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Putting the Puzzle Together: Breast Collaborative Staging

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.

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Putting the Puzzle Together: Breast Collaborative Staging

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  1. Putting the Puzzle Together:Breast Collaborative Staging Melissa Riddle, RHIT, CTR October 6, 2012

  2. Objectives • Understand why collaborative staging was created • Learn the concepts of collaborative staging for breast cases

  3. 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and for cancer registrars to code the facts about a cancer case • General rules apply to all sites/histologies unless superseded by site-specific rule

  4. 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

  5. Collaborative Staging • Allows both clinical and pathologic information to be used to determine stage • Pathologic information takes precedence

  6. Collaborative Staging • CS Solution: Mixed or “Best Staged” • Result: more relevant to actual practice • Fewer unstageable cases Registrar records: T elements + c/p N elements + c/p M elements + c/p Site Specific Factors (tumor markers) Computer Derives: c/pT c/p N c/p M And Stage Group SS77, SS2000

  7. 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

  8. Breast CS

  9. Collaborative Staging • Evaluation Fields: • Code based on the procedure performed • Scans • Biopsies • Surgery • Derives the TNM as clinical or pathologic

  10. Breast Evaluation Codes

  11. Breast CS Data Items • Tumor Size • Extension • Lymph Nodes • Lymph Node Positive/Exam • Distant Mets at Diagnosis • Site Specific Factors 1-24

  12. Tumor Size/Extension

  13. 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

  14. 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

  15. 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

  16. Example: L breast partial mastectomy Path report partial mastectomy: 2cm invasive ductal carcinoma invading into skin CS Extension: 200 (invade skin) Cs breast: extension

  17. 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

  18. Regional Lymph Nodes

  19. 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/dissection- pathologic

  20. 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

  21. 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) Cs breast: Lymph nodes

  22. 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

  23. 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

  24. Distant Mets at Diagnosis

  25. 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

  26. 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

  27. Distant Mets • Code 50: • Distant LN • Distant Sites (listed in codes 40-44) • Code 60: • Distant mets, NOS

  28. 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) CS breast: mets at DX

  29. Site Specific Factors

  30. 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

  31. 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

  32. 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

  33. 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

  34. 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

  35. 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

  36. 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

  37. 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

  38. 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

  39. 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

  40. 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

  41. Current Version CSv02.04 http://www.cancerstaging.org/cstage/manuals/coding0204.html Additional Help: http://cancerbulletin.facs.org/forums/

  42. 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!

  43. Thank You! Melissa Riddle, RHIT, CTR melissariddlespeaks@ymail.com

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