IIA T2b N0 M0

T1a N1 M0T1b N1 M0T2a N1 M0

IIB T2b N1 M0T3 N0 M0

IIIA T1a N2 M0T1b N2 M0T2a N2 M0T2b N2 M0T3 N1 M0T3 N2 M0T4 N0 M0T4 N1 M0

IIIB T1a N3 M0T1b N3 M0T2a N3 M0T2b N3 M0T3 N3 M0T4 N2 M0T4 N3 M0

IV Any T Any N M1aAny T Any N M1b

PATHOLOGICGROUP T N M

Occult TX N0 M00 Tis N0 M0IA T1a N0 M0

T1b N0 M0IB T2a N0 M0IIA T2b N0 M0

T1a N1 M0T1b N1 M0T2a N1 M0

IIB T2b N1 M0T3 N0 M0

IIIA T1a N2 M0T1b N2 M0T2a N2 M0T2b N2 M0T3 N1 M0T3 N2 M0T4 N0 M0T4 N1 M0

IIIB T1a N3 M0T1b N3 M0T2a N3 M0T2b N3 M0T3 N3 M0T4 N2 M0T4 N3 M0

IV Any T Any N M1aAny T Any N M1b

Stage unknown Stage unknown

PROGNOSTIC FACTORS (SITE-SPECIFIC FACTORS)REQUIRED FOR STAGING: NoneCLINICALLY SIGNIFICANT:

Pleural/Elastic Layer Invasion (based on H&E and elastic stains)___________________

Separate Tumor Nodules __________________________________________________

General Notes: For identification of special cases of TNM or pTNM classifications, the "m" suffix and "y," "r," and "a" prefixes are used. Although they do not affect the stage grouping, they indicate cases needing separate analysis.

L UNG S TAGING F ORM


A N A T O M I C S T A G E • P R O G N O S T I C G R O U P S

What’s New in CSv2 4/1/2010 1ACTUR Conference 2010 [email protected]

1

What’s New in CSv2?New Sites, New

Rules, New SSFs

ACTUR Conference 2010April Fritz, RHIT, CTR

CSv2 Overview 4/1/2010 2

What We’ll Cover

Rules changes and revisions New Data Fields

Lymph-Vascular Invasion Grade Path Value/Grade Path System Mets at Dx – Metastatic Sites

Overview of Site-Specific Factors Sites with Major Changes

Esophagus and Stomach Biliary Tract Testis Gastrointestinal Stromal Tumor (GIST)


CSv2 Changes

New name Collaborative Stage Data Collection System (CS)

Based on AJCC Cancer Staging Manual, seventh edition

Commitment to make staging more clinically relevant Better definitions and instructions More site-specific factors

Compatible with 2010 CAP Protocols


Other Features of CSv2

Histology inclusions rather than exclusions Code ranges rather than specific terms

Consistency of code structures from site to site More non-specific terms, “Stated as T_, NOS” More non-anatomic factors

Treatment decisions, prognostic/predictive data Data items more complete for lab values

Colon, rectum, appendix: CEA and CEA Lab Value



CSv2 Field Changes

CS Extension expanded Two digits to three digits

CS Lymph Nodes expanded Two digits to three digits

7th and 6th Edition mapping fields Additional site-specific factors


Example CS Extension Table: ColonSS2000

MapSS77 Map

TNM 6 Map

TNM 7 Map

DescriptionCode

RERET4T4bAdherent to other organs or structures, NOS570

RERET4T4aAny of [(420) to (450)] + (500)550

RERET4T4aInvasion of/through serosa (mesothelium) (visceral peritoneum)

Stated as T4a, NOS

500

RERET4T4NOSStated as T4, NOS490

RERET3T3Adherent to other organs or structures, but no microscopic tumor found in adhesion(s)

460

RERET3T3Extension to:All colon sites:

Adjacent tissue(s), NOSConnective tissueMesenteric fat

…Ascending and descending colon

Retroperitoneal fat Transverse colon/flexures

Gastrocolic ligamentGreater omentum

450

RERET3T3Fat, NOS420


New CSv2 Schemas

Mucosal melanoma of head and neck (26) Esophagus-GE Junction Appendix Gastrointestinal stromal tumor (7) Neuroendocrine tumor (neuroendocrine/carcinoid) (4) Intrahepatic bile ducts Perihilar bile ducts Distal bile duct Other biliary Merkel cell carcinoma Ocular adnexal lymphoma Adrenal gland

8

Rules Changes



CS General Guidelines

Timing rule• Includes all information gathered through

completion of surgery(ies) in first course of treatment OR

• within four months of diagnosis in absence of disease progression

• whichever is LONGER.• Timing rule NOT identical to TNM7.

I-14


CS General Guidelines, cont’d

Clinician statement of T, N, M Codes included in CS version 2

Stated as T1, NOS; Stated as T1a, NOS Use only when there is no information available

to assign more specific code Discrepancies between clinician statement

and documentation Documentation takes precedence Discuss case with clinician

I-17



Reportable-by-Agreement Cases Staging systems available in TNM for neoplasms that

may not be reportable to population-based registries The presence of a schema in CSv2 does not imply

that the disease is reportable Examples

High grade dysplasia (esophagus) PanIN III of pancreas, severe ductal dysplasia Carcinoid of appendix Squamous carcinoma of skin

Follow instructions of population-based registry regarding reportability If reportable, follow instructions in schema If not reportable, follow policies of facility collecting the data

I-17



No forward compatibility Cannot rerun computer algorithm to derive TNM

7th edition on a pre-2010 case. CS version 2 maps to both TNM 6th and 7th

editions For new schemas, no backward

compatibility Cases not previously staged will not generate a

TNM 6th edition

I-17



CS General Comments

Obsolete codes Necessary as a result of TNM 6 to 7 changes

Splitting of previous codes Moving a structure from Extension to Mets at Dx Correcting mapping errors in CS version 1

Labeled in CSv2 Obsolete codes may be hidden in software

Do not use obsolete codes for current coding Retained as a reference for researchers

I-7


CS General Comments

Schema Discriminator Some primary sites have multiple schemas

Example: Colon (carcinoma), GIST Colon, NET Colon, Lymphoma determined by histology

Some ICD-O-3 codes have multiple schemas Example: C24.0 Extrahepatic bile ducts (distal bile duct;

cystic duct; right, left, and common hepatic ducts) determined by schema discriminator

Example: Peritoneum (usually soft tissue sarcomas, but sometimes primary peritoneal carcinoma in women)

Schema discriminator brings appropriate schema to computer screen

I-5


CS General Comments

Inaccessible lymph nodes Nodes within body cavities that cannot be

palpated or easily examined Examples: regional nodes for bladder, kidney,

colon, prostate, esophagus, stomach, lung, liver, corpus, ovary (not all-inclusive)

Accessible lymph nodes Breast, oral cavity, salivary gland, skin, thyroid,

etc. Code regional nodes as negative if general

statement in chart ‘remainder of exam negative’

I-20


CS General Comments

Inaccessible lymph nodes rule Record regional and distant metastases as

NEGATIVE (rather than unknown) when no mention of LN or mets involvement in PE, Dx testing

or surgical explorationAND patient receives ‘usual’ treatment to primaryAND clinically early stage (T1, T2, localized) tumors

All three conditions have to be met Code unknown if reasonable doubt that tumor is

not localized

I-20



CS General Comments

Unknown status of distant metastasis No MX category in TNM 7th edition CS Mets at Dx code 99 (unknown) maps to M0

Registrar can assume no distant mets unless there is Evidence of mets clinically (physical exam,

imaging, etc.) Microscopically proven distant mets Use code 00 instead

I-20


Eval Fields – General Guidelines

Assign Eval code that describes diagnostic procedure associated with corresponding data field May not be numerically highest code

Eval code corresponds to highest T, N, or M category, not necessarily to highest code in CS field

Use a pathologic Eval code if a biopsy documents highest T, N, or M without resection


CS Nodes Eval – Rules

Linked to CS Lymph Nodes Code as clinical or pathologic based on

intent of procedure and assessment of T If LN procedure part of workup, staging basis is

clinical (codes 0, 1, 5, 9) If LN procedure part of treatment, code as

pathologic (codes 2, 3, 6) Must have resection of primary site meeting pT criteria

Document farthest involved regional nodes May not be highest eval code Pathologic information takes priority Document highest N subcategory

I-49


Most sites use standard tableGeneral structure 0 Clinical only; no nodes removed 1 No nodes removed; endoscopy or invasive

techniques; surgical observationOR FNA, needle bx; or excisional bx as part of diagnostic workup without removal of primary site sufficient for pTbx does not meet criteria for pathologic N

2 Autopsy (known or suspected dx)

CS Nodes Eval – Rules, cont’d



General structure, cont’d

3 Any microscopic assessment of regional nodes WITH removal of primary site sufficient for pTOR Positive biopsy of highest N category regardless of Tmeets criteria for pathologic N

5 Pre-op tx and resection; clinical evidence 6 Pre-op tx and resection; path evidence more

extensive 8 Autopsy (dx not suspected) 9 Unknown, not assessed; no TNM schema




Code 9 Always 9 for sites without TNM mapping Avoid 9 if possible when CS Lymph Nodes is 999

Sentinel nodes Code as pathologic when tumor size/extension

meets criteria for pT When no pT, exam of single LN or sentinel nodes

is clinical Code as pathologic when there is a positive

biopsy of node in highest N category

I-53


Regional Nodes Positive/ExaminedGeneral Rules

Counting nodes (positive or examined) Do not count positive aspiration or core biopsy of

node in same chain removed at surgery Do count positive aspiration or core biopsy of

node in different region If location of biopsied/aspirated node unknown,

do not count Priority of node counts

Final dx, synoptic report, microscopic, gross

I-57


CS Mets at Dx Rules

Generally used for discontinuous, blood-borne, or fluid-borne mets and involved distant lymph nodes

Code the farthest documented metastasis Usually clinical or inferred If no pre-op tx: path when available; if pre-op

tx: clinical Mets at Dx codes (general structure)

10 Distant lymph nodes 40 Specific named structures or

carcinomatosis 50 Distant nodes plus distant mets 60 Nonspecific distant metastases

I-60



CS Mets at DX

When to code 00 vs. 99 Code 00 when

No clinical or pathologic evidence of distant mets and patient is not treated as if mets are present or suspected

Only history and physical exam needed Code 99 when

Reasonable doubt that tumor no longer localized Maps to MX in TNM 6th edition and M0 in 7th edition

No MX in TNM 7th edition Registrar can code Mets at Dx 00 unless distant

mets are identified and classified as cM1 or pM1 CTCs and DTCs

Breast only: code as 05 Code 98

Lymphoma, heme-retic, and some other sites

I-61

26

New Fields


Lymph-Vascular Invasion (1)

Coding instructions Based on all pathology reports or information

available Priority given to positive results

Includes lymphatic invasion, vascular invasion, or lymph-vascular invasion

Do not use for perineural invasion Use CAP checklist as primary source

Other sources may be used in the absence of a checklist


Lymph-Vascular Invasion (2)

Code structure0 – Lymph-vascular invasion not present (absent)/

Not identified1 – Lymph-vascular invasion present/identified8 – Not applicable9 – Unknown/Indeterminate



Grade Path Value (1)

Does not replace Grade/Differentiation (#440) Record grade specified in Grade Path System Code structure

1 Recorded as Grade I or 12 Recorded as Grade II or 23 Recorded as Grade III or 34 Recorded as Grade IV or 4Blank No 2-, 3-, or 4-grade system available; unknown


Grade Path Value (2)

Coding instructions Record grade reported in patient record Based on same tissue as Grade/Differentiation field Do not use for site-specific grading systems

Part of the SSF fields If grade is described as a fraction (x/y)

This data field is the numerator Histologic grade is another name for overall grade or

grade NOS Takes priority over a nuclear or architectural grade


Grade Path System (1)

New item In addition to Grade Differentiation (#440)

Record stated grade system; not converted Used in conjunction with “Grade Path Value” Code Structure

2 Two-grade system3 Three-grade system4 Four-grade system

Blank Not a 2-, 3- or 4-grade system; unknown


Grade Path System (2)

Coding instructions Record the grading system in the record Based on same tissue as Grade/Differentiation field Do not use for site-specific grading systems

Part of the SSF fields If grade is described as a fraction (x/y)

This data field is the denominator



Mets at Dx-Metastatic Sites

4 new fields Bone excluding marrow Lung excluding pleura and pleural fluid Brain excluding spinal cord and other CNS Liver

Code 0 when CS Mets at Dx is 00

Code structure0 – No1 – Yes8 – Not applicable9 – Unknown

34

New SSFs


Site-Specific Factors

25 SSFs Based on AJCC 7th edition Some needed for TNM mapping

Number of positive axillary nodes, extracapsular extension; thickness of melanoma

Some tumor markers and lab values CA 125, CA 19-9, AFP, HCG, KRAS, Ki-67

Some prognostic/predictive Gleason tertiary pattern; IPI, FLIPI, IPS (lymphomas), HER2

Some for future research/special interest Microsatellite instability (GI cancers), tumor infiltrating

lymphocytes (TILs; Merkel cell)

Some for patient history of other diseases History of asbestos exposure (pleural mesothelioma),

retinoblastoma gene mutation

I-76


Site-Specific Factors, cont’d

SSF data sets Breast – 24 Eyelid, lacrimal gland – 15 to 16 Ocular adnexal lymphoma – 12 Prostate – 12 Head & Neck sites (carcinoma, melanoma) – 9 to 11 Colon and Rectum – 9 CNS – 9

Standards setters have decided which SSFs are required



SSF1 Melanoma—Thickness Actual Breslow depth of invasion Required for TNM 6th and 7th staging

SSF2 Melanoma—Ulceration Adds ‘a’ or ‘b’ to T1 - T4 Required for TNM 6th and 7th staging

SSF8, SSF10 Prostate—Gleason Score Records actual score for TNM 7th stage grouping

SSF1 Breast—Estrogen Receptors Predictive information for response to hormones

SSF1 Brain—WHO Grade Different from ICD-O-3 6th digit grade

SSF10 Head and Neck sites—HPV Status Human papilloma virus (HPV) infection may be risk

factor for oral and other mucosal cancers

Examples of CSv2 SSFs


Site-Specific Factors, cont’d

If information regarding SSF is not in path report or medical record, Registrar is not required to go looking for it Information may not be available in some facilities Not registrar’s role to enforce practice standards Instructions included in schemas on how to code

missing information

39

Sites with Major Changes


CSv2 Schema Changes

Schemas for some sites split by morphology Head and neck: mucosal melanomas vs. carcinomas GIST and neuroendocrine tumors of GI tract separate

from carcinomas Liver and intrahepatic bile ducts separate

Liver (Hepatocellular ca) Intrahepatic BD (Cholangioca)

Esophagus: separate stagings for squamous vs. adenocarcinoma



Schemas Split/Revised

Intrahepatic bile ducts (separate from Liver) Liver Hepatocellular carcinoma IHB Cholangiocarcinoma

Extrahepatic bile ducts Perihilar bile ducts Cystic duct Distal bile duct

Skin Cutaneous Squamous Cell Carcinoma and Other

Cutaneous Carcinoma Merkel cell Malignant melanoma


CSv2 Coding Issues, continued

Topography codes split into different schemas Esophagus schema now includes

Gastroesophageal junction (C16.0) Stomach fundus (C16.1) Part of stomach body (C16.2)

Extrahepatic bile ducts (C24.0) split into Perihilar (proximal) Distal bile duct Gallbladder schemas


Esophagus-Stomach Changes

Shift of C16.0, parts of C16.1 and C16.2 to esophagus

Esophagogastric junction (EGJ) tumors: If midpoint (epicenter) within 5 cm of EGJ and also

extends into esophagus, classify and stage as esophagus

Stage all others with midpoint in stomach > 5 cm from EGJ or those within 5 cm of the EGJ with noextension into esophagus as gastric carcinoma


New Schema: Esophagus GE Junction

From Edge et al. Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, seventh edition (2009) published by Springer Science and Business Media LLC, www.springerlink.com.

Esophago-gastric Junction Gastroesophageal Junction



SSF 25: Involvement of Cardia and Distance from GE Junction 000 No involvement of esophagus or EGJ Stomach 010 Tumor located in Cardia or EGJ EsophGEJ 020 Esoph or EGJ involved AND tumor midpoint

from EGJ ≤ 5 cm EsophGEJ 030 Esoph or EGJ involved AND tumor midpoint

from EGJ > 5 cm Stomach 040 Esoph or EGJ involved AND tumor midpoint

from EGJ unknown EsophGEJ 050 Esoph and EGJ not involved but tumor midpoint

from EGJ is ≤ 5 cm Stomach 060 Esoph involved or esoph involvement unknown

AND tumor midpoint from EGJ > 5 cm or unknownAND MD stages case using esoph definitions EsophGEJ

999 Involvement of esoph not stated, unk or no info, not documented Stomach

Blank for Stomach cases C16.3-C16.9 Stomach Blank for Cardia/EGJ cases C16.0 EsophGEJ


EsophagusGEJunction – CS Extension

000 Carcinoma in situ /High-grade dysplasia110 Lamina propria (T1a)120 Muscularis mucosae (T1a)160 Submucosa (T1b)200 Muscularis propria (T2)420 Adventitia (T3)450 Adjacent structures (T4a)600 Diaphragm (T4a)610 Pleura, pericardium (T4a)700 Adjacent peritoneum (T4a)800 Other adjacent structures, e.g. aorta, vertebral

body, trachea (T4b)


Esophagus – 7th Edition N and M

N based on Lymph Nodes PositiveN0 No regional lymph node metastasisN1 1 to 2 regional lymph nodesN2 3 to 6N3 > 6 [N1 was site dependent]

M0 No distant MetastasisM1 Distant metastasis [M1a,b were site dependent]

Anatomical/Prognostic Stage Group Mapping Based on histologic type, grade, location within

esophagus and T, N, M


SSF 4 Distance to Proximal Edge SSF 5 Distance to Distal Edge Measure from front teeth

Code in cm (001 – 050/060) Primary site defined by

uppermost point (proximal edge) Cervical (15-20 cm) Upper thoracic (20-25 cm) Middle thoracic (25-30 cm) Lower thoracic (30-40 cm)

Figure I-2-3. Anatomic Landmarks of Esophagus. From Edge et al. Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, seventh edition (2009) published by Springer Science and Business Media LLC, www.springerlink.com.



Stomach – CS Extension

T1 split into T1a and T1b T1a Ext 100, 110, 120, 125 T1b Ext 130, 140, 160, 170 T1, NOS Ext 160, 300 (localized), 340

T2b Subserosa now T3 (Ext 400) T3 Perforation of serosa now T4a (Ext 500) T4 split into T4a and T4b

N based on Lymph Nodes Positive N1 1 to 2 nodes N2 3 to 6 nodes (was N1) N3a 7 - 15 nodes (was N2) N3b 16 or more (was N3)


C24.0 Extrahepatic Bile Ducts

Extrahepatic Bile Ducts. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer Staging Atlas. New York: Springer, 2006: 139-145. ©American Joint Committee on Cancer.Used with permission of the American Joint Committee on Cancer (AJCC®), Chicago, Illinois.


SSF 25 Subsite of Extrahepatic Bile Ducts 010 Perihilar bile duct(s);Proximal extrahepatic

bile duct(s); Hepatic duct(s) BDPerihilar 020 Stated as Klatskin tumor BDPerihilar 030 Cystic bile duct; cystic duct CysticDuct 040 Common bile duct; Common duct, NOS BDDistal 050 Diffuse involvement; > 1 subsite

involved, subsite of origin not stated BDPerihilar 060 Subsite of extrahepatic bile ducts not

stated, but treated with combined hepatic and hilar resection BDPerihilar

070 Subsite of extrahepatic bile ducts not stated, but treated with pancreatico-duodenectomy BDDistal

999 Subsite not stated and not classifiable in codes 050-070 BDPerihilar


C24.0 Extrahepatic Bile Ducts

?

Distal BD

schema

Cystic Duct

schema

Klatskin tumor

Extrahepatic bile duct [NOS]

Sphincter of Oddi

Hepatic bile duct –right, left, common

Cystic bile duct

Common bile (choledochal) duct

PerihilarBD

schema



Gastrointestinal Stromal Tumor (GIST)

What are GISTs? Rare type of soft tissue sarcoma

4500-6000 adults (2009) – all sites Different from carcinomas

Develop in muscle layer of gut rather than mucosa Grow outward (exophytic)

Described as a distinct entity in 1998 Umbrella term for most mesenchymal tumors of

stomach and intestine Most tumors historically called leiomyosarcoma are

now classified as GISTs


GIST Schemas

Esophagus Stomach Small Intestine Appendix Colon Rectum Peritoneum

Omentum and mesentery

T, N, M definitions common to all GIST sites

TNM7 mapping driven by tumor size, not depth of invasion T category cut points:

2, 5, 10 cm Stage groupings

different


GIST CS Extension

Varies by primary site Very similar to carcinoma schema for same

site (depth of invasion) Slight differences in wording Elimination of T subcategories (T1a, T1b, …) Carcinoma polyp codes generate error in TNM7


GIST Site-Specific Factors

Mitotic count Kit immunohistochemistry Kit gene mutation PDGFRA gene mutation Tumor multiplicity

Location (SSF #) varies by primary site



Mitotic Count

Mitotic count: number of cells actively dividing <5 mitoses/high power field – low mitotic rate >5 mitoses/high power field – high mitotic rate

Source: pathology report/protocol Pathologist instructions: scan slide for area of

greatest mitotic activity

Source: www.ncbi.nlm.nih.gov/About/primer/genetics_cell.html. In the public domain.

MITOSIS


Mitotic Count

Usually documented as mitoses per 50 high power fields (HPF) Standard magnification is 40X Also described as ‘per 5 mm2 ’ (square

millimeters) Site-specific factor code

Implied decimal between 2nd and 3rd digit .8 mitoses/50HPF 008 5 mitoses/50HPF 050


KIT Immunohistochemistry (IHC)

Source: pathology report (special immuno-fluorescent stain) Mutated cells stain brown Confirms diagnosis of GIST

Also known as CD117, c-kit receptor, SCFR (stem cell factor receptor)

Source: Immunoportal.com. Used with permission of image owner, Ole Johnny Steffensen, Aalesund Norway


KIT Gene Mutation

Source: specialty/reference lab report C-kit gene regulates cell growth and

differentiation 85-90% of GISTs contain oncogenic

mutations of KIT receptor tyrosine kinase gene Mutations primarily of exon 11 and 9, and rarely of

exons 13 and 17 Exon: A segment of a gene that contains

instructions for making a protein Specific exon mutation may indicate

potential response to targeted therapy drugs Imatinib mesylate (Gleevec) and Sutent



PDGFRA Gene Mutation

Source: specialty/reference lab report Platelet-Derived Growth Factor Receptor,

Alpha polypeptide type A.k.a. CD140A; MGC74795; PDGFR2; Rhe-

PDGFRA Gene encodes a cell surface tyrosine kinase

receptor Found in mesenchymal cells Mutually exclusive with KIT

PDGFR regulates cell proliferation, cellular differentiation, cell growth and development 30-40% of KIT-negative GISTs contain mutations

of PDGFRA


Tumor Multiplicity

Source: pathology report Record presence of anatomically separate,

multiple GISTs Various sizes May occur in the setting of neurofibromatosis

type 1 or familial GIST syndrome


Testis

Mapping requires SSF4 and Lymph-Vascular Invasion fields

Lymph-vascular invasion 0 Lymph-vascular invasion not present

(absent)/Not identified 1 Lymph-vascular invasion present/Identified 8 Not applicable 9 Unknown if lymph-vascular invasion present;

indeterminate


Investing Layers of Testis

Source: Medi-Clip: Grant’s Atlas Images I, Thorax and Abdomen. Williams and Wilkins, 1998.

Parietal peritoneum

Cremaster muscle

Extraperitoneal fat

Transverse abd. muscle

Dartos muscle

External spermatic fasciaTestis

Scrotal skin

Skin and subcutaneous tissues

Internal spermatic fascia

Tunicavaginalis

Rectus abdominismuscle

Internal abd. oblique m.External abd. oblique m.



Testis – Collaborative Stage Fields

Tumor Size—standard Extension TS/Ext Eval—standard Lymph Nodes LN Eval—standard LN Pos—standard LN Exam—standard Mets at Dx Mets Eval—standard

Site-Specific Factors 1 Obsolete, see SSF6-7 2 Obsolete, see SSF8-9 3 Obsolete, see SSF 10 4 Radical orchiectomy 5 Size of LN mets 6 Preorch AFP Value 7 Preorch AFP Interp 8 Preorch HCG Value 9 Preorch HCG Interp 10 Preorch LDH 11 Persistence of

Elevated Tumor Mkrs


Testis – CS Extension

Codes 160 Testis, rete testis; tunica albuginea 200 Tunica vaginalis; surface implants 300 Localized, NOS 310 Tunica, NOS 460 Epididymis 500 Spermatic cord, ipsilat; vas deferens 600 Dartos muscle, ipsilat; scrotum, ipsilat 700 Scrotum, contralat; ulceration of scrotum 750 Penis 800 Further contiguous extension


160 + LVI 0300 + LVI 9

160 + LVI 1460 + LVI 1

Source: TNM Atlas3rd ed. 2nd rev. 1992, Springer Verlag

into rete testisno vasc/lym invas

into tunica albuginea,w/ vasc/lym invas

into epididymisw/ vasc invas

limited to testis

CS Extension Examples


Ext 500Ext 700

invades spermatic cord

invadesscrotumwith ulceration

CS Extension Examples

Source: TNM-interactive. Wiley-Liss, 1998



Staging Landmarks

Source: Clinical Anatomy for Medical Students

5th ed., 1995, Little, Brown and Co.

Tunica vaginalis

Contralateral scrotum

Vas deferensTunica albuginea

Epididymis

Skin of scrotum


Testis – Regional Lymph Nodes

Source: Medi-Clip: Grant’s Atlas Images 3, Perineum, Pelvis and Lower Limb. Williams and Wilkins, 1998.

Regional lymph nodes of testis

Testis


CS Regional Lymph Nodes

1 Interaortocaval

2 Paracaval

3 Precaval

4 Retrocaval

5 Preaortic

1

23

4

56

C A

Source: Cancer: PPO, DeVita et al

Code 200

Code 100

Code number of positive nodes in Reg LN Posand size of mass in SSF5.

6 Retroaorticalso: peri-/para-aortic


Additional Regional Lymph Nodes

Code 300 (with previous scrotal/inguinal surgery)

Code 100Lateral aortic (lumbar)RetroperitonealRegional nodes, NOS

Pelvic, NOSExternal iliac

Inguinal (superficial or deep)Code 400 (with previous scrotal/inguinal surgery)



CS Mets at Dx

Distant lymph nodes (M1a) 11 (without previous scrotal/inguinal surgery)

Pelvic, NOS External iliac

12 (without previous scrotal/inguinal surgery Inguinal (superficial or deep)

13 Other specified distant lymph nodes Distant metastases (M1b)

20 Lung 25 Lung and distant nodes 40 Other distant sites; carcinomatosis 60 Distant metastasis, NOS


SSF 4 – Radical Orchiectomy Performed

Both diagnostic and therapeutic000 Not performed001 Performed999 Unknown if performed

DefinitionRadical inguinal orchiectomy Complete removal of

testicle, epididymis andspermatic cord to the level of the internal inguinal ring

www.tc-cancer.com/treatment.html

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SSF 5 – Size of Mets in Lymph Nodes

Size of mass, not just size of mets Codes

000 No LN mets 010 Mass < 2 cm; no extranodal extension (N1) 020 Mass > 2 and < 5 cm; OR pathologic

extranodal extension (N2) 030 Mass > 5 cm (N3) 998 Nodes involved, size of mass unknown 999 Unknown if performed


SSF 6 – Preorchiectomy Alpha-Fetoprotein Value Marker for teratocarcinoma, yolk sac or

embryonal carcinoma. Not found in other histologies Also called FP, AFP, alpha-fetoglobulin Normal range: < 15 ng/ml in adults

Record value prior to orchiectomy in 1st course Read carefully; value ranges change Examples

000 0 ng/ml 001 1-19 ng/ml 002 20-29 ng/ml 020 200-299 ng/ml 120 2000-2999 ng/ml 200 ≥ 10,000 ng/ml



SSF 7 – Preorchiectomy Alpha-Fetoprotein Interpretation Field information collected in CSv1

Now preorchiectomy only Codes

000 Within normal limits (S0) 010 < 1000 ng/ml (S1) 020 1000 – 10,000 ng/ml (S2) 030 > 10,000 ng/ml (S3) 997 Ordered, results not in chart 998 Test not done (SX) 999 Unknown; no information


SSF 8 – Preorchiectomy human Chorionic Gonadotropin Value Marker for choriocarcinoma or embryonal

carcinoma. Not found in other histologies Also called hCG, beta unit hCG, HCG Normal range: 0 ng/ml in adult men

Record value prior to orchiectomy in 1st course Read carefully; value ranges change Examples

000 0 ng/ml 001 1-19 ng/ml 002 20-29 ng/ml 020 200-299 ng/ml 120 2000-2999 ng/ml 220 20,000-29,999 ng/ml 250 ≥ 50,000 ng/ml


SSF 9 – Preorchiectomy human Chorionic Gonadotropin Interpretation Field information collected in CSv1

Now preorchiectomy only Codes

000 Within normal limits (S0) 010 Above normal and < 5000 mIU/ml (S1) 020 5000 – 50,000 mIU/ml (S2) 030 > 50,000 mIU/ml (S3) 997 Ordered, results not in chart 998 Test not done (SX) 999 Unknown; no information


SSF 10 – Preorchiectomy LDH Interpretation Marker for both non-seminomatous and

seminomatous advanced disease Also called lactate dehydrogenase, LD, Lactic acid

dehydrogenase Non-specific for testicular cancer; only bulky disease Normal range: varies by patient age and laboratory

Record range prior to orchiectomy Codes

000 Within normal limits (S0) 010 < 1.5 x N {upper limit of normal} (S1) 020 1.5 to 10 x N (S2) 030 > 10 x N (S3) 997 Test ordered, results not in chart 998 Test not done (SX) 999 Unknown; no information



Calculating the LDHRead the lab report to determine the upper limit of normal and the result. Examples:

Lab A 105 to 333 IU/LLab B Female: 46-100 IU/L Male: 46-232 IU/LLab C 45 - 90 U/L

Result is 195

What is the upper limit of normal?If result is within normal limits, code 000.

What is 1.5 times that result? (For B, 1.5 x 100 = 150)If result is > normal but < 1.5 x normal, code 010.

What is 10 times that result? (For B, 10 x 100 = 1000)If result is > 1.5 x normal but < 10 x normal, code 020.If result is > 10 x normal, code 030.


SSF 11 – Persistence of Elevated Tumor Markers Needed for Stage Group IS Code presence or absence of persistent

elevated tumor markers POST-orchiectomy If markers return to normal post-orch, code 000

Codes 000 No persistence or pre-orch markers were normal;

Tumor markers returned to normal post-orch 010 Persistence of elevated markers; Markers still

elevated post-orch; Stated as Stage IS 999 Unknown if persistence; Not documented


SSF Summary

Number of SSFs 1038 Average SSF per schema 6.8

COC/SEER Required SSFs 673 Average required schemas/SSF 4.2

Top 5 sites Average SSFs 10.2 Average required by COC/SEER 7.8


CS Coding Instructions

Electronic document Designed for desktop use so it can be easily

accessed PDF will allow sticky notes, word search, cross-

referencing Print manual will be available through NCRA

Part I extensively revised and expanded Improvements based on suggestions from users

and reliability studies Part I rules to be cross-referenced in Part II

Hyperlinks in electronic manual



CS Coding Instructions Part I

Section 1 General rules Data fields rules More examples with rules

Section 2 – Site-specific notes Lymph nodes (head and neck, breast) Other problematic data items

Clinical status of regional lymph nodes (stomach, colon)

Lab values and tumor markers Other site-specific factors

Appendices


Summary

Read and understand the CS general rules Refer to the site-specific schema every time—

do not memorize Read the notes for each data field Understand the anatomy

Primary site, adjacent structures and regional nodes Record the most extensive code

Greatest size/extension or farthest documented mets Code the Eval field that documents the field

most important for TNM staging Understand the inaccessible nodes rule

Know when to apply it Code SSFs as required

Breast Cancer CSv2 Coding 1ACTUR Training 2010 [email protected]

The Anatomy of Staging:

Breast Cancer

Image source: usps.gov Breast Cancer CSv2 Coding 2

Basic Anatomy

Pectorialis musclesPectorialis fascia

Source: Medi-clip: Grant’s Atlas Images I, Thorax and Abdomen. Williams and Wilkins, 1998.

Breast Cancer CSv2 Coding 3

Nipple

Areola

Ducts

Fatty parenchyma

Lobules

Skin

Ribs

Intercostal muscles

Pectoralis muscle

Serratus anterior muscle

Chest wall

Breast Sagittal View


Breast – Basic Anatomy

• 50.0 Nipple• 50.1 Central• 50.2 UIQ• 50.3 LIQ• 50.4 UOQ• 50.5 LOQ• 50.6 Ax. Tail• 50.8 Overlapping• 50.9 Breast, NOS

Source: UICC TNM-interactive, Wiley-Liss, 1998



Breast - Orientation

• Quadrants are mirror images

• Clock positions are same for each breast 9:00 Left = 3:00 Right 4:00 Left = 8:00 Right

• Terminology Superior = upper Inferior = lower Lateral = Outer Medial = Inner

211211

10

9

87 6 5

4

3

RIGHT OR LEFT BREAST


Central Portion of Breast (C50.1)

• Area extending 1 cm. radius around areola• Retroareolar• Subareolar• Behind nipple• Beneath nipple• Under/underneath nipple


Regional Anatomy

1 Superficial axillary nodes (low axillary, Level I)

2 Brachial axillary lymph nodes3 Interpectoral axillary lymph

nodes (Rotter’s nodes, Level II)4 Deep axillary lymph nodes

(high axillary, apical, Level III)5 Infraclavicular lymph lymph

nodes (subclavicular)6 Supraclavicular lymph nodes7 Parasternal lymph nodes

(internal mammary nodes)8 Paramammary or intramammary

lymph nodes (Level I) Adapted from: Pocket Atlas of Human Anatomy, third edition. H Feneis, Georg Thieme Verlag, Stuttgart, 1994. Used with permission.

6

7

543

8

2

1


Breast Cancer – CS Fields

• Collaborative Stage fields• Tumor Size—special codes• Extension• TS/Ext Eval—standard • Lymph Nodes• LN Eval—standard • LN Pos• LN Exam—standard • Mets at Dx• Mets Eval—standard• SSFs 1 - 24




• Site-Specific Factors SSF1 ERA SSF2 PRA SSF3 Pos Axillary LN SSF4 IHC reg LN SSF5 Molecular studies SSF6 Size of invasive tumor SSF7 Nottingham or Bloom-

Richardson (BR) Score/Grade

HER2 FIELDS• SSF8 HER2: IHC Test Lab Value• SSF9 HER2: IHC Test

Interpretation• SSF10 HER2: Fish Test Lab Value• SSF11 HER2: FISH Test

Interpretation• SSF12 HER2: CISH Test Lab Value• SSF13 HER2: CISH Test

Interpretation• SSF14 HER2: Result of other or

unknown test• SSF15 HER2: Summary Result of

Testing



• Site-Specific Factors, continued SSF16 Combinations of ER, PR, and HER2 SSF17 Circulating Tumor Cells (CTC) and method of

detection SSF18 Disseminated Tumor Cells (DTC) and method of

detection SSF19 Assessment of Positive Ipsilateral

Axillary Lymph Nodes SSF20 Assessment of Positive Distant Metastases SSF21 Response to Neoadjuvant Therapy SSF22 Multigene Signature Method SSF23 Result/score of the multigene signature SSF24 Paget Disease


CS Tumor Size• Critical part of TNM T1 - T3 categories• Site-specific (not common) table• Code invasive tumor size in millimeters• If microinvasion only, code size of largest focus• If stated as T1, NOS, use code 005• If stated as > 5 cm, use code 051• Special codes

990 Microinvasion; microscopic focus or foci only,no size given; described as < 1 mm; stated asT1mi, NOS with no other information on size

991-995 less than y cm, greater than x cm, between x andy cm, or “Stated as T_, NOS”

• Use if precise size not available 996 Seen on mammo only but no size given 997 Paget’s of nipple, no underlying tumor 998 Diffuse


Tumor Size—General Rules

• Record the largest size reported If no pre-op treatment, use path size If pre-op treatment, use pre-op (clinical) size Imaging takes priority over physical exam Record size of invasive component, if given Special site-specific code 998 takes

precedence over a stated size Do not add pieces together



Nonspecific Tumor Size Descriptions

• 991 Described as “less than 1 cmStated as T1b, NOS*

• 992 Described as “less than 2 cm,” or “greaterthan 1 cm,” or “between 1 cm and 2 cm”Stated as T1, NOS or T1c, NOS*

• 993 Described as “less than 3 cm,” or “greaterthan 2 cm,” or “between 2 cm and 3 cm”

• 994 Described as “less than 4 cm,” or “greaterthan 3 cm,” or “between 3 cm and 4 cm”

• 995 Described as “less than 5 cm,” or “greaterthan 4 cm,” or “between 4 cm and 5 cm”Stated as T2*

* with no other information on size


Notes Added in Part I – Tumor Size

• If the tumor is multi-focal or there are multiple tumors being reported as a single primary, code the size of the largest tumor.

• For an incisional biopsy, code tumor size 999 in the absence of a clinical size.


1. Changes such as dimpling of the skin, tethering, and nipple retraction do not alterthe classification.

2. Adherence, attachment, fixation, induration, and thickening are clinical evidence ofextension to skin or subcutaneous tissue; code to 200.

3. Fixation, NOS is coded to 300, involvement ofpectoralis muscle.Also code “skeletal muscle, NOS” here

CS Extension – Notes


New CS Extension Codes

Code Description 170 Stated as T1 [NOS] * 180 Stated as T2 [NOS] * 190 Stated as T3 [NOS] * 380 Stated as T4 [NOS] * 390 Stated as T4a ** 590 Stated as T4b ** 680 Stated as T4c ** 780 Stated as T4d **

• * with no other information on extension or size• ** with no other information on extension



CS Extension 000, 050, 070 (Tis)

000 Carcinoma in situ050 Paget disease of nipple without underlying tumor070 Paget disease of nipple without underlying

invasive carcinoma


Ext 050, 070 – Paget disease of nipple


CS Size and ExtensionExamples that map to T1

TS 011 + Ext 300

TS 990 + Ext 100

TS 005 + Ext 100

TS 018 + Ext 200

TS 008 + Ext 100

Adapted from: AJCC Cancer Staging Atlas, Springer-Verlag, 2006.

A

B

C

DE


CS Size and ExtensionExamples that map to T2, T3

TS 031 + Ext 100A

BTS 055 + Ext 200

Source: UICC TNM-interactive, Wiley-Liss, 1998 Breast Cancer CSv2 Coding 20

CS Extension 400Extension to chest wall (T4a)

Chest wall includesRibsIntercostal musclesSerratus anterior muscle

Does NOT includePectoral muscle (Ext 300)




CS Extension 512Extensive skin involvement (T4b)

Skin ulceration

Satellite skin nodule

Source: UICC TNM-interactive, Wiley-Liss, 1998 Breast Cancer CSv2 Coding 22

CS Extension 514-580, 590, 600Any of the following conditions without a stated diagnosis of inflammatory carcinoma with or without dermal lymphatic invasion:

Edema of skin; En cuirasse; Erythema; Inflammationof skin; Peau d'orange ("pigskin")

514 described as < 33%518 described as > 33% to 50%520 described as > 50%580 with amount or percentage

not stated590 stated as T4b with no other

information on extension600 Diagnosis of inflammatory carcinoma

but < 33% of breast involvedSource: UICC TNM-interactive, Wiley-Liss, 1998

Edema


Combination Codes

• Avoids repeating large amount of text• 516, 519, 575, 585• 612, 615

• Example 585—(580) + (512) means patient has one or

more of the conditions in 580 and one or more of the conditions in 512

such as ulceration of breast (512) AND peaud’orange with percent of breast involvement not stated (580)


CS Extension 612-615, 680Chest wall and skin involvement (T4c)

612 Chest wall plus skin involvement < 33% ofbreast(codes 400 + 512)

615 Chest wall plus skininvolvement > 33% ofbreast (codes 400 + 520-585)

680 Stated as T4c with noother information onextension

code 400

code

512




CS Extension 725, 730, 750, 780Inflammatory carcinoma (T4d)

Image source: National Cancer Institute

“Diffuse dermal lymphatic involvement causing edema and reddening of the skin”


6. Inflammatory carcinoma (abridged) Clinical AND pathologic entity Presence of diffuse erythema and edema (peau

d'orange) of breast involving majority of breast skin NOT the same as neglected locally advanced cancer

presenting late in the course of disease. May or may not be apparent on skin biopsy Primarily a clinical diagnosis. Involvement of dermal

lymphatics alone does not indicate inflammatory carcinoma in the absence of clinical findings.

In addition to the clinical picture, a biopsy is still necessary to demonstrate dermal lymphatic or breast parenchyma involvement.



7. Recording inflammatory breast carcinoma (IBC) A stated diagnosis of inflammatory carcinoma Record clinical description* in a narrative field Inflammatory carcinoma codes: 600 – Dx of IBC involving < 33% of breast skin DO NOT USE CODE 715 725 – Dx of IBC involving 33% to 50% of breast skin 730 – Dx of IBC involving > 50% of breast skin 750 – Dx of IBC only, no clinical description* of skin

involvement 780 – Stated as T4d, no other info on extension If a clinical description* but no statement of

inflammatory carcinoma—code to 510, 514, 610 or 620 as appropriate

* inflammation, erythema, edema, peau d'orange, etc.



CS TS/Ext Eval, CS Reg Nodes Eval, CS Mets Eval

• All standard tables 0 Clinical only (physical exam, imaging, other non-

invasive)• Does not meet criteria for pathologic staging

1 Invasive techniques, no bx; or needle bx• Does not meet criteria for pathologic T or N

2 Autopsy (known or suspected dx) 3 Surgical resection, no pre-op treatment;

pathologic exam of resected specimen• Meets criteria for pathologic T, N or M

5 Pre-op tx, clinical evidence 6 Pre-op tx, path evidence more extensive 8 Autopsy (dx not suspected) 9 Unknown, not assessed



CS Eval Guidelines

• CS TS/Ext Eval Includes information from surgical resection

(mastectomy), physical exam, imaging Unless there is skin or chest wall involvement,

assign Eval code based on how size was determined. If there is skin or chest wall involvement (T4 disease), assign Eval code based on extension.

• CS Lymph Nodes Eval Single node biopsy or sentinel node procedure Clinical if diagnostic (pre-treatment) Pathologic if therapeutic


Regional Lymph Nodes

Pectoralis minor muscle


Other Names for RegionalLymph Nodes

Labels 1i, 1ii, 1iiiLevel I Intramammary,

Nodule(s) inaxillary fat

Level II Rotter’s nodes,Interpectoral

Level III Infraclavicular,subclavicular

Label 2 Internal mammary(parasternal)


CS Lymph Nodes – Notes

• Assume nodes are movable if not stated as fixed or matted

• Assume mets are > 0.2 mm if stated as positive but size of mets not mentioned

• Use code 600 if no other information about positive nodes.

• Axillary nodes defined as ipsilateral Level I and II, ipsilateral intramammary Does not include Level III (infraclavicular or

apical), internal mammary, or ipsilateral supraclavicular nodes


• Clinical evaluation should use only 000, 255, 260, 290, 510, 600, 740, 745, 750, 760, 780, 790, 800, 999.

• Codes 130-600 are used for positive axillary nodes without internal mammary nodes.

CS Lymph Nodes – Notes

Micrometastases130, 150

Positive supraclavicular nodes800

Positive infraclavicular nodes750

Positive axillary AND internal mammary nodes710-790

Positive regional nodes, NOS600

Positive axillary LN; no mention of internal mammary node status

250-520

Negative nodes or ITCs only000-050

Code Ranges for Lymph Nodes



• Isolated tumor cells (ITCs) (codes 000, 050) Epithelial cells inside a lymph node Single tumor cells or small clusters < 0.2 mm Detected only by immunohistochemical (IHC) or

molecular methods May be verified on “routine” H&E

stains Questionable evidence of malig-

nant activity (no proliferation or stromal reaction) Lymph nodes with ITCs only are NOT considered

positive lymph nodes.

What are Isolated Tumor Cells?


What is H&E?

• Hematoxylin and Eosin• Hematoxylin Stains nucleus (nucleic

acids) of cell blue• Eosin Stains cytoplasm (protein)

pink• Other names for H&E Hematoxylin and eosin;

routine/standard stains

Source: : http://biolog-e.ls.biu.ac.il/synapse/uploads2/Introduction_to_pathology-1.pdf

Image source: National Cancer Institute


IHC – Immunohistochemistry

• IHC stains identify epithelial cells (keratin) • Synonyms Immunohistochemistry Immunocytochemistry Immunochemistry Cytokeratin Pankeratin Keratin IHC staining AE1/AE3 or AE1/3 (special stains) MNF116 CAM 5.2


Regional Lymph Nodes – Size

• Micrometastases (codes 130, 150) Minimal size (>0.2 to 2 mm) OR more than 200 cells Tumor cells implanted in node with

extravasation, proliferation, and/or stromal reaction

In other words, micromets show malignant activity

“Occult” metastases Positive nodes

• Metastases (codes 250-800) > 2 mm Positive nodes



CS Lymph NodesSelecting the Right Code

How detectedSize of metastasis Size IHC H&E

Isolated tumor cells < 0.2 mm 000 050

Micrometastasis > 0.2 to 130 150< 2 mm

Metastasis > 2 mm --- 250–800(macrometastasis)


Code 000 – No regional lymph node involvement or ITCs detected by immuno-histochemistry or molecular methods onlyCode 050 – No regional lymph nodes

positive but ITCs detected on routine H & Estains

When to Use Codes 000, 050Negative nodes vs Isolated Tumor Cells (ITCs)


Code 130 – Axillary nodes, micrometastases*detected only by immunohistochemistry (IHC)Code 150 – Axillary nodes, micrometastasis

only, detected or verified on routine H & Estains; Micrometastasis, NOS

* Micrometastasis: > 0.2 mm (or > 200 cells) and < 2 mm

When to Use Codes 130, 150Method of Detecting Micrometastases


When to Use Codes 250, 255, 260

• 250 Movable axillary node(s), ipsilateral,positive with > micrometastasis(at least one metastasis > 2 mm)

Use when positive nodes are pathologically separate, and size of mets in node is known to be > 2 mm

• 255 Clinically positive movable axillary node(s) Use when there is no pathology or when patient has

neoadjuvant therapy and only clinical assessment • 260 Stated as N1, NOS Use when no physical exam or other assessment,

only a clinician statement of N1



When to Use Codes 290, 300

• 290 Clinically stated only as N2, NOS No physical exam or other assessment, only a

clinician statement of N2 Use when there is no pathology or when

patient has neoadjuvant therapy and only clinical assessment

• 300 Pathologically stated only as N2 NOS No information on which nodes were involved


When to Use Codes 510/520, 600

• 510 Fixed/matted ipsilateral axillary nodesclinically; Stated clinically as N2a, NOS

Use when positive nodes are described clinically as fixed to each other or matted together and there is

• No pathology OR• Patient had pre-operative radiation or systemic

therapy Use when there is no pathology, or no physical

exam or other assessment, only a clinician statement of N2a



• 520 Fixed/matted ipsilateral axillary nodesclinically with pathologic involvement oflymph nodes at least one metastasis > 2mm

Use when positive nodes are described as fixed to each other or matted together AND size of mets is known to be > 2 mm

Description of fixation/matting can be by clinician or by pathologist in gross exam of specimen



• 600 Axillary/regional lymph node(s), NOS; Lymph nodes NOS

Use when size of metastasis in lymph node is not stated

Can be either clinical or pathologic If stated as fixed/matted, use 510-520 instead If stated as movable or not stated as fixed/matted,

use 250-255 instead



Internal Mammary Nodes Definitions

Lymphoscintigraphy• Mapping of sentinel lymph nodes using radioisotopes

to identify nodes for removal by sentinel node biopsy

Not clinically apparent (CS LN codes 710, 720, 730)Positive only on sentinel node biopsy

Clinically apparent (CS LN codes 740, 745, 760)Includes Imaging (CT, CXR, etc) but not lymphoscintigraphy Physical exam (palpable) Visible nodes on gross pathology

Regional Lymph Nodes – Location


Sentinel Lymph Node Biopsy


CS Lymph Nodes – N1 Examples

Code 710 -- Microscopic IM* nodes; no pos axillary LN (pN1b)


+

*IM = internal mammary Microscopic = positive sentinel nodes but not PE or imaging

Code 250, 255 -- Movable axillary LN only (N1)

(1-3 pos = pN1a)

Code 720 -- Microscopic IM* nodes AND

1-3 pos axillary LN (pN1c)


Code 510, 520 Fixed/matted

axillary LN only (N2a)(4-9 pos = pN2a)

Code 740Clin pos IM* nodes;

no pos axillary LN (N2b)



*IM = internal mammary



with/without axillary nodes

Code 750 – Infraclavicular nodes (N3a)Code 760 – Internal mammary AND 4+ axillary nodes (N3b)

Code 800 – Supraclavicular nodes (N3c)

750



800

760+


CS Mets at DX

• Mets at Dx codes 05 CTCs or DTCs in asymptomatic patient 10 Distant lymph nodes 40 Distant metastases, NOS; Carcinomatosis 42 Further skin involvement (axilla, sternum,

contralateral breast, upper abdomen) 44 Metastases to specific sites (bone, lung, ovary,

adrenal, etc.) 50 Distant nodes plus distant mets 60 Distant metastasis, NOS; Stated as M1, NOS


CS Mets at DX

• Code 00: CTCs and DTCs – M0(i+) Patient is asymptomatic Tumor cells detected microscopically or

molecularly• In circulating blood (CTC)• In bone marrow • In non-regional nodal tissue (DTC)

Tumor cell deposits < 0.2 mm • Called micrometastases (not same size definition as

for LN) CTCs and DTCs may be prognostic for

recurrence or survival


CS Mets at DX – Guidelines

• Note 2 paraphrased Assume no distant metastases (cM0) unless there

is documentation of mets clinically (cM1) or by biopsy of a metastatic site (pM1)

Code 00 includes negative physical exam, negative imaging, and negative biopsies of distant sites

No pM0



SSF1: ERA – SSF2: PRA

• Required by COC, SEER, NPCR• Guidelines Record highest value

• If any sample is positive code as 010

If neoadjuvant treatment given, code from pre-treatment specimens

• If no pre-treatment specimens, code from post-treatment

Code 030 (borderline) rarely used Do not code ERA or PRA from multigene test



000 Test not done (not ordered and not performed)010 Positive/elevated020 Negative/normal; within normal limits 030 Borderline; undetermined whether positive

or negative080 Ordered, but results not in chart996 Ordered, results not interpretable999 Unknown or no information; Not documented

in record



• Laboratory tests that include ERA and PRA Breast profile studies Hormone receptors Estrogen/Progesterone binding protein Estradiol receptor (ER) PgR (progesterone receptor) ERICA (estradiol receptor immunocyto-

chemical assay)/PRICA (progesterone receptor immunocytochemical assay)

DO NOT CODE from OncotypeDX or other multigene tests


SSF3 Number of Positive Ipsilateral Axillary Lymph Nodes

• Required by COC, SEER• Information needed to assign pN1, pN2, pN3

by number of positive axillary nodes• Applies to positive ipsilateral Levels I and II

and intramammary axillary nodes• Same guidelines as for CS Lymph Nodes Record even if preoperative treatment Definitions of ITC vs micrometastases Do not count ITC-only nodes as positive

• Same code structure as Reg Nodes Pos Use code 098 if no nodes were removed or if no

nodes found in specimen



• Required by COC, SEER• Use 000-009 ONLY when lymph nodes are

negative on H&E (code 000 in CS Lymph Nodes)000 LN neg on H&E, no IHC done, or unk if IHC done001 LN neg on H&E, IHC done and negative002 LN neg on H&E, IHC done and positive for ITCs009 LN neg on H&E, IHC done and positive, size of

mets unk; stated as N0(i+)• If nodes are positive on H&E, use code 987• If no statement whether IHC tests were done,

assume they were not done and code 000• See also SSF 5, molecular markers

SSF4 Immunohistochemistry (IHC) of Regional Lymph Nodes


• Required by COC, SEER• Not commonly performed• If IHC done (SSF 4), molecular studies not

done • Generic name: RT-PCR; Reverse

transcriptase-polymerase chain reaction• Other names: GeneSearch, TaqMan®, OSNA

(one step nucleic acid amplification), Molecular Beacons, Scorpions® and SYBR® Green, Fluorescence Resonance Energy Transfer (FRET), Amplifluor/Sunrise, others

SSF5Molecular Studies of Regional LN


• Use codes 000-002 ONLY when lymph nodes are negative (CS Lymph Nodes codes 000).

• If nodes are positive, use code 987• If no statement whether molecular tests

were done, assume they were not done• Isolated tumor cells (ITC): same

definition as for CS Lymph Nodes

SSF5Molecular Studies of Regional LN


SSF6 Size of Invasive Tumor

• Required by COC, SEER• Code the phrase that indicates how

pathologic tumor size was coded in CS Tumor Size

• “Mixed" Tumor with both invasive and in situ

components. Examples: mixed infiltrating ductal and DCIS mixed infiltrating ductal and LCIS

• "Pure" a tumor containing only invasive or only in situ

carcinoma



000 All INV (no IS)010 All IS (no INV)020 Mixed INV and IS, INV reported030 Mixed INV and IS, entire size coded (INV size not

stated) AND minimal IS (< 25%)040 Mixed INV and IS, entire size coded (INV size not

stated) AND extensive IS (25% or more) 050 Mixed INV and IS, entire size coded (INV size not

stated, IS proportion not stated) 060 Mixed INV and IS, size not known (TS coded 999)987 Unknown if INV and IS present, unknown if TS

is mixed or "pure" tumor. Clinical tumor size coded.

INV = invasiveIS = in situTS = tumor size

SSF6 Size of Invasive Tumor


SSF7Bloom-Richardson Score/Grade

• Required by COC, SEER• Many other names (same concept) Also called BR, SBR Key words: Bloom, Richardson, Scarff, Elston-

Ellis, Nottingham, Tenovus• May be expressed as Score (range 3-9) Grade (low, intermediate, high) derived from score

• Histologic score features (1-3 points each)1) extent of tubule formation (% composed of

tubular structures)2) nuclear pleomorphism (change in cells)3) mitotic rate (number of mitoses)


SSF7Bloom-Richardson Score/Grade

• Sum points for extent of tubule formation + nuclear pleomorphism + mitotic rate

• Code exact score as priority (030 – 090)• Code grade if score not stated (110-130) Do not translate grade into numeric score 110 Low grade; BR grade 1 120 Medium/intermediate grade; BR grade 2 130 High grade; BR grade 3

• Other codes 988 Not applicable: information not collected

for this case 998 No histologic examination of primary site

(clinical diagnosis) 999 No grade or score given; no information


Bloom-Richardson Score/Grade

Can convert score into ICD-O-3 grade Note: conversion of B-R low, intermediate, and

high is different from conversion used for all other tumors

B-R B-R ICD-O-3 5-yr Scores Grade Terminology 6th Digit Survival

3, 4, 5 1 (lowest) Well differentiated 1 95%6, 7 2 Moderately 2 75%

differentiated8, 9 3 (highest) Poorly differentiated 3 50%

Adapted from http://imaginis.com/breasthealth/histologic_grades.asp



SSFs 8-15 HER2 Fields

• HER2 Human Epidermal growth factor Receptor 2 Overexpression indicates aggressive behavior,

likelihood of recurrence Patient may be treated with Herceptin

• Site-Specific Factors Required by COC, SEER, NPCR 8-9 HER2: IHC Test Lab Value and Interpretation 10-11 HER2: Fish Test Lab Value and Interpretation 12-13 HER2: CISH Test Lab Value and Interpretation 14 HER2: Result of other or unknown test 15 HER2: Summary Result of Testing



• 8-9 IHC – Immunohistochemistry Most common HER2 test Special stain done in pathology If IHC inconclusive, MD may request FISH test

• 10-11 FISH – Fluorescence In Situ Hybridization Fluorescent DNA attaches to HER2 genes More expensive, longer to report than IHC Reported as ratio of HER2 receptors to control

• 12-13 CISH - Chromogenic In Situ Hybridizaton FDA approved 2009; less expensive than FISH Looks for color changes not fluorescence Counts average number of gene copies per cell


IHC – FISH – CISH

• First field – result IHC 1+, 2+ 3+ FISH Ratio (1.00 to 9.87) CISH Mean number of gene copies per cell

• Second field – interpretation All three tests

• Positive/elevated (amplified)• Negative/normal (not amplified)• Borderline• Test ordered, results not in chart• Test not done (not ordered and not performed• Unknown



• 14 Result of Other or Unknown Test Required by COC, SEER Record other HER2 test or unknown type of test

• 15 Summary Result of Testing Summary of SSFs 9, 11, 13, 14 Record final result if multiple tests

• 16 Combinations of ER, PR, and HER2 Summary field that identifies “triple negative”

patients quickly (code 000) Results of SSFs 1, 2, 15

___ ___ ___ 0 = negativeER PR HER2 1 = positive



SSF17 – CTCs and Method of Detection

• CTC Circulating Tumor Cells Small clusters of tumor cells or individual

tumor cells in blood• Method of detection Type of test that discovered CTCs Immunocytochemical and molecular assays

• Code structure – 3 digits___ ___ _0__Test result Type of test0 Negative 0 RT-PCR1 Positive 1 Immunomagnetic separation2 Borderline 3 Other type

4 Unknown test type Other codes available


SSF18 – DTCs and Method of Detection

• DTC Disseminated Tumor Cells Small clusters of tumor cells or individual

tumor cells in bone marrow• Method of detection Type of test that discovered CTCs Immunohistochemical and molecular assays

• Code structure – 3 digits___ ___ _0__Test result Type of test0 Negative 0 RT-PCR1 Positive 1 Immunhistochemistry2 Borderline 3 Other type

4 Unknown test type Other codes available


SSF19 – Assessment of Positive Ipsilateral Axillary Nodes

• Supplemental information on how number of positive Level I and II nodes determined for SSF3, N category and stage group

• First digit 0 indicates single procedure only• First digit 1 indicates combination of

sentinel node biopsy results and lymph node dissection results


SSF19 – Assessment of Positive Ipsilateral Axillary Nodes

• Codes 000 No positive ipsilateral axillary nodes 010 Clinical assessment (only) positive 020 Positive Fine Needle Aspiration (FNA) only 030 Positive Core biopsy: incisional 040 Positive Core biopsy: excisional 050 Positive Core biopsy: type not specified 100 Positive SLNB, no ALND 110 Positive SLNB, negative ALND 120 Positive SLNB, positive ALND 130 Negative SLNB, positive ALND 140 No SLNB, positive ALND Other codes available

SLNB = sentinel lymph node biopsy(ies)ALND = axillary lymph node dissection



SSF20 – Assessment of Positive Distant Metastases

• Records how information about positive mets in CS Mets at Dx and site-specific Mets at Dx fields was determined

• Code only positive results If Mets at Dx field is 000, SSF20 must be 000

• Codes 000 No positive metastases were identified 010 Clinical assessment 020 Radiography; Imaging (US, CT, MRI, PET) 030 Incisional biopsy; FNA 040 Excisional biopsy or resection with

microscopic confirmation other than bybiopsy


SSF21 – Response to Neoadjuvant Therapy

• Required by COC, SEER• Code physician statement of response to

pre-operative systemic or radiation therapy Do not infer a response based on medical record

• Codes 010 Complete Response (CR) 020 Partial Response (PR) 030 No Response (NR) 988 Not applicable: Information not collected 998 No neoadjuvant therapy 999 Unknown if response


SSF22 – Multigene Signature Method

• Required by COC, SEER• Other names Oncotype Dx, MammaPrint, genomic profiling,

multigene testing/assay• Predicts risk of recurrence for node-

negative patients May also be useful in predicting recurrence for

node-positive patients• Tailors treatment specific to person• Codes (name of test) 010 Oncotype DX 020 Mamma Print 030 Other


Example of an OncotypeDx Report



Example of an MammaPrint Report


SSF23 – Result/Score of MultigeneSignature

• Required by COC, SEER• Record result of test named in SSF22• Codes 001-099 Actual score 100 100+ 200 Low risk of recurrence

(good prognosis) 205 High risk of recurrence

(poor prognosis) Other codes available

Oncotype DX results

MammaPrint results


SSF24 – Paget Disease

• Paget disease of nipple does not always get captured in ICD-O-3 code or stage information

• Codes 000 Paget disease absent/not mentioned 010 Paget disease present 988 Not applicable: Information not collected 999 Unknown or no information


Breast – Related CS Fields

• CS Tumor Size• CS Extension• CS TS/Ext Eval• SSF6 Size of invasive

tumor

• CS Mets at DX• CS Mets Eval• SSF 17-18 CTC, DTC• SSF20 Assess Pos

Distant Mets

• SSF1 ERA• SSF2 PRA • SSF7 BR Score• SSF8-15 HER2 fields

• CS Lymph Nodes• CS Nodes Eval• Reg LN Pos• Reg LN Exam• SSF3 # Pos Ax LN• SSF4 IHC• SSF5 Molecular studies • SSF19 Assess Pos Ax LN

• SSF16 Combination of markers• SSF21 Neoadj Tx Response• SSF22-23 Multigene method/result• SSF24 Paget disease

Breast Case # 1

CSv2 Training Materials Page 1 of 5

HISTORY AND PHYSICAL

Date: March 01, 2010

CHIEF COMPLAINT: Abnormal mammogram right breast HISTORY OF THE PRESENT ILLNESS: The patient is a 64 year old Caucasian female who had a mammogram and ultrasound performed, which revealed a suspicious spiculated lesion in the right breast at the 3 o’clock position. The patient’s last mammogram prior to the most recent was, I believe, a couple of years ago. The patient herself denies any symptoms referable to the breast whatsoever. The patient has a past history of having a mastectomy performed in 1998 for breast cancer. She did not receive any adjuvant treatment and I presume this is a lymph node negative malignancy, although I do not have any final pathology on this. She was administered five years of hormonal treatment. The patient now comes in for further recommendations. IMPRESSION: Indeterminate lesion, right breast. Rule our malignancy. PLAN: The patient will undergo an ultrasound-guided core biopsy today and further recommendations will be based upon the results of the biopsy. I will see her March 6th for biopsy result and discuss further recommendations at that time. HISTORY AND PHYSICAL #2 Date: April 24, 2010 History of Present Illness: The patient is here for recheck after having a re-excision of the lumpectomy margins on April 13th. The patient is very disappointed that we were not able to proceed with the MammoSite catheter radiation, but I do not feel that there was enough space between the skin surface and the balloon, and also was very concerned with her wound healing at the time of the repeat lumpectomy. Her Oncotype DX came back with a score of 34 putting her at high risk, that is, 24% at 10 years. She has started radiation therapy today. She will be referred for an oncology consult.

PROGRESS REPORT

Date: March 15, 2010 The patient is a very nice 64 year old Caucasian female who has a history of carcinoma of the left breast treated with mastectomy in the past. The patient presented with a new lesion in the right breast on imaging. This was biopsied and proven to be consistent with a carcinoma. This was an ER and PR positive carcinoma about 1.4 centimeters in size. The patient is to proceed with breast conservation at her request. We will place a temporary MammoSite balloon catheter and radiate. If things go well with the MammoSite, she will receive partial breast radiation. We will get the patient scheduled at the earliest time possible.

Breast Case # 1


RADIOLOGY REPORT Procedure: Diagnostic Mammography Unilateral Digital Date: February 13, 2010 Reason for Exam: History of Breast Cancer BC Mammo Diagnost Unilat Digital: UNILATERAL RIGHT DIGITAL DIAGNOSTIC MAMMOGRAM WITH MEDIOLATERAL SPOT COMPRESSION. COMPARISON IS MADE TO MAMMOGRAM DATED 2/16/2007. The tissue of the right breast is predominantly fatty. There is a 2.0 cm irregular mass with a spiculated margin in the right breast at 3 o’clock anterior depth. The mass is confirmed on additional views. No other significant masses or calcifications are seen in the breast. IMPRESSION: HIGHLY SUGGESTIVE OF MALIGNANCY The 2.0 cm irregular mass in the right breast likely represents carcinoma and is indeterminate. An ultrasound and biopsy are recommended. Procedure: Right Breast Ultrasound. Mass in breast on mammogram. CLINICAL INFORMATION: 64 year old female with spiculated mass on diagnostic mammogram. Transverse and longitudinal real time imaging through the right breast at the 3 o’clock position shows a 1.1 x 1.1 x 1.4 cm irregular hypoechoic mass corresponding to the mammographic abnormality. This is highly suspicious for a cancer. The borders are irregular and there is a posterior shadowing. No additional masses are seen in the area. IMPRESSION: Suspicious irregular hypoechoic mass in the right breast at 3 o’clock position corresponding to the mammographic abnormality. This area should be biopsied to confirm a histologic diagnosis. BIRADS IV- Suspicious abnormality – patient will be scheduled for a needle core biopsy. US CORE BIOPSY DATE: MARCH 01, 2010 FINAL REPORT: ULTRASOUND GUIDED CORE BIOPSY RIGHT BREAST: This procedure was performed for the 1.4 cm mass located in the middle depth at 3 o’clock as described on the previous ultrasound. The mass was localized and a small incision was made in the breast. An 18 gauge biopsy needle was placed into the mass guided by ultrasound. Once the needle was in the mass, three core specimens were obtained at different sites within the mass using guided by ultrasound. Post procedure images of the breast show partial removal of the mass. Awaiting pathology results. A surgical consult is recommended.

Breast Case # 1


OPERATIVE REPORT

PROCEDURE #1 Date: 03/23/2010 PREOPERATIVE DIAGNOSIS: Carcinoma of the right breast. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE:

1. Ultrasound guided needle localization for right lumpectomy 2. Right axillary sentinel lymph node localization and biopsy

FINDINGS OF OPERATION: Negative sentinel nodes on frozen section evaluation. These nodes were hot with counts about 164 and were stained blue. SPECIMEN:

1. Sentinel nodes right axilla. 2. Right lumpectomy with a long suture margin to the lateral margin, short suture marking

to superior margin. COMPLICATIONS: None.

PROCEDURE #2

Date: 04/12/2010 Operation: Reoperative Segmental Resection Specimen: Inferior and anterior margin with a suture marking of new margin. Brief History: 64 Caucasian female s/p sentinel node biopsy few weeks ago. Anterior and inferior margins were close, here for re-excision. Patient interested in Mammosite catheter radiation. Planned as part of procedure. Procedure: Lumpectomy performed by excising the anterior and inferior margin sharply with electrocautery. Unfortunately, the superficial margin that is the anterior margins was not anywhere near even 7mm. I didn’t think it wise to place the Mamma site balloon catheter for fear of having radiation close to the skin. Wound irrigated, layers closed. Patient taken to recovery room in stable condition.

Breast Case # 1


PATHOLOGY REPORT

REPORT #1 Date Specimen Collected: 3/01/2010 Date Specimen Reported: 03/02/2010 S07-2378 Clinical History: History of left mastectomy, mass right breast 3 o’clock FINAL DIAGNOSIS: RIGHT BREAST, 3’OCLOCK, NEEDLE CORE BIOPSY: INFILTRATING MAMMARY CARCINOMA, INTERMEDIATE GRADE, NOTTINGHAM SCORE 3+2+1=6. NO MICROCALCIFICATIONS ENCOUNTED.

Gross Description: Received in formalin labeled Breast Case 1 and “right breast biopsy” are multiple cores of fibrofatty tissue from minute to 1.5 x 0.1 cm which are filtered and submitted in total in cassette A1. Microscopic Description: Microscopic examination performed. E-cadherin stains show strong membrane positivity in tumor cells. HORMONE RECEPTOR STATUS: ESTROGEN RECEPTOR (IHC): POSITIVE. PROGESTERONE RECEPTOR (IHC): NEGATIVE. HER-2/NEU ONCOGEN (FISH): PENDING, SEE ADDENDUM REPORT. ADDENDUM DIAGNOSIS: RIGHT BREAST, HER-2/NEU (FISH): NOT AMPLIFIED: The HER-2/cen-17 ratio = 1.3 IMPRESSION: This lady would appear to have a T1 primary breast carcinoma, ER positive, and is interested in breast conservation. She was not interested in reconstructive surgery to her left breast at this particular juncture. Following a discussion of local management options, she wished to consider the option of partial breast radiotherapy. She appears to be a good candidate for postoperative hormonal adjuvant therapy and may be a candidate for systemic chemotherapy, depending on the remainder of her clinical features. Her surgical management will likely consist of a wide local excision and sentinel lymph node biopsy. MammoSite catheter insertion could be entertained if appropriate at that particular time. Should her sentinel lymph node biopsy prove positive, an axillary dissection would likely be necessary. I will plan to arrange for Radiation Oncology consultation next week and I will plan to see her back approximately two weeks postoperative to make additional management plans. REPORT #2 Date Specimen Collected: 03/23/2010 S07-3272 Date Specimen Reported: 03/25/2010 Source: A. Sentinel node right breast. B. Right Lumpectomy FINAL DIAGNOSIS A. Lymph Node, Right Axilla, Sentinel nodes (6): Negative for malignancy. B. Right Breast Lumpectomy: Infiltrating mammary carcinoma (1.5 x 1.5 x 0.9 cm.). Intermediate grade. Nottingham score 3+2+1=6

Breast Case # 1


Ductal carcinoma in situ (High grade, comedo pattern) present. DCIS extends to anterior margin. Nearest margin (anterior) less than 1 mm. No vascular/lymphatic invasion. Hormone Receptor Status (See 07-2378): Estrogen Receptor (IHC): Positive. Progesterone Receptor (IHC): Negative. HER-2/neu (FISH): negative TNM Stage: T1c N0 MX Gross Description: A. Received fresh “sentinel node right”, 2.5 cm adipose tissue with six lymph nodes identified from 0.5 x 0.2 x. 0.2 cm to 1.7 cm. B. “Right Lumpectomy” is 5.5 x 5 x 2.7 cm ovoid fibrofatty breast tissue. There is a 1.5 x 1.5 x 0.9 cm firm tumor nodule focally approaching the anterior margin. Other margins clear. Microscopic Description: Microscopic examination performed. Breast: Complete Excision MACROSCOPIC: Specimen Type: Excision Lymph Node Sampling: Sentinel lymph node(s) only Specimen Size: 5.5 x 5 x 2.7 Laterality: Right Tumor Site: Not Specified MICROSCOPIC: Size of Invasive Component: 1.5 x 1.5 x 0.9 cm Histological Type: Ductal carcinoma in situ, Invasive ductal carcinoma Histological Grade: 3+2+1=6 Grade II TNM Staging: T1c Tumor more than 1.0 cm but not more than 2.0 cm in greatest dimension

N0 No Regional Lymph Node mets (ie, none greater than 0.2 mm,), no additional examination for isolated tumor cells

MX Cannot be assessed Margins: Margins(s) involved by invasive carcinoma. Anterior margin. Margins(s) involved by DCIS. Anterior margin. Venous/Lymphatic (Large/Small Vessel) Invasion: Absent Microcalcifications: Not identified Hormone Receptor Study: Ordered

CSv2 ANSWER WORKSHEET

CSv2 Education and Training Page 1 of 1

FIELD# FIELD NAME CODE AND RATIONALE/DOCUMENTATION 1 Patient Name -

CANCER IDENTIFICATION 2 Primary Site 3 Histology 4 Behavior 5 Grade 6 Grade system type 7 Grade system value 8 Lymph-vascular invasion

STAGE OF DISEASE AT DIAGNOSIS 9 CS Mets at Dx - Bone

10 CS Mets at Dx - Lung 11 CS Mets at Dx - Liver 12 CS Mets at DX - Brain

COLLABORATIVE STAGING 13 CS Tumor Size 14 CS Extension 15 CS Tumor Size/Ext Eval 16 CS Lymph Nodes 17 CS Lymph Nodes Eval 18 Regional Nodes Positive 19 Regional Nodes Examined 20 CS Mets at Dx 21 CS Mets Eval 22 CS Site-Specific Factor 1 23 CS Site-Specific Factor 2 24 CS Site-Specific Factor 3 25 CS Site-Specific Factor 4 26 CS Site-Specific Factor 5 27 CS Site-Specific Factor 6 28 CS Site-Specific Factor 7 29 CS Site-Specific Factor 8 30 CS Site-Specific Factor 9 31 CS Site-Specific Factor 10 32 CS Site-Specific Factor 11 33 CS Site-Specific Factor 12 34 CS Site-Specific Factor 13 35 CS Site-Specific Factor 14 36 CS Site-Specific Factor 15 37 CS Site-Specific Factor 16 38 CS Site-Specific Factor 17 39 CS Site-Specific Factor 18 40 CS Site-Specific Factor 19 41 CS Site-Specific Factor 20 42 CS Site-Specific Factor 21 43 CS Site-Specific Factor 22 44 CS Site-Specific Factor 23 45 CS Site-Specific Factor 24 46 CS Site-Specific Factor 25

BREAST SCHEMA CSv2 1 03/10/2010

CS Tumor Size

Note 1: See part I for information on timing and rules for coding this field.

Note 2: Code the specific tumor size as documented in the medical record. If the ONLY information regarding tumor size is the physician's statement of the "T" category, assign code 990 (T1mi), 991 (T1b), 992 (T1 or T1c), or 995 (T2). If the physician's statement of the "T" category is T1a, NOS with no documentation of tumor size, code tumor size as 005. If the physician's statement of the "T" category is T3, NOS with no documentation of tumor size OR a statement only specifying that the tumor size is greater than 5 cm, code tumor size as 051.

Note 3: For tumor size, some breast cancers cannot be sized pathologically.

Note 4: When coding pathologic size, code the measurement of the invasive component. For example, if there is a large in situ component (e.g., 4 cm) and a small invasive component see Site-Specific Factor 6 to code more information about the reported tumor size. If the size of invasive component is not given, code the size of the entire tumor and record what it represents in Site-Specific Factor 6.

Note 5: Microinvasion is the extension of cancer cells beyond the basement membrane into the adjacent tissues with no focus more than 0.1 cm in greatest dimension. When there are multiple foci of microinvasion, the size of only the largest focus is used to classify the microinvasion. (Do not use the sum of all the individual foci.)

Code Description

000 No mass/tumor found

001-988 001 - 988 millimeters (code exact size in millimeters)

989 989 millimeters or larger

990 Microinvasion; microscopic focus or foci only, no size given; described as less than 1 mm Stated as T1mi, NOS with no other information on size

991 Described as "less than 1 cm" Stated as T1b, NOS with no other information on size

992 Described as "less than 2 cm," or "greater than 1 cm," or "between 1 cm and 2 cm" Stated as T1, NOS or T1c, NOS with no other information on size

993 Described as "less than 3 cm," or "greater than 2 cm," or "between 2 cm and 3 cm"

994 Described as "less than 4 cm," or "greater than 3 cm," or "between 3 cm and 4 cm"

995 Described as "less than 5 cm," or "greater than 4 cm," or "between 4 cm and 5 cm" Stated as T2 with no other information on size

996 Mammographic/xerographic diagnosis only, no size given; clinically not palpable

997 Paget Disease of nipple with no demonstrable tumor

998 Diffuse

999 Unknown; size not stated Not documented in patient record

CS Extension

Note 1: See Part 1 for what information this field is based on including timing rules.

Note 2: Changes such as dimpling of the skin, tethering, and nipple retraction are caused by tension on Cooper's ligament(s), not by actual skin involvement. They do not alter the classification.

Note 3: Consider adherence, attachment, fixation, induration, and thickening as clinical evidence of extension to skin or subcutaneous tissue, code '200'.

Note 4: Consider "fixation, NOS" as involvement of pectoralis muscle, code '300'.

Note 5: If extension code is 000, then Behavior code must be 2; if extension code is 050 or 070, then behavior code may be 2 or 3; and, if extension code is 100, then behavior code must be 3.

Note 6: Inflammatory Carcinoma. AJCC includes the following text in the 7th edition Staging Manual, "Inflammatory carcinoma is a clinicopathologic entity characterized by diffuse erythema and edema (peau d'orange) of the breast, often without an underlying palpable mass. These clinical findings should involve the


majority of the skin of the breast. Classically, the skin changes arise quickly in the affected breast. Thus the term of inflammatory carcinoma should not be applied to a patient with neglected locally advanced cancer of the breast presenting late in the course of her disease. On imaging, there may be a detectable mass and characteristic thickening of the skin over the breast. This clinical presentation is due to tumor emboli within dermal lymphatics, which may or may not be apparent on skin biopsy. The tumor of inflammatory carcinoma is classified T4d. It is important to remember that inflammatory carcinoma is primarily a clinical diagnosis. Involvement of the dermal lymphatics alone does not indicate inflammatory carcinoma in the absence of clinical findings. In addition to the clinical picture, however, a biopsy is still necessary to demonstrate cancer either within the dermal lymphatics or in the breast parenchyma itself."

Note 7: For Collaborative Staging, the abstractor should record a stated diagnosis of inflammatory carcinoma, and also record any clinical statement of the character and extent of skin involvement in the text area. Code 600 should be used if there is a stated diagnosis of inflammatory carcinoma and a clinical description of the skin involvement is less than one-third (33%) of the skin of the breast. Code 725 should be used if there is a stated diagnosis of inflammatory carcinoma and a clinical description of the skin involvement is greater than or equal to one-third (33%) and less than or equal to one half (50%) of the skin of the breast. Code 730 should be used if there is a stated diagnosis of inflammatory carcinoma and a clinical description of the skin involvement in more than 50% (majority or diffuse) of the skin of the breast. Cases with a stated diagnosis of inflammatory carcinoma but no such clinical description should be coded 750. A clinical description of inflammation, erythema, edema, peau d'orange, etc. without a stated diagnosis of inflammatory carcinoma should be coded 510, 514, 610, or 620, depending on described extent of the condition.

Code Description TNM 7 Map

TNM 6 Map

SS77 Map

SS2000 Map

000 In situ: noninfiltrating; intraepithelial Intraductal WITHOUT infiltration Lobular neoplasia

Tis Tis IS IS

050 Paget Disease of nipple (WITHOUT underlying tumor)

Tis Tis ** **

070 Paget Disease of nipple (WITHOUT underlying invasive carcinoma pathologically)

Tis Tis ** **

100 Confined to breast tissue and fat including nipple and/or areola Localized, NOS

^ * L L

170 Stated as T1 [NOS] with no other information on extension or size

T1NOS T1NOS RE RE


T2 T2 RE RE


T3 T3 RE RE

200

Invasion of subcutaneous tissue Local infiltration of dermal lymphatics adjacent to primary tumor involving skin by direct extension Skin infiltration of primary breast including skin of nipple and/or areola

^ * RE RE

300

Attached or fixation to pectoral muscle(s) or underlying tissue Deep fixation Invasion of (or fixation to) pectoral fascia or muscle

^ * RE RE

380 Stated as T4 [NOS] with no other information on extension

T4NOS T4NOS RE RE

390 Stated as T4a with no other information on extension

T4a T4a RE RE

400

Invasion of (or fixation to): Chest wall Intercostal or serratus anterior muscle(s) Rib(s)

T4a T4a RE RE


510

OBSOLETE DATA RETAINED V0200 Extensive skin involvement, including: Satellite nodule(s) in skin of primary breast Ulceration of skin of breast Any of the following conditions described as involving not more than 50% of the breast, or amount or percent of involvement not stated: Edema of skin En cuirasse Erythema Inflammation of skin Peau d'orange ("pigskin")

ERROR T4b RE RE

512 Extensive skin involvement, including: Satellite nodule(s) in skin of primary breast Ulceration of skin of breast

T4b T4b RE RE

514

Any of the following conditions described as involving less than one-third (33%) of the breast WITHOUT a stated diagnosis of inflammatory carcinoma WITH or WITHOUT dermal lymphatic infiltration Edema of skin En cuirasse Erythema Inflammation of skin Peau d'orange ("pigskin")

T4b T4b RE RE

516 (514) + (512) T4b T4b RE RE

518

Any of the following conditions described as involving one third (33%) or more but less than or equal to half (50%) of the breast WITHOUT a stated diagnosis of inflammatory carcinoma WITH or WITHOUT dermal lymphatic infiltration: Edema of skin En cuirasse Erythema Inflammation of skin Peau d'orange ("pigskin")

T4b T4b RE RE

519 (518) + (512) T4b T4b RE RE

520

Any of the following conditions described as involving more than 50% of the breast WITHOUT a stated diagnosis of inflammatory carcinoma WITH or WITHOUT dermal lymphatic infiltration: Edema of skin En cuirasse Erythema Inflammation of skin Peau d'orange ("pigskin")

T4b T4b RE RE

575 (520) + (512) T4b T4b RE RE

580

Any of the following conditions with amount or percent of breast involvement not stated and WITHOUT a stated diagnosis of inflammatory carcinoma WITH or WITHOUT dermal lymphatic infiltration: Edema of skin En cuirasse Erythema Inflammation of skin Peau d'orange ("pigskin")

T4b T4b RE RE

585 (580) + (512) T4b T4b RE RE


590 Stated as T4b with no other information on extension

T4b T4b RE RE

600

Diagnosis of inflammatory carcinoma WITH a clinical description of inflammation, erythema, edema, peau d'orange, etc., involving less than one-third (33%) of the skin of the breast, WITH or WITHOUT dermal lymphatic infiltration

T4b T4d RE RE

610 OBSOLETE DATA RETAINED V0200 (400) + (510)

ERROR T4c RE RE

612 Any of (512-514) + (400) T4c T4b RE RE

615 Any of (520-585) + (400) T4c T4b RE RE


ERROR T4c RE RE

680 Stated as T4c with no other information on extension

T4c T4c RE RE

710

OBSOLETE DATA RETAINED V0200 Diagnosis of inflammatory carcinoma WITH a clinical description of inflammation, erythema, edema, peau d'orange, etc., involving not more than 50% of the skin of the breast, WITH or WITHOUT dermal lymphatic infiltration Inflammatory carcinoma, NOS

ERROR T4d RE RE

715

Diagnosis of inflammatory carcinoma WITH a clinical description of inflammation, erythema, edema, peau d'orange, etc., involving not more than one-third (33%) of the skin of the breast,WITH or WITHOUT dermal lymphatic infiltration

T4b T4d RE RE

720

OBSOLETE DATA CONVERTED V0102 Diagnosis of inflammatory WITH a clinical diagnosis of inflammation, erythema, edema, peau d'orange, etc., of not more than 50% of the breast, WITH or WITHOUT dermal lymphatic infiltration Inflammatory carcinoma, NOS NOTE: Code 720 has been combined with code 710. Any cases coded to 720 should be re-coded to code 710.

ERROR ERROR ERROR ERROR

725

Diagnosis of inflammatory carcinoma WITH a clinical description of inflammation, erythema, edema, peau d'orange, etc., involving one-third (33%) or more but less than or equal to half (50%) of the skin of the breast, WITH or WITHOUT dermal lymphatic infiltration

T4d T4d RE RE

730

Diagnosis of inflammatory carcinoma WITH a clinical description of inflammation, erythema, edema, peau d'orange, etc., involving more than 50% of the skin of the breast, WITH or WITHOUT dermal lymphatic infiltration

T4d T4d RE RE


750

Diagnosis of inflammatory carcinoma WITH a clinical description of inflammation, erythema, edema, peau d'orange, etc., but percent of involvement not stated, WITH or WITHOUT dermal lymphatic infiltration. If percentage is known, code to 600, 725, or 730. Diagnosis of inflammatory carcinoma WITHOUT a clinical description of inflammation, erythema, edema, peau d'orange, etc., WITH or WITHOUT dermal lymphatic infiltration Inflammatory carcinoma, NOS

T4d T4d RE RE

780 Stated as T4d with no other information on extension

T4d T4d RE RE

950 No evidence of primary tumor T0 T0 U U

999 Unknown extension Primary tumor cannot be assessed Not documented in patient record

TX TX U U

For Extension codes 100, 200, and 300 ONLY, the T category is assigned based on value of CS Tumor Size as shown in the Extension Size Table for this site.

^ For Extension codes 100, 200, and 300 ONLY, the T category is assigned based on value of CS Tumor Size as shown in the Extension Size Table for this site.

** For codes 050 and 070 ONLY, summary stage is assigned based on the value of Behavior Code ICD-O-3 as shown in the Extension Behavior Table for this site.

CS Tumor Size/Ext Eval Code Description Staging

Basis

0 Does not meet criteria for AJCC pathologic staging: No surgical resection done. Evaluation based on physical examination, imaging examination, or other non-invasive clinical evidence. No autopsy evidence used.

c

1 Does not meet criteria for AJCC pathologic staging: No surgical resection done. Evaluation based on endoscopic examination, diagnostic biopsy, including fine needle aspiration biopsy, or other invasive techniques, including surgical observation without biopsy. No autopsy evidence used.

c

2 Meets criteria for AJCC pathologic staging: No surgical resection done, but evidence derived from autopsy (tumor was suspected or diagnosed prior to autopsy)

p


3 Either criteria meets AJCC pathologic staging: Surgical resection performed WITHOUT pre-surgical systemic treatment or radiation OR surgical resection performed, unknown if pre-surgical systemic treatment or radiation performed AND Evaluation based on evidence acquired before treatment, supplemented or modified by the additional evidence acquired during and from surgery, particularly from pathologic examination of the resected specimen. No surgical resection done. Evaluation based on positive biopsy of highest T classification.

p

5 Does not meet criteria for AJCC y-pathologic (yp) staging: Surgical resection performed AFTER neoadjuvant therapy and tumor size/extension based on clinical evidence, unless the pathologic evidence at surgery (AFTER neoadjuvant) is more extensive (see code 6).

c

6 Meets criteria for AJCC y-pathologic (yp) staging: Surgical resection performed AFTER neoadjuvant therapy AND tumor size/extension based on pathologic evidence, because pathologic evidence at surgery is more extensive than clinical evidence before treatment.

yp

8 Meets criteria for autopsy (a) staging: Evidence from autopsy only (tumor was unsuspected or undiagnosed prior to autopsy)

a

9 Unknown if surgical resection done Not assessed; cannot be assessed Unknown if assessed Not documented in patient record

c

CS Lymph Nodes

Note 1: Code only regional nodes and nodes, NOS, in this field. Distant nodes such as cervical (excluding supraclavicular) or contralateral axillary are coded in the field Mets at DX.

Note 2: If the pathology report indicates that nodes are positive but size of the metastases is not stated, assume the metastases are greater than 0.2 mm and code the lymph nodes as positive in this field. Use code 600 in the absence of other information about regional nodes.

Note 3: In a physical exam if palpable nodes are not described as fixed, assume that nodes are movable.

Note 4: Codes 130-600 are used for positive axillary nodes. Axillary lymph nodes refer to level I and level II ipsilateral axillary lymph nodes and ipsilateral intramammary nodes only. It does not include ipsilateral level III axillary lymph nodes which are also known as infraclavicular or apical nodes and are coded in 750 or higher. Axillary does not include internal mammary or ipsilateral supraclavicular lymph nodes.

Note 5: If no lymph nodes were removed for evaluation (Reg Nodes Eval code 0 or 1) or if it is unknown if lymph nodes were removed (Reg Nodes Eval code 9), or if neoadjuvant therapy was given and clinical lymph node involvement is AS extensive or MORE extensive than pathologic lymph node involvement (Reg Nodes Eval code 5), then use only the following codes for clinical evaluation of regional nodes: 000, 255, 260, 290, 510, 600, 740, 745, 750, 760, 780, 790,800, and 999. Do not use codes 290 and 510 when Reg Nodes Eval 2, 3, 6, or 8.

Note 6: Isolated tumor cells (ITC) are defined as single tumor cells or small clusters not greater than 0.2 mm, usually detected only by immunohistochemical (IHC) or molecular methods but which may be verified on H and E stains. ITCs do not usually show evidence of malignant activity (e.g., proliferation or stromal reaction). Lymph nodes with ITCs only are not considered positive lymph nodes. If the record only states N0(i+), code to 000 and see CS SSF-4.


Note 7: Unless nodes are stated to be fixed or matted, assume that they are moveable.


TNM 6 Map

SS77 Map

SS2000 Map

000

None; no regional lymph node involvement, or ITCs detected by immunohistochemistry or molecular methods ONLY. (See Note 6 and Site-specific Factors 4 and 5.)

^ * NONE NONE

050 None; no regional lymph node(s) but with (ITCs) detected on routine H and E stains. (See Note 6)

N0(i+) N0(i+) NONE NONE

130

Axillary lymph node(s), ipsilateral, micrometastasis ONLY detected by immunohistochemical (IHC) means ONLY (at least one micrometastasis greater than 0.2 mm or more than 200 cells and all micrometastases less than or equal to 2 mm)

N1mi N1mi RN RN

150

Axillary lymph node(s), ipsilateral, micrometastasis ONLY detected or verified on H&E (at least one micrometastasis greater than 0.2 mm (or more than 200 cells) and all micrometastases less than or equal to 2 mm) Micrometastasis, NOS

N1mi N1mi RN RN

250 Movable axillary lymph node(s), ipsilateral, positive with more than micrometastasis (i.e., at least one metastasis greater than 2 mm) (See Note 7.)

^^ ** RN RN

255 Clinically movable axillary lymph node(s), ipsilateral, positive (clinical assessment because of neoadjuvant therapy or no pathology)(See Note 7.)

N1 N1 RN RN

260 Stated as N1, NOS N1 ** RN RN

280 OBSOLETE DATA RETAINED V0200- Stated as N2, NOS

ERROR ** RN RN

290 Clinically stated only as N2, NOS (clinical assessment because of neoadjuvant therapy or no pathology)

N2NOS ** RN RN

300 Pathologically stated only as N2 NOS; no information on which nodes were involved

^^ ** RN RN

500

OBSOLETE DATA RETAINED V0200- Fixed/matted ipsilateral axillary nodes, positive with more than micrometastasis (i.e., at least one metastasis greater than 2 mm) Fixed/matted ipsilateral axillary nodes, NOS

ERROR ** RN RN

510

Fixed/matted ipsilateral axillary nodes clinically (clinical assessment because of neoadjuvant therapy or no pathology) Stated clinically as N2a, NOS (clinical assessment because of neoadjuvant therapy or no pathology)

^^ ** RN RN

520 Fixed/matted ipsilateral axillary nodes clinically with pathologic involvement of lymph nodes at least one metastasis greater than 2mm

^^ ** RN RN

600 Axillary/regional lymph node(s), NOS Lymph nodes NOS

^^ ** RN RN

710

Internal mammary node(s), ipsilateral, positive on sentinel nodes but not clinically apparent (no positive imaging or clinical exam) WITHOUT axillary lymph node(s), ispilateral

N1b N1b RN RN


720

Internal mammary node(s), ipsilateral, positive on sentinel nodes but not clinically apparent (no positive imaging or clinical exam) WITH axillary lymph node(s), ispilateral

^^ ** RN RN

730

Internal mammary node(s), ipsilateral, positive on sentinel nodes but not clinically apparent (no positive imaging or clinical exam) UNKNOWN if positive axillary lymph node(s), ispilateral

N1b N1b RN RN

740 Internal mammary node(s), ipsilateral, clinically apparent (on imaging or clinical exam) WITHOUT axillary lymph node(s), ispilateral

N2b N2b RN RN

745

Internal mammary node(s), ipsilateral, clinically apparent (on imaging or clinical exam) and UNKNOWN if positive axillary lymph node(s), ispilateral

N2b N2b RN RN

750 Infraclavicular lymph node(s)(subclavicular) (level III axillary nodes) (apical), ispilateral

N3a N3a D RN

760

Internal mammary node(s), ipsilateral, clinically apparent (on imaging or clinical exam) WITH axillary lymph node(s), ipsilateral, codes 150 to 600 WITH or WITHOUT infraclavicular (level III axillary nodes) (apical) lymph nodes

N3b N3b RN RN

770

OBSOLETE DATA RETAINED V0200 Internal mammary node(s), ipsilateral, clinically apparent (on imaging or clinical exam) UNKNOWN if positive axillary lymph node(s), ispilateral

ERROR N2b RN RN


ERROR N3a D RN

790 Stated as N3, NOS N3NOS N3NOS RN RN

800 Supraclavicular node(s), ispilateral N3c N3c D D

999 Unknown; not stated Regional lymph node(s) cannot be assessed Not documented in patient record

NX NX U U

For code 000 ONLY, the N category is assigned based on the coding of Site-Specific Factors 4 and 5 using the IHC MOL Table for this site.

^ For code 000 ONLY, the N category is assigned based on the coding of Site-Specific Factors 4 and 5 using the IHC MOL Table for this site.

** For codes 250, 260, 280, 290, 300, 500, 510, 520, 600, and 720 ONLY, the N category is assigned based on the values of Site-Specific Factor 3 (Number of Positive Ipsilateral Axillary Lymph Nodes) and CS Reg Nodes Eval. If the Eval code is 2 (p), 3 (p), 6 (y), or 8 (a), the N category is determined by reference to the Lymph Nodes Pathologic Evaluation Table. If the Eval code is 0 (c), 1(c), 5(c), or 9 (c), the N category is determined by reference to the Lymph Nodes Clinical Evaluation Table. If the Eval field is not coded, the N category is determined by reference to the Lymph Nodes Positive Axillary Node Table.

^^ For codes 250, 260, 280, 290, 300, 500, 510, 520, 600, and 720 ONLY, the N category is assigned based on the values of Site-Specific Factor 3 (Number of Positive Ipsilateral Axillary Lymph Nodes) and CS Reg Nodes Eval. If the Eval code is 2 (p), 3 (p), 6 (y), or 8 (a), the N category is determined by reference to the Lymph Nodes Pathologic Evaluation Table. If the Eval code is 0 (c), 1(c), 5(c), or 9 (c), the N category is determined by reference to the Lymph Nodes Clinical Evaluation Table. If the Eval field is not coded, the N category is determined by reference to the Lymph Nodes Positive Axillary Node Table.


CS Lymph Nodes Eval

Note 1: This field is used primarily to derive the staging basis for the N category in the TNM system. It records how the code for the item "CS Lymph Nodes" was determined based on the diagnostic methods employed and their intent.

Note 2: In the 7th edition of the AJCC manual, the clinical and pathologic classification rules for the N category were changed to reflect current medical practice. The N is designated as clinical or pathologic based on the intent (workup versus treatment) matching with the assessment of the T classification. When the intent is workup, the staging basis is clinical, and when the intent is treatment, the staging basis is pathologic. A. Microscopic assessment including biopsy of regional nodes or sentinel nodes if being performed as part of the workup to choose the treatment plan, is therefore part of the clinical staging. When it is part of the workup, the T category is clinical, and there has not been a resection of the primary site adequate for pathologic T classification (which would be part of the treatment). B. Microscopic assessment of regional nodes if being performed as part of the treatment is therefore part of the pathologic staging. When it is part of the treatment, the T category is pathologic, and there has been a resection of the primary site adequate for pathologic T classification (all part of the treatment).

Note 3: Microscopic assessment of the highest N category is always pathologic (code 3).

Note 4: If lymph node dissection is not performed after neoadjuvant therapy, use code 0 or 1.

Note 5: Only codes 5 and 6 are used if the node assessment is performed after neoadjuvant therapy.

Code Description Staging Basis

0

Does not meet criteria for AJCC pathologic staging: No regional lymph nodes removed for examination. Evidence based on physical examination, imaging examination, or other non-invasive clinical evidence. No autopsy evidence used.

c

1

Does not meet criteria for AJCC pathologic staging based on at least one of the following criteria: No regional lymph nodes removed for examination. Evidence based on endoscopic examination, or other invasive techniques including surgical observation, without biopsy. No autopsy evidence used. OR Fine needle aspiration, incisional core needle biopsy, or excisional biopsy of regional lymph nodes or sentinel nodes as part of the diagnostic workup, WITHOUT removal of the primary site adequate for pathologic T classification (treatment).

c

2

Meets criteria for AJCC pathologic staging: No regional lymph nodes removed for examination, but evidence derived from autopsy (tumor was suspected or diagnosed prior to autopsy).

p

3

Meets criteria for AJCC pathologic staging based on at least one of the following criteria: Any microscopic assessment of regional nodes (including FNA, incisional core needle bx, excisional bx, sentinel node bx or node resection), WITH removal of the primary site adequate for pathologic T classification (treatment) or biopsy assessment of the highest T category. OR Any microscopic assessment of a regional node in the highest N category, regardless of the T category information.

p

5

Does not meet criteria for AJCC y-pathologic (yp) staging: Regional lymph nodes removed for examination AFTER neoadjuvant therapy AND lymph node evaluation based on clinical evidence, unless the pathologic evidence at surgery (AFTER neoadjuvant) is more extensive (see code 6).

c


6

Meets criteria for AJCC y-pathologic (yp) staging: Regional lymph nodes removed for examination AFTER neoadjuvant therapy AND lymph node evaluation based on pathologic evidence, because the pathologic evidence at surgery is more extensive than clinical evidence before treatment.

yp

8 Meets criteria for AJCC autopsy (a) staging: Evidence from autopsy; tumor was unsuspected or undiagnosed prior to autopsy.

a

9

Unknown if lymph nodes removed for examination Not assessed; cannot be assessed Unknown if assessed Not documented in patient record

c

Reg LN Pos

Note 1: Record this field even if there has been preoperative treatment.

Note 2: Lymph nodes with only isolated tumor cells (ITCs) are NOT counted as positive lymph nodes. Only lymph nodes with metastases greater than 0.2mm (micrometastases or larger) should be counted as positive. If the pathology report indicates that nodes are positive but size of the metastases is not stated, assume the metastases are > 0.2mm and code the lymph nodes as positive in this field.

Note 3: Record all positive regional lymph nodes in this field. Record the number of positive ipsilateral regional level I-II axillary nodes separately in the appropriate Site-Specific Factor field.

Code Description

00 All nodes examined negative.

01-89 1 - 89 nodes positive (code exact number of nodes positive)

90 90 or more nodes positive

95 Positive aspiration or core biopsy of lymph node(s)

97 Positive nodes - number unspecified

98 No nodes examined

99 Unknown if nodes are positive; not applicable Not documented in patient record

Reg LN Exam Code Description


01-89 1 - 89 nodes examined (code exact number of regional lymph nodes examined)

90 90 or more nodes examined

95 No regional nodes removed, but aspiration or core biopsy of regional nodes performed

96 Regional lymph node removal documented as sampling and number of nodes unknown/not stated

97 Regional lymph node removal documented as dissection and number of nodes unknown/not stated

98 Regional lymph nodes surgically removed but number of lymph nodes unknown/not stated and not documented as sampling or dissection; nodes examined, but number unknown

99 Unknown if nodes were examined; not applicable or negative Not documented in patient record


CS Mets at DX

Note 1: Do not code involvement of supraclavicular (transverse cervical) lymph nodes in CS Mets at DX (see CS Lymph Nodes).

Note 2: Cases in which there are no distant metastasis as determined by clinical and/or radiographic methods are designated cM0 (use code 00), and cases in which one or more distant metastases are identified by clinical and/or radiographic methods are designated cM1. A case is classified as clinically free of metastases (cM0) unless there is documented evidence of metastases by clinical means or by biopsy of a metastatic site (pathologic).


TNM 6 Map

SS77 Map

SS2000 Map

00 No; none M0 M0 NONE NONE

05

No clinical or radiographic evidence of distant metastasis, but deposits of molecularly or microscopically detected tumor cells in circulating blood, bone marrow or other non-regional nodal tissue that are 0.2mm or less in a patient without symptoms or signs of metastases.

M0(i+) M0 NONE NONE

10

Distant lymph node(s) Cervical, NOS Contralateral/bilateral axillary and/or internal mammary Other than above Distant lymph node(s), NOS

M1 M1 D D

40 Distant metastases except distant lymph node(s) (code 10) Carcinomatosis

M1 M1 D D

42

Further contiguous extension: Skin over: Axilla Contralateral (opposite) breast Sternum Upper abdomen

M1 M1 D D

44

Metastasis: Adrenal (suprarenal) gland Bone, other than adjacent rib Contralateral (opposite) breast - if stated as metastatic Lung Ovary Satellite nodule(s) in skin other than primary breast

M1 M1 D D

50 (10) + any of [(40 to 44)] Distant lymph node(s) plus other distant metastases

M1 M1 D D

60 Distant metastasis, NOS Stated as M1, NOS

M1 M1 D D

99 Unknown if distant metastasis Distant metastasis cannot be assessed Not documented in patient record

M0 MX U U


CS Mets Eval

Note: This item reflects the validity of the classification of the item CS Mets at DX only according to the diagnostic methods employed.


0

Does not meet criteria for AJCC pathologic staging of distant metastasis: Evaluation of distant metastasis based on physical examination, imaging examination, and/or other non-invasive clinical evidence. No pathologic examination of metastatic tissue performed or pathologic examination was negative.

c

1

Does not meet criteria for AJCC pathologic staging of distant metastasis: Evaluation of distant metastasis based on endoscopic examination or other invasive technique, including surgical observation without biopsy. No pathologic examination of metastatic tissue performed or pathologic examination was negative.

c

2

Meets criteria for AJCC pathologic staging of distant metastasis: No pathologic examination of metastatic specimen done prior to death, but positive metastatic evidence derived from autopsy (tumor was suspected or diagnosed prior to autopsy).

p

3

Meets criteria for AJCC pathologic staging of distant metastasis: Specimen from metastatic site microscopically positive WITHOUT pre-surgical systemic treatment or radiation OR specimen from metastatic site microscopically positive, unknown if pre-surgical systemic treatment or radiation performed OR specimen from metastatic site microscopically positive prior to neoadjuvant treatment.

p

5

Does not meet criteria for AJCC y-pathologic (yp) staging of distant metastasis: Specimen from metastatic site microscopically positive WITH pre-surgical systemic treatment or radiation, BUT metastasis based on clinical evidence.

c

6

Meets criteria for AJCC y-pathologic (yp) staging of distant metastasis: Specimen from metastatic site microscopically positive WITH pre-surgical systemic treatment or radiation, BUT metastasis based on pathologic evidence.

yp

8

Meets criteria for AJCC autopsy (a) staging of distant metastasis: Evidence from autopsy based on examination of positive metastatic tissue AND tumor was unsuspected or undiagnosed prior to autopsy.

a

9 Not assessed; cannot be assessed Unknown if assessed Not documented in patient record

c


CS Site-Specific Factor 1 Estrogen Receptor Assay (ERA)

Note 1: A. In cases where ER and PR are reported on more than one tumor specimen, record the highest value (if any sample is positive, record as positive). B. If neoadjuvant therapy is given, record the assay from tumor specimens prior to neoadjuvant therapy. C. If neoadjuvant therapy is given and there are no ER or PR results from pre-treatment specimens, report the findings from post-treatment specimens.

Note 2: In general, ER/PR is only done on one sample. In cases where it is done on more than one sample, there is not necessarily any reason to think that the most accurate is the test done on the "largest" tumor specimen. Clinically, treatment will be based on any positive test - in other words, given the benefit and minimal toxicity of hormonal therapy, most patients will be given the "benefit of the doubt" and given hormonal therapy if any ER test is positive.

Note 3: The most recent interpretation guidelines for ER/PR do not allow for a borderline result. Therefore, code 030 will rarely be used. If 1% or greater cells stain positive, the test results are considered positive. If less than 1% stain positive, the results are considered negative.

Note 4: If the patient is ER positive and node negative a multigene test such as OncotypeDX may be performed in which case another ER/PR test will be done. Do not record the results of that test in this field. Record only the results of the test which made the patient eligible to be given the multigene test.

Code Description

000 Test not done (test was not ordered and was not performed)

010 Positive/elevated

020 Negative/normal; within normal limits

030 Borderline; undetermined whether positive or negative

080 Ordered, but results not in chart

996 Ordered, results not interpretable

999 Unknown or no information Not documented in patient record

CS Site-Specific Factor 2 Progesterone Receptor Assay (PRA)

Note 1: A. In cases where ER and PR are reported on more than one tumor specimen, record the highest value (if any sample is positive, record as positive). B. If neoadjuvant therapy is given, record the assay from tumor specimens prior to neoadjuvant therapy. C. If neoadjuvant therapy is given and there are no ER or PR results from pre-treatment specimens, report the findings from post-treatment specimens.

Note 2: In general, ER/PR is only done on one sample. In cases where it is done on more than one sample, there is not necessarily any reason to think that the most accurate is the test done on the "largest" tumor specimen.

Note 3: The most recent interpretation guidelines for ER/PR do not allow for a borderline result. Therefore, code 030 will rarely be used. If 1% or greater cells stain positive, the test results are considered positive. If less tha 1% stain positive, the results are considered negative.

Note 4: If the patient is ER positive and node negative a multigene test such as OncotypeDX may be performed in which case another ER/PR test will be done. Do not record the results of that test in this field. Record only the results of the test which made the patient eligible to be given the multigene test.


Code Description





080 Ordered, but results not in chart

996 Ordered, results not interpretable


CS Site-Specific Factor 3 Number of Positive Ipsilateral Level I-II Axillary Lymph Nodes

Note 1: Only include the number of positive ipsilateral level I and II axillary lymph nodes and intramammary lymph nodes in this field beginning with CS version 2. Intramammary are not the same as internal mammary.

Note 2: Record this field even if there has been preoperative treatment.

Note 3: Lymph nodes with only isolated tumor cells (ITCs) are NOT counted as positive lymph nodes. Only lymph nodes with metastases greater than 0.2 mm (micrometastases or larger) should be counted as positive. If the pathology report indicates that nodes are positive but size of the metastases is not stated, assume the metastases are greater than 0.2 mm and code the lymph nodes as positive in this field.

Note 4: This field is based on pathologic information only. If no ipsilateral axillary nodes were removed for examination, or if an ipsilateral axillary lymph node drainage area was removed but no lymph nodes were found, code 098.

Note 5: The general coding instructions in Part I for Regional Nodes Positive also apply to this field (although the codes in Regional Nodes Positive are 2 digits rather than 3). When positive ipsilateral axillary lymph nodes are coded in this field, the number of positive ipsilateral axillary lymph nodes must be less than or equal to the number coded in Regional Nodes Positive (i.e., the number of positive ipsilateral axillary nodes will always be a subset of the number of positive regional nodes.)

Code Description

000 All ipsilateral axillary nodes examined negative



095 Positive aspiration of lymph node(s)


098 No axillary nodes examined

099 Unknown if axillary nodes are positive; not applicable Not documented in patient record


CS Site-Specific Factor 4 Immunohistochemistry (IHC) of Regional Lymph Nodes

Note 1: Use codes 000-009 only to report results of IHC on otherwise histologically negative or that have only ITCs on routine H and E stains., i.e., only when CS Lymph Nodes is coded 000. Otherwise code 987 in this field.

Note 2: Isolated tumor cells (ITC) are defined as single tumor cells or small clusters not greater than 0.2 mm, usually detected by immunohistochemical (IHC), H and E (see code 050 of CS Lymph Nodes), or molecular methods (RT-PCR: Reverse Transcriptase Polymerase Chain Reaction) (see CS Site-Specific Factor 5). ITCs do not usually show evidence of malignant activity (e.g., proliferation or stromal reaction.) If both IHC and H and E report positive ITC findings, record as 002 or 009 depending on whether size of clusters was given.

Note 3: If it is unstated whether or not tests were done for IHC assume they were not done.

Note 4: If the record states N0(i+) and no other information, code to 009.

Code Description

000 Regional lymph nodes negative on routine H and E, no IHC studies or Unknown if tested for ITCs by IHC studies Nodes clinically negative, not examined pathologically

001 Regional lymph nodes negative on routine H and E, IHC studies done, negative for tumor

002 Regional lymph nodes negative on routine H and E, IHC studies done, positive for ITCs (tumor cell clusters not greater than 0.2mm)

009 Regional lymph nodes negative on routine H and E, positive for tumor detected by IHC, size of tumor cell clusters or metastases not stated; stated as N0(i+) with no further information

888 OBSOLETE DATA CONVERTED V0200 See code 987 Not applicable CS Lymph Nodes not coded 000

987 Not applicable CS Lymph Nodes not coded 000

CS Site-Specific Factor 5 Molecular Studies of Regional Lymph Nodes

Note 1: Use codes 000-002 only to report results of molecular studies (RT-PCR: Reverse Transcriptase Polymerase Chain Reaction) on otherwise histologically negative lymph nodes on routine H and E stains, i.e., only when CS Lymph Nodes is coded 000. Otherwise code 987 in this field.

Note 2: Isolated tumor cells (ITC) are defined as single tumor cells or small clusters not greater than 0.2 mm, detected by immunohistochemical (IHC) (see CS Site_Specific Factor 4) or by H and E (CS Lymph Nodes code 050) or molecular methods (RT-PCR: Reverse Transcriptase Polymerase Chain Reaction). ITCs do not usually show evidence of malignant activity (e.g., proliferation or stromal reaction.)

Note 3: If it is not stated whether molecular tests were done, assume they were not done.

Code Description

000 Regional lymph nodes negative on H and E, no RT-PCR molecular studies done or unknown if RT-PCR studies done Nodes clinically negative, not examined pathologically

001 Regional lymph nodes negative on H and E, RT-PCR molecular studies done, negative for tumor

002 Regional lymph nodes negative on H and E, RT-PCR molecular studies done, positive for tumor


888 OBSOLETE DATA CONVERTED V0200

See code 987

Not applicable CS Lymph Nodes not coded 000

987 Not applicable CS Lymph Nodes not coded 000

CS Site-Specific Factor 6 Size of Tumor--Invasive Component

Note 1: Record the code that indicates how the pathological tumor size was coded in CS Tumor Size.

Note 2: For this field, "mixed" indicates a tumor with both invasive and in situ components. Such a "mixed" tumor may be a single histology such as mixed infiltrating ductal and ductal carcinoma in situ or combined histology such as mixed infiltrating ductal and lobular carcinoma in situ. "Pure" indicates a tumor that contains only invasive or only in situ tumor.

Note 3: This information is collected for analytic purposes and does not affect the stage grouping algorithm. Different codes in this field may explain differences in outcome for patients in the same T category or stage group. Example: Patient 1 has a "mixed" (see Note 2) tumor measuring 2.5 cm with extensive areas of in situ tumor, and the size of the invasive component is not stated. This would be coded 025 in CS Tumor Size, and would be classified as T2. It would be coded 040 in Site-Specific Factor 6. Patient 2 has a purely invasive tumor measuring 2.5 cm. This would also be coded 025 in CS Tumor Size and would also be classified as T2. However, it would be coded 000 in Site-Specific Factor 6. Patient 1's tumor would probably have a better survival than Patient 2's tumor, since it would more likely be a T1 lesion if the true dimensions of the invasive component were known.

Code Description

000 Entire tumor reported as invasive (no in situ component reported)

010 Entire tumor reported as in situ (no invasive component reported)

020 Invasive and in situ components present, size of invasive component stated and coded in CS Tumor Size

030 Invasive and in situ components present, size of entire tumor coded in CS Tumor Size because size of invasive component not stated AND in situ described as minimal (less than 25%)

040 Invasive and in situ components present, size of entire tumor coded in CS Tumor Size because size of invasive component not stated AND in situ described as extensive (25% or more)

050 Invasive and in situ components present, size of entire tumor coded in CS Tumor Size because size of invasive component not stated AND proportions of in situ and invasive not known

060 Invasive and in situ components present, unknown size of tumor (CS Tumor Size coded 999)

888 OBSOLETE DATA CONVERTED V0200

See code 987

Unknown if invasive and in situ components present, unknown if tumor size represents mixed tumor or a "pure" tumor. (See Note 2.) Clinical tumor size coded.

987 Unknown if invasive and in situ components present, unknown if tumor size represents mixed tumor or a "pure" tumor. (See Note 2.) Clinical tumor size coded.


CS Site-Specific Factor 7 Nottingham or Bloom-Richardson (BR) Score/Grade

Note 1: BR may also be called: modified Bloom-Richardson, Scarff-Bloom-Richardson, SBR grading, BR grading, Elston-Ellis modification of Bloom Richardson score, the Nottingham modification of Bloom Richardson score, Nottingham-Tenovus, or Nottingham grade.

Note 2: Code the tumor grade using the following priority order: a). Bloom-Richardson scores 3-9; b). Bloom Richardson grade (low, intermediate, high).

Note 3: BR score may be expressed as a range, 3-9. The score is based on three morphologic features of "invasive no-special-type" breast cancers (degree of tubule formation/histologic grade, mitotic activity, nuclear pleomorphism/nuclear grade of tumor cells). If a report describes any of the factors with words (low, intermediate, high) rather than numbers, do NOT attempt to translate these words into a score/number.

Code Description

030 Score of 3

040 Score of 4

050 Score of 5

060 Score of 6

070 Score of 7

080 Score of 8

090 Score of 9

110 Low Grade, BR grade 1, score not given

120 Medium Grade, BR grade 2, score not given

130 High Grade, BR grade 3, score not given

988 Not applicable: Information not collected for this case

998 No histologic examination of primary site

999 Neither BR grade nor BR score given Unknown or no information Not documented in patient record

CS Site-Specific Factor 8 HER2: IHC Test Lab Value

Note 1: Record the results of only the ImmunoHistoChemical (IHC) test for Human Epidermal growth factor Receptor 2 (HER2) in this field. The test determines whether there are additional copies of the HER2/neugene in the tumor cells compared to the normal number.

Note 2: If the test was done but the actual score is not stated, code 998.

Code Description

000 Score 0

001 Score 1+

002 Score 2+

003 Score 3+


997 Test ordered, results not in chart




CS Site-Specific Factor 9 HER2: IHC Test Interpretation

Note 1: Record the results of only the ImmunoHistoChemical (IHC) test for Human Epidermal growth factor Receptor 2 (HER2) in this field.

Code Description








CS Site-Specific Factor 10 HER2: Fish Test Lab Value

Note 1: Record the results of only the Fluorescence In Situ Hybridization (FISH) test for Human Epidermal growth factor Receptor 2 (HER2) in this field. The test determines whether there are additional copies of the HER2/neugene in the tumor cells compared to the normal number. The results are reported as a ratio between the number of copies of the HER2/neugene and the control.

Note 2: Record the actual ratio if given. Enter the stated ratio to two decimal places. Use a trailing zero if needed. Example: a ratio of 1.8 is entered as 180. Ratio of 5.64 is entered as 564.

Note 3: If the test was done but the actual ratio is not stated, code 998.

Code Description

100-986 Ratio of 1.00 to 9.86 (enter exact ratio to two decimal places)

987 Ratio of 9.87 or greater






CS Site-Specific Factor 11 HER2: FISH Test Interpretation

Note: Record the interpretation of only the Fluorescence In Situ Hybridization (FISH) test for Human Epidermal growth factor Receptor 2 (HER2) in this field.

Code Description

010 Positive/elevated; amplified

020 Negative/normal; within normal limits; not amplified

030 Borderline; equivocal; undetermined whether positive or negative





CS Site-Specific Factor 12 HER2: CISH Test Lab Value

Note 1: Record the results of only the Chromogenic In Situ Hybridization (CISH) test for Human Epidermal growth factor Receptor 2 (HER2) in this field. The test determines whether there are additional copies of the HER2/neugene in the tumor cells. The results are reported as the mean number of copies of the HER2/neugene on either 30 or 60 tumor cells.

Note 2: Record the actual mean if given. Enter the stated mean to two decimal places. Use a trailing zero if needed. Example: a mean of 1.8 is entered as 180. A mean of 5.64 is entered as 564.

Note 3: If the test was done but the actual mean is not stated, code 998.

Code Description

100-986 Mean of 1.00 to 9.86 (enter exact mean to two decimal places)

987 Mean of 9.87 or greater






CS Site-Specific Factor 13 HER2: CISH Test Interpretation

Note: Record the interpretation of only the Chromogenic In Situ Hybridization (CISH) test for Human Epidermal growth factor Receptor 2 (HER2) in this field.

Code Description








CS Site-Specific Factor 14 HER2: Result of other or unknown test

Note: If the Human Epidermal growth factor Receptor 2 (HER2) test wasn't a FISH test or IHC test OR it is unknown which HER2 test was performed, record the results here.

Code Description



030 Borderline; equivocal; undetermined whether positive or negative






CS Site-Specific Factor 15 HER2: Summary Result of Testing

Note 1: The summary of the results of the IHC, FISH, or other/unknown Human Epidermal growth factor Receptor 2 (HER2) test is recorded here. This variable can be derived from the results of CS Site-Specific Factors 9,11,13,14.

Note 2: If both an IHC and a gene-amplification test (FISH, CISH, etc.) were given, record the result of the gene-amplification test in this field. However, if the gene-amplification test was given first and the result was borderline/equivocal and an IHC was done to clarify these equivocal results, take the result of the IHC.

Code Description








CS Site-Specific Factor 16 Combinations of ER, PR, and HER2

Note 1: There is an interest in triple negative breast cancer. This field could be derived from SSF 1, 2, and 15.

Note 2: ER: the first digit is 0 for negative and 1 for positive for ER.

Note 3: PR: the second digit is 0 for negative and 1 for positive for PR.

Note 4: HER2: the third digit is 0 for negative and 1 for positive for HER2.

Code Description

000 ER Negative, PR Negative, HER2 Negative (Triple Negative)

001 ER Negative, PR Negative, HER2 Positive

010 ER Negative, PR Positive, HER2 Negative

011 ER Negative, PR Positive, HER2 Positive

100 ER Positive, PR Negative, HER2 Negative

101 ER Positive, PR Negative PR, HER2 Positive

110 ER Positive, PR Positive, HER2 Negative

111 ER Positive, PR Positive, HER2 Positive


999 One or more tests were unknown if performed One or more tests had unknown or borderline results Not documented in patient record


CS Site-Specific Factor 17 Circulating Tumor Cells (CTC) and method of detection

Note: The immunomagnetic separation test takes precedence over RT-PCR test.

Code Description

010 Positive, RT-PCR test

020 Positive, immunomagnetic separation (IMS) test

030 Positive, other test type

040 Positive, unknown test type

110 Negative/normal, RT-PCR test

120 Negative/normal, immunomagnetic separation (IMS) test

130 Negative/normal, other test type

140 Negative/normal, unknown test type

210 Borderline, undetermined if positive or negative, RT-PCR test

220 Borderline, undetermined if positive or negative, immunomagnetic separation (IMS) test

230 Borderline, undetermined if positive or negative, other test type

240 Borderline, undetermined if positive or negative, unknown test type





CS Site-Specific Factor 18 Disseminated Tumor Cells (DTC) and method of detection

Note: The immunohistochemical test takes precedence over RT-PCR test.

Code Description

010 Positive, RT-PCR test

020 Positive, immunohistochemical separation (IHC) test

030 Positive, other test type

040 Positive, unknown test type

110 Negative/normal, RT-PCR test

120 Negative/normal, immunohistochemical separation (IHC) test

130 Negative/normal, other test type

140 Negative/normal, unknown test type

210 Borderline, undetermined if positive or negative, RT-PCR test

220 Borderline, undetermined if positive or negative, immunohistochemical separation (IHC) test

230 Borderline, undetermined if positive or negative, other test type

240 Borderline, undetermined if positive or negative, unknown test type






CS Site-Specific Factor 19 Assessment of Positive Ipsilateral Axillary Lymph Nodes

Note: Includes ipsilateral level I and II axillary plus intramammary. Code the assessment used for the number of positive axillary lymph nodes SSF3 (Number of positive axillary lymph nodes).

Code Description

000 No ipsilateral axillary lymph nodes were positive

010 Only clinical assessment showed positive nodes

020 Positive Fine Needle Aspiration (FNA) only

030 Positive Core biopsy: incisional

040 Positive Core biopsy: excisional

050 Positive Core biopsy: type not specified

100 Positive sentinel lymph node biopsy(ies) and no lymph node dissection

110 Positive sentinel lymph node biopsy(ies) and negative lymph node dissection

120 Positive sentinel lymph node biopsy(ies) and positive lymph node dissection

130 Negative sentinel node biopsy(ies) AND positive lymph node dissection

140 No sentinel node biopsy AND positive lymph node dissection


998 Nodes positive, but method of assessment unknown


CS Site-Specific Factor 20 Assessment of Positive Distant Metastases

Note 1: This Site-Specific Factor evaluates how the information regarding positive metastasis in CS metastasis and CS metastasis to the bone, lung, liver, and brain were determined. If distant metastasis is coded as 00 - no positive metastasis, this field must also be coded to 000.

Note 2: Code to the highest code if multiple assessments. See part I for tests to be included.

Code Description

000 No positive metastases were identified

010 Clinical assessment

020 Radiography; Imaging (US, CT, MRI, PET)

030 Incisional biopsy; FNA

040 Excisional biopsy or resection with microscopic confirmation other than by biopsy




CS Site-Specific Factor 21 Response to Neoadjuvant Therapy

Note: The registrar should look in the medical record for a specific statement as to the response to neoadjuvant therapy. The registrar should not try to interpret or infer a response based on the medical record.

Code Description

010 Complete Response (CR)

020 Partial Response (PR)

030 No Response (NR)


998 No neoadjuvant therapy

999 Unknown if response Unknown or no information Not documented in patient record

CS Site-Specific Factor 22 Multigene Signature Method

Code Description

010 Oncotype DX

020 Mamma Print

030 Other





CS Site-Specific Factor 23 Code the result/score of the multigene signature

Code Description

001-099 Actual score

100 100+

200 Low risk of recurrence (good prognosis)

205 High risk of recurrence (poor prognosis)






CS Site-Specific Factor 24 Paget Disease

Note: Record any mention of Paget disease, whether clinical or pathological, giving priority to the pathologic assessment. Interpret a negative exam of the nipple as Paget disease not present. Code unknown when no examination of the nipple, clinical or pathologic, is available in the medical record.

Code Description

000 Paget disease absent

010 Paget disease present




FIELD# FIELD NAME CODE AND RATIONALE/DOCUMENTATION 1 Patient Name - Breast Case 1

CANCER IDENTIFICATION 2 Primary Site C508 New cancer: >5 years following L breast cancer 3 Histology 8500 4 Behavior 3 5 Grade 2 6 Grade system type 7 Grade value 8 Lymph-vascular invasion 0

STAGE OF DISEASE AT DIAGNOSIS 9 CS Mets at Dx - Bone 0

10 CS Mets at Dx - Lung 0 11 CS Mets at Dx - Liver 0 12 CS Mets at DX - Brain 0

COLLABORATIVE STAGING 13 CS Tumor Size 015 14 CS Extension 100 15 CS Tumor Size/Ext Eval 3 16 CS Lymph Nodes 00 17 CS Lymph Nodes Eval 3 18 Regional Nodes Positive 00 19 Regional Nodes Examined 06 20 CS Mets at Dx 00 21 CS Mets Eval 00 22 CS Site-Specific Factor 1 ERA 010 IHC + 23 CS Site-Specific Factor 2 PRA 020 IHC - 24 CS Site-Specific Factor 3 # AX LN 000 25 CS Site-Specific Factor 4 IHC - ITC 000 Node -, unknown if test done 26 CS Site-Specific Factor 5 RT – ITC 000 Node - , unknown if test done 27 CS Site-Specific Factor 6 Which TS 000 Conflicting info. Size of invasive comp stated as 015 28 CS Site-Specific Factor 7 SBR 060 3+2+1 29 CS Site-Specific Factor 8 IHC HER2 Result 998 Assume test not done 30 CS Site-Specific Factor 9 IHC HER2 Interp 998 Assume test not done 31 CS Site-Specific Factor 10 FISH HER2 Res 130 32 CS Site-Specific Factor 11 FISH HER2 Interp 020 Not amplified 33 CS Site-Specific Factor 12 CISH HER2 Res 998 Assume test not done 34 CS Site-Specific Factor 13 CISH HER2 Interp 998 Assume test not done 35 CS Site-Specific Factor 14 Other HER2 Interp 998 36 CS Site-Specific Factor 15 Summary HER2 020 37 CS Site-Specific Factor 16 Comb ER,PR,HER2 100 ER+,PR-,HER2- 38 CS Site-Specific Factor 17 CTCs 998 Assume test not done 39 CS Site-Specific Factor 18 DTCs 998 Assume test not done 40 CS Site-Specific Factor 19 Ax LN Assess 000 No ispilateral axillary nodes were positive 41 CS Site-Specific Factor 20 Dist Mets Assess 000 42 CS Site-Specific Factor 21 Neoadj Response 998 43 CS Site-Specific Factor 22 Multigene Method 010 OncogeneDx 44 CS Site-Specific Factor 23 Multigene Score 034 Score = 34% 45 CS Site-Specific Factor 24 Paget 000 No mention in pathology report 46 CS Site-Specific Factor 25 Not Applicable 988




Rational for specific data elements:

Head and Neck Cancers CSv2 CodingACTUR Conference April 2010

1

18. TNM Staging: Head and Neck Cancers 1

The Anatomy of Staging:

Head and Neck Cancers

Presentation developed byApril Fritz, RHIT, CTRA.Fritz and Associates, LLCReno, [email protected]

Head and Neck CSv2 Coding 2

Passageways of Head and Neck


Head and Neck Issues

TNM Chapters 6Summary Stage Sites 22Collaborative Staging v2 58

• Determining the correct primary site is VERY important!

• In CS, site-specific factors are the same for all head and neck sites.

• So many structures, so close together• So many names and synonyms• So many staging schemes


Head and Neck Groups

A. Lip and oral cavity (C00 – C05.0)B. Pharynx

• Oropharynx (C05.1, C05.2, C10) • Nasopharynx (C11)• Hypopharynx (C12.9, C13)

C. Larynx (C32)D. Thyroid (C73.9)

Others• Salivary glands (C07)• Paranasal sinuses (C31)

• Maxillary (C31.0)• Ethmoid (C31.1)

• Nasal cavity and middle ear (C30)


2


TNM Supplement Guidelines

• Tumor involving two sites• Classify to site in which greater part of tumor

is located• Consider only invasive component if tumor as

associated carcinoma in situ• Extension

• Superficial spread limited to mucosa not sufficient for T4

• Deep muscles, bones or other deep structures (vertical or

horizontal invasion)


Head and Neck Cancer – CS Fields

Collaborative Stage Fields (in general)• Tumor Size—standard • Extension• TS/Ext Eval—standard • Lymph Nodes• LN Eval—standard • LN Pos—standard • LN Exam—standard • Mets at Dx• Mets Eval—standard

Site-Specific Factors1. SSF1 Size of LN2. OBSOLETE3. SSF3 Levels I-III4. SSF4 Levels IV-V,

Retrophar5. SSF5 Levels VI-VII, Facial6. SSF6 Other H&N nodes7. Upper/Lower Cervical

Node Levels8. Extracaps Exten Clinical9. Extracaps Exten Path10. HPV Status11. Measured Thickness

(Depth)


What’s New in CSv2?

• New Schemas • Pharyngeal Tonsil• Mucosal Melanoma

Lip and Oral Cavity Pharynx Nasal Cavity and Accessory Sinuses Larynx

• Schema Discriminator Nasopharynx Pharyngeal Tonsil

• New criteria for anaplastic carcinoma of thyroid


Mucosal Melanomas

• TNM mapping very different• No T1 or T2 equivalent codes• Ext 105 Confined to mucosa = T3• Further involvement

500-600 range moderately advanced = T4aExamples: Deep soft tissues, skin of face, maxillary cartilage

800 range very advanced = T4bExamples: Brain, dura, cranial nerves, encasing internal carotid artery

• Depth of invasion collected in SSF• Not used in TNM mapping

• Stage III and IV only


3


Lip• Upper • Lower • Other

Tongue• Base• Anterior

Gum• Upper • Lower • Other

Floor of Mouth Palate

• Hard • Soft

Other Mouth Buccal Mucosa Salivary Glands

• Parotid • Submandibular• Other Salivary

Pharynx• Oropharynx • Anterior Epiglottis • Nasopharynx • Hypopharynx• Other Pharynx *

Nasal Cavity Middle Ear Sinus

• Maxillary• Ethmoid• Other *

Larynx• Glottic• Supraglottic• Subglottic• Other

Head and Neck – Tumor Size Required

• Thyroid is NOT included* no TNM stagingABC requires Tumor Size for TNMXYZ Tumor Size not a factor in TNM


Head and Neck – CS Extension

• General format • 000 In situ• 100 Lamina propria/submucosa• 300 Localized, NOS• 400-590 Adjacent structures (T3)• 600-690 Mixed T3-T4 (site specific)• 700-800 Adjacent structures (T4)• 950 No evidence of primary tumor


CS TS/Ext Eval, CS Reg Nodes Eval, CS Mets Eval

• All standard tables• General structure

• 0 clinical only• 1 invasive techniques, no bx; or needle bx does not meet criteria for pathologic T or N

• 2 autopsy (known or suspected dx)• 3 pathology meets criteria for pathologic T, N or M

• 5 pre-op tx, clinical eval• 6 pre-op tx, path eval• 8 autopsy (dx not suspected)• 9 unknown, not assessed


When to Code TS/Ext Evalfor Size versus Extension

• Accessible sites• Code for size when Tumor is localized and size determines the T category

(T1 vs T2 vs T3)• Code for extension when Tumor involves involves structures that map to T4

• Inaccessible sites• Code for extension because size is not a factor

in TNM mapping


4


Head and Neck Regional Nodes

1. Submental2. Submandibular3. Jugular (deep cervical)4. Superficial cervical5. Supraclavicular6. Prelaryngeal* and

paratracheal*7. Retropharyngeal8. Parotid9. Buccal

10. Retroauricular andoccipital


Head and Neck Lymph NodesOverview Level I (* = not shown)

A SubmentalB Submandibular (submaxillary)Level IIC Upper deep cervical (upper jugular)* Jugulodigastric (subdigastric)Level IIID Middle deep cervical (mid-jugular)Level IVE Lower deep cervical (lower jugular)* Jugulo-omohyoid (supraomohyoid)Level VF Posterior cervicalG Posterior triangle* Supraclavicular, NOSLevel VIH Pre/paralaryngeal and pre/paratracheal

(anterior deep cervical)Level VIIJ Upper mediastinalAdapted from: TNM Interactive (CD-ROM),

Wiley-Liss

J

A

BB

C

C

D

E

E

F

G

G

H H

H


Lymph Node Levels

Image source: voice-center.com (The Voice Center, Norfolk, VA)

I Submental and submandibularII Upper jugularIII Middle jugularIV Lower jugular and

supraclavicularV Superficial cervical (along

spinal accessory nerve)VI Anterior compartment

(prelaryngeal and paratracheal)

VII Upper mediastinal

VII


Lymph Node Metastases at Diagnosis

• Pyriform sinus – 70%• Postcricoid area – 40%• Posterior hypopharynx – 50%• Nasopharynx – 75%• Tonsil – 70% • Base of tongue – 70% • Soft palate – 30-65%• Pharyngeal wall – 30-65% • Paranasal sinuses – 20%• Medullary ca of thyroid – 50%


5


General Guidelines – N

• Lymph Node fields definitions the same for all sites except nasopharynx and thyroid

• N category mapping by size of lymph node mass: < 3 cm; > 3 < 6 cm; > 6 cm

• N category mapping by number of lymph nodes involved• SEER rule: if laterality of lymph nodes is

not stated, assume they are ipsilateral• "Fixed" and "matted" are considered

involvement. • "Enlarged," "palpable," "shotty,”

“lymphadenopathy" are NOT considered involvement.


Head and Neck Lymph NodesCS Overview

• Regional lymph node information coded in several fields• CS Lymph Nodes field

nodes involved, their number and laterality

• Site-Specific Factor 1 size of involved lymph nodes

• Site-Specific Factors 3-6 presence or absence of lymph node involvement in each

of 7 different levels and other groups defined by AJCC. • Site-Specific Factor 7

presence of extracapsular extension• Site-specific Factors 8-9

Extracapsular extension, clinical and pathologic


Lymph Nodes—Specific Fields

• CS LN: Which nodes, number and laterality• SSF1: Size of involved node• SSF3: Levels I-III• SSF4: Levels IV-V• SSF5: Levels VI-VII and face• SSF6: Other LN groups• SSF7: Upper and lower

cervical node levels• SSF8: Extracapsular

extension clinical• SSF9: Extracapsular

extension pathologic

Image source: AJCC Cancer Staging Manual, 6th edition


Head and Neck Lymph NodesCS Lymph Nodes—Notes

• Contains information about the nodes involved, their general number and laterality

• Code ranges vary by primary site• Code any regional LN involvement in this field• Major categories:

Single positive ipsilateral node involvedMultiple positive ipsilateral nodesBilateral or contralateral positive nodesPositive regional nodes, NOS

• If laterality not specified, assume nodes are ipsilateral

• Midline nodes grouped with ipsilateral nodes


6


Head and Neck Lymph NodesCS Lymph Nodes – Example

• Parotid Gland000 None100-190 Single positive ipsilateral node involved200-290 Multiple positive ipsilateral nodes300-320 Positive ipsilateral nodes, unk. if 1 or > 1400-490 Bilateral or contralateral positive nodes500-520 Regional nodes, NOS, unk. number and

laterality800 Lymph nodes, NOS


Head and Neck Lymph NodesCS Lymph Nodes—N Categories

Example—Parotid Gland000 N0180 N1, no other information190 N2a, no other information290 N2b, no other information490 N2c, no other information600 N2, NOS700 N3, no other information

When to Code 100-700 vs. 800

Codes 100 - 700• Nodes are definitely

regional

Code 800• Can’t tell whether

regional or distantnodes

• Rarely used


Site-Specific Factor 1Size of Involved Node—Notes

• Required by COC, SEER• Code size of NODE, not size of metastasis• Code largest diameter measured clinically or

pathologically• Code regional nodes only• Size format same as tumor size with extra choices

• 996 Described as less than 6 cm• 997 Described as more than 6 cm

• OBSOLETE—Data now collected in SSFs 8-9

Site-Specific Factor 2Extracapsular Extension


Site-Specific Factors 3-6

• Required by COC, SEER• Definitions of levels are the same for all

applicable head and neck sites.

SSF 3 Levels I-IIISSF 4 Levels IV and V and retropharyngeal

nodesSSF 5 Levels VI and VII and facial nodesSSF 6 Other groups as defined by AJCC


7


Coding Site-Specific Factors 3-6

SSF 3 Levels I-III ___ ___ ___I II III

SSF 4 Levels IV-V, ___ ___ ___retropharyngeal (RP) IV V RP

SSF 5 Levels VI-VII, ___ ___ ___Facial (F) VI VII F

SSF 6 Other groups ___ ___ ___ Parapharyngeal (PP), PP PA SParotid (PA), Suboccipital (S)

• Default is 0, not involved.• If any level/chain is involved, code as 1, involved.


Coding SSF 3-6 Example

LRND: 2 positive parotid node (< 3 cm with extra-capsular exten.), 1 positive buccal (facial) node (2 cm), and 1 positive 2 cm submandibular node.

SSF 3 Levels I-III _1_ _0_ _0_I II III

SSF 4 Levels IV-V, _0_ _0_ _0_Retropharyngeal (RP) IV V RP

SSF 5 Levels VI-VII, _0_ _0_ _1_Facial (F) VI VII F

SSF 6 Other groups _0_ _1_ _0_Parapharyngeal (PP), PP PA SParotid (PA), Suboccipital (S)


Site-Specific Factor 7Upper/Lower Cervical Node Levels • Documents whether involved nodes are

above or below level of cricoid cartilage• Lower cervical nodes have worse prognosis

• If not obvious, refer to list in Part I, Section 2 of CS User Documentation

• If unknown, use code 040

Image source: CSv2 User Documentation, Part I Section 2

Level of cricoid cartilage


Table I-2-3 ExampleLymph Nodes of the Head and Neck Showing Level and Site-Specific Factor Positions

Name Level SSF7 Code SSF3-6 Position

-- ---- --

-- --

Note 1. Look for a statement of upper or lower cervical nodes or that the involved nodes are above or below the lower border of the cricoid cartilage and code appropriately. If no further information, use code 40 in SSF 4.


8


Site-Specific Factors 8-9Extracapsular Extension—Notes • Code extracapsular extension identified

clinically (SSF 8) and/or pathologically (SSF 9)• Code regional nodes only• Code 000 if nodes are negative• Read carefully—codes differ• If extracapsular extension not mentioned in

PE/Imaging (SSF 8) or path report (SSF 9), use code 010.

Pathologic Lymph Nodes 010 No extracapsular extension030 Macroscopic extracapsular

extension pathologically

Image source: TNM Interactive (CD-ROM), Wiley-Liss Head and Neck CSv2 Coding 30

Site-Specific Factor 8Extracapsular Extension Clinically• Clinical information

• Physical exam may show matted mass of nodes

• Imaging studies may show amorphous spiculated margins on nodes involvement of internodal fat loss of normal oval to round shape

• Codes • 000 No lymph nodes involved • 010 Nodes involved, no extracapsular extension • 020 Nodes involved, extracapsular extension• 030 Nodes involved, unk if extracapsular exten.• 988 Not applicable: no node involvement• 997 Clin exam of nodes, unk results• 998 No clin exam of nodes• 999 Unknown; not documented; not assessed


Site-Specific Factor 9Extracapsular Extension Pathologic• Required by COC, SEER• Pathologic information

• Priority: “macroscopic” over “microscopic” Macro or micro from final diagnosis Macro from gross section Micro from microscopic section

• Codes • 000 No lymph nodes involved • 010 Nodes involved, no extracapsular extension • 020 Nodes involved, microscopic extracap exten• 030 Nodes involved, macroscopic extracap exten• 988 Not applicable: no node involvement• 997 Clin exam of nodes, unk results• 998 No clin exam of nodes• 999 Unknown; not documented; not assessed


Coding SSF 1-9 Example

LRND: 2 positive parotid node (< 3 cm with extra-capsular exten.), 1 positive buccal (facial) node (2 cm), and 1 positive 2 cm submandibular node.

SSF 1 Size of node 993 Described as < 3 cmSSF 2 [obsolete]SSF 3 Levels I-III 100 Level 1 onlySSF 4 Levels IV-V, RP 000 All nodes negSSF 5 Levels VI-VII, F 001 Facial nodes onlySSF 6 Other groups 010 Parotid nodes onlySSF 7 Upper/Lower 010 All above cricoid cartilageSSF 8 Clin extracap ext 999 Unknown if clin involvedSSF9 Path extracap ext 040 Extracap exten, unk if

micro or macroComputer derived N: pN2b


9


Site-Specific Factor 10HPV Status• Required by COC, SEER for some H&N sites• Human papilloma virus (HPV) infection may be

risk factor for oral and other mucosal cancers• Highest risk strains for cancer are types 16 and 18

• Code results from any tissue, not just primary site

• Many codes—read carefully


Site-Specific Factor 10HPV Status• Codes

• 000 HPV test neg; not pos for any HPV types; Negative, NOS• 010 LOW RISK pos (all pos type(s) low risk)• 020 HIGH RISK pos, spec type(s) other than 16 or 18* • 030 HIGH RISK pos for HPV 16 WITHOUT pos results

for HPV 18 or pos of HPV 18 unknown* ^ • 040 HIGH RISK pos for HPV 18 WITHOUT pos results for

HPV 16 or pos of HPV 16 unknown* ^ • 050 HIGH RISK pos for HPV 16 AND HPV 18 * ^ • 060 HIGH RISK positive, NOS, type(s) not specified• 070 Positive, NOS, risk and type(s) not stated• 988 Not applicable: Information not collected • 997 Test ordered, results not in chart• 998 Test not done (not ordered and not performed), including

no pathologic specimen available for HPV testing• 999 Unknown or no information; Not documented

* WITH or WITHOUT positive results for low risk type(s)^ WITH or WITHOUT positive results for other high-risk types


Site-Specific Factor 11Measured Thickness (Depth)• Required by COC, SEER where listed in schema• Not in all schemas

• All H&N melanomas require thickness for T mapping• Measurement different from skin melanomas• Codes

• 000 No mass/tumor found• 001-979 Exact thickness in tenths of mm • 980 98.0 millimeters or larger• 987 Not applicable: in situ carcinoma• 988 Not applicable: Information not collected• 990 Microinvasion; Microscopic focus or foci

only; no depth given• 998 No surgical specimen• 999 Not documented in patient record; Unknown


Related CS Fields for Head & Neck

• CS Tumor Size• CS Extension• CS TS/Ext Eval• SSF11 Measured

thickness (depth)

• CS Mets at Dx• Mets Eval

• CS Lymph Nodes• CS Reg Nodes Eval• Reg LN Pos• Reg LN Exam• SSF1 Size of LN• SSF3 Levels I-III• SSF4 Levels IV-V, Retrophar• SSF5 Levels VI-VII, Facial• SSF6 Other H&N nodes• SSF7 Upper/lower cervical LN• SSF8 Extracaps exten clin• SSF9 Extracaps exten path

• SSF10 HPV status


10


Anatomical References for TNM Staging and Coding of Head and NeckCancers


LIP AND ORAL CAVITY


Lip and Oral Cavity

• T category by size of primary• T1 < 2 cm• T2 > 2 and < 4 cm• T3 > 4 cm

• T4 Direct invasion of other structures (bone, muscle)• T4a (lip) cortical bone, floor of mouth, skin of face• T4b (oral cavity) adjacent structures: cortical bone,

deep muscle of tongue, maxillary sinus, skin of face• T4b masticator space, pterygoid plates, skull base,

encasing internal carotid artery


Lip and Oral Cavity

• Lip• Assign to lip (C00._) if more than 50% of tumor is

located on vermillion surface.

• Oral Cavity• Tumor that extends to oropharynx via mucosa is

classified only by size.

• Tongue• Anterior 2/3 = mobile tongue• Base (root) of tongue in oropharynx


11


Head and Neck – CS Extension

• Muscles of the tongue• Used in shaping the mouth for speech, chewing

and swallowing• Intrinsic musculature

• Muscles within the tongue (no bony attachment)• Also called lingual• Used to curl sides of tongue upward• When mentioned as involved, code in Ext 200 range (T1-T3)• NOT part of T4 category in TNM

• Extrinsic musculature• Muscles anchoring the tongue in the mouth • Attached to mandible, hyoid bone, styloid process of

temporal bone, or palate• When mentioned as involved, code in CS Extension 700-750

(T4) range (except sites: floor of mouth and submandibular gland)

• When involved, map to T4 in TNM


Tongue(Ant. 2/3)

Gum

Lips

Gum

Lip and Oral Cavity Structures

Floor of mouth

Hard palate

Not shown: Cheek Mucosa, Retromolar Trigone


Gum/gingiva

Lip

Commissureof lips

Retromolartrigone

OROPHARYNX

Tongue

Soft palate

Uvula

Tonsillar pillar

ORAL CAVITY

Tonsil

Posterior wall of oropharynx

Hard palate

Structures of the Mouth

Not shown:Base of tongue


750 Tongue200 Musculature

100 Labial mucosa

510 Gum

775 Floor of mouth

Not shown: 300 Localized, NOS500 Cheek mucosa 760 Skin of face/neck800 Further contiguous extension

100 Skin of lip

535 Cortical bone

CS Extension Codes – Lip


12


CS Extension Codes – Gum/Gingiva

650 Hard palate

500 Mucosa of tongue

500 Floor of mouth

Not shown: 300 Localized, NOS500 Buccal mucosa 550 Subcutaneous soft tissue of face 600 Tonsils, lateral pharyngeal wall805 Skull 760 Skin of face805 Further contiguous extension

500 Lip, labialmucosa

535 Mandible

650 Soft palate

720 Deep musclesof tongue

740 Nasal cavity

Upper Gum Only

535 Maxilla (not shown)

Not shown: 100 Mucoperiosteum (stroma)

Lower Gum Only


CS Extension Codes – Mobile Tongue

200 Intrinsic musclesof tongue

500 Lowergingiva

500 Floor ofmouth

Not shown: 300 Localized, NOS400 Tumor crosses midline800 Further contiguous extension

750 Extrinsic musclesof tongue

500 Base of tongue

600 Soft palate

535 Mandible


CS Extension Codes – Floor of Mouth

500 Mobile tongue

530 Sublingual gland

Not shown: 300 Localized, NOS

400 Tumor crosses midline

550 Subcutaneous soft tissue

760 Skin of undersurface of chin/neck

805 Further contiguous extension

620 Deep musclesof tongue

500 Base of tongue

600 Epiglottis

600 Vallecula530 Submaxillarygland and ducts

500 Lowergingiva

535 Mandible


100 Mucoperiosteum(stroma)



500 Buccal mucosa

535 Maxillary bone

745 Maxillary sinus, sphenoid bone, pterygoid bone


500 Soft palate

500 Upper gum

535 Palatine bone

745 Nasal cavity

CS Extension Codes – Hard Palate


13


PHARYNX


Three Subsites of Pharynx

Nasopharynx

Oropharynx

Hypopharynx


Esophagus

Hypopharynx

Oropharynx

Nasopharynx

Three Subsites of Pharynx from back

Nasal cavity

Base of tongue

Postcricoid area


Subsites of Oropharynx

• C01.9 Base of tongue• C05.1 Soft palate• C05.2 Uvula• C09.1 Tonsillar fossa• C09.2 Tonsillar pillar• C09.9 Tonsil, NOS• C10.0 Vallecula• C10.2 Lateral wall• C10.3 Posterior wall• C10.9 Oropharynx, NOS


14


Gum/gingiva

Lip

Commissureof lips

Retromolartrigone

OROPHARYNX

Tongue

Soft palate

Uvula

Tonsillar pillar

ORAL CAVITY

Tonsil

Posterior wall of oropharynx

Hard palate

Structures of the Mouth

Not shown:Base of tongue


Pharynx, NOS: Waldeyer’s ring

Lymphoid tissue in nasopharynx and oropharynx• No TNM staging for pharynx, NOS

• Lymphomas are coded with lymphoma schema

Nasopharynxadenoids

OropharynxLingual tonsilsPalatine tonsils


CS Extension Codes – Soft Palateand Uvula

650 Hard palate

Not shown:300 Localized, NOS400 Tumor crosses midline500 Buccal mucosa600 Lateral pharyngeal wall700 Maxilla710 Pterygoid muscle740 Maxillary sinus800 Further contiguous extension

500 Upper gum

700 Palatine bone

670 Nasal cavity

720 Tongue700 Mandible

740 Nasopharynx

730 Larynx


CS Extension Codes – Tonsil and Other Oropharynx (1)

150 Confined to one:Anterior wallLateral wallPosterior wall

200 Two or more subsites involved

300 Localized, NOS

DefinitionsAnterior wall Base of tongue and vallecula

Lateral wall Tonsil, tonsillar fossa, tonsillarpillars and glossotonsillar sulci

Posterior wall Mucosa at back of throat

Tonsil

Tonsillarpillar

Posteriorwall of oropharynx


15


CS Extension Codes – Tonsil and Other Oropharynx (2)

700 Hard palate

Not shown:630 Pyriform sinus510 Any 150-500 with fixation610 Soft tissue of neck800 Further contiguous extension

400 Soft palate, uvula

500 Upper gum

500 Base of tongue700 Mandible

710 Nasopharynx, NOS

650 Larynx

500 Floor of mouth

708 Prevertebralfascia/muscle

700 Extrinsic musclesof tongue


CS Extension Codes – Base of Tongue and Lingual Tonsil

500 Anterior 2/3of tongue

500 Lower gingiva

500 Floor of mouth



610 Lateral pharyngeal wall

780 Skin


750 Extrinsic muscles of tongue

200 Intrinsic musclesof tongue

600 Soft palate

710-720 Mandible

530 Sublingual gland 640 Epiglottis

610 Vallecula


Nasopharynx Structures

Nasopharynx

Lateral wall

Lateral wallSuperior surface of soft palate

Superior wall (roof)

Posterior wall

C11.0 Superior wallC11.1 Posterior wallC11.2 Lateral wallC11.3 Anterior wallC11.8 Overlapping lesion of nasopharynxC11.9 Nasopharynx, NOS


CS Extension Codes – Nasopharynx (1)

Nasopharynx

Lateral wall


105 Confined to one:Posterior superior wallLateral wallInferior wall

200 Two or more subsites involved 305 Localized, NOS

Superior wall (roof)

Posterior wall


16


Superior wall Posterior wall

Lateral wall


400 Soft palate

605 Skull

400 Oropharynx

500 Nasal Cavity

710 HypopharynxNot shown:585 Pterygopalatine fossa565 Any 10-50 with fixation620 Paranasal sinus710 Infratemporal fossa; orbit800 Further contiguous extension

700 Brain; cranial nerves

CS Extension Codes – Nasopharynx (2)


Hypopharynx Sites

• C12.9 Pyriform sinus• C13.0 Postcricoid region• C13.1 Hypopharyngeal aspect of

aryepiglottic fold• C13.4 Posterior wall• C13.9 Hypopharynx, NOS


CS Extension Codes – Hypopharynx (1)

Hypopharynx

100 Confined to one:Postcricoid areaPyriform sinusPosterior pharyngeal wall

200 Two or more adjacent subsites involved (not fixed)

300 Localized, NOS

Hypopharyngealsurface of aryepiglottic foldPyriform sinusPosterior pharyngeal wall

Esophagus

Postcricoid area


500 Larynx

400 Oropharynx

Not shown:420 100 with fixation450 Any 200, 300, or 400

with fixation550 Fixation of hemilarynx

or larynx

650 Carotid artery800 Further contiguous

extension

560 Esophagus620 Thyroid

640 Prevertebralfascia/muscle

600 Soft tissuesof neck

CS Extension Codes – Hypopharynx (2)


17


LARYNX


Subsites of Larynx

Supraglottis

SubglottisGlottis

Pyriform sinus

Epiglottis

False cords

True cords

Ventricle


Front of Larynx from behind

Epiglottis

Trachea

Thyrohyoidmembrane

Thyroid cartilage

Arytenoid cartilage


Larynx – View from Above

LeftVocal cords

abductedto breathe

RightVocal cords

adductedto speak


18


Structures of Glottis and Supraglottis

Arytenoid

True vocal cords

False vocal cords

Anterior commissure

Posterior commissure

Epiglottis

Aryepiglotticfold

Supraglottic/Glottic


CS Extension Codes – Glottic Larynx (1)

300 Arytenoid

130 True vocal cords, NOS110 One cord120 Both cords

300 False vocal cords

300 Epiglottis

300 Aryepiglottic fold

300 Subglottis Not shown:350 Impaired vocal cord mobility400 Limited to larynx with fixation450 Localized, NOS


CS Extension Codes – Glottic Larynx (2)

700 Oropharynx

Not shown:600 Pyriform sinus;

postcricoid

680 Cricoid cartilage


710 Esophagus, cervical700 Thyroid

600 Hypopharynx

700 Soft tissues of neck 700 Trachea

600 Vallecula

600 Base of tongue

600 Pre-epiglottictissues


CS Extension Codes – SupraglotticLarynx (1)

Arytenoid

False vocal cords

Epiglottis

Aryepiglottic fold

100 Confined to one subsite (normal vocal cord mobility)200 Involves more than one subsite in supraglottis230 Involves glottis, no fixation390 Involves subglottis, no fixation

Not shown:250 Impaired vocal cord mobility400 Limited to larynx with fixation450 Localized, NOS


19


CS Extension Codes – SupraglotticLarynx(2)

230 Glottis

700 Oropharynx

Not shown:625 Code 60 with

fixation

650 Postcricoid

690 Cricoid cartilage


700 Esophagus700 Thyroid

650 Hypopharynx

700 Soft tissues of neck 730 Trachea

320 Vallecula

660 Deep base of tongue

650 Pre-epiglottic tissues


CS Extension Codes – SubglotticLarynx

100 Subglottis (normal vocal cord mobility) (T1)

300 Involves adjacent region of larynx; no fixation (T2)400 Limited to larynx with fixation (T3)

450 Localized, NOS

680 Thyroid/cricoid cartilage; other tissues beyond (T4)

700 Oropharynx; cervical esophagus; soft tissues of neck; strap muscles; thyroid gland; trachea; skin (T4)

800 Further contiguous extension (T4)

600 Base of tongue; hypopharynx; postcricoid area;pyriform sinus; vallecula (T4)


SALIVARY GLANDS


Major Salivary Glands

Parotid gland

Submaxillary gland

Sublingual gland

Masseter muscle


20


Salivary Gland Guidelines

• MAJOR salivary glands• Schemas for parotid, submandibular,

salivary gland other• Tumor Size more important than Extension• Lymph node scheme same as other head

and neck sites

• MINOR salivary gland • Code and stage minor salivary gland cancers

according to the site of origin• Example: adenoid cystic carcinoma of

minor salivary gland in hard palate Code primary as C05.0 hard palate

• If no site of origin is described, use C06.9 Head and Neck CSv2 Coding 78

Parotid gland

Submaxillary gland

400 Digastric muscle

700 Facial nerve (p)

750 Facial artery and vein(s)

750 Jugular vein (p)

400 Masseter muscle (p)

400 Mylohyoid muscle (s)

400 Stylohyoid muscle

420 Skin overlying gland (p)

(p) Parotid only(s) Submaxillary

only

Not shown:300 Localized, NOS450 Periosteum of mandible500 Cortex of mandible760 Base of skull405 Spinal accessory nerve

Not shown:800 Further contiguous extension

100 Confined to gland of origin400 Other major salivary gland involved

CS Extension Codes for Major Salivary Glands


PARANASAL SINUSES


Maxillary sinuses

Frontal sinuses

Ethmoid and sphenoid sinuses

Paranasal Sinuses

Ohngren’sline


21


Maxillary Sinus – Ohngren’s Line

Divides maxillary sinus intoInfrastructure (anterior and inferior) (T2)

• Hard palate; middle nasal meatus; nasal cavity; palatine bone

Suprastructure (superior and posterior) (T3)

• Anterior ethmoid sinus; floor of orbit; posterior wall of maxillary sinus


CS Extension Codes – Maxillary Sinus

100 Confined to maxillary sinus300 Localized, NOS

Ohngren’s line divides maxillary sinus into400 Infrastructure (anterior and inferior)

• Hard palate; middle nasal meatus; nasal cavity; palatine bone

600 Suprastructure (superior and posterior)• Anterior ethmoid sinus; floor of orbit; posterior wall of

maxillary sinus660 Ethmoid sinus; pterygoid sinus680 Anterior orbit; frontal sinus; sphenoid sinus; eye675 Base of skull710 Soft palate750 Brain; cranial nerves; dura; nasopharynx


Nasal Cavity and Ethmoid Sinuses

C30.0Nasal cavity

Nasal cavity subsites: septum, floor, lateral wall, and vestibule

Ethmoid sinus subsites: right and left


Extension Codes – Nasal Cavity

000 In situ; non-invasive (Tis)100 Invasive tumor confined to site of origin

Meatus (superior, middle, inferior); Nasal chonchae (superior, middle, inferior); Septum; Tympanic membrane (T1)

300 Localized, NOS (T1)400 Extending to adjacent connective tissue within

nasoethomoidal complex; Nasolacrimal duct (T2)600 Adjacent organs/structures including: Bone of

skull; Choana; Frontal sinus; Hard palate; Nasopharynx (T3)

650 Cribiform plate (T3)660 Maxillary sinus (T3)


22


Extension Codes – Nasal Cavity

670 Medial wall or floor of the orbit (T3)700 Tumor invades: Anterior orbital contents; Skin of

nose; Skin of cheek; Minimal extension to: Anterior cranial fossa; Pterygoid plates; Sphenoid or frontal sinuses (T4a)

760 Tumor invades: Orbital apex; Dura; Brain; Middle cranial fossa; Cranial nerves (other than V2), nasopharynx, or clivus (T4b)


Extension Codes – Ethmoid Sinuses

000 In situ; non-invasive; intraepithelial 120, 160 Confined to one ethmoid sinus (or NOS) without

bone involvement (T1)220, 260 Confined to one ethmoid sinus (or NOS) WITH

bony invasion (involvement of perpendicular plate of ethmoid bone or ethmoid air cells) (T1)

300 Localized, NOS (T1)320 Confined to both ethmoid sinuses without bone

involvement (T2)340 Confined to both ethmoid sinuses (or NOS) WITH

bony invasion (involvement of perpendicular plate of ethmoid bone or ethmoid air cells) (T2)

400 Extension to nasal cavity with/without bony invasion (involvement of perpendicular plate of ethmoid bone or ethmoid air cells) (T2)

Floor; Lateral wall; Nasal vestibule; Septum; Turbinates


Extension Codes – Ethmoid Sinuses

620 Base of skull, NOS (T3)630 Cribriform plate (T3)640 Medial wall or floor of orbit; orbital plate (T3)650 Maxillary sinus (T3)660 Palate (T3)700 Anterior orbital contents; Frontal sinus; Maxillary

nerve; Minimal extension to anterior cranial fossa; Pterygoid plates; Skin of external nose or cheek; Sphenoid sinus (T4a)

720 (660) + (700) (T4a)760 Brain; Clivus; Cranial nerves other than the

maxillary nerve; Dura; Middle cranial fossa; Nasopharynx; Orbital apex or roof (T4b)

780 (660) + (760) (T4b)800 Further contiguous extension (T4)


Middle Ear

External ear Middle ear

Internal ear

C30.1


23


THYROID GLAND


Thyroid Gland


000 In situ (CIS)100 Single invasive tumor confined to thyroid200 Multiple foci confined to thyroid300 Localized, NOS400 Into thyroid capsule but not beyond450 Minimal extrathyroid extension including

strap muscles (T3)480 Pericapsular soft/

connective tissue (T3)

CS Extension - Thyroid (1)

Code 450 Minimal extension

Source: TNM-Interactive, UICC, 1998 Head and Neck CSv2 Coding 92

500 Parathyroid; Recurrent laryngeal or vagus nerve

520 Cricoid cartilage; esophagus; larnynx;SCM muscle

550 Trachea600 Thyroid cartilage; fixed to adjacent

tissues620 Major blood vessels; carotid artery,

jugular vein, thyroid artery/vein700 Bone; skeletal muscle800 Further contiguous extension;

mediastinal tissues; prevertebral fascia

CS Extension - Thyroid (2)

T4a

T4b


24


CS Extension Codes

Source: Medi-clip: Grant’s Atlas Images 4, Head and Neck. Williams and Wilkins, 1998.

520 Esophagus

620 Carotid artery

620 Jugular vein

700 Bone

550 Trachea600 Thyroid cartilage

520 Sternocleido-mastoid muscle

450 Strap muscle


CS Lymph Nodes

• 000 No regional lymph node involvement• 120 Level VI nodes• 130 Cervical nodes, levels I – V; cervical, NOS• 150 Supraclavicular; Level VII nodes (superior

mediastinum)• 500 Regional nodes, NOS• 800 Lymph nodes, NOS• 999 Unknown; not stated


Site-specific Factor 1Solitary vs. Multifocal

• 000 None• 001 Solitary tumor• 002 Multifocal tumor• 999 Insufficient

information; notdocumented inpatient record

Code 001

Code 002Source: TNM-Interactive, UICC, 1998

Head & Neck Case # 2


DISCHARGE SUMMARY

Date of Admission: 11/12/2010 Date of Discharge: 11/21/2010

Admission Diagnosis: Status Post Resection of Laryngeal Cancer.

Procedures Performed: Total laryngectomy, bilateral modified radical neck dissection, pectoralis flap on 11/12/2010.

Indications: This is a 65-year-old female, who had been seen and evaluated with findings of a laryngeal cancer that necessitated resection, as mentioned above.

Hospital Course: Ms. XX was admitted and observed in the ICU setting on postoperative day 1. This was after undergoing the mentioned procedures above. For complete operative details, please refer to a separately dictated note. . . .

Discharge Medications: 1. She is to go back on her previous medications. 2. Pain medicine to be used as needed.

RADIOLOGY REPORT # 1

Date: 10/19/2010

CT Soft Tissue of the Neck w/o Contrast (including thorax)

Addendum: 10/22/2010 – these is soft tissue density thickening/mass density along the left of the airway at the level of the epiglottis. There is asymmetry at the false vocal cords with some prominence of the right false vocal cord.

Clinical History: Swelling in head and neck.

Procedure/Results: Noncontrast images were obtained of the neck and chest at the request of the ordering physician. Technical note is made that lack of intravenous contrast makes visualization of soft tissue structures in the neck difficult. The visualized paranasal sinuses are clear. The salivary glands are normal in size and symmetric with no significant abnormalities, the vascular structures in the neck show no obvious abnormalities with this noncontrast study. There are several normal sized lymph nodes scattered in the neck bilaterally with no evidence of pathologic enlargement. The thyroid gland is normal. The airway is patent with no obvious laryngeal mass noted. Within the chest, the lungs demonstrate emphysematous change bilaterally, predominantly in the apices. There is a calcified granuloma in the superior segment of the right lower lobe and a second in the right lower lobe near the diaphragm. A 6 mm noncalcified nodule is noted in the right middle lobe. Follow-up recommendations in this patient would include a CT in 12 months if there is no increased risk for malignancy. If there is an increased risk, a CT in 6-12 and 18-24 months is recommended. The heart and mediastinum show no significant abnormalities. Atherosclerotic calcification is noted at the aortic arch. In the upper abdomen, a single



hypodensity is noted in the medial segment of the left hepatic lobe which is too small to characterize. No other significant findings are noted.

Impression: 1. Normal sized lymph nodes are identified involving the neck in this patient with a history of swelling; 2. Noncalcified pulmonary nodule in the right middle lobe with follow-up recommended as detailed above.

RADIOLOGY REPORT # 2

Date: 10/31/2010

PET CT of the Whole Body

Clinical History: 65 year-old female with squamous cell carcinoma.

After the administration of 16 mCi FDG, whole body attenuation corrected positron emission tomography was obtained from the base of the skull to the proximal thighs (5 to 8 beds). Coronal, sagittal, transaxial and MIP images were displayed. A noncontrast CT scan was obtained for attenuation correction and anatomical localization purposes. PET CT fusion images were also generated. Standard uptake values were obtained as needed. The glycemia at the time of injection was 86mg/d1.

Findings: Whole body positron emission tomography demonstrates multiple areas of intense increased uptake of FDG. These areas include the laryngeal region which demonstrates heterogeneous uptake with SUV max as high as 7.5. This probably corresponds to patient’s primary laryngeal carcinoma. This is also multiple bilateral hypermetabolic lymphadenopathy affecting cervical chains bilaterally (deep and superficial as well as posterior triangle). The most intense hypermetabolic lymphadenopathy is the right midcervical region with SUV max of 80. No evidence of any hypermetabolic activity in the lungs. The small 0.6 cm nodule seen in right middle lobe does not show any FDG metabolism. However, it is too small for the FDG PET resolution. There was atherosclerosis seen in the aorta and major vessels. There is otherwise, normal excretion of the kidneys and bladder.

Impression:

1. Hypermetabolic large laryngeal lesion that is compatible with patient’s primary laryngeal cancer.

2. Hypermetabolic metastatic cervical lymphadenopathy bilaterally more pronounced on the right side.

3. No evidence of distant metastatic disease.

OPERATIVE REPORT



Date: 11/12/2010

Preoperative Diagnosis: Laryngeal Cancer with Cervical Metastasis Bilaterally and Base of Tongue Extension. Procedures performed:

1. Total laryngectomy with right modified neck dissection and base of tongue resection. 2. Left modified neck dissection. 3. Pectoralis myofascial flap reconstruction. Specimens: 1. Right neck contents. 2. Left neck contents. 3. Larynx. Indications: This is a 65-year-old female who had been seen and evaluated for hoarseness x 3 months, upon evaluation with an initial scope and a panendoscopy with biopsies. This was confirmed to be squamous cell carcinoma, invasive.

Procedure: Informed consent was obtained prior to the procedure. On the date of the surgery, the patient was identified and brought to the operating room and placed on the table in supine position. General endotracheal tube anesthesia as well as an A-line and a Foley was placed and the table turned to 90 degrees to face the operating surgeon. A nasogastric feeding tube was then placed, confirmed and secured at the membranous columella. The area of the neck bilaterally, as well as the chest were prepped and draped in the usual fashion for the above-mentioned procedures. . . . Attention was initially turned to the left side. On this side a modified neck dissection was planned and at the end the internal jugular and the accessory muscles were preserved. . . . Attention was then turned to the contralateral side. This was treated in a similar manner up to the point where metastatic nodes were identified with significant extension into the lateral skull base area. At this juncture it was necessary to suture ligate the external carotid branch of the carotid artery as the mass was completely adherent. The mass was also adherent to the hypoglossal nerve; however, this was carefully dissected off and saved. Dissection superiorly was, therefore, continued carefully to the superior extent of the mass which was at the skull base. Once all the structures mentioned on the contralateral side were preserved the mass was removed en bloc. On this side the neck dissection resulted in sacrifice of internal jugular vein and sternocleidomastoid muscle. Accessory nerve was preserved. Once this was done, attention was turned to the total laryngectomy portion. Initial dissection was done by identifying the trachea and dissecting the thyroid gland off of the anterior tracheal wall by dividing the isthmus. All surrounding tissue was also removed. An incision was then made at the second ring and dissected circumferentially, sparing the putty wall. . . . Attention was then turned to dissecting the laryngeal structure off of the surrounding strap muscles. Once this was done the thyroid cornu was identified and constrictor musculature was dissected off of the lateral attachments. This was initially done on the left side and subsequently on the right. Once this was completed the hyoid bone was skeletonized, working medially to laterally, and the larynx was entered through the left side. This was done by making a small incision and, with complete visualization, entering the piriform sinus wall, conserving as much mucosa as necessary and as possible with no signs of involvement by the tumor. The larynx was therefore entered on the left side and dissection carried out in inferiorly and around onto the right side. At the superior extent, the tumor was easily visible and the tongue base could be palpated. The right tongue base was found to be full with indications of potential tumor involvement. Dissection was therefore extended to



this point, after which the larynx was brought out en bloc. . . . At this point margins were taken at the tongue base and these were found to be negative. Once this was completed and all frozen sectioning back with negative results closure was begun by fashioning a pectoralis myocutaneous myofascial flap from the right-hand side. . . . In brief, a small stomal inclusion incision was made on the skin included within the apron incision and the inferior residual trachea was freed from surrounding fascia and tunneled outward. The stoma was then secured with 4-0 chromic sutures. The superior end of the stoma was left for closure with the incision. The pectoralis flap was then used to provide closure, particularly on the right side where the carotid sheath had been extensively dissected. This flap was tacked down with 3-0 Vicryls. Once this was completed closure of all incisions was done over Hemovac drains. This was done in a layered manner using Vicryl stitches. Overall skin was closed using staples. The remaining superior aspect of the stoma was then closed using Vicryl. . . . The patient tolerated the procedure well. PATHOLOGY REPORT # 1

Date: 10/24/2010

Clinical Diagnosis: Laryngeal Lesion. Specimen: 1-2. Biopsies of Supraglottic Mass of the Larynx

Final Diagnosis: Invasive Poorly Differentiated Squamous Cell Carcinoma.

Gross: Received fresh are multiple fragments of rubbery, tan to pink tissue measuring 1 x 0.8 x 0.2 cm. Invasive squamous carcinoma. 2. Received in formalin are multiple fragments of rubbery, lobulated, pink to dark brown tissue measuring 1 x 0.3 cm.

PATHOLOGY REPORT # 2

Date: 11/12/2010

Procedure:

1. Total laryngectomy with right modified neck dissection and base of tongue resection. 2. Left modified neck dissection. 3. Pectoralis myofascial flap reconstruction.

Clinical Diagnosis: Squamous Cell Carcinoma of the Larynx. Specimen: 1. Left anterior lobe level V node. 2. High left jugular node. 3. Left modified neck dissection (stitch is high level II). 4. Right modified neck dissection - 2A, 2B, 3, 4, and 5 (short superior, long lateral). 5. Left base of tongue.



6. Left mid tongue base. 7. Right tongue base. 8. Right mid tongue base. 9. Mid tongue base. 10. Total larynx and base of tongue. 11. Re-excision of base of tongue - suture on left. 12. Right lateral tongue.

Final Diagnosis:

1. Left anterior lobe level V node: one lymph node with metastatic squamous cell carcinoma

2. High left jugular node: one lymph node with metastatic squamous cell carcinoma

3. Left modified neck dissection: metastatic squamous cell carcinoma to 5 (including extranodal extension), of 12 lymph nodes (3 of 10 in the high level and 2 of 2 in the lower portion)

4. Right Modified Neck Dissection: metastatic squamous cell carcinoma to 7 lymph nodes (including extranodal invasion) of level II; 2 of 2 level III; 1 of 1 level IV; and 2 (including extranodal invasion) of 4 level V lymph nodes

5. Left base of tongue

6. Left mid base of tongue

7. Right tongue base

8. Right mid tongue base

9. Mid tongue base

10. Laryngectomy with base of tongue: deeply infiltrating poorly differentiated squamous cell carcinoma of the epiglottis with no carcinoma identified in resection margins

11. Re-excision of base of tongue - suture on left

12. Right lateral tongue

P.S.: Specimens 1-4 and 10 positive for carcinoma; Specimens 5-9, 11 and 12 no cancer seen.

Gross: 1. Received fresh, labeled left anterior lobe level V node, is a 0.7 x 0.5 x 0.3 cm lymph node. Bisected and entirely submitted following frozen section.

2. Received in formalin, labeled high left jugular node, is a 0.6 x 0.3 x 0.3 cm rubbery, firm, tan to pink lymph node. Bisected and entirely submitted.



3. Received in formalin, labeled left modified neck dissection without stitch at level 2, is an8.5 x 5.5 x 3 cm tissue with orientation, stitch is high at level 2. Specimen is divided in half. . . . Lymph nodes are identified and entirely submitted . . .

4. Received in formalin is a right modified neck dissection labeled 2A, 2B, 3, 4, 5. The specimen has orientation, short: suture superior, long suture lateral. Specimen includes some fatty tissue. Part of the sternocleidomastoid. The jugular vein looks unremarkable. . . . Lymph nodes are identified and entirely submitted . . .

5. Received fresh is a 1.9 x 0.6 x 0.6 cm rubbery, pink-tan piece of tissue.

6. Received fresh is a 1.2 x 0.6 x 0.6 cm piece of rubbery, pink to tan tissue.

7. Received fresh are two pieces of rubbery, lobulated, tan-pink tissue measuring together 1.5 x 1 x 0.4 cm.

8. Received fresh is a 1.8 x 0.4 x 0.3 cm piece of rubbery, tan to yellow tissue.

9. Received fresh are two fragments of rubbery, pink-tan tissue measuring together 1.5 x 1.5 x 0.5 cm.

10. Received in formalin is a 7 cm from proximal to distal, 6 cm from right to left, 5.2 cm from anterior to posterior larynx. In the epiglottis there is a 2.2 x 2.5 cm ulcerated infiltrative lesion that occupies and destroys almost the entire epiglottis. The tumor extends inferiorly into the anterior commissure and the medial parts of the left and right true vocal cords. The lesion is at 3.5 cm from the distal margin (which contains tracheal cartilage). The tumor is widely separated from the mucosal margins of the laryngeal portion of the specimen. The tumor on cut surface is firm and light gray. The tumor invades superior to the thyroid cartilage 6 mm anteriorly, but is clearly separated from anterior resection margins.

11. Received in formalin is a 6 cm in length x 1.5 x 0.7 cm fragment indicated as tongue. The specimen has orientation with a short suture indicating the left side. Surgical margin is inked black. Microscopic:

10. The grossly described tumor which destroys the epiglottis is a poorly differentiated squamous cell carcinoma. It infiltrates deeply. No tumor is identified in the resection margins (a right superolateral section has fragmented margin on the slide; the tumor was clearly separated from that connective tissue margin grossly). Thus no carcinoma is identified in the margins of the specimen.



FIELD# FIELD NAME CODE AND RATIONALE/DOCUMENTATION 1 Patient Name -

CANCER IDENTIFICATION 2 Primary Site 3 Histology 4 Behavior 5 Grade 6 Grade system type 7 Grade system value 8 Lymph-vascular invasion

STAGE OF DISEASE AT DIAGNOSIS 9 CS Mets at Dx - Bone

10 CS Mets at Dx - Lung 11 CS Mets at Dx - Liver 12 CS Mets at DX - Brain

COLLABORATIVE STAGING 13 CS Tumor Size 14 CS Extension 15 CS Tumor Size/Ext Eval 16 CS Lymph Nodes 17 CS Lymph Nodes Eval 18 Regional Nodes Positive 19 Regional Nodes Examined 20 CS Mets at Dx 21 CS Mets Eval 22 CS Site-Specific Factor 1 23 CS Site-Specific Factor 2 24 CS Site-Specific Factor 3 25 CS Site-Specific Factor 4 26 CS Site-Specific Factor 5 27 CS Site-Specific Factor 6 28 CS Site-Specific Factor 7 29 CS Site-Specific Factor 8 30 CS Site-Specific Factor 9 31 CS Site-Specific Factor 10 32 CS Site-Specific Factor 11 33 CS Site-Specific Factor 12 34 CS Site-Specific Factor 13 35 CS Site-Specific Factor 14 36 CS Site-Specific Factor 15 37 CS Site-Specific Factor 16 38 CS Site-Specific Factor 17 39 CS Site-Specific Factor 18 40 CS Site-Specific Factor 19 41 CS Site-Specific Factor 20 42 CS Site-Specific Factor 21 43 CS Site-Specific Factor 22 44 CS Site-Specific Factor 23 45 CS Site-Specific Factor 24 46 CS Site-Specific Factor 25

SUPRAGLOTTIC LARYNX SCHEMA CSv2 1 03/10/2010

CS Tumor Size Note 1: Code the specific tumor size as stated in the medical record. Use code 992, 994, or 995 if the

physician's statement about T value is the ONLY information available about the size of the tumor. (Refer to the CS Extension table for instructions on coding extension.) Code Description 000 No mass/tumor found

001-988 001 - 988 millimeters (code exact size in millimeters) 989 989 millimeters or larger 990 Microscopic focus or foci only, no size of focus given 991 Described as "less than 1 cm" 992 Described as "less than 2 cm," or "greater than 1 cm," or "between 1 cm and 2 cm"

Stated as T1 with no other information on size 993 Described as "less than 3 cm," or "greater than 2 cm," or "between 2 cm and 3 cm" 994 Described as "less than 4 cm," or "greater than 3 cm," or "between 3 cm and 4 cm"

Stated as T2 with no other information on size 995 Described as "less than 5 cm," or "greater than 4 cm," or "between 4 cm and 5 cm"

Stated as T3 with no other information on size 996 Described as "greater than 5cm" 999 Unknown; size not stated

CS Extension Note 1: Use code 450 for localized tumor ONLY if no information is available to assign codes 100 through 400. Note 2: Use code 685, 735, 810, or 815 if the physician's assignment of T category is the ONLY information

available about the extent of the tumor.


TNM 6 Map

SS77 Map

SS2000 Map

000 In situ; noninvasive; intraepithelial Tis Tis IS IS 100 Invasive tumor with normal vocal cord mobility confined to:

Supraglottis (one subsite): Aryepiglottic fold Arytenoid cartilage Corniculate cartilage Cuneiform cartilage Epilarynx, NOS False cords Ventricular bands Ventricular cavity Ventricular fold Infrahyoid epiglottis Laryngeal cartilage, NOS Laryngeal (posterior) surface of epiglottis Suprahyoid epiglottis (including tip, lingual {anterior} and laryngeal surfaces) Stated as T1 with no further information on extension

T1 T1 L L

200 Tumor involves more than one subsite of supraglottis as listed in code 100 WITHOUT fixation of larynx or NOS

T2 T2 L L

230 Tumor involves glottis WITHOUT fixation of larynx or NOS T2 T2 L L 250 Involvement of any structures in supraglottic larynx (code 100)

and larynx with impaired vocal cord mobility T2 T2 L L


300 OBSOLETE DATA RETAINED V0200 Tumor involves adjacent region(s) of larynx

ERROR T2 L L

320 Tumor involves regions outside supraglottis, including: Mucosa of base of tongue Vallecula Medial wall of pyriform sinus WITHOUT fixation of larynx or NOS

T2 T2 RE RE

350 OBSOLETE DATA RETAINED V0200 Impaired mobility split between codes 250 and 360, improved mapping Impaired vocal cord mobility

T2 T2 L L

360 Involvement of any structures in code 320 with impaired vocal cord mobility

T2 T2 RE RE

375 Stated as T2 with no other information on extension T2 T2 L L 390 Involvement of subglottis WITHOUT vocal cord fixation T3 T3 L L 395 390 + 320

(Subglottis + any structure in code 320 WITHOUT vocal cord fixation)

T3 T3 RE RE

400 Involvement of any structures in supraglottis (code 100), glottis, and subglottis WITH vocal cord fixation

T3 T3 L L

450 Localized, NOS T1 T1 L L 520 Paraglottic space WITHOUT vocal cord fixation T3 T3 RE RE 600 OBSOLETE DATA RETAINED V0200

Improved mapping, see code 320 Tumor involves region outside the supraglottis WITHOUT fixation, including: Medial wall pyriform sinus Mucosa of base of tongue Vallecula

ERROR T2 RE RE

620 OBSOLETE DATA RETAINED V0200 Code 600 WITH fixation

ERROR T3 RE RE

625 Involvement of any structures in codes 320 or 520 WITH vocal cord fixation

T3 T3 RE RE

650 Hypopharynx, NOS Postcricoid area Pre-epiglottic tissues

T3 T3 RE RE

660 Deep base of tongue T3 T3 RE RE 670 OBSOLETE DATA CONVERTED V0200

See code 690 Cricoid cartilage

ERROR ERROR ERROR ERROR

680 Minor thyroid cartilage erosion (e.g., inner cortex) T3 T3 RE D 685 Stated as T3 with no other information on extension T3 T3 RE RE 690 Cricoid cartilage T4a T4a RE RE 695 690 + 680

(Cricoid cartilage + Minor thyroid cartilage erosion) T4a T4a RE D

700 Extension to/through: Esophagus Oropharynx Soft tissues of neck Thyroid cartilage (except minor erosion, see code 680) Thyroid gland

T4a T4a D D


720 Extension to/through: Strap muscle(s) Omohyoid Sternohyoid Sternothyroid Thyrohyoid Skin

T4a T4a D D

730 Extension to/through: Deep extrinsic muscle of tongue Trachea

T4a T4a D D

735 Stated as T4a with no other information on extension T4a T4a RE RE 800 Further contiguous extension, including:

Mediastinal structures Prevertebral space Carotid artery (encased)

T4b T4b D D

810 Stated as T4b with no other information on extesnion ERROR T4b D D 815 Stated as T4 NOS with no other information on extension T4NOS T4NOS RE RE 950 No evidence of primary tumor T0 T0 U U 999 Unknown extension

Primary tumor cannot be assessed Not documented in patient record

TX TX U U

CS Tumor Size/Ext Eval


0 Does not meet criteria for AJCC pathologic staging:

No surgical resection done. Evaluation based on physical examination, imaging examination, or other non-invasive clinical evidence. No autopsy evidence used.

c


No surgical resection done. Evaluation based on endoscopic examination, diagnostic biopsy, including fine needle aspiration biopsy, or other invasive techniques, including surgical observation without biopsy. No autopsy evidence used.

c

2 Meets criteria for AJCC pathologic staging:

No surgical resection done, but evidence derived from autopsy (tumor was suspected or diagnosed prior to autopsy)

p

3 Either criteria meets AJCC pathologic staging:

Surgical resection performed WITHOUT pre-surgical systemic treatment or radiation OR surgical resection performed, unknown if pre-surgical systemic treatment or radiation performed AND Evaluation based on evidence acquired before treatment, supplemented or modified by the additional evidence acquired during and from surgery, particularly from pathologic examination of the resected specimen.

No surgical resection done. Evaluation based on positive biopsy of highest T classification.

p


5 Does not meet criteria for AJCC y-pathologic (yp) staging:

Surgical resection performed AFTER neoadjuvant therapy and tumor size/extension based on clinical evidence, unless the pathologic evidence at surgery (AFTER neoadjuvant) is more extensive (see code 6).

c

6 Meets criteria for AJCC y-pathologic (yp) staging:

Surgical resection performed AFTER neoadjuvant therapy AND tumor size/extension based on pathologic evidence, because pathologic evidence at surgery is more extensive than clinical evidence before treatment.

yp

8 Meets criteria for autopsy (a) staging:

Evidence from autopsy only (tumor was unsuspected or undiagnosed prior to autopsy)

a

9 Unknown if surgical resection done Not assessed; cannot be assessed Unknown if assessed Not documented in patient record

c

CS Lymph Nodes Note 1: For head and neck schemas, this field includes all lymph nodes defined as Levels I-VII and Other by

AJCC. The complete definitions are provided in the General Instructions. Note 2: For head and neck schemas, additional information about lymph nodes (size of involved nodes,

extracapsular extension, levels involved, and location of involved nodes above or below the lower border of the cricoid cartilage) is coded in Site-Specific Factors 1, 3-9.

Note 3: If laterality of lymph nodes is not specified, assume nodes are ipsilateral. Midline nodes are considered ipsilateral.

Note 4: For head and neck cancers, if lymph nodes are described only as "supraclavicular", try to determine if they are in Level IV (deep to the sternocleidomastoid muscle, in the lower jugular chain) or Level V (in the posterior triangle, inferior to the transverse cervical artery) and code appropriately. If the specific level cannot be determined, consider them as Level V nodes.

Note 5: The description of lymph nodes has been standardized across the head and neck schemas. All lymph node levels and groups listed here are considered regional nodes for AJCC staging. Summary Stage 1977 and Summary Stage 2000 divide these nodes into regional and distant groups.

Note 6: Level III nodes have been moved from code 100 in CSV1 to code 110. Level IV nodes have been added to code 120.

Code Description TNM 7

Map TNM 6 Map

SS77 Map

SS2000 Map

000 None; no regional lymph node involvement N0 N0 NONE NONE 100 Single positive ipsilateral regional node:

Level II node- Upper jugular Jugulodigastric (subdigastric) Upper deep cervical Level VI node – Anterior compartment group Laterotracheal Paralaryngeal Paratracheal - above suprasternal notch Perithyroidal Precricoid (Delphian) Pretracheal - above suprasternal notch Recurrent laryngeal Cervical, NOS Deep cervical, NOS Internal jugular NOS: Regional lymph node, NOS

^ * RN RN


110 Single positive ipsilateral regional node: Level I Level IA - Submental Level IB - Submandibular (submaxillary), sublingual Level III - Middle jugular Middle deep cervical Retropharyngeal

^ * D RN

120 Single positive ipsilateral regional node: Level IV - Lower jugular Jugulo-omohyoid (supraomohyoid) Lower deep cervical Virchow node Level V node - Posterior triangle group Level VA - Spinal accessory Level VB - Transverse cervical, supraclavicular (see Note 4) Level VII node - Superior mediastinal group (for other mediastinal nodes see CS Mets at DX) Esophageal groove Paratracheal - below suprasternal notch Pretracheal - below suprasternal notch Other groups: Facial: Buccinator (buccal) Mandibular Nasolabial Parotid: Infraauricular Intraparotid Periparotid Preparotid Parapharyngeal Retroauricular (mastoid) Suboccipital

^ * D D

180 Stated as N1, no other information N1 N1 RN RN 190 Stated as N2a, no other information N2a N2a RN RN 200 Multiple positive ipsilateral nodes listed in code 100 ^ * RN RN 210 Multiple positive ipsilateral nodes, any listed in code 110

(WITH or WITHOUT nodes listed in code 100) ^ * D RN

220 Multiple positive ipsilateral nodes, any listed in code 120 (WITH or WITHOUT nodes listed in code 100 or 110)

^ * D D

290 Stated as N2b, no other information N2b N2b RN RN 300 Regional lymph nodes listed in code 100:

Positive ipsilateral node(s), not stated if single or multiple ^ * RN RN

310 Regional lymph nodes listed in code 110: Positive ipsilateral node(s), not stated if single or multiple

^ * D RN

320 Regional lymph nodes listed in code 120: Positive ipsilateral node(s), not stated if single or multiple

^ * D D

400 Regional lymph nodes listed in code 100: Positive bilateral or contralateral nodes

^ * RN RN

410 Regional lymph nodes, any listed in code 110: Positive bilateral or contralateral nodes (WITH or WITHOUT nodes listed in code 100)

^ * D RN

420 Regional lymph nodes, any listed in code 120: Positive bilateral or contralateral nodes (WITH or WITHOUT nodes listed in code 100 or 110

^ * D D

490 Stated as N2c, no other information N2c N2c RN RN 500 Regional lymph nodes as listed in code 100:

Positive node(s), not stated if ipsilateral, or bilateral, or contralateral,AND not stated if single or multiple

^ * RN RN


510 Regional lymph nodes, any listed in code 110: delete any Positive node(s), not stated if ipsilateral, or bilateral, or contralateral,AND not stated if single or multiple

^ * D RN

520 Regional lymph nodes, any listed in code 120: delete any Positive node(s), not stated if ipsilateral, or bilateral, or contralateral,AND not stated if single or multiple

^ * D D

600 Stated as N2NOS N2NOS N2NOS RN RN 700 Stated as N3, no other information N3 N3 RN RN 800 Lymph nodes, NOS, no other information ^ * RN RN 999 Unknown; not stated

Regional lymph nodes cannot be assessed Not documented in patient record

NX NX U U

^ For codes 100-120, 200-220, 300-320, 400-420, 500-520, and 800 ONLY, the N category for AJCC 7th Edition staging is assigned based on the value of Site-Specific Factor 1, Size of Lymph Nodes, using the extra table Lymph Nodes Size Table, for this site.

* For codes 100-120, 200-220, 300-320, 400-420, 500-520, and 800 ONLY, the N category for AJCC 6th Edition staging is assigned based on the value of Site-Specific Factor 1, Size of Lymph Nodes, using the extra table Lymph Nodes Size Table, for this site.

CS Lymph Nodes Eval Note 1: This field is used primarily to derive the staging basis for the N category in the TNM system. It records

how the code for the item "CS Lymph Nodes" was determined based on the diagnostic methods employed and their intent.

Note 2: In the 7th edition of the AJCC manual, the clinical and pathologic classification rules for the N category were changed to reflect current medical practice. The N is designated as clinical or pathologic based on the intent (workup versus treatment) matching with the assessment of the T classification. When the intent is workup, the staging basis is clinical, and when the intent is treatment, the staging basis is pathologic. A. Microscopic assessment including biopsy of regional nodes or sentinel nodes if being performed as part of the workup to choose the treatment plan, is therefore part of the clinical staging. When it is part of the workup, the T category is clinical, and there has not been a resection of the primary site adequate for pathologic T classification (which would be part of the treatment). B. Microscopic assessment of regional nodes if being performed as part of the treatment is therefore part of the pathologic staging. When it is part of the treatment, the T category is pathologic, and there has been a resection of the primary site adequate for pathologic T classification (all part of the treatment).

Note 3: Microscopic assessment of the highest N category is always pathologic (code 3). Note 4: If lymph node dissection is not performed after neoadjuvant therapy, use code 0 or 1. Note 5: Only codes 5 and 6 are used if the node assessment is performed after neoadjuvant therapy.



No regional lymph nodes removed for examination. Evidence based on physical examination, imaging examination, or other non-invasive clinical evidence. No autopsy evidence used.

c

1 Does not meet criteria for AJCC pathologic staging based on at least one of the following criteria:

No regional lymph nodes removed for examination. Evidence based on endoscopic examination, or other invasive techniques including surgical observation, without biopsy. No autopsy evidence used. OR Fine needle aspiration, incisional core needle biopsy, or excisional biopsy of regional lymph nodes or sentinel nodes as part of the diagnostic workup, WITHOUT removal of the primary site adequate for pathologic T classification (treatment).

c


2 Meets criteria for AJCC pathologic staging:

No regional lymph nodes removed for examination, but evidence derived from autopsy (tumor was suspected or diagnosed prior to autopsy).

p

3 Meets criteria for AJCC pathologic staging based on at least one of the following criteria:

Any microscopic assessment of regional nodes (including FNA, incisional core needle bx, excisional bx, sentinel node bx or node resection), WITH removal of the primary site adequate for pathologic T classification (treatment) or biopsy assessment of the highest T category. OR Any microscopic assessment of a regional node in the highest N category, regardless of the T category information.

p

5 Does not meet criteria for AJCC y-pathologic (yp) staging:

Regional lymph nodes removed for examination AFTER neoadjuvant therapy AND lymph node evaluation based on clinical evidence, unless the pathologic evidence at surgery (AFTER neoadjuvant) is more extensive (see code 6).

c

6 Meets criteria for AJCC y-pathologic (yp) staging:

Regional lymph nodes removed for examination AFTER neoadjuvant therapy AND lymph node evaluation based on pathologic evidence, because the pathologic evidence at surgery is more extensive than clinical evidence before treatment.

yp

8 Meets criteria for AJCC autopsy (a) staging:

Evidence from autopsy; tumor was unsuspected or undiagnosed prior to autopsy.

a

9 Unknown if lymph nodes removed for examination Not assessed; cannot be assessed Unknown if assessed Not documented in patient record

c

Reg LN Pos Note: Record this field even if there has been preoperative treatment.

Code Description

00 All nodes examined negative.



95 Positive aspiration or core biopsy of lymph node(s)



99 Unknown if nodes are positive; not applicable Not documented in patient record


Reg LN Exam

Code Description


01-89 1 - 89 nodes examined (code exact number of regional lymph nodes examined)

90 90 or more nodes examined

95 No regional nodes removed, but aspiration or core biopsy of regional nodes performed

96 Regional lymph node removal documented as sampling and number of nodes unknown/not stated

97 Regional lymph node removal documented as dissection and number of nodes unknown/not stated

98 Regional lymph nodes surgically removed but number of lymph nodes unknown/not stated and not documented as sampling or dissection; nodes examined, but number unknown

99 Unknown if nodes were examined; not applicable or negative Not documented in patient record

CS Mets at DX

Note: Supraclavicular and transverse cervical lymph nodes are coded in CS Lymph Nodes because they are categorized as N rather than M in AJCC TNM.


TNM 6 Map

SS77 Map

SS2000 Map

00 No; none M0 M0 NONE NONE 10 Distant lymph node(s)

Mediastinal Distant lymph node(s), NOS

M1 M1 D D

40 Distant metastases except distant lymph node(s)(code 10) Carcinomatosis

M1 M1 D D

50 (10) + (40) Distant lymph node(s) plus other distant metastases

M1 M1 D D

60 Distant metastasis, NOS Stated as M1, NOS

M1 M1 D D

99 Unknown if distant metastasis Distant metastasis cannot be assessed Not documented in patient record

M0 MX U U


CS Mets Eval Note: This item reflects the validity of the classification of the item CS Mets at DX only according to the

diagnostic methods employed.


0 Does not meet criteria for AJCC pathologic staging of distant metastasis:

Evaluation of distant metastasis based on physical examination, imaging examination, and/or other non-invasive clinical evidence. No pathologic examination of metastatic tissue performed or pathologic examination was negative.

c

1 Does not meet criteria for AJCC pathologic staging of distant metastasis:

Evaluation of distant metastasis based on endoscopic examination or other invasive technique, including surgical observation without biopsy. No pathologic examination of metastatic tissue performed or pathologic examination was negative.

c

2 Meets criteria for AJCC pathologic staging of distant metastasis:

No pathologic examination of metastatic specimen done prior to death, but positive metastatic evidence derived from autopsy (tumor was suspected or diagnosed prior to autopsy).

p

3 Meets criteria for AJCC pathologic staging of distant metastasis:

Specimen from metastatic site microscopically positive WITHOUT pre-surgical systemic treatment or radiation OR specimen from metastatic site microscopically positive, unknown if pre-surgical systemic treatment or radiation performed OR specimen from metastatic site microscopically positive prior to neoadjuvant treatment.

p

5 Does not meet criteria for AJCC y-pathologic (yp) staging of distant metastasis:

Specimen from metastatic site microscopically positive WITH pre-surgical systemic treatment or radiation, BUT metastasis based on clinical evidence.

c

6 Meets criteria for AJCC y-pathologic (yp) staging of distant metastasis: Specimen from metastatic site microscopically positive WITH pre-surgical systemic treatment or radiation, BUT metastasis based on pathologic evidence.

yp

8 Meets criteria for AJCC autopsy (a) staging of distant metastasis:

Evidence from autopsy based on examination of positive metastatic tissue AND tumor was unsuspected or undiagnosed prior to autopsy.

a

9 Not assessed; cannot be assessed Unknown if assessed Not documented in patient record

c


CS Site-Specific Factor 1 Size of Lymph Nodes Note: Code the largest diameter, whether measured clinically or pathologically, of any involved regional lymph

node(s). Do not code the size of any nodes coded in CS Mets at DX.

Code Description 000 No involved regional nodes

001-979 001-979 millimeters (code exact size in millimeters) 980 980 millimeters or larger

981-988 OBSOLETE DATA CONVERTED V0200 See code 980 981-988 millimeters

989 OBSOLETE DATA CONVERTED V0200 See code 980 989 millimeters or larger

990 Microscopic focus or foci only, no size of focus given 991 Described as "less than 1cm" 992 Described as "less than 2cm" or "greater than 1cm" or "between 1cm and 2cm" 993 Described as "less than 3cm" or "greater than 2cm" or "between 2cm and 3cm" 994 Described as "less than 4cm" or "greater than 3cm" or "between 3cm and 4cm" 995 Described as "less than 5cm" or "greater than 4cm" or "between 4cm and 5cm" 996 Described as "less than 6cm" or "greater than 5cm" or "between 5cm and 6cm" 997 Described as "more than 6cm" 999 Regional lymph node(s) involved, size not stated

Unknown if regional lymph node(s) involved Not documented in patient record

CS Site-Specific Factor 2 OBSOLETE - Extracapsular Extension, Lymph Nodes for Head and Neck CS Site-Specific Factor 3 Levels I-III, Lymph Nodes for Head and Neck Note: Site-Specific Factors 3-6 are used to code the presence or absence of lymph node involvement in each of

7 different levels and other groups defined by AJCC. The definitions of the levels are the same for all applicable head and neck sites. One digit is used to represent lymph nodes of a single level, with the three digits of Site-Specific Factor 3 representing lymph nodes of, respectively, Levels I-III; the digits of Site-Specific Factor 4 representing lymph nodes of Levels IV and V and the retropharyngeal nodes; the digits of Site-Specific Factor 5 representing lymph nodes of Levels VI and VII and the facial nodes; and the digits of Site-Specific Factor 6 representing the remaining Other groups as defined by AJCC. In each digit, a code 1 means Yes, the nodes are involved. Code Description 000 No lymph node involvement in Levels I, II, or III 100 Level I lymph node(s) involved 010 Level II lymph node(s) involved 001 Level III lymph node(s) involved 110 Level I and II lymph nodes involved 101 Level I and III lymph nodes involved 011 Level II and III lymph nodes involved


111 Level I, II and III lymph nodes involved 999 Unknown if regional lymph node(s) involved, not stated


CS Site-Specific Factor 4 Levels IV-V and Retropharyngeal Lymph Nodes for Head and Neck Note: Site-Specific Factors 3-6 are used to code the presence or absence of lymph node involvement in each of

7 different levels and other groups defined by AJCC. The definitions of the levels are the same for all applicable head and neck sites. One digit is used to represent lymph nodes of a single level, with the three digits of Site-Specific Factor 3 representing lymph nodes of, respectively, Levels I-III; the digits of Site-Specific Factor 4 representing lymph nodes of Levels IV and V and the retropharyngeal nodes; the digits of Site-Specific Factor 5 representing lymph nodes of Levels VI and VII and the facial nodes; and the digits of Site-Specific Factor 6 representing the remaining Other groups as defined by AJCC. In each digit, a code 1 means Yes, the nodes are involved.

Code Description 000 No lymph node involvement in Levels IV or V or retropharyngeal 100 Level IV lymph node(s) involved 010 Level V lymph node(s) involved 001 Retropharyngeal nodes involved 110 Level IV and V lymph nodes involved 101 Level IV and retropharyngeal nodes involved 011 Level V and retropharyngeal nodes involved 111 Level IV and V and retropharyngeal lymph nodes involved 999 Unknown if regional lymph node(s) involved, not stated


CS Site-Specific Factor 5 Levels VI-VII and Facial Lymph Nodes for Head and Neck Note 1: Site-Specific Factors 3-6 are used to code the presence or absence of lymph node involvement in each

of 7 different levels and other groups defined by AJCC. The definitions of the levels are the same for all applicable head and neck sites. One digit is used to represent lymph nodes of a single level, with the three digits of Site-Specific Factor 3 representing lymph nodes of, respectively, Levels I-III; the digits of Site-Specific Factor 4 representing lymph nodes of Levels IV and V and the retropharyngeal nodes; the digits of Site-Specific Factor 5 representing lymph nodes of Levels VI and VII and the facial nodes; and the digits of Site-Specific Factor 6 representing the remaining Other groups as defined by AJCC. In each digit, a code 1 means Yes, the nodes are involved.

Note 2: Facial nodes including buccinator, mandibular, and nasolabial lymph nodes.

Code Description 000 No lymph node involvement in Levels VI or VII or facial nodes 100 Level VI lymph node(s) involved 010 Level VII lymph node(s) involved 001 Facial lymph node(s) involved 110 Level VI and VII lymph nodes involved 101 Level VI and facial nodes involved 011 Level VII and facial nodes involved


111 Level VI and VII and facial lymph nodes involved 999 Unknown if regional lymph node(s) involved, not stated


CS Site-Specific Factor 6 Parapharyngeal, Parotid, and Suboccipital/Retroauricular Lymph Nodes, Lymph Nodes for Head and Neck Note: Site-Specific Factors 3-6 are used to code the presence or absence of lymph node involvement in each of

7 different levels and other groups defined by AJCC. The definitions of the levels are the same for all applicable head and neck sites. One digit is used to represent lymph nodes of a single level, with the three digits of Site-Specific Factor 3 representing lymph nodes of, respectively, Levels I-III; the digits of Site-Specific Factor 4 representing lymph nodes of Levels IV and V and the retropharyngeal nodes; the digits of Site-Specific Factor 5 representing lymph nodes of Levels VI and VII and the facial nodes; and the digits of Site-Specific Factor 6 representing the remaining Other groups as defined by AJCC. In each digit, a code 1 means Yes, the nodes are involved.

Code Description 000 No involvement of any group:

Parapharyngeal lymph nodes Parotid (preauricular, periparotid, and/or intraparotid) lymph nodes Suboccipital/retroauricular lymph nodes

100 Parapharyngeal lymph node(s) involved 010 Parotid (preauricular, periparotid, and/or intraparotid) lymph node(s) involved 001 Suboccipital/retroauricular lymph node(s) involved 110 Involvement of two groups:

Parapharyngeal lymph nodes Parotid (preauricular, periparotid, and/or intraparotid) lymph nodes

101 Involvement of two groups: Parapharyngeal lymph nodes Suboccipital/retroauricular lymph nodes

011 Involvement of two groups: Parotid (preauricular, periparotid, and/or intraparotid) lymph nodes Suboccipital lymph nodes

111 Involvement of three groups: Parapharyngeal lymph nodes Parotid (preauricular, periparotid, and/or intraparotid) lymph nodes Suboccipital/retroauricular lymph nodes

999 Unknown if regional lymph node(s) involved, not stated Regional lymph nodes cannot be assessed Not documented in patient record


CS Site-Specific Factor 7 Upper and Lower Cervical Node Levels Note 1: AJCC requires that nodes be designated as involving upper or lower levels within the neck. The

boundary between upper and lower levels is the lower border of the cricoid cartilage. Note 2: Nodes in Levels I, II, and III are upper level nodes. Nodes in Level IV and VII are lower level nodes.

Level VA nodes are upper level nodes, and Level VB are lower level nodes. Level VI nodes span both upper and lower levels. Nodes included in "Other groups" (Facial, Parotid, Parapharyngeal, Retropharyngeal, Retroauricular, and Suboccipital) are all upper level nodes.

Note 3: Code the location of nodal involvement in relation to the lower border of the cricoid cartilage of all involved nodes, whether assessed clinically or pathologically, as stated by a physician.

Note 4: If there is no physician statement of upper and/or lower level nodal involvement, assign levels I, II, III, and VA nodes to upper level. Assign level IV, VB, and VII to lower level. If Level V (A and B not specified) and/or Level VI nodes are involved with no further information about location, use code 040.

Note 5: A description of "mid neck" requires clarification with the physician. Code 040, unknown level, if "mid neck" is the only information available.

Code Description

000 No lymph nodes involved

010 Upper level lymph nodes involved (all involved nodes above the lower border of the cricoid cartilage)

020 Lower level lymph nodes involved (all involved nodes below the lower border of the cricoid cartilage)

030 Upper and lower level lymph nodes involved (all involved nodes both above and below the lower border of the cricoid cartilage)

040 Unknown level lymph nodes involved (unable to determine if involved nodes above or below the lower border of the cricoid cartilage)


999 Unknown if regional lymph node(s) involved, not stated Not documented in patient record

CS Site-Specific Factor 8 Extracapsular Extension Clinically, Lymph Nodes for Head and Neck Note 1: Code the status of extracapsular extension accessed clinically for any involved regional lymph node(s)

coded in the CS Lymph Nodes field. Do not code extracapsular extensio in any nodes coded in CS Mets at DX in this field.

Note 2: If nodes are involved clinically, and documentation of physical examination or imaging is available without a statement of extracapsular extension, use code 010.

Note 3: If the only documentation is a reference to clinically involved nodes with no reference to extracapsular extension, use code 030.

Note 4: If there is no information about clinical assessment of nodes, use code 999. Note 5: Clinical assessment can be by physical examination or imaging. According to AJCC, "ECS can be

diagnosed clinically by a matted mass of nodes adherent to overlying skin, adjacent soft tissue, or clinical evidence of cranial nerve tissue. Radiologic signs of ECS include amorphous, spiculated margins of a metastatic node and stranding of the perinodal soft tissue in previously untreated patients."

Code Description 000 No lymph nodes involved clinically 010 Nodes involved clinically, no extracapsular extension clinically 020 Nodes involved clinically, extracapsular extension clinically (nodes described as fixed or

matted)


030 Nodes involved clinically, unknown if extracapsular extension 988 Not applicable:

Information not collected for this case 997 Clinical examination of lymph nodes performed, unknown results 998 No clinical examination of lymph nodes 999 Unknown if regional lymph node(s) involved clinically, not stated Regional lymph nodes

cannot be accessed Not documented in patient record CS Site-Specific Factor 9 Extracapsular Extension Pathologically, Lymph Nodes for Head and Neck Note 1: Code the status of extracapsular extension assessed pathologically of any involved regional lymph

node(s) coded in the CS Lymph Nodes field. Do not code extracapsular extension in any nodes coded in CS Mets at DX in this field.

Note 2: If nodes are involved pathologically but there is no statement of extranodal extension in the pathology report, use code 010.

Note 3: Code "microscopic" or "macroscropic" extranodal extension as stated in the final diagnosis. If not stated in the final diagnosis, code "microscopic" if extranodal extension is described only in the microscopic section of the pathology report and "macroscopic" if extranodal extension is described in the gross section of the pathology report.

Note 4: "Macroscopic" extension takes priority over "microscopic" extension. Note 5: Use code 040 if pathologic extracapsular extension is described with no further information and the

pathology report is not available for review. Note 6: Use code 050 if nodes involved pathologically with no further information about extracapsular extension.

Code Description 000 No lymph nodes involved pathologically 010 Nodes involved pathologically, no extracapsular extension pathologically 020 Nodes involved pathologically, MICROSCOPIC extracapsular extension pathologically 030 Nodes involved pathologically, MACROSCOPIC extracapsular extension pathologically 040 Nodes involved pathologically, extracapsular extension pathologically, unknown if

microscopic or macroscopic 050 Nodes involved pathologically, unknown if extracapsular extension 988 Not applicable:

Information not collected for this case 997 Pathologic examination of lymph nodes performed, results not available 998 No pathologic examination of lymph nodes 999 Unknown if regional lymph node(s) involved pathologically, not stated


CS Site-Specific Factor 10 HPV (Human Papilloma Virus) Status Note 1: There is evidence that human papilloma virus (HPV) plays a role in the pathogenesis of some cancers. Note 2: Record the results of any HPV testing performed on pathologic specimens from the primary tumor or a

metastatic site, including regional nodes. HPV testing may be performed for prognostic purposes; testing may also be performed on metastatic sites to aid in the determination of the primary site.

Note 3: The highest risk HPV types are types 16 and 18. Other high risk types are 31, 33, 35, 36, 45, 51, 52, 56, 58, 59, 68, 26, 53, 66, 67, 69, 70, 73, 82, 85 Low risk types are 6, 11, 32, 34, 40, 42, 44, 54, 61, 62, 64, 71, 72, 74, 81, 83, 84, 87, 89. The HPV vaccine is designed to protect against types 16 and 18 (associated with cervical cancer) and types 6 and 11 (associated with genital warts).

Note 4: High risk may be abbreviated "hrHPV" or "HR-HPV". Note 5: Some tests for HPV, such as a hybrid capture test, only report negative or positive for high risk HPV

without identifying types; use codes 025 and 050, respectively to report those test results.

Code Description 000 HPV test negative; not positive for any HPV types

Negative, NOS 010 LOW RISK positive (all positive type(s) are low risk) 020 HIGH RISK positive, specified type(s) other than types 16 or 18,

WITH or WITHOUT positive results for low risk type(s) 030 HIGH RISK positive for HPV 16 WITHOUT positive results for HPV 18 or positivity of

HPV 18 unknown, WITH or WITHOUT positive results for other high-risk types, WITH or WITHOUT positive results for low risk type(s)

040 HIGH RISK positive for HPV 18 WITHOUT positive results for HPV 16 or positivity of HPV 16 unknown, WITH or WITHOUT positive results for other high-risk types, WITH or WITHOUT positive results for low risk type(s)

050 HIGH RISK positive for HPV 16 AND HPV 18, WITH or WITHOUT positive results for other high-risk types, WITH or WITHOUT positive results for low risk type(s)

060 HIGH RISK positive, NOS, type(s) not specified 070 Positive, NOS, risk and type(s) not stated 988 Not applicable:

Information not collected for this case 997 Test ordered, results not in chart 998 Test not done (test was not ordered and was not performed), including no pathologic

specimen available for HPV testing 999 Unknown or no information

Not documented in patient record

CSv2 WORKSHEET

FIELD# FIELD NAME CODE AND RATIONALE/DOCUMENTATION 1 Patient Name - Head Neck #2

CANCER IDENTIFICATION 2 Primary Site C321 Epiglottis (laryngeal surface) - Path 2 3 Histology 8070 Squamous cell carcinoma - Path 2 4 Behavior 3 Malignant 5 Grade 3 Poorly differentiated - Path 2 6 Grade system type Numeric grade system not used 7 Grade value Numeric grade system not used 8 Lymph-vascular invasion 9 Not documented - Path 2

STAGE OF DISEASE AT DIAGNOSIS 9 CS Mets at Dx - Bone 0 No metastasis identified - PET 10 CS Mets at Dx - Lung 0 No metastasis identified 11 CS Mets at Dx - Liver 0 No metastasis identified 12 CS Mets at DX - Brain 0 No metastasis identified COLLABORATIVE STAGING 13 CS Tumor Size 025 2.2x2.5 cm tumor - Path 2 14 CS Extension 660 Extension into base of tongue - Op, Path 2 15 CS Tumor Size/Ext Eval 3 Tumor resected 16 CS Lymph Nodes 420 Multiple positive bilateral nodes in code 120 - Path 2 17 CS Lymph Nodes Eval 3 Lymph node dissection 18 Regional Nodes Positive 19 19 nodes positive - Path 2 19 Regional Nodes Examined 28 28 nodes removed - Path 2 20 CS Mets at Dx 00 No indication of metastatic disease 21 CS Mets Eval 0 Clinical evaluation 22 CS SSF1, Size of Nodal Met 999 Size of largest node not stated - Op, Path 2 23 CS SSF2, OBSOLETE 988 Factor not applicable 24 CS SSF3, Node Levels I, II, III 011 Levels 2, 3 involved - Path 2 25 CS SSF4, Nodes IV,V, Other 110 Levels 4, 5 involved - Path 2 26 CS SSF5, Nodes VI, VII, Other 000 Levels not involved 27 CS SSF6, Node Levels Other 000 Levels not involved 28 CS SSF7, Upper/Lower Nodes 030 Upper and lower level nodes involved - Path 2 29 CS SSF8, Clinical Extracap Ext 010 Nodes involved clinically, extracap not stated - PET 30 CS SSF9, Pathologic Extracap Ext 040 Extracap extension path, unknown micro/macro - Path 2 31 CS SSF10, HPV Status 998 HPV status not reported, assume not done for exercise 32 CS Site-Specific Factor 11 988 33 CS Site-Specific Factor 12 988 34 CS Site-Specific Factor 13 988 35 CS Site-Specific Factor 14 988 36 CS Site-Specific Factor 15 988 37 CS Site-Specific Factor 16 988 38 CS Site-Specific Factor 17 988 39 CS Site-Specific Factor 18 988 40 CS Site-Specific Factor 19 988 41 CS Site-Specific Factor 20 988 42 CS Site-Specific Factor 21 988 43 CS Site-Specific Factor 22 988 44 CS Site-Specific Factor 23 988 45 CS Site-Specific Factor 24 988 46 CS Site-Specific Factor 25 988

CSv2 WORKSHEET

Rationale for specific data elements: Example – #2, Determine on which side of epiglottis tumor arises #16, code 4XX if any bilateral involvement of nodes #29, Code extracapsular invasion not present if nodes clinically positive but extracapsular invasion not mentioned #30, Code extracapsular lymph node involvement