Collaborative Stage Update

1
Collaborative Stage Update

• Louanne Currence, RHIT, CTR

2
(No Transcript)
3
(No Transcript)
4
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

5
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

6
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)

7
Front of the Book

• 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

• 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

8
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)

9
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

10
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

11
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

12
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

13
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

• CS Tumor Size

14
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

15
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

16
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

17
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

18
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)

19
CS Mets at Dx

• Discontinuous, blood-borne, implants
• Distant LNs
• If structure or LN not listed in T Exten or Reg
  LN, then its distant
• Ignore mets developing after extent established
• Inaccessible rule
• If tumor not local, mets could be unknown

20
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

21
Site Specific Factors

• Site-Specific Factors replace Tumor Markers
• Necessary for TNM changes
• Only used as needed by site
• Table 2. pg 13

22
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

23
Data Analysis

• Cant compare to pre-CS
• Cases after 1/1/04
• Derived AJCC (6th ed)
• Cant compare to older editions if there were
  changes
• Derived SS 2000
• Will be comparable over time
• Caution If p)TNM, dont get c)TNM

24
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

25
All sites Histo excluded

• NOT KS (9140) or lymphomas to end (9590-9989)
• Except Mycosis fungoides (9700), Sezary (9701)

26
Head Neck

• C00, C01, C02, C03, C04, C05, C06, C07, C08, C09,
  C10, C12, C13, C14, C32
• Except C10.1, C11

27
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

28
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

29
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

30
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

31
Melanoma SSF

• CS SSF 1 (Thickness) code 990 Obsolete
• Incorporated into code 999
• CS SSF4 (LDH)
• Stated as elevated, NOS added in code 004

32
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

33
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

34
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 HE stains
• do not usually show evidence of malignant
  activity (stromal reaction, etc)
• LN with ITC only are NOT considered positive

35
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

36
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

37
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

38
Illustration by Steve Oh / KO Studios
globalrph.mediwire.com
www.upmccancercenters.com
39
nld.by/e/current/stat13.htm9
40
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
• lt 40 y.o. -- PSA lt 2.0 normal
• Over 75 y.o. -- lt 6.5 normal
• Different labs have different values are positive

41
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

42
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

43
Apex samples
44
SSF 5, SSF 6 (Gleasons)

• 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 Gleasons relating
  to largest specimen

45
Gleason Score Conversion 2, 3, 4 Grade I 5, 6
Grade II 7, 8, 9, or 10 Grade III
46
NCRA Sample Small nodule felt on DRE in upper
posterior lobe. PSA normal (4.5). Needle bx shows
Gleason 34 adenoca in one lobe. Pt opts for
radiation
47
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 lt 2cm AND no
  extranodal extension

48
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

49
Brain, Meninges, CNS (C70,C71, C72)

• Mapping Change CS Ext Codes 40, 50, 51, 60 from
  RE in Summary Stage to RNOS

50
WHO Grading, ICD-O-3 Behavior,
ICD-O-3 Grade Code
WHO GRADE
most
least
aggressive
aggressive
ICD-O-3 BEHAVIOR
ICD-O-3 GRADING
gr 1 gr 2 gr 3 gr 4
51
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

52
Thymus, Adrenal, Other Endocrine

• SSF 1 WHO grade includes Does not apply

53
www.facs.org/cancer
54
Frequently Asked Questions
55
Part 1 update (10/05)

• Definition of Obsolete codes
• Size instructions when lt 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)

56
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

57
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

58
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)

59
Contact Information

• AJCC/CS Website (electronic manuals, QA,
  computer programs, other info)
• www.cancerstaging.org
• SEER Training Website
• www.training.seer.cancer.gov
• Central contact person
• Valerie Vesich, CTR
• vvesich_at_facs.org
• 312-202-5435

60
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

61
Contact Information

• Louanne.Currence_at_nkch.org