Putting the Puzzle Together:Breast Collaborative Staging

Melissa Riddle, RHIT, CTROctober 6, 2012

ObjectivesObjectives

• Understand why collaborative staging was created

• Learn the concepts of collaborative staging for breast cases

Collaborative StagingCollaborative Staging• 5yr group effort among all standard setters in

North America

• Designed by and for cancer registrars to code the facts about a cancer case

• General rules apply to all sites/histologies unless superseded by site-specific rule

Collaborative StagingCollaborative Staging

• Used for cases diagnosed 1/1/2004 and forward– CSv2 for cases diagnosed 1/1/2010 and forward

• Derives:– AJCC TNM– SEER Summary

• Understand SEER Summary and TNM is necessary in order to analyze cases

Collaborative StagingCollaborative Staging

• Allows both clinical and pathologic information to be used to determine stage– Pathologic information takes precedence

Collaborative StagingCollaborative Staging• CS Solution: Mixed or “Best Staged”

– Result: more relevant to actual practice– Fewer unstageable cases

Registrar records:T elements + c/pN elements + c/pM elements + c/pSite Specific Factors (tumor markers)

c/pT c/p N c/p M

And

Stage Group

SS77, SS2000

Computer Derives:

Data Elements:Data Elements:• CS Tumor Size

• CS Extension

• CS TS/Exten Eval

• CS Lymph Nodes

• CS LN Eval

• Regional LN Positive

• Regional LN Exam

• CS Mets @ DX

• CS Mets Eval

• SSF 1-25

Breast CSBreast CS

Collaborative StagingCollaborative Staging

• Evaluation Fields:– Code based on the procedure performed

• Scans• Biopsies• Surgery

– Derives the TNM as clinical or pathologic

Breast Evaluation CodesBreast Evaluation CodesCODE DESCRIPTION STAGING

0 Physical Exam; Imaging c

1 Diagnostic BX; FNA c

3 Resection without neoadjuvant TX p

5 Neoadjuvant TX; Based on Clinical information

c

6 Neoadjuvant TX; Resection information yp

9 Unknown c

Breast CS Data ItemsBreast CS Data Items

• Tumor Size• Extension• Lymph Nodes• Lymph Node Positive/Exam• Distant Mets at Diagnosis• Site Specific Factors 1-24

Tumor Size/ExtensionTumor Size/Extension

Tumor SizeTumor Size• Code the specific size of the tumor in mm

– Convert any size in cm to mm• Pathologic size:

– Take pathologic size over clinical– Record the invasive sizeExample:Invasive Ductal Carcinoma, 0.5cm; DCIS, 2cmCode Tumor Size: 005

Tumor SizeTumor Size

• Special Codes:– 990 Microinvasion; Microscopic focus– 991-995 No specific size: “less than ___cm”– 996 seen on mammogram only but no size given– 997 Paget’s of nipple, no underlying tumor– 998 Diffuse

ExtensionExtension• In Situ only: 000

– No invasive disease

• Invasive cancer without skin involvement: 100

• Skin involvement: 200– Adherence, Attachment, Fixation, Induration &

Thickening– Without diagnosis Inflammatory Breast CA

CS BREAST: EXTENSIONCS BREAST: EXTENSION

Example:L breast partial mastectomyPath report partial mastectomy: 2cm invasive ductal carcinoma invading into skin

CS Extension: 200 (invade skin)

ExtensionExtension• Inflammatory Breast CA:

– Based on clinical information– Codes based on percentage of breast involved:

• Code 600: 33% or less• Code 725: more than 33% but less than 50%• Code 730: more than 50%• Code 750*: percentage unknown

*Most common code for IBC

Regional Lymph NodesRegional Lymph Nodes

Lymph NodesLymph Nodes• Regional Lymph Nodes Only:

– Do NOT code cervical or contralateral axillary LN – Includes Levels 1-3 Ipsilateral Axillary LN, internal

mammary LN and Supraclavicular LN– Clinical vs. Pathologic

• If the only information about involved regional LN is from physical exam or imaging- clinical

• If there are positive LN found on sampling/dissection- pathologic

Level 1 & 2 Axilla LNLevel 1 & 2 Axilla LN• Code 250:

– Pathologic involvement LN

• Code 255:– Clinical involvement moveable LN

• Code 510:– Clinical involvement fixed/matted LN

• Code 520:– Pathologic involvement fixed/matted LN

• Code 600:– Axillary, NOS

CS BREAST: LYMPH NODESCS BREAST: LYMPH NODESExample:R breast modified radical mastectomy (MRM)Path from R MRM: 3cm invasive ductal carcinoma; 2/4 R axillary LN involved with metastatic disease

CS LN: 250 (pathologic positive movable axillary LN)

Reg LN PositiveReg LN Positive• Record all positive pathologic examined

regional lymph nodesExample:3/5 R axillary LN involved with invasive duct

carcinoma CODE: 03• Code 95:

– Positive LN only on core biopsy or FNA• Code 98:

– No regional LN were examined pathologically

Reg LN ExaminedReg LN Examined• Record the total number of pathologically

examined regional LNExample:3/5 R axillary LN involved with invasive duct

carcinoma CODE: 05• Code 95:

– Regional LN examined by core biopsy or FNA only• Code 00:

– No regional LN examined pathologically

Distant Mets at DiagnosisDistant Mets at Diagnosis

Distant MetsDistant Mets• Code 00:

– No evidence of metastatic disease• Code 10:

– Involvement distant LN:• Cervical• Contralateral/Bilateral Axillary and/or internal

mammary LN

• Code 40:– Distant met site except distant LN

Distant MetsDistant Mets• Code 42:

– Further contiguous extension:• Skin over axilla, contralateral breast, sternum, upper

abdomen

• Code 44:– Involve any of the following:

• Adrenal gland• Bone• Contralateral breast- if stated metastatic• Lung• Ovary• Sat nodules skin other than primary breast

Distant MetsDistant Mets• Code 50:

– Distant LN – Distant Sites (listed in codes 40-44)

• Code 60:– Distant mets, NOS

CS BREAST: METS AT DXCS BREAST: METS AT DX

ExampleR breast with palpable mass 4cm with fixed R axillary LN mass. CT AB/Pelvis: Innumerable liver mets

CS Mets @ DX: 40 (Distant mets other than distant LN)

Site Specific FactorsSite Specific Factors

Collaborative StagingCollaborative Staging

• Site-Specific Factors– Not all 25 SSF are used for every case

• Breast has the most with 24 to complete

– Additional information needed to derive TNM– Prognostic Tumor Markers/Labs– Special Interest/Future Research– Other clinically significant information

SSF 1: ER & SSF 2: PRSSF 1: ER & SSF 2: PR• If there is any sample positive, record as

positive• Do NOT record ER results from Oncotype DX

or other multigene test• 010- Positive• 020- Negative• 997- Test ordered results not in chart• 999- Unknown

SSF 3: Pos Level 1 & 2 LNSSF 3: Pos Level 1 & 2 LN• Based on pathologic information ONLY• Code 098:

– No pathologically examined LN• Code 000:

– Negative LN• Code 001-089:

– Code the exact number of positive LN • Code 095:

– Positive LN by biopsy or FNA

SSF 7: BR ScoreSSF 7: BR Score• Priority Order:

– BR Score– BR Grade

• Codes 030-090:– BR Score range of 3-9

• Codes 110-130:– BR Grade: Low, Intermediate, High

• Code 998:– No histologic exam of primary tumor

HER 2HER 2• SSF 8: IHC test value

– Scores 0, 1+, 2+, 3+• SSF 9: IHC interpretation

– Record the pathologists interpretation of the test value: positive, negative, equivocal

• SSF 10: FISH value– Record ratio as given – Code 991: ratio less than 1.00

• SSF 11: FISH interpretation– Record the interpretation of the test value

HER 2HER 2• SSF 14: Other/Unknown test

– Statement in medical record on HER2, unknown type of testing performed

– Other type of test performed

• SSF 15: Summary of results– Based on codes in SSF 9, 11, 13 and 14– Both IHC and FISH/CISH record results of FISH/CISH

• Except when IHC is performed to clarify equivocal test of FISH/CISH

SSF 16: ER, PR & HER2SSF 16: ER, PR & HER2• Identifies Triple negative patients• Code Pattern:

– First digit: ER– Second digit: PR– Third digit: HER2

• Digits: – 0= negative– 1= positive

• Information unknown on one or more test code 999

SSF 16SSF 16• Example:

ER: positive (SSF1: 010)PR: positive (SSF2: 010)HER2: negative (SSF 15: 020)

SSF 16 Code: 110

• Triple Negative patients code 000

SSF 22: Multigene MethodSSF 22: Multigene Method• Assess:

– likelihood of response to chemotherapy– evaluate prognosis or distant recurrence

• Code 010: Oncotype DX

• Code 020: MammaPrint

• Code 030: Other test

SSF 23: Multigene ResultSSF 23: Multigene Result• Record the results of the multigene method:

– Oncotype DX: Scores range 0-100– MammaPrint: Low Risk or High Risk

• Codes 000-100– Record actual Oncotype DX score

• Code 200: Low Risk• Code 300: Intermediate Risk• Code 400: High Risk

SSF 24: Paget’s DiseaseSSF 24: Paget’s Disease• Record any mention of Paget’s disease

– Pathologic takes precedence over clinical info• Negative exam of nipple

– Interpret as no Paget’s disease• Pathology report mentions pagetoid

involvement of nipple, Code 020– Does NOT include pagetoid involvement of ducts

or lobules

Current VersionCurrent Version

CSv02.04http://www.cancerstaging.org/cstage/manuals/coding0204.html

Additional Help:http://cancerbulletin.facs.org/forums/

The Whole PictureThe Whole Picture• Now you can put

these pieces together while using the CS Manual to create a beautiful picture!

• Always read your notes for CS, they are the little pieces that create the whole!

Thank You!Thank You!

Melissa Riddle, RHIT, CTRmelissariddlespeaks@ymail.com