Nicole Catlett, CTR
KCR Abstractor’s Training
April 21-23, 2015
1
Discussion about collaborative staging data items:
 Tumor
Size
 Extension
 Tumor size/Extension Eval
 Lymph Nodes
 Lymph Node Eval
 Mets @ DX
 Mets Eval
2
General Rules:
1. Code largest primary tumor size documented.
2. Code primary tumor size from pathology report
when patient has a resection.
3. Code largest primary tumor size prior to
neoadjuvant treatment unless tumor is more
extensive after treatment.
4. Code largest primary tumor size from radiology
or endoscopy when no surgery is performed.
3
 Record
the tumor size in millimeters
 You will convert cm to mm by multiplying by
10
4
Pathology report states: 3.9 cm mucinous
adenocarcinoma located in the cecum.
CSTS =
Colonoscopy states: 6 cm tumor in the sigmoid
colon suspicious for malignancy.
CSTS =
5
 Do
not code the size of a polyp, cyst or ulcer, only
the size of the cancer.
EXAMPLE #1:
Pathology report states tubulovillous adenoma 2 cm in size.
Size of invasive carcinoma: 1.1 cm
CSTS = ?
Answer: 011
EXAMPLE #2:
Pathology report states 1.9 cm tubular adenoma with foci of
adenocarcinoma. (HINT: review tumor size extension table)
CSTS = ?
Answer: 990 Foci
6
 Rounding
rules for coding tumor size when
described in fractions of millimeters.
EXAMPLES:
1. Tumor 3.7 mm = 004 mm
2. Tumor 0.9 mm = ?
Answer = 001
3. Tumor 5.1 mm = ?
Answer = 005
NOTE: If the tumor size is a fraction of a millimeter
you will round up to 1 mm, you will not round down
Example: Tumor 0.3 mm = 001 mm.
7
 Using
“stated as” codes
EXAMPLES:
Tumor stated to be “between 4 and 5 cm
CSTS = 995
Tumor stated to be less than 1 cm
CSTS = ?
Answer: 991
8
General Rules
1. Code the farthest tumor extension documented.
2. Code pathologic tumor extension when patient
does not receive neoadjuvant treatment.
3. Code clinical tumor extension when patient does
receive neoadjuvant treatment unless the
tumor extension is worse after neoadjuvant
treatment then you use pathologic extension.
4. Code tumor extension based on list of ambiguous
terms to be used to determine involvement.
9
The complete list of ambiguous terminology that can
be used to determine involvement are listed on page
23 of Section I, Part I of CS manual.
10
SOME TERMS THAT CAN BE USED:
- Compatible with
- Consistent with
- Favors
- Most likely
- Probable
- Presumed
- Suspected
- Suspicious
SOME TERMS NOT TO BE USED:
- abuts
- approaching
- attached
- encased/encasing
- equivocal
- possible
- questionable
- worrisome
11
 Identifies
contiguous growth (extension) of the
primary tumor within the organ of origin or its
direct extension into neighboring organs.
 When
coding tumor extension you are
documenting the depth of tumor invasion through
the colon wall layers.
Now lets take a look at the colon layers
12
Layers from inside out…
 Lumen (interior surface of colon "tube")
 Mucosa
 Surface epithelium
 Lamina propria or basement membrane—
dividing line between in situ and invasive
lesions
 Muscularis mucosae
13
 Submucosa—lymphatics;
potential for
metastases increases
 Muscularis propria
 Subserosa—sometimes called pericolic fat,
subserosal fat, mesenteric or retroperitoneal fat
 Serosa—present on ascending, transverse,
sigmoid only (also called the visceral
peritoneum)
SEER Training Modules, Colon Module, U. S. National Institutes of Health, National Cancer
Institute, 1/13/12. <http://training.seer.cancer.gov/>.
14
SEER Training Modules, Colon Module , U S National Institutes of Health, National Cancer
Institute. 1/13/12 <http://training.seer.cancer.gov/>.
15
Lets review the CS Extension codes located in the
extension table:
000 In-situ, intraepithelial, noninvasive
050 Adeno(carcinoma), noninvasive in a polyp or
adenoma
100 Invasive tumor confined to mucosa, nos
including intramucosal, nos (pTis)
110 Invasive tumor confined to lamina propria,
including lamina propria in the stalk of a
polyp
16
120 Confined to and not through muscularis
mucosae, including muscularis mucosae in a
polyp
130 Confined to head of polyp, NOS
140 Confined to stalk of polyp, NOS
150 Invasive tumor in polyp, NOS
160 Invades submucosa (superficial invasion),
including submucosa in stalk of polyp
170 Stated as T1 with no other information
17
18
200 Invasion of muscularis propria OR stated as T2
with no other information
19
20
400 Extension through wall, NOS, Invasion through
muscularis propria or muscularis, NOS,
Subserosal tissue/(sub)serosal fat invaded,
Transmural, NOS, Wall, NOS
450 Extension to:
Adjacent tissue(s), NOS
Connective tissue
Mesenteric fat
Mesentery
Pericolic fat
21
458 Extension to fat, NOS
470 Stated as T3 with no other information
22
23
500 Invasion of/through serosa (mesothelium)
(visceral peritoneum); Tumor penetrates to
surface of visceral peritoneum
550 500 + (450, 458) *COMBINATION CODE*
560 Stated as T4a with no other information
565 Adherent to other organs or structures clinically
with no microscopic examination OR Tumor
found in adhesion(s) if microscopic
examination [T4b]
24
25
570 Adherent to other organs or structures, NOS
600 Greater omentum, small intestine (*site specific)
655 Abdominal wall or retroperitoneum (excluding
fat) *except sigmoid which is code 675
660 Kidney or ureter *see note about sites applicable
700 Fallopian tube or Ovary or Uterus
750 Adrenal (suprarenal) gland
Bladder
Diaphragm,
Fistula to skin
Gallbladder
Other segment(s) of colon/rectum via serosa
26
800 Kidney
Liver
Ureter
Other contiguous extension
850 Stated as T4b with no other information
900 Stated as T4 [NOS] with no other information
950 No evidence of primary tumor
999 Unknown
Extension not stated
Primary tumor cannot be assessed
Not documented in patient record
27
Coding extension examples:
 Your
path report states “invasion of muscularis
propria into the pericolic fat with extension to
serosal surface”.
What code would be used?
CSEXT = 550
 Pathology report states “invasion through the
bowel wall”.
What code would be used?
CS EXT = 400
28
 This
field is used primarily to derive the staging
basis for the T category in the TNM system. In
most circumstances it records how the codes for
the two items “CS Tumor Size” and “CS
Extension” were determined, based on the
diagnostic methods employed.
29
Instructions for coding:
1. Document the staging basis for the farthest
extension and/or greatest tumor size.
The underlying purpose of this field is to capture the
staging basis for the highest T category assigned to
the case. In most circumstances, this will be the
staging basis for the highest Tumor Size code or
Extension code as appropriate to the site.
In coding colon cancer the extension code is used to
derive the T category.
30
Clinical Code 0 (c)
Physical Exam
 Imaging (CT, MRI, PET)
 Other non-invasive
methods of examining
tissues

31
Clinical code 1 (c)
 Scopes

Observations at surgery
 Diagnostic
biopsies
32
Pathologic Code 3 (p)
Based on surgical resection
(no or unknown prior neoadjuvant
treatment)

OR
Based on biopsy that
determines the highest T or N
category

33
Clinical Code 5 (c)


Neoadjuvant treatment received
Clinical evidence unless
pathologic evidence is more
extensive than clinical
34
Pathologic Code 6 (yp)


Neoadjuvant treatment AND
pathologic evidence at Surgery is
more extensive than clinical
evidence before treatment
Neoadjuvant therapy given,
pathologic evidence available,
clinical evaluation prior to
neoadjuvant therapy not available
35


Autopsy Code 2 (p)
- Autopsy performed
- Prior knowledge of malignancy
(suspected OR diagnosed)
Autopsy Code 8 (a)
- Autopsy performed
- Malignancy diagnosed at autopsy
with no prior knowledge of
malignancy (unsuspected OR
undiagnosed)
36
Clinical Code 9 (c)

Unknown
- Unknown how T, N or M
determined
- Defaults to clinical (c)
37
Example #1
You have a CT scan showing a 8.4 cm lesion located
in the cecum with stranding seen in the mesenteric
tissue. The patient underwent a colonoscopy that
showed adenocarcinoma. A colon resection was
performed showing the cancer extended through the
muscularis propria into pericolic adipose tissue.
What is the Tumor Size?
What is the Extension Code?
What is the TS/EXT eval?
38
Example #2
A patient undergoes a screening colonoscopy and a large
mass was seen in the cecum which was biopsied showing
adenocarcinoma. The patient then had a CT scan of
abdomen & pelvis showing a mass in cecum measuring
72 mm consistent with patient’s known history of newly
diagnosed colon cancer. There is associated bowel wall
thickening and stranding in adjacent mesentery,
suspicious for invasion. The patient refused any other
workup.
What is the Tumor Size ?
What is the Extension code ?
What is TS/EXT Eval ?
39
40
 This
field identifies the regional lymph nodes
involved with cancer at the time of diagnosis.
Record the specific involved regional lymph node
chain(s) farthest from the primary site. The lymph
nodes may be involved by tumor either clinically or
pathologically. Record the highest applicable code
in the following order:
 pathology report, imaging, physical exam.
41
 Pathologic
information takes precedence. If
there is a discrepancy between clinical information
and pathologic information about the same lymph
nodes, pathologic information takes precedence if
no preoperative treatment was administered. It is
not necessary to biopsy every lymph node in the
suspicious area to disprove involvement.
Example: Mesenteric lymph nodes stated as
“suspicious for involvement” on CT scan. After
colon resection all lymph nodes are negative.
Code CS Lymph Nodes as 000, no regional lymph
node involvement.
42
 Inaccessible
lymph nodes rule for regional
lymph nodes. For inaccessible lymph nodes,
record CS Lymph Nodes as Code 000 (None)
rather than Code 999 (Unknown) when the
following three conditions are met:
1. There is no mention of regional lymph node
involvement in the physical examination,
pretreatment diagnostic testing or surgical
exploration.
2. The patient has clinically low stage (T1, T2, or
localized) disease.
43
Note: Code 999 can and should be used in situations
where there is reasonable doubt that the tumor is no
longer localized and there is no documentation of
involved regional lymph nodes
44
45
Segment
Regional Lymph Nodes
 Cecum - Pericolic, anterior cecal, posterior cecal,
ileocolic, right colic
 Ascending colon - Pericolic, ileocolic, right colic,
middle colic
 Hepatic flexure - Pericolic, middle colic, right
colic
 Transverse colon - Pericolic, middle colic
 Splenic flexure - Pericolic, middle colic, left colic,
inferior mesenteric
 Descending colon - Pericolic, left colic, inferior
mesenteric, sigmoid
46
Segment
Regional Lymph Nodes
 Sigmoid colon - Pericolic, inferior mesenteric,
superior rectal, superior hemorrhoidal, sigmoidal,
sigmoid mesenteric
 Rectosigmoid - Perirectal, left colic, sigmoid
mesenteric, sigmoidal, inferior mesenteric, superior
rectal, superior hemorrhoidal, middle hemorrhoidal
 Rectum - Perirectal, sigmoid mesenteric, inferior
mesenteric, lateral sacral, presacral, internal iliac,
sacral promontory (Gerota's) superior hemorrhoidal,
inferior hemorrhoidal
 Anus - Perirectal, anorectal, superficial inguinal,
internal iliac, hypogastric, femoral, lateral sacral
47
000 No regional LN involvement
050 TD in the subserosa, mesentery, or
nonperitonealized pericolic or perirectal tissues
WITHOUT regional nodal metastasis
Stated as N1c with no other information on regional
110 Regional lymph nodes:
Colic (NOS)
Epicolic (adjacent to bowel wall)
Mesocolic (NOS)
Paracolic/pericolic
Nodule(s) or foci in pericolic fat/adjacent
mesentery/mesocolic fat
48
210 Regional lymph nodes, for specific colon sites
300 Mesenteric, NOS
Regional lymph node(s), NOS
410-480 Stated as pathologic N1 with no other
information on regional lymph nodes
49
800 Lymph nodes, NOS
999 Unknown; regional lymph nodes not stated
Regional lymph nodes cannot be assessed
Not documented in patient record
50
Example #1
A patient presents with abdominal distention and
pain. A CT of abdomen and pelvis is performed and
shows descending colon mass with regional lymph
node metastasis.
What code would you use for CSLN?
Answer: CSLN = 300 regional lymph nodes, nos
51
Example #2
A patient underwent a screening colonoscopy where
a transverse colon cancer was identified and biopsy
shows Adenocarcinoma. The patient had surgery and
the path report has 15/15 positive pericolic lymph
nodes.
What is the code for CSLN?
Answer: CSLN = 110
52
 This
field is used primarily to derive the staging
basis for the N category in the TNM system. It
records how the code for the item “CS Lymph
Nodes” was determined, based on the diagnostic
methods employed and their intent.
 Document the farthest involved regional nodes.
Select the CS Lymph Nodes Eval code that identifies
the type of report or procedure from which the
information about the farthest involved regional
lymph nodes was obtained.
53
Clinical Code 0 (c)
Physical Exam
 Imaging (CT, MRI, PET)
 Other non-invasive
methods of examining
tissues

54
Clinical code 1 (c)
 Endoscopic

exam
Observations at surgery
 Diagnostic
biopsy
55
Pathologic Code 3 (p)
Based on surgical resection
(no or unknown prior neoadjuvant
treatment)

OR
Based on biopsy that
determines the highest N
category

56
Clinical Code 5 (c)


Neoadjuvant treatment received
Clinical evidence unless
pathologic evidence is more
extensive than clinical
57
Pathologic Code 6 (yp)




Neoadjuvant treatment AND
Pathologic evidence at
Surgery is more extensive
than clinical evidence before
treatment
Neoadjuvant therapy given,
pathologic evidence available,
clinical evaluation prior to
neoadjuvant therapy not available
58


Autopsy Code 2 (p)
- Autopsy performed
- Prior knowledge of malignancy
(suspected OR diagnosed)
Autopsy Code 8 (a)
- Autopsy performed
- Malignancy diagnosed at autopsy
with no prior knowledge of
malignancy (unsuspected OR
undiagnosed)
59
Clinical Code 9 (c)

Unknown
- Unknown how T, N or M
determined
- Defaults to clinical (c)
60
Example #1
Patient comes to ER with abdominal pain, bloating
and rectal bleeding. A CT abdomen/pelvis is
performed which shows colon cancer with pericolic
lymph node involvement as well as liver metastasis.
What is the CSLN code?
Answer: 110 pericolic LNs
What is the LN eval code?
Answer: 0 clinical per CT
61
Example #2
Patient was found to have colon cancer after
undergoing a screening colonoscopy. Surgery was
performed. Path report says ascending colon
adenocarcinoma with involvement of 10 out of 15
lymph nodes.
What is the code for CSLN ?
Answer: 300 regional lymph nodes, nos
What is the LN eval code ?
Answer: 3 pathologic
62
Description
 This field records the exact number of regional lymph nodes
examined by the pathologist and found to contain
metastases.

Based on pathologic information only. This field is to be
recorded regardless of whether the patient received
preoperative treatment.

Record the total number of regional lymph nodes removed
and found to be positive by pathologic examination. The
number of regional lymph nodes positive is cumulative
from all procedures that remove lymph nodes through the
completion of surgeries in the first course of treatment.
63
 Use
of code 95.
Use code 95 when the only procedure for regional
lymph nodes is a needle aspiration (cytology) or core
biopsy (tissue).
Use code 95 when a positive lymph node is aspirated
and there are no surgically resected lymph nodes.
64
 Definition
of code 97.
Use code 97 for any combination of positive
aspirated, biopsied, sampled or dissected lymph
nodes if the number of involved nodes cannot be
determined on the basis of cytology or histology.
65
 Use
of code 98. Code 98 may be used in several
situations.
a. When the assessment of lymph nodes is clinical
only.
b. When no lymph nodes are removed and examined.
c. When a “dissection” of a lymph node drainage
area is found to contain no lymph nodes at the
time of pathologic examination.
d. If Regional Nodes Positive is coded as 98,
regional Nodes Examined is usually coded 00.
66
 Use
of code 99.
Use code 99 if it is unknown whether regional
lymph nodes are positive.
67

This field records the total number of regional lymph
nodes that were removed and examined by the
pathologist.

Based on pathologic information only. This field is
to be recorded regardless of whether the patient
received preoperative treatment.

Cumulative nodes removed and examined. Record
the total number of regional lymph nodes removed and
examined by the pathologist. The number of regional
lymph nodes examined is cumulative from all
procedures that removed lymph nodes through the
completion of surgeries in the first course of treatment.
68



Use of code 95. Use code 95 when the only procedure for
regional lymph nodes is a needle aspiration (cytology) or
core biopsy (tissue).
Definition of “sampling” (code 96). A lymph node
“sampling” is removal of a limited number of lymph nodes.
Other terms for removal of a limited number of nodes
include lymph node biopsy, berry picking, sentinel lymph
node procedure, sentinel node biopsy, selective dissection.
Use code 96 when a limited number of nodes are removed
but the number is unknown.
9. Definition of “dissection” (code 97). A lymph node
“dissection” is removal of most or all of the nodes in the
lymph node chain(s) that drain the area around the primary
tumor. Other terms include lymphadenectomy, radical node
dissection, lymph node stripping. Use code 97 when more
than a limited number of lymph nodes are removed and the
number is unknown.
69
 This
field identifies the distant site(s) of metastatic
involvement at time of diagnosis.
Use highest applicable code. Assign the highest
applicable code for metastasis at diagnosis, whether
the determination was clinical or pathological and
whether or not the patient had any preoperative
Systemic therapy.
Progression of disease. Metastasis known to have
developed after the extent of disease was established
(also referred to as progression of disease) should not
be recorded in the CS Mets at Dx field.
70
 Coding
00 versus 99
Record CS Mets at Dx as Code 00 (None) if there is
no clinical or pathologic evidence of distant
metastases and the patient is not treated as if
metastases are present or suspected. This presumes
that there are no distant metastasis that would
otherwise alter the treatment approach.
Code 99 may be used in situations where there is
reasonable doubt that the tumor is no longer
localized and there is no documentation of distant
metastases. Note that code 99 maps to MX in sixth
edition and cM0 in seventh edition.
71
00 No distant metastasis
08 Metastasis limited to a single distant lymph node chain:
For cecum, ascending, hepatic flexure and transverse
colon:
Superior mesenteric lymph nodes
16 Metastasis limited to a single distant lymph node chain:
For all colon sites:
Common iliac
Distant lymph node(s), NOS
External iliac
Para-aortic
Retroperitoneal
18 Metastasis limited to a single distant lymph node chain,
72
26 Metastasis limited to a single distant organ except
peritoneum
27 Stated as M1a with no other information on distant
metastasis
31 Metastases to a single distant lymph node chain listed in
code 08 and to a single distant lymph node chain listed in
code 16
OR
Multiple distant lymph node chains listed in code 16, with
or without distant lymph nodes listed in code 08
33 Metastases to multiple distant lymph node chains, NOS
73
36 Metastases to more than one distant organ except
distant lymph node(s)
Metastasis to peritoneum
Carcinomatosis
45 (26 or 36) + any of (08, 16, 18, or 31)
Metastases to distant organs plus distant nodes
48 Stated as M1b with no other information on
distant metastasis
74
60 Distant metastasis, NOS
Stated as M1 [NOS] with no other information
on distant metastasis
99 Unknown; distant metastasis not stated
Distant metastasis cannot be assessed
Not documented in patient record
75
Example #1
CT scan that shows evidence of liver metastasis.
What is METS at DX code?
ANSWER: 26 (single distant organ)
Example #2
CT scan shows evidence of carcinomatosis.
What is METS at DX code?
ANSWER : 36 (carcinomatosis)
76

This field is used primarily to derive the staging basis
for the M category in the TNM system. It records how
the code for the item “CS Mets at Dx” was determined
based on the diagnostic methods employed.
Document the highest code in CS Mets at Dx. The
primary use of the CS Mets Eval field is to assign a “c”
or “p” to the M category derived from the CS Mets at Dx
field. Since both clinical and pathologic evidence might
be available for assessing distant metastasis, the coding
of the Eval field can be confusing. The goal is to assign
the Eval code that indicates the best evidence used to
determine the M category.
77
 Mapping
of M1 subcategories. If a specific
subcategory of M1 will be derived (such as M1a),
determine if there was any pathological evidence for
the specific subcategory. If so, select an Eval code
that will derive a “p” staging basis. If there was only
clinical evidence of the subcategory disease, select
an Eval code that will derive a “c” staging basis.
78
Eval code 0
 Does
not meet criteria for AJCC pathologic staging
of distant metastasis:
Evaluation of distant metastasis based on physical
examination, imaging examination, and/or other noninvasive clinical evidence. No microscopic
examination of metastatic specimen performed or
microscopic examination was negative.
This will derive a clinical M.
79
Eval code 3

Meets criteria for AJCC pathologic staging of distant
metastasis:
Specimen from metastatic site microscopically positive
WITHOUT pre-surgical systemic treatment or radiation
OR specimen from metastatic site microscopically
positive, unknown if pre-surgical systemic treatment or
radiation performed
OR specimen from metastatic site microscopically
positive prior to neoadjuvant treatment
80
Examples:
 Cecum carcinoma with lung metastases on chest X-ray
and positive liver biopsy. CS Mets at Dx is coded 36
(Metastases to more than one distant organ), which
maps to M1b. Code CS Mets Eval as 0, which maps to
the “c” staging basis because only one organ/site was
microscopically proven.

Sigmoid adenocarcinoma with liver metastases on
ultrasound and positive peritoneal nodule biopsy. CS
Mets at Dx is coded 36 (Metastasis to peritoneum).
Code CS Mets Eval as 3, which maps to the “p”
staging basis because although only one organ/site is
microscopically confirmed, that one organ/site is the
peritoneum (M1b).
81
82
CASE #1
A patient presents with abdominal pain. A CT scan was
performed that showed sigmoid colon wall thickening, no
LAD identified and no evidence of distant disease. A
colonoscopy was performed where a sigmoid colon mass
was BX’d showing adenocarcinoma. Patient then
underwent sigmoid colon resection. The path report
describes a 4.6 cm adenocarcinoma invading the
muscularis propria. There were 17 benign mesenteric
lymph nodes examined.
83
Case #1
CSTS = 046
CS EXT = 200
CS TS/EXT EVAL = 3
CSLN = 000
LN EVAL = 3
LNS POSITIVE = 0
LNS EXAMINED = 17
METS AT DX = 00
METS EVAL = 0
84
Case #2
A patient has an abnormal screening colonoscopy
showing an obstructing colon cancer. The patient has
a CT scan performed which shows evidence of liver
and lung METS. The colon cancer appears to invade
the abdominal wall. There is probable mesenteric
lymph node involvement noted. The patient
undergoes a CT guided BX of both the lung nodule
and liver mass. Pathology from both shows
metastatic carcinoma from colon primary. The
patient is referred to Hospice.
85
Case #2
CSTS = 999
CS EXT = 655
CS TS/EXT EVAL = 0
CSLN = 300
LN EVAL = 0
LNS POSITIVE = 98
LNS EXAMINED = 00
METS AT DX = 36
METS EVAL = 3
86
Case #3
A patient presented to ER with severe rectal bleeding
and pain. CT scan showed a large mass in the
descending colon. The patient was taken to operating
room where a laparotomy showed a large mass in the
left colon directly invading the spleen. There are
mesenteric LNs suspicious for involvement. The
liver was palpated and there were 3 small nodules
suspicious for implants. One of these nodules was
biopsied and sent for frozen, which came back as
metastatic signet ring adenocarcinoma consistent
with colon primary. After discussion with family,
decision to abort operation.
87
Case #3
CSTS = 999
CS EXT = 565
CS TS/EXT EVAL = 1
CSLN = 300
LN EVAL = 0
LNS POSITIVE = 98
LNS EXAMINED = 00
METS AT DX = 26
METS EVAL = 3
88
89
Nicole Catlett, CTR
KCR Senior Regional Coordinator
Kentucky Cancer Registry
nicole@kcr.uky.edu
90
91