Collaborative staging system
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Collaborative Staging System. Part II Data Elements And Codes Stuart Herna, CTR. Data Elements. CS Tumor Size CS Extension CS Tumor Size/Ext Eval CS Lymph Nodes CS Reg Nodes Eval Regional LN Examined Regional LN Positive CS Mets At Dx CS Mets Eval CS Site Specific Factors 1-6.

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Collaborative staging system

Collaborative Staging System

Part II

Data Elements And Codes

Stuart Herna, CTR


Data elements

Data Elements

  • CS Tumor Size

  • CS Extension

  • CS Tumor Size/Ext Eval

  • CS Lymph Nodes

  • CS Reg Nodes Eval

  • Regional LN Examined

  • Regional LN Positive

  • CS Mets At Dx

  • CS Mets Eval

  • CS Site Specific Factors 1-6


Collecting the t equivalent

Collecting the T Equivalent

Computer derives

TNM

Registrar records

cT1

pT2

yT3

cTX

etc.

CS Tumor Size (3 digits)

T

CS Extension (2 digits)

CS TS/Ext Eval (1 digit)


Cs tumor size

CS Tumor Size

CS Tumor Size records the largest lateral dimension or diameter of the primary tumor in millimeters, including melanoma

  • If no pre-operative treatment was performed, always code Pathologic Tumor Size

  • If pre-operative treatment was performed, code pre-treatment Clinical Tumor Size

  • Record the size of the invasive component of the tumor

  • Microscopic residual tumor does not affect Tumor Size


Coding cs tumor size lung

Coding CS Tumor Size (Lung)

T0

T1/T2

T2

T1

T1/T2

TX

T4

M1

TX

000No mass/tumor found

001 - 988001 - 988 millimeters (code exact size in millimeters)

989989 millimeters or larger

990Microscopic focus or foci only, no size of focus given

991Described as less than 1 cm

995Described as less than 5 cm

996Malignant cells present in bronchopulmonary secretions, but no tumor seen radiographicallyor during bronchoscopy; "occult" carcinoma

997Diffuse (entire lobe)

998Diffuse (entire lung or NOS)

999Unknown; size not stated Not documented in patient record


Cs extension

CS Extension

  • CS Extension identifies contiguous growth of the primary tumor within the organ of origin or its direct extension into surrounding tissues (except Corpus Uteri and Ovary)

    • Always code the farthest extension of the primary tumor

    • If no neo-adjuvant treatment was performed, use the information in the path report to determine extension

    • If neo-adjuvant treatment was performed, use pre- treatment clinical information to determine extension


Coding cs extension lung

Coding CS Extension (Lung)

00In situ; noninvasive; intraepithelial

10Tumor confined to one lung; NO extension or conditions in 20-80 (EXCLUDES primary in main stem bronchus) (EXCLUDES superficial tumor as described in code 11)

11Superficial tumor of any size with invasive component limited to bronchial wall, with or without proximal extension to the main stem bronchus

20Extension from other parts of lung to main stem bronchus, NOS (EXCLUDES superficial tumor as described in code 11)

Tumor involving main stem bronchus > 2 cm from carina (primary in lung or main stem bronchus)

21Tumor involving main stem bronchus, NOS (distance from carina not stated, no surgery)

Tis

T1/T2*

*based on size

T1

T2

T2


Coding cs extension lung1

Coding CS Extension (Lung)

T1/T2

T1/T2

T1

T2

T2

T3

T3

T3

23Tumor confined to hilus

25Tumor confined to the carina

30Localized, NOS

40Atelectasis/obstructive pneumonitis that extends to the hilar region but does not involve the entire lung (or NOS) WITHOUT pleural effusion

45Extension to (without pleural effusion):Pleura, visceral or NOSPulmonary ligament

50Tumor of/involving main stem bronchus < 2.0 cm from carina

52(40) + (50)

53(45) + (50)


Coding cs extension lung2

Coding CS Extension (Lung)

55Atelectasis/obstructive pneumonitis involving entire lung

56Parietal pericardium or pericardium, NOS

59Invasion of phrenic nerve

60Extension to: (discontinuous ext.--see Mets at Dx)Brachial plexus (inferior branches or NOS) from superior sulcusChest (thoracic) wallDiaphragmPancoast tumor (superior sulcus syndrome)Parietal pleura

61Superior sulcus tumor with encasement of subclavian vessels or uniquivocal involvement of superior branches of brachial plexus

65Multiple masses/separate tumor nodule(s) in the SAME lobes; “Satellite nodules” in same lobe

T3T3

T3

T3

T4

T4


Coding cs extension lung3

Coding CS Extension (Lung)

T4

T4

T4

T3

70Blood vessel(s) (major): Azygos vein, Pulmonary

artery or vein, Superior vena cava (SVC syndrome)

Carina from lung/mainstem bronchus

Compression of esophagus or trachea not specified

as direct extension

Esophagus

Mediastinum, extrapulmonary or NOS

Nerve(s): Cervical sympathetic (Horner's syndrome),

Phrenic, Recurrent laryngeal (vocal cord paralysis),

Vagus

Trachea

71Heart

Visceral pericardium

72Malignant pleural effusion

Pleural effusion, NOS

73Adjacent rib


Coding cs extension lung4

Coding CS Extension (Lung)

74Aorta

75Vertebra(e)Neural foramina

76Pleural tumor foci separate from direct pleural invasion

77Inferior vena cava

79Pericardial effusion, NOS; malignant pericardial effusion

80Further contiguous extension (see also Mets at Dx)

95No evidence of primary tumor

98Tumor proven by presence of malignant cells in sputum or bronchial washings but not visualized by imaging or bronchoscopy; "occult" carcinoma

99Unknown extension; Primary tumor cannot be assessed; Not documented in patient record

T4

T4

T4

T4

T4

T4

T0

TX

TX


Cs tumor size ext eval

CS Tumor Size/Ext Eval

  • CS Tumor Size/Ext Eval records how the codes for “CS Tumor Size” and “CS Extension” were determined based upon the methods employed (PE, Radiographic, Surgery, Autopsy, Etc.)

    • Select the code that documents the report or procedure from which the farthest tumor extension or size of the primary tumor was determined


Coding cs tumor size ext eval lung

Coding CS Tumor Size/Ext Eval (Lung)

c

p

p

p

0PE, imaging, other non-invasive clinical evidence. No surgery; no autopsy

1Endoscopy, dx biopsy, incl. FNA biopsy, or otherinvasive techniques including surgical observationwithout biopsy. No surgery, no autopsy

2No surgery; based on autopsy (tumor suspected ordx’d prior to autopsy)

3Surgical resection, NO pre-surgical systemic tx or RT OR Surgical resection, Unknown if pre-surgical systemic tx or RT. Evidence acquired before tx, supplemented by information obtained from surgery and pathologic examination of the resected specimen.


Collaborative staging system

Coding CS Tumor Size/Ext Eval(Lung)

c

y

a

c

5Surgical resection with pre-surgical systemic tx or RT; TS/Ext based on clinical evidence

6Surgical resection with pre-surgical systemic tx or RT; TS/Ext based on pathologic evidence

8Autopsy only (tumor unsuspected or undiagnosed prior to autopsy)

9Unknown if surgical resection done; Not assessed;cannot be assessed; Unknown if assessed; Not documented in patient record


Collecting the n equivalent

Collecting the N Equivalent

Computer derives

TNM

Registrar records

CS Lymph Nodes (2 digits)

cN0

pN1

yN0

cNX

etc.

N

CS Reg Nodes Eval (1 digit)

Regional LN Positive (2 digits)

Regional LN Examined (2 digits)


Cs lymph nodes

CS Lymph Nodes

CS Lymph Nodes identifies the regional lymph nodes involved with cancer at the time of diagnosis

  • Record the RLN chain farthest from the primary site that is involved with cancer, either Clinically or Pathologically

  • For inaccessible sites, record RLN’s as negative rather than unknown if no mention is made of RLN involvement and patient receives usual standard cancer directed treatment

  • If patient receives neoadjuvant treatment, code the farthest involved RLN’s based upon information prior to treatment

  • If RLN’s are more involved after neoadjuvant treatment, code the most extensive RLN involvement


Collaborative staging system

Coding CS Lymph Nodes (Lung)

N0

N1

N2

00None; no regional lymph node involvement

10Regional lymph nodes (LN), ipsilateral: Bronchial; Hilar (bronchopulmonary) (proximal lobar)(pulmonary root); Intrapulmonary: Interlobar,Lobar, Segmental, Subsegmental,Peri/parabronchial

20Regional LN, ipsilateral: Aortic [above diaphragm],NOS--Peri/para-aortic, NOS (Ascending aorta{phrenic}, Subaortic {aortico-pulmonary window});Carinal (tracheobronchial) (tracheal bifurcation);Mediastinal, NOS--Anterior, Posterior (tracheo-esophageal); Pericardial; Peri/paraesophageal;Peri/paratracheal, NOS--Azygos (lowerperitracheal), Pre- and retrotracheal,NOS(Precarinal); Pulmonary ligament; Subcardial;Subcarinal


Collaborative staging system

Coding CS Lymph Nodes (Lung)

N1

N3

N1

NX

50Regional Lymph Nodes, NOS

60Contralateral/bilateral hilar (bronchopulmonary) (proximal lobar) (pulmonary root); Contra-lateral/bilateral mediastinal; Scalene (inferior deepcervical), ipsilateral or contralateral;Supraclavicular (transverse cervical), ipsilateral orcontralateral

80Lymph nodes, NOS

99Unknown; not statedRegional lymph nodes cannot be assessedNot documented in patient record


Cs reg nodes eval

CS Reg Nodes Eval

  • CS Reg Nodes Eval records how the code for “CS Lymph Nodes” was determined based upon the diagnostic methods employed

    • Select the code that indicates the report or procedure from which information about the farthest involved RLN’s was obtained


Collaborative staging system

Coding CS Reg Nodes Eval (Lung)

c

p

p

p

0PE, imaging, other non-invasive clinical evidence. No LN removed; no autopsy

1Endoscopy, dx biopsy, incl. FNA biopsy, or otherinvasive techniques including surgical observationwithout biopsy. No LN removed, no autopsy

2No LN removed; based on autopsy (tumorsuspected ordx’d prior to autopsy)

3LN removed; NO pre-surgical systemic tx or RT OR LN removed, unk. if pre-surgical systemic tx or RT


Collaborative staging system

Coding CS Reg Nodes Eval (Lung)

c

y

a

c

5LN removed with pre-surgical systemic tx or RT; LN based on clinical evidence

6LN removed with pre-surgical systemic tx or RT; LN based on pathologic evidence

8Autopsy only (tumor not suspected or dx’d prior toautopsy)

9Unknown if surgical resection done; Not assessed;cannot be assessed; Unknown if assessed; Not documented in patient record


Regional lymph nodes positive

Regional Lymph Nodes Positive

  • Regional LN Positive records the exact number of RLN’s examined by the pathologist and found to be positive

    • The fields Regional Lymph Nodes Positive and Reg Ln’s Examined are based upon pathologic information only


Collaborative staging system

Coding Regional LN Positive

p

p

p

p

p

c

c

00All nodes examined negative.

01 - 891 - 89 nodes positive (code exact number ofnodes positive)

9090 or more nodes positive

95Positive aspiration of lymph node(s)

97Positive nodes - number unspecified

98No nodes examined

99Unknown if nodes are positive; not applicable; Not documented in record


Regional ln examined

Regional LN Examined

  • Regional LN Examined records the total number of RLN’s that were removed and examined by the pathologist

    • The number of RLN’s examined is cumulative from all procedures that removed RLN’s through the completion of surgery in the first course of treatment


Collaborative staging system

Coding Regional LN Examined

00No nodes examined.

01 - 891 - 89 nodes examined (code exact number ofnodes examined)

9090 or more nodes examined

95No regional nodes removed but aspiration ofregional nodes performed

96LN “sampling,” number unk/not stated

97LN “dissection,” number unk/not stated

98LN removed, number unk/not stated; proceduretype not stated; nodes examined, number unk

99Unknown if nodes were examined; not applicable or negative; Not documented inpatient record


Collecting the m equivalent

Collecting the M Equivalent

Computer derives

TNM

Registrar records

cM0

pM1a

yM0

cMX

etc.

CS Mets at Dx (2 digits)

M

CS Mets Eval (1 digit)


Cs mets at dx

CS Mets At Dx

  • CS Mets At Dx identifies the distant site or sites of metastatic involvement at the time of diagnosis including distant lymph nodes

    • Assign the highest code for CS Mets At Dx whether determined clinically or pathologically and whether or not the patient had any neoadjuvant treatment


Coding cs mets at dx lung

Coding CS Mets at Dx (Lung)

00No distant metastases

10Distant lymph node(s)

35Separate tumor nodule(s) in different lobe, same lung

37Extension to: Sternum, Skeletal muscle, Skin of chest

39Extension to: Contralateral lung, Contralateral mainstem bronchus; Separate tumor nodule(s) incontralateral lung

40 Distant metastases (other than code 10), except those in 35-39, including separate lesion in chest wallor diaphragmDistant metastasis, NOS; Carcinomatosis

50(40) + (10); any of (35-39) + 10

99Unknown; distant metastasis cannot be assessed; not stated in patient record

M0

M1

M1

M1

M1

M1

M1

MX


Cs mets eval

CS Mets Eval

  • CS Mets Eval records how the code for data item “CS Mets at DX” was determined based upon the diagnostic methods employed

    • Select the CS Mets Eval code that documents the report or procedure from which the information was obtained about metastatic involvement farthest from the primary site

    • If the patient receives neoadjuvant treatment use the clinical status of metastatic involvement prior to treatment


Collaborative staging system

Coding CS Mets Eval

c

c

p

p

0PE, imaging, other non-invasive clinical evidence. No mets tissue examined; no autopsy

1Endoscopy or other invasive techniques, includingsurgical observation without biopsy. No metstissue examined, no autopsy

2No mets tissue examined prior to death; based onautopsy (tumor suspected or dx’d prior to autopsy)

3Mets tissue examined; NO pre-surgical systemic TXor RT OR Mets tissue examined, unk. if pre-surgical systemicTX or RT


Coding cs mets eval

Coding CS Mets Eval

c

y

a

c

5Mets tissue examined with pre-surgical systemicTX or RT; Mets based on clinical evidence

6Mets tissue examined with pre-surgical systemicTX or RT; Mets based on pathologic evidence

8Autopsy only (tumor not suspected or dx’d prior toautopsy)

9Unknown if surgical resection done; Not assessed;cannot be assessed; Unknown if assessed; Not documented in patient record


Cs site specific factors

CS Site Specific Factors

  • CS Site-Specific Factors 1-6 identify additional information necessary to generate stage or prognostic factors that effect stage or survival including HIV status and tumor markers


Collecting site specific factors ssf

Collecting Site-Specific Factors (SSF)

  • Replace existing “tumor marker” fields

  • Necessary for AJCC TNM changes(6th ed.)

  • Only used as needed by disease site


Example ssf2 melanoma

Example: SSF2 Melanoma

Ulceration

Note: Melanoma ulceration is the absence of an

intact epidermis overlying the primary

melanoma based upon histopathological

examination.

If no ulceration is documented in path report,

code to 000.

CodeDescription

000No ulceration presentadds ‘a’ to T1-T4

001Ulceration presentadds ‘b’ to T1-T4

999Unknown; Not stated;

Not documented in patient record


Example ldh ssf4 melanoma ssf3 testis

Example: LDH (SSF4 Melanoma; SSF3 Testis)

LDH (Lactate Dehydrogenase)

CodeDescription

000Not done (SX)

002Within normal limits (SO)

004Range 1 (S1) < 1.5 x upper limit of normal for LDH assay

005Range 2 (S2) 1.5 - 10 x upper limit of normal for LDH assay

006Range 3 (S3) > 10 x upper limit of normal for LDH assay

008Ordered, but results not in chart

999Unknown; Not stated; Not documented in patient record

Note:Per AJCC 6th ed. page 211, “An elevated serum LDH should only be used when there are two or more determinations obtained more than 24 hours apart, because an elevated serum LDH on a single determination can be falsely positive as a result of hemolysis or other factors unrelated to melanoma metastases.”


Collaborative staging system

Collaborative Staging System

Coding Practicum

Lung


Example lung cancer case 1

Example: Lung Cancer Case 1

6 months PTA: minimal cough; night sweats; 5-10 lb weight loss. 1½ PPD cigarette smoker x 30 years.

PE: No lymphadenopathy or organomegaly.

CXR: Solitary 3 cm. nodule in right upper lobe

CT bone, brain and liver: within normal limits

Bronchoscopy with biopsy: undiff large cell ca.

Bronchoscopy brushings: positive for malignant cells

Right upper lobectomy: 2.5 cm right upper lobe tumor; No gross hilar or mediastinal nodes noted.

Pathology: Nodular 4 cm. mass showing poorly differentiated adenocarcinoma of right upper lobe, 0/12 hilar lymph nodes positive.


Collaborative staging system

Example: Lung Case 1--Coded

CS Tumor Size

040 4 cm per path report

CS Extension

10 confined to one lung

3resection, no pre-op (p)

CS TS/Ext Eval

CS Lymph Nodes

00lymph nodes negative

CS Reg Nodes Eval

3resection, no pre-op (p)

00per path report

Reg LN Pos

Reg LN Exam

12per path report

CS Mets at Dx

00none

0 clinical (imaging) only (c)

CS Mets Eval

Site Specific Factors

SSF1 - SSF6

888 not applicable


Collaborative staging system

Example: Lung Case 1--Derived

Derived Stage

  • TNM pT2 pN0 cM0Stage IB

  • SS 1977 LocalizedSS 2000 Localized


Example lung cancer case 2

Example: Lung Cancer Case 2

HX: Chest pain, productive cough, hoarseness with partial vocal cord paralysis. One PPD x 40 years.

PE: Wheezing on expiration in both lungs. Otherwise no abnormal findings.

CXR: 6 cm. RUL mass, incomplete atelectasis same lung. Pneumonitis and pleural effusion apparent.

Scans of liver, brain: negative

Bronchoscopy with biopsy: Right upper lobe mass noted with extension along lateral wall of main stem bronchus involving trachea. Washings and brushings positive for malignant cells.

Scalene node biopsy (one node removed): metastatic SCC.

Lung biopsy: Squamous cell carcinoma, poorly differentiated.


Collaborative staging system

Example: Lung Case 2--Coded

CS Tumor Size

060 6 cm per CXR

72pleural effusion

CS Extension

1endoscopy

CS TS/Ext Eval

60scalene lymph nodes

CS Lymph Nodes

CS Reg Nodes Eval

3 LN bx established highest N

Reg LN Pos

01scalene node

01scalene node

Reg LN Exam

CS Mets at Dx

00none

CS Mets Eval

0 clinical (imaging) only

Site Specific Factors

SSF1 - SSF6

888 not applicable


Collaborative staging system

Example: Lung Case 2--Derived

Derived Stage

  • TNM cT4 pN3 cM0Stage IIIB

  • SS 1977 DistantSS 2000 Distant


Cs training opportunities

CS Training Opportunities

  • Workshops

    • State and regional associations

  • Web-based training module

    • www.training.seer.cancer.gov

  • CS website

    • Presentations and exercises available

    • Algorithms, updates, additional

      information

    • www.cancerstaging.org/collab.html


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