Putting the Puzzle Together:Breast Collaborative Staging
Melissa Riddle, RHIT, CTROctober 6, 2012
ObjectivesObjectives
• Understand why collaborative staging was created
• Learn the concepts of collaborative staging for breast cases
Collaborative StagingCollaborative Staging• 5yr 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• General rules apply to all sites/histologies unless superseded by site-specific rule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 StagingCollaborative Staging
• Used for cases diagnosed 1/1/2004 and forward– CSv2 for cases diagnosed 1/1/2010 and forward
• Derives:– AJCC TNM– SEER Summary
• Understand SEER Summary and TNM is necessary in order to analyze cases
Collaborative StagingCollaborative Staging
• Allows both clinical and pathologic information to be used to determine stage– Pathologic information takes precedence
Collaborative StagingCollaborative Staging• CS Solution: Mixed or “Best Staged”
– Result: more relevant to actual practice– Fewer 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
And
Stage Group
SS77, SS2000
Computer Derives:
Data Elements:Data Elements:• CS Tumor Size
• CS Extension
• CS TS/Exten Eval
• CS Lymph Nodes
• CS LN Eval
• Regional LN Positive
• Regional LN Exam
• CS Mets @ DX
• CS Mets Eval
• SSF 1-25
Breast CSBreast CS
Collaborative StagingCollaborative Staging
• Evaluation Fields:– Code based on the procedure performed
• Scans• Biopsies• Surgery
– Derives the TNM as clinical or pathologic
Breast Evaluation CodesBreast Evaluation Codes
CODE DESCRIPTION STAGING
0 Physical Exam; Imaging c
1 Diagnostic BX; FNA c
3 Resection without neoadjuvant TX p
5 Neoadjuvant TX; Based on Clinical information
c
6 Neoadjuvant TX; Resection information yp
9 Unknown c
Breast CS Data ItemsBreast CS Data Items
• Tumor Size• Extension• Lymph Nodes• Lymph Node Positive/Exam• Distant Mets at Diagnosis• Site Specific Factors 1-24
Tumor Size/ExtensionTumor Size/Extension
Tumor SizeTumor Size• Code the specific size of the tumor in mm
– Convert any size in cm to mm
• Pathologic size:– Take pathologic size over clinical– Record the invasive sizeExample:Invasive Ductal Carcinoma, 0.5cm; DCIS, 2cmCode Tumor Size: 005
Tumor SizeTumor Size
• Special Codes:– 990 Microinvasion; Microscopic focus– 991-995 No specific size: “less than ___cm”– 996 seen on mammogram only but no size given– 997 Paget’s of nipple, no underlying tumor– 998 Diffuse
ExtensionExtension• In Situ only: 000
– No invasive disease
• Invasive cancer without skin involvement: 100
• Skin involvement: 200– Adherence, Attachment, Fixation, Induration &
Thickening– Without diagnosis Inflammatory Breast CA
CS BREAST: EXTENSIONCS BREAST: EXTENSION
Example:L breast partial mastectomyPath report partial mastectomy: 2cm invasive ductal carcinoma invading into skin
CS Extension: 200 (invade skin)
ExtensionExtension• Inflammatory Breast CA:
– Based on clinical information– Codes based on percentage of breast involved:
• Code 600: 33% or less• Code 725: more than 33% but less than 50%• Code 730: more than 50%• Code 750*: percentage unknown
*Most common code for IBC
Regional Lymph NodesRegional Lymph Nodes
Lymph NodesLymph Nodes• Regional Lymph Nodes Only:
– Do NOT code cervical or contralateral axillary LN – Includes Levels 1-3 Ipsilateral Axillary LN, internal
mammary LN and Supraclavicular LN– Clinical vs. Pathologic
• If the only information about involved regional LN is from physical exam or imaging- clinical
• If there are positive LN found on sampling/dissection- pathologic
Level 1 & 2 Axilla LNLevel 1 & 2 Axilla LN• Code 250:
– Pathologic involvement LN
• Code 255:– Clinical involvement moveable LN
• Code 510:– Clinical involvement fixed/matted LN
• Code 520:– Pathologic involvement fixed/matted LN
• Code 600:– Axillary, NOS
CS BREAST: LYMPH NODESCS 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 PositiveReg LN Positive• Record all positive pathologic examined
regional lymph nodesExample:3/5 R axillary LN involved with invasive duct
carcinoma CODE: 03
• Code 95:– Positive LN only on core biopsy or FNA
• Code 98:– No regional LN were examined pathologically
Reg LN ExaminedReg LN Examined• Record the total number of pathologically
examined regional LNExample:3/5 R axillary LN involved with invasive duct
carcinoma CODE: 05
• Code 95:– Regional LN examined by core biopsy or FNA only
• Code 00:– No regional LN examined pathologically
Distant Mets at DiagnosisDistant Mets at Diagnosis
Distant MetsDistant Mets• Code 00:
– No evidence of metastatic disease
• Code 10:– Involvement distant LN:
• Cervical• Contralateral/Bilateral Axillary and/or internal
mammary LN
• Code 40:– Distant met site except distant LN
Distant MetsDistant Mets• Code 42:
– Further contiguous extension:• Skin over axilla, contralateral breast, sternum, upper
abdomen
• Code 44:– Involve any of the following:
• Adrenal gland• Bone• Contralateral breast- if stated metastatic• Lung• Ovary• Sat nodules skin other than primary breast
Distant MetsDistant Mets• Code 50:
– Distant LN – Distant Sites (listed in codes 40-44)
• Code 60:– Distant mets, NOS
CS BREAST: METS AT DXCS BREAST: METS AT DX
ExampleR 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 FactorsSite Specific Factors
Collaborative StagingCollaborative Staging
• Site-Specific Factors– Not all 25 SSF are used for every case
• Breast has the most with 24 to complete
– Additional information needed to derive TNM– Prognostic Tumor Markers/Labs– Special Interest/Future Research– Other clinically significant information
SSF 1: ER & SSF 2: PRSSF 1: ER & SSF 2: PR• If there is any sample positive, record as
positive• Do NOT record ER results from Oncotype DX
or other multigene test• 010- Positive• 020- Negative• 997- Test ordered results not in chart• 999- Unknown
SSF 3: Pos Level 1 & 2 LNSSF 3: Pos Level 1 & 2 LN• Based on pathologic information ONLY• Code 098:
– No pathologically examined LN
• Code 000:– Negative LN
• Code 001-089:– Code the exact number of positive LN
• Code 095:– Positive LN by biopsy or FNA
SSF 7: BR ScoreSSF 7: BR Score• Priority Order:
– BR Score– BR Grade
• Codes 030-090:– BR Score range of 3-9
• Codes 110-130:– BR Grade: Low, Intermediate, High
• Code 998:– No histologic exam of primary tumor
HER 2HER 2• SSF 8: IHC test value
– Scores 0, 1+, 2+, 3+
• SSF 9: IHC interpretation– Record the pathologists interpretation of the test
value: positive, negative, equivocal
• SSF 10: FISH value– Record ratio as given – Code 991: ratio less than 1.00
• SSF 11: FISH interpretation– Record the interpretation of the test value
HER 2HER 2• SSF 14: Other/Unknown test
– Statement in medical record on HER2, unknown type of testing performed
– Other type of test performed
• SSF 15: Summary of results– Based on codes in SSF 9, 11, 13 and 14– Both IHC and FISH/CISH record results of FISH/CISH
• Except when IHC is performed to clarify equivocal test of FISH/CISH
SSF 16: ER, PR & HER2SSF 16: ER, PR & HER2• Identifies Triple negative patients• Code Pattern:
– First digit: ER– Second digit: PR– Third digit: HER2
• Digits: – 0= negative– 1= positive
• Information unknown on one or more test code 999
SSF 16SSF 16• Example:
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 MethodSSF 22: Multigene Method• Assess:
– likelihood of response to chemotherapy– evaluate prognosis or distant recurrence
• Code 010: Oncotype DX
• Code 020: MammaPrint
• Code 030: Other test
SSF 23: Multigene ResultSSF 23: Multigene Result• Record the results of the multigene method:
– Oncotype DX: Scores range 0-100– MammaPrint: Low Risk or High Risk
• Codes 000-100– Record actual Oncotype DX score
• Code 200: Low Risk• Code 300: Intermediate Risk• Code 400: High Risk
SSF 24: Paget’s DiseaseSSF 24: Paget’s Disease• Record any mention of Paget’s disease
– Pathologic takes precedence over clinical info
• Negative exam of nipple– Interpret as no Paget’s disease
• Pathology report mentions pagetoid involvement of nipple, Code 020– Does NOT include pagetoid involvement of ducts
or lobules
Current VersionCurrent Version
CSv02.04http://www.cancerstaging.org/cstage/manuals/coding0204.html
Additional Help:http://cancerbulletin.facs.org/forums/
The Whole PictureThe Whole Picture• Now 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!