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, 2012ObjectivesUnderstand why collaborative staging was created Learn the concepts of collaborative staging for breast casesCollaborative Staging5yr group effort among all standard setters in North AmericaDesigned by and for cancer registrars to code the facts about a cancer caseGeneral rules apply to all sites/histologies unless superseded by site-specific ruleCollaborative StagingUsed for cases diagnosed 1/1/2004 and forwardCSv2 for cases diagnosed 1/1/2010 and forwardDerives:AJCC TNMSEER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 casesCollaborative StagingAllows both clinical and pathologic information to be used to determine stagePathologic information takes precedenceCollaborative StagingCS Solution: Mixed or Best StagedResult: more relevant to actual practiceFewer unstageable casesRegistrar records:T elements + c/pN elements + c/pM elements + c/pSite Specific Factors (tumor markers)c/pT c/p N c/p MAndStage GroupSS77, SS2000Computer Derives:Data Elements:CS Tumor SizeCS ExtensionCS TS/Exten EvalCS Lymph NodesCS LN EvalRegional LN PositiveRegional LN ExamCS Mets @ DXCS Mets EvalSSF 1-25Breast CSCollaborative StagingEvaluation Fields:Code based on the procedure performed ScansBiopsiesSurgeryDerives the TNM as clinical or pathologicBreast Evaluation CodesCODEDESCRIPTIONSTAGING0Physical Exam; Imagingc1Diagnostic BX; FNAc3Resection without neoadjuvant TX p5Neoadjuvant TX; Based on Clinical informationc6Neoadjuvant TX; Resection informationyp9UnknowncBreast CS Data ItemsTumor SizeExtensionLymph NodesLymph Node Positive/ExamDistant Mets at DiagnosisSite Specific Factors 1-24Tumor Size/ExtensionTumor 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: 005Tumor SizeSpecial 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 DiffuseExtensionIn Situ only: 000No invasive diseaseInvasive cancer without skin involvement: 100Skin involvement: 200Adherence, Attachment, Fixation, Induration & ThickeningWithout diagnosis Inflammatory Breast CACS BREAST: EXTENSIONExample:L breast partial mastectomyPath report partial mastectomy: 2cm invasive ductal carcinoma invading into skinCS 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 IBCRegional Lymph NodesLymph 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- pathologicLevel 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, NOSCS 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 diseaseCS 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 pathologicallyReg 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 pathologicallyDistant Mets at DiagnosisDistant 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 LNDistant 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 breastDistant MetsCode 50:Distant LN Distant Sites (listed in codes 40-44)Code 60:Distant mets, NOSCS BREAST: METS AT DXExample R breast with palpable mass 4cm with fixed R axillary LN mass. CT AB/Pelvis: Innumerable liver metsCS Mets @ DX: 40 (Distant mets other than distant LN)Site Specific FactorsCollaborative 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 informationSSF 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- UnknownSSF 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 FNASSF 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 tumorHER 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 valueHER 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/CISHSSF 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 999SSF 16Example:ER: positive (SSF1: 010)PR: positive (SSF2: 010)HER2: negative (SSF 15: 020)SSF 16 Code: 110Triple Negative patients code 000SSF 22: Multigene MethodAssess: likelihood of response to chemotherapyevaluate prognosis or distant recurrenceCode 010: Oncotype DXCode 020: MammaPrintCode 030: Other testSSF 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 RiskSSF 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 lobulesCurrent VersionCSv02.04http://www.cancerstaging.org/cstage/manuals/coding0204.htmlAdditional 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.comWe 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.******