Putting the Puzzle Together: Breast Collaborative Staging

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Putting the Puzzle Together: Breast Collaborative Staging . Melissa Riddle, RHIT, CTR October 6, 2012. Objectives. Understand why collaborative staging was created Learn the concepts of collaborative staging for breast cases. Collaborative Staging. - PowerPoint PPT Presentation


  • Putting the Puzzle Together:Breast Collaborative Staging

    Melissa Riddle, RHIT, CTROctober 6, 2012

  • Objectives

    Understand why collaborative staging was created

    Learn the concepts of collaborative staging for breast cases

  • Collaborative Staging5yr 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    General rules apply to all sites/histologies unless superseded by site-specific rule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 Staging

    Used for cases diagnosed 1/1/2004 and forwardCSv2 for cases diagnosed 1/1/2010 and forwardDerives:AJCC TNMSEER SummaryUnderstand SEER Summary and TNM is necessary in order to analyze cases

  • Collaborative Staging

    Allows both clinical and pathologic information to be used to determine stagePathologic information takes precedence

  • Collaborative StagingCS Solution: Mixed or Best StagedResult: more relevant to actual practiceFewer 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


    Stage Group

    SS77, SS2000

    Computer Derives:

  • Data Elements:CS Tumor Size

    CS Extension

    CS TS/Exten Eval

    CS Lymph Nodes

    CS LN EvalRegional LN Positive

    Regional LN Exam

    CS Mets @ DX

    CS Mets Eval

    SSF 1-25

  • Breast CS

  • Collaborative Staging

    Evaluation Fields:Code based on the procedure performed ScansBiopsiesSurgeryDerives the TNM as clinical or pathologic

  • Breast Evaluation Codes

    CODEDESCRIPTIONSTAGING0Physical Exam; Imagingc1Diagnostic BX; FNAc3Resection without neoadjuvant TX p5Neoadjuvant TX; Based on Clinical informationc6Neoadjuvant TX; Resection informationyp9Unknownc

  • Breast CS Data Items

    Tumor SizeExtensionLymph NodesLymph Node Positive/ExamDistant Mets at DiagnosisSite Specific Factors 1-24

  • Tumor Size/Extension

  • Tumor SizeCode the specific size of the tumor in mmConvert any size in cm to mmPathologic size:Take pathologic size over clinicalRecord the invasive sizeExample:Invasive Ductal Carcinoma, 0.5cm; DCIS, 2cmCode Tumor Size: 005

  • Tumor Size

    Special Codes:990 Microinvasion; Microscopic focus991-995 No specific size: less than ___cm996 seen on mammogram only but no size given997 Pagets of nipple, no underlying tumor998 Diffuse

  • ExtensionIn Situ only: 000No invasive disease

    Invasive cancer without skin involvement: 100

    Skin involvement: 200Adherence, Attachment, Fixation, Induration & ThickeningWithout diagnosis Inflammatory Breast CA


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

    CS Extension: 200 (invade skin)

  • ExtensionInflammatory Breast CA:Based on clinical informationCodes based on percentage of breast involved:Code 600: 33% or lessCode 725: more than 33% but less than 50%Code 730: more than 50%Code 750*: percentage unknown

    *Most common code for IBC

  • Regional Lymph Nodes

  • Lymph NodesRegional Lymph Nodes Only:Do NOT code cervical or contralateral axillary LN Includes Levels 1-3 Ipsilateral Axillary LN, internal mammary LN and Supraclavicular LNClinical vs. PathologicIf the only information about involved regional LN is from physical exam or imaging- clinicalIf there are positive LN found on sampling/dissection- pathologic

  • Level 1 & 2 Axilla LNCode 250:Pathologic involvement LNCode 255:Clinical involvement moveable LNCode 510:Clinical involvement fixed/matted LNCode 520:Pathologic involvement fixed/matted LNCode 600:Axillary, NOS

  • CS 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 PositiveRecord all positive pathologic examined regional lymph nodesExample:3/5 R axillary LN involved with invasive duct carcinomaCODE: 03Code 95:Positive LN only on core biopsy or FNACode 98:No regional LN were examined pathologically

  • Reg LN ExaminedRecord the total number of pathologically examined regional LNExample:3/5 R axillary LN involved with invasive duct carcinomaCODE: 05Code 95:Regional LN examined by core biopsy or FNA onlyCode 00:No regional LN examined pathologically

  • Distant Mets at Diagnosis

  • Distant MetsCode 00:No evidence of metastatic diseaseCode 10:Involvement distant LN:CervicalContralateral/Bilateral Axillary and/or internal mammary LNCode 40:Distant met site except distant LN

  • Distant MetsCode 42:Further contiguous extension:Skin over axilla, contralateral breast, sternum, upper abdomenCode 44:Involve any of the following:Adrenal glandBoneContralateral breast- if stated metastaticLungOvarySat nodules skin other than primary breast

  • Distant MetsCode 50:Distant LN Distant Sites (listed in codes 40-44)

    Code 60:Distant mets, NOS

  • CS BREAST: METS AT DXExample R 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 Factors

  • Collaborative StagingSite-Specific FactorsNot all 25 SSF are used for every caseBreast has the most with 24 to completeAdditional information needed to derive TNMPrognostic Tumor Markers/LabsSpecial Interest/Future ResearchOther clinically significant information

  • SSF 1: ER & SSF 2: PRIf there is any sample positive, record as positiveDo NOT record ER results from Oncotype DX or other multigene test010- Positive020- Negative997- Test ordered results not in chart999- Unknown

  • SSF 3: Pos Level 1 & 2 LNBased on pathologic information ONLYCode 098:No pathologically examined LNCode 000:Negative LNCode 001-089:Code the exact number of positive LN Code 095:Positive LN by biopsy or FNA

  • SSF 7: BR ScorePriority Order:BR ScoreBR GradeCodes 030-090:BR Score range of 3-9Codes 110-130:BR Grade: Low, Intermediate, HighCode 998:No histologic exam of primary tumor

  • HER 2SSF 8: IHC test valueScores 0, 1+, 2+, 3+SSF 9: IHC interpretationRecord the pathologists interpretation of the test value: positive, negative, equivocalSSF 10: FISH valueRecord ratio as given Code 991: ratio less than 1.00SSF 11: FISH interpretationRecord the interpretation of the test value

  • HER 2SSF 14: Other/Unknown testStatement in medical record on HER2, unknown type of testing performedOther type of test performed

    SSF 15: Summary of resultsBased on codes in SSF 9, 11, 13 and 14Both IHC and FISH/CISH record results of FISH/CISHExcept when IHC is performed to clarify equivocal test of FISH/CISH

  • SSF 16: ER, PR & HER2Identifies Triple negative patientsCode Pattern:First digit: ERSecond digit: PRThird digit: HER2Digits: 0= negative1= positiveInformation unknown on one or more test code 999

  • SSF 16Example: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 MethodAssess: likelihood of response to chemotherapyevaluate prognosis or distant recurrence

    Code 010: Oncotype DX

    Code 020: MammaPrint

    Code 030: Other test

  • SSF 23: Multigene ResultRecord the results of the multigene method:Oncotype DX: Scores range 0-100MammaPrint: Low Risk or High RiskCodes 000-100Record actual Oncotype DX scoreCode 200: Low RiskCode 300: Intermediate RiskCode 400: High Risk

  • SSF 24: Pagets DiseaseRecord any mention of Pagets diseasePathologic takes precedence over clinical infoNegative exam of nippleInterpret as no Pagets diseasePathology report mentions pagetoid involvement of nipple, Code 020Does NOT include pagetoid involvement of ducts or lobules

  • Current Version


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

  • The Whole PictureNow 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!

    Melissa Riddle, RHIT, CTRmelissariddlespeaks@ymail.com

    We have been gathering data for years. But each time we use a new edition of a staging manual, there is going to be some changes which make comparison to previous data not possible without reviewing all the cases. What if there was a way to gather the data so it would just plug into the current edition allowing for comparison?Collaborative staging is NOT staging. It is data gatheringbut with the future in mind.******