Transcript Collaborative Stage Update

Collaborative Stage Update
Louanne Currence, RHIT, CTR
Diagram of Inputs and Outputs for CS Site-Specific Scheme
Note: Use Site-Specific Scheme as Determined by Site and Histology
CS Tumor Size
AJCC T
CS Extension
T Descriptor C/P
Other input items always used:
Histology, Behavior
AJCC N
AJCC
N Descriptor C/P
Stage Group
CS Size/Ext Eval
CS Lymph Nodes
AJCC M
Reg LNs Pos
M Descriptor C/P
Other input items occasionally
used: Age, Grade
Reg LNs Exam
SEER Summary
Stage 1977
SS77 Ext
CS Reg LNs Eval
SS2000 Ext
CS Mets at DX
SS77 Nodes
SEER Summary
Stage 2000
CS Mets Eval
SS2000 Nodes
CS Site-Spec Factors 1-6
SS77 Mets
SS2000 Mets
Inputs
Interim (Temporary) Outputs
Final Outputs
Always used
Sometimes used,
or future use
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 6 – Schemas NA
for AJCC pg 18
• Table 2 – SSF
Schemas Used pg 13
• Ambiguous Terms pg 20
(like SSM)
• Table 3 – Histology
Specific Coding
Schemas pg 15
• How To Code CS pg 21
• Use of Autopsy Info pg
18
• 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
80 – 84)
(pg
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
• Size in mm
• Neoadjuvant? Code
largest size (pre or
post)
• Priority
• Residual = NO effect
• Primary tumor only
– Path report
– Imaging
– PE
– Invasive
• In situ if NO
invasive
• 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
5 LN removed w/presug tx (info clinical)
1 Endoscopy, surg
observe, none removed
6 LN removed w/presurg tx (info path)
2 None removed, aut only
8 Autopsy only
3 LN removed w/o presurg tx
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
5 Met tiss w/pre-sug tx
(info clinical)
1 Endoscopy, surg
observe, no tiss or aut
6 Met tiss w/pre-surg tx
(info path)
2 None removed, aut only
8 Autopsy only
3 Met tiss w/o pre-surg tx
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 • Code 040 now T2 –
REVIEW
Extracapsular now T2
• Note 5 changed – 031, • Code 048 Excludes
seminal vesicle
033, 034 Obsolete
margins
• Old Notes 5-8 shift
• Code 098 Reworded
• Note 9 reworded
(cT versus pT)
– 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 samples
Code
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
WHO GRADE
most
aggressive
least
aggressive
"slow growing" "invasive"
Grade I
0
benign
"malignant"
Grade II
Grade III
1
borderline
3
invasive
ICD-O-3 GRADING
gr 1
"highly malignant"
Grade IV
ICD-O-3 BEHAVIOR
gr 2
gr 3
gr 4
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
Colon
Lymphoma
Breast
Primary Unknown
to Known
CS Lymph
Nodes
“Down Staging”
Rule
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 2
Print 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
[email protected]
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
Contact Information
[email protected]