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
• 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unless superseded by site-specific rule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 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 Staging
• Allows both clinical and pathologic
information to be used to determine stage
– Pathologic information takes precedence
Collaborative Staging
• CS Solution: Mixed or “Best Staged”
– Result: more relevant to actual practice
– Fewer unstageable cases
Computer Derives:
Registrar records:
T elements + c/p
N elements + c/p
M elements + c/p
Site Specific Factors
(tumor markers)
c/pT
c/p N
And
Stage Group
SS77, SS2000
c/p M
Data Elements:
• CS Tumor Size
• Regional LN Positive
• CS Extension
• Regional LN Exam
• CS TS/Exten Eval
• CS Mets @ DX
• CS Lymph Nodes
• CS Mets Eval
• CS LN Eval
• SSF 1-25
Breast CS
Collaborative Staging
• Evaluation Fields:
– Code based on the procedure performed
• Scans
• Biopsies
• Surgery
– Derives the TNM as clinical or pathologic
Breast 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 Items
•
•
•
•
•
•
Tumor Size
Extension
Lymph Nodes
Lymph Node Positive/Exam
Distant Mets at Diagnosis
Site Specific Factors 1-24
Tumor Size/Extension
Tumor 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 size
Example:
Invasive Ductal Carcinoma, 0.5cm; DCIS, 2cm
Code Tumor Size: 005
Tumor 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
Extension
• 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: EXTENSION
Example:
L breast partial mastectomy
Path report partial mastectomy: 2cm invasive
ductal carcinoma invading into skin
CS Extension: 200 (invade skin)
Extension
• 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 Nodes
Lymph 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/dissectionpathologic
Level 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 NODES
Example:
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 Positive
• Record all positive pathologic examined
regional lymph nodes
Example:
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 Examined
• Record the total number of pathologically
examined regional LN
Example:
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 Diagnosis
Distant 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 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 Mets
• Code 50:
– Distant LN
– Distant Sites (listed in codes 40-44)
• Code 60:
– Distant mets, NOS
CS BREAST: METS AT DX
Example
R 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 Factors
Collaborative 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: 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 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 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 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 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 & 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 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 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 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 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 Version
CSv02.04
http://www.cancerstaging.org/cstage/manuals/coding0204.html
Additional Help:
http://cancerbulletin.facs.org/forums/
The 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!
Thank You!
Melissa Riddle, RHIT, CTR
melissariddlespeaks@ymail.com