Embed Size (px)
Citation preview
Collaborative Stage Update
Louanne Currence, RHIT, CTR
CS Tumor Size
CS Site-Spec Factors 1-6
CS Size/Ext Eval
CS Reg LNs Eval
CS Mets Eval
AJCC T
T Descriptor C/P
AJCC N
N Descriptor C/P
AJCC M
M Descriptor C/P
AJCC
Stage Group
CS Extension
CS Lymph Nodes
Reg LNs Pos
Reg LNs Exam
CS Mets at DX
SEER Summary Stage 1977
SEER Summary Stage 2000
Inputs Final OutputsInterim (Temporary) Outputs
SS77 Ext
SS2000 Ext
SS77 Nodes
SS2000 Nodes
SS77 Mets
SS2000 Mets Always used
Sometimes used, or future use
Diagram of Inputs and Outputs for CS Site-Specific Scheme
Note: Use Site-Specific Scheme as Determined by Site and Histology
Other input items occasionally used: Age, Grade
Other input items always used: Histology, Behavior
Data Items
• 15 items in data set
– 5 existing data items
• Size, extension, regional nodes
– 10 new data items
• Mets at diagnosis
• 3 “method of evaluation” for T, N, M
• 6 “site specific” factors–Only used if required for TNM
CS Histology Exclusion Tables
• Determines when TNM is applicable to site
• Based on statements in AJCC manual
– EX: Histology for Lower Lip excludes
• 8240/1 carcinoid tumor, uncertain
• 8240/3 carcinoid tumor
• 8241 Enterochromaffin cell carcinoid
• etc carcinoids
• T-NA, N-NA, M-NA, Stage NA
Reporting Requirements
• COC-approved progams
– all 15 CS elements
– derived collab stage goes to NCDB
• SEER
– all CS except eval fields
• NPCR
– ONLY extension, CS Lymph nodes, Mets at dx, SSF3 (prostate), SSF1 (pleural effus)
Front of the Book
• Table 1 – Allowable values/format for CS stage (NAACCR #) pg 5-6
• Table 2 – SSF Schemas Used pg 13
• Table 3 – Histology Specific Coding Schemas pg 15
• Table 6 – Schemas NA for AJCC pg 18
• Use of Autopsy Info pg 18
• Ambiguous Terms pg 20 (like SSM)
• How To Code CS pg 21
• Data Item Instructions pg 25 - 58
Appendices (in front!)
• App 1 Determining Descriptive Tumor Size (conversion)
• App 2a – 2e Allowable Values
• App 3 Summary Stage Conversion Algorithm for All Schemas
• App 4 Site Specific Factors (by site)
• App 5 Histology Exclusion Groups
• Index to Part I (pg 80 – 84)
What about TNM staging?
• Required of physicians in COC programs
• NCDB will rely on dr staging until – CS routine in registry
– CS derived codes validity assessed
• FORDS coding instructions– requires c)TNM and p)TNM when possible
– FORDS changes for 2006? --- sigh
General Rules
• Should be micro confirmed
• Data collected on all sites & histologies
• Timing rule
– Through completion surgery(ies) if FCOT
– Within 4 months dx if no progression
– Which is LONGER
– NOT 4-month rule any longer
Still General Rules
• Greatest EOD based on combined c and p info
– If no pre-op treatment, path info priority
– If pre-op treatment, clinical info priority
• Site specific rules take precedence over general rules
NEW Rule: ‘Inaccessible’ Sites (pg 14)
• Regional LN and distant mets negative
– NO mention of LN or mets involvement in
• PE, Diagnostic testing, Surgical exploration
– Patient receives “usual” treatment to site
– Only early stage (T1, T2, localized) tumors
– Unknown coded if reasonable doubt
• No rule change for “accessible” sites
– “remainder of exam negative” means negative, not unknown
First . . . Tell me the size, Guys
• Primary tumor only
• Size in mm
• Priority
– Path report
– Imaging
– PE
– Invasive
• In situ if NO invasive
• Neoadjuvant? Code largest size (pre or post)
• Residual = NO effect
• Do NOT add
• Special rules
– 990, 998, 999
– Melanoma
Tumor Extension - General
• Direct or contiguous (except uterus, ovary)
– Ignore + tumor margins or micro residual
• If no pre-op, use path
• If pre-op, code clinical extension
– Unless post-op path is greater than clinical
• Imaging has priority over PE
• If organ not listed, find in anatomy book
• CanNOT be in situ w/LNs or mets
CS Tumor Evaluation
• What reports or procedures prove size and extension?
• If size is not factor, what proved exten?
• Whatever you answer for extension must match your evaluation of how you know
– Ex: If you used size and chose 10 for local tumor based on CT only, you cannot use bx code
CS Lymph Nodes
• Farthest regional LN chain– Not distant
– Path report if no pre-op tx
– If pre-op tx, use clinical info
– General, size of mets NOT size of node
• Use “Inaccessible” rule– If tumor not local, LN could be unknown
CS LN Evaluation
0 PE, imaging, none removed
1 Endoscopy, surg observe, none removed
2 None removed, aut only
3 LN removed w/o pre-surg tx
5 LN removed w/pre-sug tx (info clinical)
6 LN removed w/pre-surg tx (info path)
8 Autopsy only
9 Unk, not documented
CS LN Positive/Examined
• Regional LN Positive and LN Examined w/o change
• Cumulative field– 01-89 = absolute number
– 90 90 LNs
– Special codes (aspiration, dissection, etc)
CS Mets at Dx
• Discontinuous, blood-borne, implants
• Distant LNs
– If structure or LN not listed in T Exten or Reg LN, then it’s distant
• Ignore mets developing after extent established
• “Inaccessible” rule
– If tumor not local, mets could be unknown
CS Mets Evaluation
0 PE, imaging, no tissue or aut
1 Endoscopy, surg observe, no tiss or aut
2 None removed, aut only
3 Met tiss w/o pre-surg tx
5 Met tiss w/pre-sug tx (info clinical)
6 Met tiss w/pre-surg tx (info path)
8 Autopsy only
9 Unk, not documented
Site Specific Factors
• Site-Specific Factors replace “Tumor Markers”
• Necessary for TNM changes
• Only used as needed by site
• Table 2. pg 13
Histology-Specific Schema
• Regardless of site¤ 8720-8790 Melanoma (multiple schemes)
¤ 9140 Kaposi Sarcoma
¤ 9510-9514 Retinoblastoma
¤ 9590-9699 Lymphoma
¤ 9700-9701 Mycosis Fungoides
¤ 9702-9729 Lympohoma
¤ 9731-9989 Hematopoietic, Myeloproliferative, etc
Data Analysis
• Can’t compare to pre-CS
• Cases after 1/1/04
– Derived AJCC (6th ed)
• Can’t compare to older editions if there were changes
– Derived SS 2000
• Will be comparable over time
• Caution: If p)TNM, don’t get c)TNM
CS Release 01.02.00
• Why? Correct errors
• Required for 2005 cases
• Recommends we correct some 2004 cases
– Yes? If you will be using CS data
– No? NCDB will not penalize
All sites – Histo excluded
• NOT KS (9140) or lymphomas to end (9590-9989)
– Except Mycosis fungoides (9700), Sezary (9701)
Head & Neck
• C00, C01, C02, C03, C04, C05, C06, C07, C08, C09, C10, C12, C13, C14, C32
– Except C10.1, C11
Changes Head/Neck
• Note 4 – add to all sites CS Lymph Nodes
• Moved supraclavicular lymph nodes from distant to regional lymph nodes– Add SC LN into code 12 on all sites
– Remove SC LN from CS Mets
• CS Mets at Dx– If CS Mets at Dx = 10 or 50, review case
Lung (C34)
• New code 78 CS Extension
– 73 (adjacent rib) +
• 61-72 multiple T4 statements OR
• 74-77 more T4 statements
– Review all cases w/61-77 codes to see if new code should be used
Renal Pelvis (C65, C66)
• New code 35 CS Extension (to ureter from renal pelvis)
– Maps now to T2, RE, RE (not T4)
– Make code 62 Obsolete (old 35 definition)
– Review/recode old 62
Melanoma
• CS Lymph Nodes Code 15 mapping reads N2c RE RN
• New CS Reg Nodes Eval
– Old referred us to Standard Table
– New incorporates satellite/in transit nodules
Melanoma SSF
• CS SSF 1 (Thickness) code 990 Obsolete
– Incorporated into code 999
• CS SSF4 (LDH)
– “Stated as elevated, NOS” added in code 004
Breast (C50)
• CS Lymph Nodes– Wording changed for codes 00 and 05
• 00 No Reg LN involvement OR ITCs detected…
• 05 “None, no reg LNs but” with (ITC)…
• SSF 6 (Invasive?)– “Clinical tumor size coded” added to 888
NCRA Reminders - Inflammatory
• Clinical AND pathologic
• Often no underlying mass
• NOT the same as neglected locally advanced
• Path statement of + dermal lymphatics alone NOT enough
• Revised codes 71,73 CS Exten to map T4d
– Code 72 Obsolete reviewed/change to code 71 per 8/04 changes
NCRA Clarification – CS LN
• Isolated Tumor Cells– single tumor cells or small clusters 0.2mm
– detected only by IHC or mollecular methods
– may be verified on “routine” H&E stains
– do not usually show evidence of malignant activity (stromal reaction, etc)
– LN with ITC only are NOT considered positive
Corpus Uteri (C54, C55)
• CS Extension code 16 reworded– Old: Serosa of corpus (tunica serosa)
– New: Tunica serosa of the visceral peritoneum (serosa covering the corpus)
• CS Ext Code 60– Added (parietal lining of the pelvic or
abdominal cavity) to explain tunica serosa
Prostate (C61) CS Ext - Clinical
• Note 1 reworded (do NOT include prostatectomy info in this field)
• Note 2 D Apex information obsolete
• New Note 3 (about apex)
• Old Notes 3-7 shift down one number
• Note 8 reworded (cT versus pT)
• Codes 31, 33, and 34 (apex) OBSOLETE
CS Ext (NCRA notes)• Code clinical extension EVEN if prostatectomy
• Code groups
– 10-15 Clinically INapparent (Not on PE or hypoechoic or other radiographic)
– 20-24 Apparent (PE, radiograph)
– 30 Local, NOS
– 41-49 Peri-prostatic extension
– 50-70 Further contiguous extension
• Disregard prostatic urethra involvement UNLESS outside prostate
Illustration by Steve Oh / KO Studios; globalrph.mediwire.com
www.upmccancercenters.com
nld.by/e/current/stat13.htm#9
SSF 1
• Factor 1 (PSA) Code 2 now 002 – 989 for values
• Round up PSA if needed (0.187 = 0.19)
• Why record twice?
– Varies by age of patient
• < 40 y.o. -- PSA < 2.0 normal
• Over 75 y.o. -- < 6.5 normal
– Different labs have different values are positive
SSF 3
• Note 4 Margins + w/o Extracapsular now T2
• Note 5 changed – 031, 033, 034 Obsolete
• Old Notes 5-8 shift
• Note 9 reworded (cT versus pT)
• Code 040 now T2 – REVIEW
• Code 048 Excludes seminal vesicle margins
• Code 098 Reworded
– Prostatectomy performed as FU
SSF 4 Apex Involvement
• Good news? No more PAP
• Bad news? New codes
– Review prostates for Apex involvement to recode
• May choose NOT to do this
• Start with 2005 cases
Apex samplesCode Clinical Pathologic
140 No involve apex Extend into apex
240 Into apex NOS Extend into apex
340 Arise in apex Extend into apex
440 Extend into apex Extend into apex
550 Apex extension unk (no mention in bx)
Apex extension unk (no prostatectomy done)
SSF 5, SSF 6 (Gleason’s)
• New Note 1 covers
– If 2 numbers in path report (pattern)
– If 1 number in path report (pattern versus score)
• New Note
– If more than one path, choose Gleason’s relating to largest specimen
Gleason Score
Conversion
2, 3, 4 = Grade I
5, 6 = Grade II
7, 8, 9,
or 10 = Grade III
NCRA Sample: Small nodule felt on DRE in upper posterior lobe. PSA normal (4.5). Needle bx shows Gleason 3+4 adenoca in one lobe. Pt opts for radiation
Tumor size 999 No size stated SSF1 045 PSA 4.5
T Extension 21 < 1/2 lobe SSF2 020 PSA normal
TX/Ext Eval 1 Diag bx SSF3 097 No prostatectomy
LN 00 Inaccessible SSF4 150 Apex not, no prost
Reg LN Eval 0 Clinical info SSF5 034 Gleason 3+4
Reg LN + 98 None exam SSF6 007 Gleason 7 score
Reg LN exam 00 None exam
Mets @ dx 00 Inaccessible
Mets Eval 0 Clinical info
Testis (C62)
• SSF3 040 new?
• SF5 (Mets in LN)– Added Note 2 Clinical positive LNs
• 001 Clinical N1 nodes
• 002 Clnical N2
• 003 Clinical N3
– Code 001 Reworded LN mets <= 2cm AND no extranodal extension
Eyes (C69)
• Melanoma Conjunctiva, Iris & Ciliary Body, Choroid
– SSF 1: 990 Obsolete (moved to 999)
• Melanoma Choroid CS Exten
– Code 66 WITH microscopic extraocular exten
– Code 68 WITH macroscopic extraocular exten
Brain, Meninges, CNS (C70,C71, C72)
• Mapping Change CS Ext Codes 40, 50, 51, 60 from RE in Summary Stage to RNOS
WHO Grading, ICD-O-3 Behavior, & ICD-O-3 Grade Code
gr 1 gr 2 gr 3 gr 4ICD-O-3 GRADING
0 benign
1 borderline
3invasive
WHO GRADE
Grade I Grade II Grade III Grade IV
"slow growing" "highly malignant""invasive" "malignant"
least aggressive
most aggressive
ICD-O-3 BEHAVIOR
Thyroid (C73.9)
• CS Lymph Nodes totally restructured
– Codes 10, 11, 20, 21, 30, 31 Obsolete
– New Codes 12, 13, 14, 15
• CS Mets at Dx totally restructured
Thymus, Adrenal, Other Endocrine
• SSF 1 WHO grade includes “Does not apply”
www.facs.org/cancer
Frequently Asked Questions
Small Intestine Thyroid CS Lymph Nodes
Colon Lymphoma “Down Staging” Rule
Breast Primary Unknown to Known
Output from CS Data
Cervix Uteri CS Tumor Size CS Algorithm
Prostate (has 2005 answers)
CS Extension CS Reliability
Part 1 update (10/05)
• Definition of Obsolete codes
• Size instructions when < 1 mm
• Diffuse code for breast 998
• Choose Size/Exten code that belongs to worst description
– EX: FNA prostate + (code 1)
– CT scan shows prostate CA through capsule into adjacent tissue (code 0)
Codes Made “Obsolete”
• Based on revisions needed
• Occurs when a single code needs to be split into other codes
• When a structure is moved from one table to another table
• Codes in CS will not be deleted
Are you Updated?
• Errata for the Printed Manual, part 2Print these replacement pages to keep your manual up-to-date:
• Replacement Pages Part II Version 01.02.00 (non-head/neck) (290K PDF) 8/19/2005
• Replacement Pages Part II Version 01.02.00 (head/neck) (825K PDF) 5/25/2005
• Melanoma Scheme Only (50K PDF) 8/19/2005
“Old” Updates
• Replacement Pages Part II Version 01.01.00 8/2004– Breast (100K PDF)
– Colon (45K PDF)
– Melanoma (80K PDF)
– Prostate (80K PDF)
– Retinoblastoma (80K PDF)
Contact Information
• AJCC/CS Website (electronic manuals, Q&A, computer programs, other info)
– www.cancerstaging.org
• SEER Training Website
– www.training.seer.cancer.gov
• Central contact person
– Valerie Vesich, CTR
312-202-5435
TNM Atlas: Illustrated Guide to the TNM Classification of Malignant Tumours, 5th ed.
• ISBN: 0-471-74301-1 (publisher John Wiley & Sons)
• For use with 6th ed. AJCC
• Published summer 2005
