New TNM

The TNM System
What’s
New in
TNM7
AJCC edition UICC edition
April Fritz, RHIT, CTR AJCC and UICC definitions are almost identical
Reno, Nevada
Why a New Edition? 7th Edition Goals
 Challenges to cancer staging  Improve clinical utility

• Anatomic staging not meeting needs of clinicians  Make changes evidence-based
• Desire for ‘personalized’ medicine  Enhance prediction of individual outcomes
• Non-anatomic / prognostic / predictive
 Treatment selection – predict response
information part of planning and outcomes
• Maintain system that meets population needs
evaluation
 Structure
 Needs for integration of new factors
• Maintain anatomic base (T, N, M)
• Biologic / molecular
• Incorporate validated non-anatomic factors
• Response to therapy • Ulceration for melanoma, Gleason for prostate, etc.
• Nomograms • Allow collection of relevant investigational factors
 Coordination with electronic records
What’s New in TNM7 3 What’s New in TNM7 4
What’s New in TNM 7? 1

april@afritz.org Spring 2010
What’s New in 7th Edition? 6th Edition to 7th Edition
 New chapters
 Some chapters revised AJCC Cancer AJCC Cancer
• Split into multiple chapters Staging Manual Staging Manual
• Include histologies formerly excluded 6th edition 7th Edition
Number of pages 435 646
 Chapter 1 revised and expanded
 Prognostic Factors Number of illustrations < 100 130
• CS Site-Specific Factors Number of chapters 48 57
 New look Thickness 7/8 inch 1.5 inch
• Staging-At-A-Glance Weight 2.5 lb 3.3 lb
• Color coding Cost $59.95 $64.95
• T, N, and M elements color coded
• Color illustrations
• Redesigned staging forms
New Look: Staging At-A-Glance Summary of Changes

 Example: Kidney

New Look: Redesigned Staging
New Look: Color Coding
Forms
 T definitions – blue
 N definitions – yellow
 M definitions – green
 Stage groupings – red
 Color illustrations Examples from esophagus chapter
Survival graph from

colorectal chapter
Chapter 1 Rules Changes
Revised and expanded  Tumor size rounding

• Clearly defined rules • Round to nearest whole millimeter
• Both text and tables • 1 – 4 down, 5 – 9 up
–
–
General rules
T, N, M elements
 Node biopsy and sentinel node(s)
– Stage groups • Clinical if diagnostic (pre-treatment)
– Classifications • Pathologic if therapeutic
• Some rules changes  New stage groups for CIS and pM1
• Can be both clinical and pathologic
• cT_ cN_ pM1 Stage Group IV
• pTis cN0 cM0 Stage Group 0
 Elimination of MX

New Rule: MX and pMX Deleted New Rule: MX and pMX Deleted
 MX (cMX) Remaining Categories
• Inappropriate – clinical assessment of mets  cM0
can be based on PE alone • Clinically no distant metastasis
• Makes cases unstageable • Physical exam is sufficient
• If pathologist doesn’t know clinical M, MX  cM1
should NOT be recorded. • Distant metastasis clinically
 pMX  pM1
• Does not exist • Distant metastasis proven microscopically
 pM0
• Does not exist (except at autopsy)
 If a tissue equivalent to cM1 is biopsied
and is negative, it becomes cM0, not pM0
Clinical Classification Rules Modified Pathologic Staging Rules Modified
 Timing  Timing
• Prior to any definitive treatment • Through completion of first course of treatment
• OR within 4 months • No pre-op systemic or radiation therapy
• Whichever is shorter • No disease progression
• OR within 4 months
 Clinical staging basis includes biopsies
• Whichever is longer
• Lymph node(s)
• Sentinel node(s)
• Metastatic site
 Also called pre-treatment staging

Post-Therapy Staging Stage Grouping
 Also called intercurrent staging (‘y’  New terminology

classification) • Stage group
• Allows assessment of response to therapy • Prognostic stage group if non-anatomic factors included
• Prognostic • Anatomic stage if only T, N, M
 yc – Clinical staging after neoadjuvant  If grouping requires non-anatomic factor

• Use lowest category if factor not available
treatment • Assume lowest or least value of non-anatomic factor
 yp – Pathologic staging after neoadjuvant • Prostate example
treatment • If PSA or Gleason unknown, can still stage group with
• Surgery meets criteria for pathologic staging known T, N and M
• Stage group notation for no residual cancer  “Any” includes X
• ypT0 ypN0 cM0 • ‘Any N’ includes NX
Prognostic Factors Prognostic Factors – Examples

 Breast Prostate
 a.k.a. CSv2 Site-Specific Factors • PSA
• Her2 (IHC, FISH, CISH)
 Two types listed in each chapter • Bloom-Richardson score • Gleason score
• Required for Staging • Multigene signature score • Number biopsy cores
• Supplement T, N, M positive/examined
 Colon-Rectum
• Clinically Significant
• Radial margin Lymphomas
• Clinically relevant but not always available • International prognostic indices
• Tumor deposits
• Tumor markers and lab values • B-cell lymphomas
• Prognostic/predictive • KRAS gene
• Follicular lymphomas
• Special interest/research • Microsatellite instability
• International Prognostic Score
• Supplementary – related diseases, exposures, etc.  Lung • Hodgkin lymphoma
 AJCC aware of data collection burden in • Pleural elastic layer Head and Neck
invasion
cancer registry • HPV (human papilloma virus)
 Esophagus-Stomach • Extracapsular extension
• Tumor location • Involvement of low neck nodes

New Chapters Chapters Split/Revised
 Mucosal melanoma of head and neck  Intrahepatic bile ducts (separate from Liver)
 Appendix (carcinomas) • Liver  Hepatocellular carcinoma
 Gastrointestinal stromal tumors (GIST) • IHB  Cholangiocarcinoma
 Neuroendocrine tumors (Carcinoids)  Extrahepatic bile ducts
• Stomach, small intestine, large intestine, • Perihilar bile ducts
appendix, pancreas, lung • Distal bile ducts
 Merkel cell carcinoma  Skin
 Adrenal cortex • Cutaneous Squamous Cell Carcinoma and Other
Cutaneous Carcinoma
 Ocular adnexal lymphoma
• Merkel cell
• Malignant melanoma
 Histology code range listed for each chapter
Few or Minor Modifications Major Modifications
 Head and Neck  Biliary  Esophagus

 Liver • Gallbladder  Stomach
 Anal canal • Ampulla  Colon
• Pancreas
 Mesothelioma,  Lung
 Gynecological sites
pleural  Prostate
 Urological sites
 Skin (carcinoma)  Breast
• Except prostate
 Small intestine

Esophagus-Stomach Changes Esophagus GE Junction
 Shift of C16.0, parts of C16.1 and C16.2 to  Esophago-gastric Junction

esophagus  Gastroesophageal Junction
 Esophagogastric junction (EGJ) tumors:
• If midpoint (epicenter) within 5 cm of EGJ and
also extends into esophagus, classify and stage
as esophagus
• Stage all others with midpoint in stomach > 5 cm
from EGJ or those within 5 cm of the EGJ with no
extension into esophagus as gastric carcinoma
 Lymph node counts harmonized
From Edge et al. Used with permission of the American Joint Committee on Cancer (AJCC), Chicago,
Illinois. The original source for this material is the AJCC Cancer Staging Manual, seventh edition
What’s New in TNM7 25 What’s New in TNM7 26 (2009) published by Springer Science and Business Media LLC, www.springerlink.com.
Esophagus – 7th Edition Esophagus – 7th Edition

Tis Carcinoma in situ /High-grade dysplasia
T1 Lamina propria or submucosa N0 No regional lymph node metastasis
T1a Lamina propria or muscularis mucosae N1 1 to 2 regional lymph nodes
T1b Submucosa N2 3 to 6
T2 Muscularis propria N3 > 6 Changes from 6th Ed.
T3 Adventitia [N1 was site dependent]
T4 Adjacent structures
T4a Pleura, pericardium, diaphragm, or adjacent M0 No distant Metastasis
peritoneum M1 Distant metastasis
T4b Other adjacent structures, e.g. aorta, [M1a,b were site dependent]
vertebral body, trachea
Anatomical/Prognostic Stage Groups
Changes from 6th Ed. based on histologic type, grade, location within
esophagus and T, N, M

Stomach – 7th Edition Colon Changes
T1 Lamina propria, submucosa  T

T1a Lamina propria • T4 subdivided based on differential prognosis
T1b Submucosa  N
T2 Muscularis propria • Potential importance of satellite tumor deposits
T3 Subserosa (was T2b) • Defined by site-specific factor Tumor Deposits (TD)
T4a Perforates serosa (was T3) Changes from 6th Ed. • TD but no lymph node metastasis classified as N1c
T4b Adjacent structures • N1 and N2 subdivided
 M
N1 1 to 2 nodes
• M1a for single metastatic site
N2 3 to 6 nodes (was N1)
• M1b for multiple metastatic sites
N3a 7 - 15 nodes (was N2)
N3b 16 or more (was N3)  Stage Groupings redefined
 Appendix now separate from colon
Stage Groupings revised • Carcinoma, carcinoid
Colon-Rectum – 7th Edition Colon-Rectum – 7th Edition
T1 – T3 Unchanged N1 Metastasis in 1 to 3 regional lymph nodes

N1a 1 node
T4 Tumor directly invades other organs or structures N1b 2 – 3 nodes
and/or perforates visceral peritoneum N1c Satellites [tumor deposits] in subserosa,
T4a Perforates visceral peritoneum without regional nodes
T4b Directly invades other organ or structures N2 Metastasis in 4 or more regional lymph nodes
N2a 4 – 6 nodes
N2b 7 or more nodes
M1 Distant metastasis
M1a One organ
M1b > one organ or peritoneum

Appendix (Carcinoma) – 7th Edition Carcinoids and
Neuroendocrine Tumors
COLON – RECTUM APPENDIX (carcinoma)
T4 Tumor directly invades Separate mucinous from
Staging
other organs or structures nonmucinous carcinomas  GI tract
and/or perforates visceral • Carcinoid: separate staging by site
peritoneum T4a Perforates visceral • Need size and/or depth of invasion
T4a Perforates visceral peritoneum / Mucinous • Small cell/large cell: stage as carcinoma
peritoneum peritoneal tumor within  Pancreas: stage as carcinoma
T4b Directly invades other right lower quadrant
organ or structures T4b Other organs or structures  Lung: stage as carcinoma
 Skin: separate classification for Merkel cell
M1 Distant metastasis M1a Intraperitoneal metastasis carcinoma
M1a One organ beyond RLQ
M1b > one organ or M1b Non-peritoneal metastasis
peritoneum
Changes from TNM 6 Changes from colon
Appendix – 7th Edition Carcinoids (NET) – 7th Edition

Gastrointestinal
CARCINOMA CARCINOID
 Like colon, based on depth;  Based mainly on size APPENDIX STOMACH
includes goblet cell carcinoid  All WD NET except goblet T1 < 2 cm Tis < 0.5 mm confined to mucosa
cell carcinoid T2 > 2 – 4 cm; cecum T1 Lam propria/submucosa and
T1 Submucosa T3 > 4 cm; ileum < 1 cm
T2 Muscularis propria T1 < 2 cm T4 Perforates peritoneum; T2 Muscularis propria or > 1 cm
T3 Subserosa, non-peritonealized T2 > 2 – 4 cm; cecum other organs, structures T3 Subserosa
periappendiceal tissues T3 > 4 cm; ileum T4 Perforates serosa; adjacent
T4a Perforates visceral peritoneum/ T4 Perforates peritoneum; SMALL INTESTINE structures
Mucinous peritoneal tumour other organs, structures T1 Lam propria/submucosa and
within right lower quadrant < 1 cm LARGE INTESTINE
N1 Regional T2 Muscularis propria or > 1 cm T1 Lam propria/submucosa and
T4b Other organs or structures
Stage I T1 N0 T3 Jejunum, ileum: subserosa < 2cm
N1 < 3 regional Ampulla, duodenum: T1a < 1 cm T1b 1 to 2 cm
Stage II T2, T3 N0
N2 > 3 regional pancreas or retroperitoneum T2 Muscularis propria or > 2 cm
Stage III T4 N0
M1a Intraperitoneal metastasis Any T N1 T4 Perforates serosa; adjacent T3 Subserosa or pericolorectal
beyond right lower quadrant Stage IV Any T Any N M1 structures tissues
M1b Non-peritoneal metastasis T4 Perforates serosa; adjacent
What’s New in TNM7 35 What’s New in TNM7 36 structures

Gastrointestinal Stromal Tumors Lung Changes
(GIST) – New in 7th Edition
ALL SITES
 Classification should be used for
T1 < 2 cm  Prognostic factors: site, size, • Non-small cell AND small cell carcinomas
T2 > 2 – 5 cm mitotic rate • Carcinoid tumors
T3 > 5 – 10 cm  T
T4 > 10 cm
ANATOMICAL/PROGNOSTIC • New tumor sizes and subclassifications
ANATOMICAL/PROGNOSTIC STAGE GROUPS • Multiple tumors in same lobe now T3
STAGE GROUPS STOMACH MR* • Multiple tumors in same lung different lobe
SMALL INTESTINE MR* Stage IA T1-2 N0 M0 Low now T4
Stage I T1-2 N0 M0 Low Stage IB T3 Low
Stage II T3 Low Stage II T4 Low
 N
Stage IIIA T4 Low T1-2 High • New international lymph node map
T1 High Stage IIIA T3 High  M
Stage IIIB T2, 3, 4 High IIIB T4 High • Malignant pleural effusion now M1a
Stage IV Any T N1 M0 Any Stage IV Any T N1 M0 Any
Any T Any N M1 Any Any T Any N M1 Any  Stage Groupings revised
What’s New in TNM7 37
* Mitotic rate What’s New in TNM7 38
Lung – 7th Edition Lung – 7th Edition

T1 <3 cm
T4 Mediastinum, heart, great vessels, carina,
T1a < 2 cm
trachea, esophagus, vertebra
T1b > 2 to 3 cm Separate tumour nodule(s) in different ipsilateral
T2 Main bronchus >2 cm from carina, invades visceral lobe (was M1)
pleura, partial atelectasis
T2a >3 to 5 cm N1 Ipsilateral peribronchial, ipsilateral hilar nodes
T2b >5 to 7 cm N2 Ipsilateral mediastinal, subcarinal nodes
T3 > 7 cm N3 Contralateral mediastinal or hilar, scalene or
Chest wall, diaphragm, pericardium, mediastinal supraclavicular nodes
pleura, main bronchus <2 cm from carina
M1a Separate tumour nodule(s) in contralateral lobe
Total atelectasis
Separate nodule(s) in same lobe (was T4) Pleural nodules
Malignant pleural or pericardial effusion (was T4)
M1b Distant metastasis

Breast Changes Breast – 7th Edition
 T T1 Tumor size in millimeters
• Guidance on determining tumor size T1mic < 1 mm
• Clarification of inflammatory carcinoma T1a > 1 to 5 mm
• Recommend grading with Nottingham/Bloom T1b > 5 to 10 mm
Richardson T1c > 10 to 20 mm
T2 > 20 to 50 mm
 N T3 > 50 mm
• Classification of isolated tumor cells more stringent
T4a Chest wall (excludes pectoralis muscle)
• Restricted use of (sn) modifier to 5 or fewer nodes
T4b Skin ulceration, nodules, edema not meeting
 M definition of inflammatory carcinoma
• Created new cM0 (i+) category T4c Chest wall and skin
• Disseminated tumor cells detectable in bone T4d Inflammatory carcinoma
marrow Definition: clinical-pathologic entity characterized by
• Circulating tumor cells diffuse erythema and edema (peau d'orange) involving
• Incidental in other tissues < 0.2 mm one third or more of the skin of the breast
Breast – 7th Edition Breast – 7th Edition

N A few changes in definitions cM0(i+) Molecularly/micro-detected tumor cells in
ITCs: < 0.2 mm size or < 200 cells in cluster circulating blood (CTCs), bone marrow or other
N1, N2 limited to Levels I and II axillary nodes non-regional nodal tissue < 0.2 mm in patient
N3: Level III, infraclavicular, supraclavicular without symptoms or signs of metastases
M1 Distant detectable metastases as determined
Internal mammary nodes by classic clinical and radiographic means
N1b Micromets or detected by sentinel lymph node and/or histologically proven larger than 0.2 mm
procedure, no axillary nodes positive
N1c Micromets or detected by SLNB and pos ax LN  M0 includes M0(i+)
N2b Clinically detected, no axillary nodes positive  pM0 is not valid; any M0 should be clinical
N3b Clinically detected and pos ax LN  No MX
OR micromets/SLNB and > 3 pos ax LN

Prostate Changes Prostate – 7th Edition
AJCC Anatomical/Prognostic Groups
Stage PSA Gleason Score
 T I T1a-c N0 M0 < 10 <6
• Microscopic bladder neck extension now T3a T2a N0 M0 < 10 <6
(was T4) T1-2a N0 M0 X X
 N IIA T1a-c N0 M0 < 20 <7
• No changes T1a-c N0 M0 > 10 to < 20 <6
T2a N0 M0 < 20 <7
 M T2b N0 M0 < 20 <7
• No changes T2b N0 M0 X X
 Stage Grouping IIB T2c N0 M0 Any Any
• T2a moved to Stage I; T2b, T2c remain in Stage II T1-2 N0 M0 > 20 Any
• Grade/differentiation no longer a factor T1-2 N0 M0 Any >8
• PSA value included in prognostic grouping III T3a-c N0 M0 Any Any
• Gleason score included in prognostic grouping IV T4 N0 M0 Any Any
• If PSA or Gleason unknown, can still stage Any T N1 M0 Any Any
Any T Any N M1 Any Any
Extrahepatic Bile Ducts – 7th Edition Mucosal Melanoma of Head and Neck
PROXIMAL /PERIHILAR BILE DUCT DISTAL EXTRAHEPATIC BILE (Upper Aerodigestive) – 7th Edition
TUMORS (New site) DUCTS
 Right, left, common hepatic ducts  From cystic duct insertion  Mucosal melanomas are ANATOMICAL STAGE GROUPS
T1 Ductal wall into common hepatic duct aggressive tumors Stage III T3 N0
T2a Beyond ductal wall T1 Ductal wall  T1 and T2, Stages I and II are Stage IVA T4a N0
T2b Adjacent hepatic parenchyma T2 Beyond ductal wall omitted T3-T4a N1
T3 Unilateral portal vein or T3 Adjacent organs Stage IVB T4b Any N
hepatic artery branches T4 Celiac axis, or superior T3 Epithelium/ submucosa Stage IVC Any T Any N M1
T4 Main portal vein or branches mesenteric artery (mucosal disease)
bilaterally; … N1 Regional T4a Deep soft tissue, bone,
N1, N2 Specific lymph node chains cartilage, overlying skin
Anatomical Stage Groups Anatomical Stage Groups T4b Brain, dura, skull base,
Stage I T1 N0 M0 Stage IA T1 N0 lower cranial nerves,
Stage II T2a-b N0 Stage IB T2 N0 masticator space, carotid
Stage IIIA T3 N0 Stage IIA T3 N0 artery, prevertebral space,
Stage IIIB T1-3 N1 Stage IIB T1-3 N1 mediastinal structures,
Stage IVA T4 N0-1 Stage III T4 Any N cartilage, skeletal muscle,
Stage IVB Any T N2 or M1 Stage IV Any T Any N M1 or bone

Skin – 7th Edition
Split into two chapters Adrenal Cortical Carcinoma – 7th Ed
CARCINOMA (non-Merkel cell) MERKEL CELL CARCINOMA  New site—carcinomas only ANATOMICAL STAGE GROUPS
T1 <2 cm with < 2 risk factors* T1 < 2 cm  Adrenal cortex produces
T2 >2 with > 2 risk factors* T2 > 2 to 5 cm steroid hormones Stage I T1 N0
T3 Maxilla, mandible, orbit, or T3 > 5 cm Stage II T2 N0
temporal bone T4 Deep extradermal structures T1 < 5 cm, no extra-adrenal Stage III T1-2 N1
T4 Skull base, axial or (bone, muscle…) invasion T3 N0
appendicular skeleton T2 > 5 cm, no extra-adrenal Stage IV T3 N1
N1a Microscopic metastasis
invasion T4 N0-1
N1 1 node < 3 cm N1b Macroscopic metastasis
T3 Local invasion Any T Any N M1
N2a 1 node > 3 to 6 cm N2 In transit metastasis
T4 Adjacent organs
N2b Mult ipsilat nodes < 6 cm
N2c Bilat/contralat nodes < 6 cm M1a Skin, subcut, distant nodes
M1b Lung N1 Regional
N3 Any node > 6 cm
M1c Other sites
M1 Distant metastasis M1 Distant
New stage groupings for Merkel
* Risk factors for carcinomas: >2 mm thickness; Clark level IV;
perineural invasion; ear or non-hair-bearing lip primary; PD or undiff
Summary The Details
 New chapters and revisions to existing  AJCC Cancer Staging Manual

Edge, S.B.; Byrd, D.R.; Compton, C.C.;
chapters Fritz, A.G.; Greene, F.L.; Trotti, A. (Eds.)
 Some staging rules changed for 7th edition 7th ed., 2010, 646 p. 130 illus. With CD-
 New look ROM., Softcover
ISBN: 978-0-387-88440-0
 User-friendly features
 Use for cases diagnosed on or after  AJCC Cancer Staging Handbook
01/01/2010 From the AJCC Cancer Staging Manual
Edge, S.B.; Byrd, D.R.; Compton, C.C.;
Fritz, A.G.; Greene, F.L.; Trotti, A. (Eds.)
7th ed., 2010, Approx. 745 p. 130 illus.,
Softcover
ISBN: 978-0-387-88442-4

AJCC Cancer Staging Manual and
Handbook
Acknowledgements
 Dr. Leslie Sobin

 www.cancerstaging.net (Springer) • Chair, UICC TNM Staging Project
• Manual $64.95
 Dr. Carolyn Compton
• Handbook $44.95
• Chair, American Joint Committee on Cancer
• Quantity discounts available from publisher
 Dr. Steven Edge
• Editor in chief, AJCC Cancer Staging Manual and
 www.Amazon.com
Handbook
• Manual $50.66
• Handbook $35.06  Donna Gress, CTR
• Technical Specialist, AJCC
 www.bn.com (Barnes and Noble)
• Manual $58.45 member price  FOR GENERAL QUESTIONS
• Handbook $40.50 member price • ajcc@facs.org

Describing Extent of Disease
How to Clinically  T Primary tumor and contiguous

tumor growth
Stage a Case  N Regional lymph node involvement
in TNM 7th Edition  M Distant metastases
ACTUR Conference
April 26, 2010
April Fritz, RHIT, CTR
Clinical TNM Staging 2
Staging Basis General Rules for Staging
 Clinical (c)  Chapter 1 TNM Manual

• Before any treatment  Used for all sites
 Pathologic (p)  Exceptions or additions in site-specific
• After neoadjuvant therapy chapters
 Retreatment (r)
 Autopsy (a)
Clinical TNM Staging 3 Clinical TNM Staging 4
How to Clinically TNM Stage a Case 1

ACTUR Conference April 2010
General Rules for Staging General Rules for Staging
1. MICROSCOPIC CONFIRMATION 2. TIMING

All cases should be confirmed  Clinical staging
microscopically. All information obtained prior to initiation of any
• Clinically diagnosed cases should be reported treatment or within 4 months of diagnosis,
separately. whichever is shorter, with no disease
• Cancers are classified by their ICD-O-3 primary progression.
• Treatment decision includes watchful waiting.
site code.
 Pathologic staging
All information obtained through completion of
first course surgery or within 4 months of
diagnosis, whichever is longer, with no
neoadjuvant treatment or disease progression.
General Rules for Staging Posttherapy Classification
3. CASES WITH NEOADJUVANT TREATMENT  yTNM

Cases treated with neoadjuvant therapy  Measures response to neoadjuvant treatment
(pre-operative systemic or radiation • Patient had systemic and/or radiation treatment
therapy) may have a second staging after before surgery
• Case staged at conclusion of therapy
treatment. • Clinical if no further treatment (ycTNM)
• Should have clinical staging as baseline • Pathologic if resection (ypTNM)
• Post-treatment staging labeled yc or yp  Provides prognostic information
• Help determine extent of surgery or subsequent
non-surgical treatment

General Rules for Staging General Rules for Staging
4. PROGRESSION OF DISEASE 6. MISSING PROGNOSTIC FACTOR

Only information obtained prior to If required non-anatomic factor is not
documented progression of disease is used available, stage group case assuming
for staging. lowest value for factor.
Example: T2a N0 M0 prostate cancer but
5. UNCERTAINTY ABOUT CATEGORY Gleason score and PSA unknown.
• If in doubt about correct T, N, or M value, use the Assign Stage Group I (PSA X, Gleason X).
lower (less advanced) category.
• If in doubt about stage grouping, choose the
lower stage.
• If in doubt about prognostic factor, assign the
lower category.
Additional Chapter 1 Notes Additional Chapter 1 Notes
 Carcinoma in situ  Subsequent primaries

• Mixed stage pTis cN0 cM0 • Stage as new cancer
• Can be reported as clinical or pathologic stage • Do not stage with ‘y’ prefix unless neoadjuvant
 Multiple tumors therapy to new primary
• Simultaneous tumors of same histology in one  Unknown primary site
organ • No evidence of primary tumor (T0)
• Classify by highest T category • Stage according to site suspected by clinician
• Add suffix of m for multiplicity or number of tumors, as
in T2(m) or T2(3)
• Simultaneous bilateral tumors: classify separately
• Thyroid, ovary, liver: multiplicity part of
definitions

Working Stage 7th Edition Rules Changes
 Combination of c) and p) information
 Used ONLY at Tumor Conference or in  Node biopsy and sentinel node(s)
chart • Clinical if diagnostic (pre-treatment)
• Not recorded in registry • Pathologic if therapeutic
• Doesn’t meet COC Standard 4.3  New stage groups for CIS and pM1
 Also called mixed stage or combined • Can be both clinical and pathologic
stage • cT_ cN_ pM1 Stage Group IV
 Example • pTis cN0 cM0 Stage Group 0
• 79 yo patient presented at Tumor Conf after
lumpectomy shows DCIS w/ microinvasion.
Does pt need LN excision?
• pT1mic cN0 cM0
T – Tumor Other T Categories

 Assessment of the primary cancer and any  Tis – Carcinoma In Situ
organs involved by contiguous extension • Can be stage grouped as either clinical or
 Increasing Values 1-4 pathologic
• Size • Primary tumor must be removed and
• Local extension microscopically proven to be non-invasive (pTis)
• Multiplicity  T0 – No evidence of primary tumor
• Symptoms • Tumor in primary site cannot be found
 T Category Patterns
• Size of primary (oral cavity, breast)
• Depth of invasion (colon, bladder)
• Location and extension (larynx, lung)
• Combination

N – Regional Lymph Nodes M – Distant Metastasis
 Absence or presence of metastases in
primary lymph node drainage area of cancer  Absence or presence of distant metastases
 N0  Categories
• Regional lymph nodes have been clinically or • M0 Absence of metastatic disease
pathologically proven to be free of metastatic • M1 Presence of at least one area of distant
disease metastases
 N1 – N3  M1 subcategory example: prostate
• N1 Regional lymph node metastasis • M1a Non-regional lymph nodes
• Increasing involvement of regional lymph nodes • M1b Bone(s)
by • M1c Other site(s)
• Number (stomach, colon)
• Location (lung, female genital organs)
• Size (renal pelvis/ureter)
Using X (Unknown) 0 vs. X

 0 “I looked for it (T, N or M) and I
 TX Primary tumor cannot be assessed
couldn’t find it.”
 NX Regional nodes cannot be assessed • No evidence of involvement (N0, M0)
• Metastases found, but no evidence of primary
 TX or NX cannot be assigned to a stage unless (T0)
• Any T or Any N M1 • Tissue removed at another facility, no report
 Use TX or NX only when absolutely necessary available (pT0, pN0)
 X “I wasn’t able to look for it.”
• No tissue removed (cTX, pTX)
• No imaging or PE (cNX)
• Patient refused workup
• Can’t confirm suspicion of involvement

No More MX or pM0 Staging Basis
 MX and pM0 eliminated
Remaining Categories  Clinical stage: essential to select and
 cM0 evaluate therapy options
• Clinically no distant metastasis • Patient stage BEFORE treatment starts
• Physical exam and history are sufficient • Basis for FIRST treatment choice
• Extensive imaging not needed
 cM1  Pathologic stage: provides most precise data
• Distant metastasis clinically to estimate prognosis, plan subsequent
 pM1 therapy, and calculate end results
• Distant metastasis proven microscopically
 If a tissue equivalent to cM1 is biopsied

and is negative, it becomes cM0, not pM0
Clinical Stage Clinical Stage

 A.k.a. Pretreatment staging
• Assigned prior to cancer-directed treatment  Using pathology information for clinical
 Derived from clinical observations staging basis
• Physical examination and clinical history • Biopsy of primary site without resection (cT)
• Imaging • No pathologic information obtained (cT)
• Extensive imaging not necessary • Biopsy of single lymph node without pathologic
• Lab markers information about primary site (cN)
• Endoscopy • Sentinel node biopsy prior to neoadjuvant treatment for
• Surgical observation breast cancer
• Surgeon’s clinical observations and judgment • If no removal of primary tumor, then lymph node biopsy
or sentinel node procedure is cN
 Ends when first cancer-directed treatment
• Negative biopsy of metastatic site (cM0 not pM0)
starts or decision is made not to treat
 Should not be changed based on subsequent
information from treatment

Clinical Staging Sites Usually Staged Clinically
 Use when  Cervix

• No surgical treatment  Head and neck sites
• Adjuvant treatment prior to surgery  Malignant lymphomas
• Insufficient information to stage pathologically
Sites Rarely Staged Clinically Sites with Clinical Staging Issues

 Hollow organs
• Colon and rectum  Prostate
• Esophagus • Path staging requires radical prostatectomy
• Stomach  Bladder
• Renal pelvis and ureter
• Requires depth of invasion
• Corpus uteri
• Path staging requires total cystectomy
 Malignant melanoma  Testis
 Breast • Requires info on vascular invasion
 Ovary

Sites Where Clinical Findings
How to Clinically Stage a Case
are Important
 Breast 1. Determine primary site
• Inflammatory breast carcinoma, skin or chest 2. Review “Rules for Classification” in
wall involvement appropriate chapter
 Lung  Review general rules if necessary
• Superior vena cava syndrome, compression of 3. Review medical records for information
esophagus or trachea
from tests and reports listed in “Clinical
• Obstructive pneumonitis, atelectasis
Staging”
 Larynx
• Vocal cord paralysis 4. Classify T, N, and M from shaded boxes in
 Prostate “Definitions of TNM”
• Clinically inapparent or apparent primary 5. Determine stage group from orange
“Anatomic Stage/Prognostic Groups” box
Clinical Staging Criteria: Breast Pathologic Staging Criteria: Breast

AJCC Cancer Staging Manual 7th Edition, page 352 AJCC Cancer Staging Manual 7th Edition, page 353
Clinical Staging. Clinical staging includes physical Pathologic Staging. Pathologic staging includes all data
examination, with careful inspection and palpation of the used for clinical staging, plus data from surgical
skin, mammary gland, and lymph nodes (axillary, exploration and resection as well as pathologic
supraclavicular, and cervical), imaging, and pathologic examination (gross and microscopic) of the primary
examination of the breast or other tissues as carcinoma, regional lymph nodes, and metastatic sites
appropriate to establish the diagnosis of breast carcinoma. (if applicable), including not less than excision of the
The extent of tissue examined pathologically for clinical primary carcinoma with no macroscopic tumor in any
staging is not as great as that required for pathologic margin of resection by pathologic examination. A cancer
staging (see “Pathologic Staging” below). Imaging can be classified pT for pathologic stage grouping if there is
findings are considered elements of staging if they are only microscopic, but not macroscopic, involvement at the
margin. If there is transected tumor in the margin of
collected within 4 months of diagnosis in the absence
resection by macroscopic examination…
of disease progression or through completion of surgery,
whichever is longer.

Breast Case 1 Breast Case 2
 2.2 cm breast tumor identified on mammogram;  Patient sees MD for lump in axilla. MD also finds small
physical examination negative (< 1 cm) mass in UOQ.
 Core needle biopsy positive for duct carcinoma  Sentinel LN biopsy positive for metastatic duct
 Patient undergoes lumpectomy and sentinel lymph carcinoma in two nodes
node biopsy  1 of 3 nodes positive; 1.6 cm  Patient undergoes 3 months of chemotherapy then
carcinoma simple mastectomy and axillary dissection: no primary
tumor and no additional axillary nodes positive.
 What is the clinical T?
 What is the clinical N?  What is the clinical T? cT1 (≤ 20 mm)
 What is the clinical N? cN1 (sn) (mets in 1-3 nodes)
Clinical Staging Criteria: Lung Pathologic Staging Criteria: Lung

AJCC Cancer Staging Manual 7th Edition, page 255 AJCC Cancer Staging Manual 7th Edition, page 256
Pathologic Staging. Pathological classification uses the

Clinical Staging. Clinical classification (cTNM) is based on
evidence acquired before treatment, supplemented or
the evidence acquired before treatment, including physical
examination, imaging studies (e.g., computed and modified by the additional evidence acquired during and
positron emission tomography), laboratory tests, and after surgery, particularly from pathologic examination.
staging procedures such as bronchoscopy or The pathologic stage provides additional precise data used
for estimating prognosis and calculating end results.
esophagoscopy with ultrasound directed biopsies
• The pathologic assessment of the primary tumor (pT) entails
(EBUS, EUS), mediastinoscopy, mediastinotomy, resection of the primary tumor sufficient to evaluate the highest
thoracentesis, and thoracoscopy (VATS) as well as pT category.
exploratory thoracotomy. • The complete pathologic assessment of the regional lymph
nodes (pN) ideally entails removal of a sufficient number of
lymph nodes to evaluate the highest pN category.
• If pathologic assessment of lymph nodes reveals negative nodes
but the number of lymph node stations examined are fewer than
suggested above, classify the N category as pN0.

Lung Case Summary
 64 year old smoker has chest x-ray showing 7.5 cm  Assign clinical staging before any treatment
mass in RUL. starts
 CT scan shows questionable adenopathy in right
 Review Rules for Classification in TNM
mediastinum
 Mediastinoscopy and FNA of mediastinal node chapter
confirms metastatic small cell carcinoma  Know the difference between diagnostic and
 Patient referred to medical oncologist therapeutic procedures
• Especially for lymph nodes
 What is the clinical T?  cM0 unless proof of M1 clinically or
 What is the clinical N? pathologically

BREAST STAGING FORM
C L I NI C AL P AT HOL OG IC
Extent of disease before STAGE CATEGORY DEFINITIONS Extent of disease through
any treatment completion of definitive surgery
y clinical – staging completed L ATERALITY: y pathologic – staging completed
after neoadjuvant therapy but T UMOR S IZE : after neoadjuvant therapy AND
before subsequent surgery
left right bilateral subsequent surgery
PRIMARY TUMOR (T)
TX Primary tumor cannot be assessed TX
T0 No evidence of primary tumor T0
Tis Carcinoma in situ Tis
Tis (DCIS) Ductal carcinoma in situ Tis (DCIS)
Tis (LCIS) Lobular carcinoma in situ Tis (LCIS)
Tis (Paget’s) Paget’s disease of the nipple is NOT associated with invasive carcinoma and/or Tis (Paget’s)
carcinoma in situ (DCIS and/or LCIS) in the underlying breast parenchyma.
Carcinomas in the breast parenchyma associated with Paget's disease are
categorized based on the size and characteristics of the parenchymal
disease, although the presence of Paget's disease should still be noted
T1 Tumor £ 20 mm in greatest dimension T1
T1mi Tumor £ 1 mm in greatest dimension T1mi
T1a Tumor >1 mm but £ 5 mm in greatest dimension T1a
T1b Tumor > 5 mm but £ 10 mm in greatest dimension T1b
T1c Tumor >10 mm but £ 20 mm in greatest dimension T1c
T2 Tumor > 20 mm but £ 50 mm in greatest dimension T2
T3 Tumor > 50 mm in greatest dimension T3
T4 Tumor of any size with direct extension to the chest wall and/or to the skin T4
(ulceration or skin nodules)*
T4a Extension to the chest wall, not including only pectoralis muscle T4a
adherence/invasion
T4b Ulceration and/or ipsilateral satellite nodules and/or edema (including peau T4b
d'orange) of the skin which do not meet the criteria for inflammatory
carcinoma
T4c Both T4a and T4b T4c
T4d Inflammatory carcinoma** T4d
*Note: Invasion of the dermis alone does not qualify as T4.
**Note: Inflammatory carcinoma is restricted to cases with typical skin changes
involving a third or more of the skin of the breast. While the histologic presence of
invasive carcinoma invading dermal lymphatics is supportive of the diagnosis, it is not
required, nor is dermal lymphatic invasion without typical clinical findings sufficient for a
diagnosis of inflammatory breast cancer.
REGIONAL LYMPH NODES (N)

NX Regional lymph nodes cannot be assessed (e.g., previously removed) NX
pNX Regional lymph nodes cannot be assessed (e.g., previously removed, or not pNX*
removed for pathologic study)
N0 No regional lymph node metastases N0
pN0 No regional lymph node metastasis identified histologically pN0
pN0(i-) No regional lymph node metastases histologically, negative IHC pN0(i-)
pN0(i+) Malignant cells in regional lymph node(s) no greater than 0.2 mm (detected by pN0(i+)
H&E or IHC including ITC)
pN0(mol-) No regional lymph node metastases histologically, negative molecular findings pN0(mol-)
(RT-PCR)
pN0(mol+) Positive molecular findings (RT-PCR), but no regional lymph node metastases pN0(mol+)
detected by histology or IHC
HOSPITAL NAME /ADDRESS PATIENT NAME / INFORMATION
(continued on next page)
Breast 371
BREAST STAGING FORM
N1 Metastases to movable ipsilateral level I, II axillary lymph node(s) N1

pN1 Micrometastases; or metastases in 1 to 3 axillary lymph nodes; and/or in pN1
internal mammary nodes with metastases detected by sentinel lymph node
biopsy but not clinically detected**
pN1mi Micrometastases (greater than 0.2 mm and/or more than 200 cells, but none pN1mi
greater than 2.0 mm)
pN1a Metastases in 1 to 3 axillary lymph nodes, at least one metastasis greater than pN1a
2.0 mm
pN1b Metastases in internal mammary nodes with micrometastases or pN1b
macrometastases detected by sentinel lymph node biopsy but not clinically
detected**
pN1c Metastases in 1 to 3 axillary lymph nodes and in internal mammary lymph pN1c
nodes with micrometastases or macrometastases detected by sentinel lymph
node biopsy but not clinically detected**
N2 Metastases in ipsilateral level I, II axillary lymph nodes that are clinically fixed
or matted; or in clinically detected* ipsilateral internal mammary nodes in the
absence of clinically evident axillary lymph node metastases
pN2 Metastases in 4 to 9 axillary lymph nodes; or in clinically detected*** internal pN2
mammary lymph nodes in the absence of axillary lymph node metastases
N2a Metastases in ipsilateral axillary lymph nodes fixed to one another (matted) or
to other structures
pN2a Metastases in 4 to 9 axillary lymph nodes (at least one tumor deposit greater pN2a
than 2.0 mm)
N2b Metastases only in clinically detected*** ipsilateral internal mammary nodes and
in the absence of clinically evident axillary lymph node metastases
pN2b Metastases in clinically detected*** internal mammary lymph nodes in the pN2b
absence of axillary lymph node metastases
N3 Metastases in ipsilateral infraclavicular (level III axillary) lymph node(s) with or
without level I, II axillary lymph node involvement; or in clinically detected*
ipsilateral internal mammary lymph node(s) with clinically evident level I, II
axillary lymph node metastases; or metastases in ipsilateral supraclavicular
lymph node(s) with or without axillary or internal mammary lymph node
involvement
pN3 Metastases in 10 or more axillary lymph nodes; or in infraclavicular (level III pN3
axillary) lymph nodes; or in clinically detected*** ipsilateral internal
mammary lymph nodes in the presence of 1 or more positive level I, II
axillary lymph nodes; or in more than 3 axillary lymph nodes and in internal
mammary lymph nodes with micrometastases or macrometastases detected
by sentinel lymph node biopsy but not clinically detected**; or in ipsilateral
supraclavicular lymph nodes
N3a Metastases in ipsilateral infraclavicular lymph node(s)
pN3a Metastases in 10 or more axillary lymph nodes (at least one tumor deposit pN3a
greater than 2.0 mm); or metastases to the infraclavicular (level III axillary
lymph) nodes
N3b Metastases in ipsilateral internal mammary lymph node(s) and axillary lymph
node(s)
pN3b Metastases in clinically detected*** ipsilateral internal mammary lymph nodes pN3b
in the presence of 1 or more positive axillary lymph nodes; or in more than 3
axillary lymph nodes and in internal mammary lymph nodes with
micrometastases or macrometastases detected by sentinel lymph node
biopsy but not clinically detected**
N3c Metastases in ipsilateral supraclavicular lymph node(s)
(continued from previous page)
372 American Joint Committee on Cancer • 2010

BREAST STAGING FORM
pN3c Metastases in ipsilateral supraclavicular lymph nodes pN3c
*Classification is based on axillary lymph node dissection with or without sentinel lymph
node biopsy. Classification based solely on sentinel lymph node biopsy without subse-
quent axillary lymph node dissection is designated (sn) for “sentinel node,” for example, pN0(sn).
**Note: Not clinically detected is defined as not detected by imaging studies
(excluding lymphoscintigraphy) or not detected by clinical examination.
***Note: Clinically detected is defined as detected by imaging studies (excluding
lymphoscintigraphy) or by clinical examination and having characteristics highly
suspicious for malignancy or a presumed pathologic macrometastasis based on
fine needle aspiration biopsy with cytologic examination. Confirmation of clinically
detected metastatic disease by fine needle aspiration without excision biopsy is
designated with an (f) suffix, for example, cN3a(f). Excisional biopsy of a lymph node
or biopsy of a sentinel node, in the absence of assignment of a pT, is classified as
a clinical N, for example, cN1. Information regarding the confirmation of the nodal status
will be designated in sitespecific factors as clinical, fine needle aspiration, core biopsy,
or sentinel lymph node biopsy. Pathologic classification (pN) is used for excision or
sentinel lymph node biopsy only in conjunction with a pathologic T assignment.
Note: Isolated tumor cell clusters (ITC) are defined as small clusters of cells not
greater than 0.2 mm, or single tumor cells, or a cluster of fewer than 200 cells in
a single histologic cross-section. ITCs may be detected by routine histology or by
immunohistochemical (IHC) methods. Nodes containing only ITCs are excluded
from the total positive node count for purposes of N classification but should be
included in the total number of nodes evaluated
DISTANT METASTASIS (M)

M0 No clinical or radiographic evidence of distant metastases (no pathologic M0;
use clinical M to complete stage group)
cM0(i+) No clinical or radiographic evidence of distant metastases, but deposits of
molecularly or microscopically detected tumor cells in circulating blood,
bone marrow or other non-regional nodal tissue that are no larger than
0.2 mm in a patient without symptoms or signs of metastases
M1 Distant detectable metastases as determined by classic clinical and M1
radiographic means and/or histologically proven larger than 0.2 mm
Breast 373
LUNG STAGING FORM
CLINICAL PATHOLOGIC
Extent of disease before STAGE CATEGORY DEFINITIONS Extent of disease through
any treatment completion of definitive surgery
y clinical – staging completed L ATERALITY: y pathologic – staging completed
after neoadjuvant therapy but T UMOR S IZE : after neoadjuvant therapy AND
before subsequent surgery left right bilateral subsequent surgery
PRIMARY TUMOR (T)
TX Primary tumor cannot be assessed TX
T0 No evidence of primary tumor T0
Tis Tis Carcinoma in situ Tis
T1 Tumor £3 cm in greatest dimension, surrounded by lung or visceral pleura, T1
without bronchoscopic evidence of invasion more proximal than the lobar
bronchus (i.e., not in the main bronchus)*
T1a Tumor £2 cm in greatest dimension T1a
T1b Tumor > 2 cm but £3 cm in greatest dimension T1b
T2 Tumor > 3 cm but £7 cm or tumor with any of the following features (T2 tumors T2
with these features are classified T2a if £ 5 cm)
Involves main bronchus, ³2 cm distal to the carina
Invades visceral pleura (PL1 or PL2)
Associated with atelectasis or obstructive pneumonitis that extends to the
hilar region but does not involve the entire lung
T2a Tumor > 3 cm but £5 cm in greatest dimension T2a
T2b Tumor > 5 cm but £7 cm in greatest dimension T2b
T3 Tumor > 7 cm or one that directly invades any of the following: parietal pleural T3
(PL3) chest wall (including superior sulcus tumors), diaphragm, phrenic
nerve, mediastinal pleura, parietal pericardium; or tumor in the main
bronchus (< 2 cm distal to the carina* but without involvement of the carina;
or associated atelectasis or obstructive pneumonitis of the entire lung or
separate tumor nodule(s) in the same lobe
T4 Tumor of any size that invades any of the following: mediastinum, heart, great T4
vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body,
carina, separate tumor nodule(s) in a different ipsilateral lobe
* The uncommon superficial spreading tumor of any size with its invasive component
limited to the bronchial wall, which may extend proximally to the main bronchus, is
also classified as T1a.
REGIONAL LYMPH NODES (N)
NX Regional lymph nodes cannot be assessed NX
N0 No regional lymph node metastasis N0
N1 Metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and N1
intrapulmonary nodes, including involvement by direct extension
N2 Metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s) N2
N3 Metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or N3
contralateral scalene, or supraclavicular lymph node(s)
DISTANT METASTASIS (M)
M0 No distant metastasis (no pathologic M0; use clinical M to complete stage group)
M1 Distant metastasis M1
M1a Separate tumor nodule(s) in a contralateral lobe; tumor with pleural nodules or M1a
malignant pleural (or pericardial) effusion**
M1b Distant metastasis M1b
**Most pleural (and pericardial) effusions with lung cancer are due to tumor. In a few
patients, however, multiple cytopathologic examinations of pleural (pericardial) fluid
are negative for tumor, and the fluid is nonbloody and is not an exudate. Where
Lung 267
LUNG STAGING FORM
these elements and clinical judgement dictate that the effusion is not related to the
tumor, the effusion should be excluded as a staging element and the patient should
be classified as M0.
ANATOMIC STAGE • PROGNOSTIC GROUPS
C LINICAL P ATHOLOGIC
GROUP T N M GROUP T N M
Occult TX N0 M0 Occult TX N0 M0
0 Tis N0 M0 0 Tis N0 M0
IA T1a N0 M0 IA T1a N0 M0
T1b N0 M0 T1b N0 M0
IB T2a N0 M0 IB T2a N0 M0
IIA T2b N0 M0 IIA T2b N0 M0
T1a N1 M0 T1a N1 M0
T1b N1 M0 T1b N1 M0
T2a N1 M0 T2a N1 M0
IIB T2b N1 M0 IIB T2b N1 M0
T3 N0 M0 T3 N0 M0
IIIA T1a N2 M0 IIIA T1a N2 M0
T1b N2 M0 T1b N2 M0
T2a N2 M0 T2a N2 M0
T2b N2 M0 T2b N2 M0
T3 N1 M0 T3 N1 M0
T3 N2 M0 T3 N2 M0
T4 N0 M0 T4 N0 M0
T4 N1 M0 T4 N1 M0
IIIB T1a N3 M0 IIIB T1a N3 M0
T1b N3 M0 T1b N3 M0
T2a N3 M0 T2a N3 M0
T2b N3 M0 T2b N3 M0
T3 N3 M0 T3 N3 M0
T4 N2 M0 T4 N2 M0
T4 N3 M0 T4 N3 M0
IV Any T Any N M1a IV Any T Any N M1a
Any T Any N M1b Any T Any N M1b
Stage unknown Stage unknown
PROGNOSTIC FACTORS (SITE-SPECIFIC FACTORS) General Notes:

REQUIRED FOR STAGING: None For identification of special cases of
TNM or pTNM classifications, the "m"
CLINICALLY SIGNIFICANT: suffix and "y," "r," and "a" prefixes are
Pleural/Elastic Layer Invasion (based on H&E and elastic stains)___________________ used. Although they do not affect the
stage grouping, they indicate cases
Separate Tumor Nodules __________________________________________________
needing separate analysis.
(continued from previous page)
268 American Joint Committee on Cancer • 2010

What We’ll Cover
What’s New in CSv2?  Rules changes and revisions
 New Data Fields
New Sites, New 

Lymph-Vascular Invasion
Grade Path Value/Grade Path System
Rules, New SSFs 
 Mets at Dx – Metastatic Sites
Overview of Site-Specific Factors
 Sites with Major Changes
 Esophagus and Stomach
 Biliary Tract
ACTUR Conference 2010  Testis
April Fritz, RHIT, CTR  Gastrointestinal Stromal Tumor (GIST)
CSv2 Overview 4/1/2010 2
CSv2 Changes Other Features of CSv2

 New name
 Collaborative Stage Data Collection System (CS)  Histology inclusions rather than exclusions
 Based on AJCC Cancer Staging Manual,  Code ranges rather than specific terms
seventh edition  Consistency of code structures from site to site
 Commitment to make staging more clinically  More non-specific terms, “Stated as T_, NOS”
relevant  More non-anatomic factors
 Better definitions and instructions  Treatment decisions, prognostic/predictive data
 More site-specific factors  Data items more complete for lab values
 Compatible with 2010 CAP Protocols  Colon, rectum, appendix: CEA and CEA Lab Value
CSv2 Overview 4/1/2010 3 CSv2 Overview 4/1/2010 4
What’s New in CSv2 4/1/2010 1

ACTUR Conference 2010 april@afritz.org
CSv2 Field Changes Example CS Extension Table: Colon
Code Description TNM 7 TNM 6 SS77 SS2000
Map Map Map Map
420 Fat, NOS T3 T3 RE RE
 CS Extension expanded 450 Extension to: T3 T3 RE RE
 Two digits to three digits All colon sites:
Adjacent tissue(s), NOS
 CS Lymph Nodes expanded Connective tissue
 Two digits to three digits Mesenteric fat
…
 7th and 6th Edition mapping fields Ascending and descending colon
Retroperitoneal fat
 Additional site-specific factors Transverse colon/flexures
Gastrocolic ligament
Greater omentum
460 Adherent to other organs or structures, but T3 T3 RE RE
no microscopic tumor found in
adhesion(s)
490 Stated as T4, NOS T4NOS T4 RE RE
500 Invasion of/through serosa (mesothelium) T4a T4 RE RE
(visceral peritoneum)
Stated as T4a, NOS
550 Any of [(420) to (450)] + (500) T4a T4 RE RE
570 Adherent to other organs or structures, NOS T4b T4 RE RE
New CSv2 Schemas

 Mucosal melanoma of head and neck (26)
 Esophagus-GE Junction


Appendix
Gastrointestinal stromal tumor (7)
Rules Changes
 Neuroendocrine tumor (neuroendocrine/carcinoid) (4)
 Intrahepatic bile ducts
 Perihilar bile ducts
 Distal bile duct
 Other biliary
 Merkel cell carcinoma
 Ocular adnexal lymphoma
 Adrenal gland
8

I-14 I-17
CS General Guidelines CS General Guidelines, cont’d
 Timing rule  Clinician statement of T, N, M

• Includes all information gathered through  Codes included in CS version 2
completion of surgery(ies) in first course of  Stated as T1, NOS; Stated as T1a, NOS
treatment OR  Use only when there is no information available
• within four months of diagnosis in absence of to assign more specific code
disease progression  Discrepancies between clinician statement
• whichever is LONGER.
and documentation
• Timing rule NOT identical to TNM7.  Documentation takes precedence
 Discuss case with clinician
I-17 I-17
CS General Guidelines, cont’d CS General Guidelines, cont’d
 Reportable-by-Agreement Cases
 Staging systems available in TNM for neoplasms that  No forward compatibility
may not be reportable to population-based registries  Cannot rerun computer algorithm to derive TNM
 The presence of a schema in CSv2 does not imply 7th edition on a pre-2010 case.
that the disease is reportable  CS version 2 maps to both TNM 6th and 7th
 Examples editions
 High grade dysplasia (esophagus)  For new schemas, no backward
 PanIN III of pancreas, severe ductal dysplasia
 Carcinoid of appendix compatibility
 Squamous carcinoma of skin  Cases not previously staged will not generate a
 Follow instructions of population-based registry TNM 6th edition
regarding reportability
 If reportable, follow instructions in schema
 If not reportable, follow policies of facility collecting the data

I-7 I-5
CS General Comments CS General Comments
 Obsolete codes  Schema Discriminator

 Necessary as a result of TNM 6 to 7 changes  Some primary sites have multiple schemas
 Splitting of previous codes  Example: Colon (carcinoma), GIST Colon, NET Colon,
 Moving a structure from Extension to Mets at Dx Lymphoma  determined by histology
 Correcting mapping errors in CS version 1  Some ICD-O-3 codes have multiple schemas
 Labeled in CSv2  Example: C24.0 Extrahepatic bile ducts (distal bile duct;
 Obsolete codes may be hidden in software cystic duct; right, left, and common hepatic ducts) 
 Do not use obsolete codes for current coding determined by schema discriminator
 Retained as a reference for researchers  Example: Peritoneum (usually soft tissue sarcomas, but
sometimes primary peritoneal carcinoma in women)
 Schema discriminator brings appropriate schema
to computer screen
I-20 I-20
CS General Comments CS General Comments
 Inaccessible lymph nodes  Inaccessible lymph nodes rule

 Nodes within body cavities that cannot be  Record regional and distant metastases as
palpated or easily examined NEGATIVE (rather than unknown) when
 Examples: regional nodes for bladder, kidney,  no mention of LN or mets involvement in PE, Dx testing
colon, prostate, esophagus, stomach, lung, liver, or surgical exploration
AND
corpus, ovary (not all-inclusive)  patient receives ‘usual’ treatment to primary
AND
 Accessible lymph nodes  clinically early stage (T1, T2, localized) tumors
 Breast, oral cavity, salivary gland, skin, thyroid,  All three conditions have to be met
etc.  Code unknown if reasonable doubt that tumor is
 Code regional nodes as negative if general not localized
statement in chart ‘remainder of exam negative’

I-20
CS General Comments Eval Fields – General Guidelines
 Unknown status of distant metastasis  Assign Eval code that describes diagnostic
 No MX category in TNM 7th edition procedure associated with corresponding
 CS Mets at Dx code 99 (unknown) maps to M0 data field
 Registrar can assume no distant mets unless  May not be numerically highest code
there is  Eval code corresponds to highest T, N, or M
 Evidence of mets clinically (physical exam, category, not necessarily to highest code in
imaging, etc.)
CS field
 Microscopically proven distant mets
 Use code 00 instead  Use a pathologic Eval code if a biopsy
documents highest T, N, or M without
resection
I-49
CS Nodes Eval – Rules CS Nodes Eval – Rules, cont’d
 Linked to CS Lymph Nodes Most sites use standard table

 Code as clinical or pathologic based on General structure
intent of procedure and assessment of T 0 Clinical only; no nodes removed
 If LN procedure part of workup, staging basis is 1 No nodes removed; endoscopy or invasive
clinical (codes 0, 1, 5, 9) techniques; surgical observation
 If LN procedure part of treatment, code as OR
pathologic (codes 2, 3, 6) FNA, needle bx; or excisional bx as part of
 Must have resection of primary site meeting pT criteria diagnostic workup without removal of primary
 Document farthest involved regional nodes site sufficient for pT
 May not be highest eval code  bx does not meet criteria for pathologic N
 Pathologic information takes priority  2 Autopsy (known or suspected dx)

 Document highest N subcategory

I-53
CS Nodes Eval – Rules, cont’d CS Nodes Eval – Rules, cont’d
General structure, cont’d  Code 9

3 Any microscopic assessment of regional nodes  Always 9 for sites without TNM mapping
WITH removal of primary site sufficient for pT  Avoid 9 if possible when CS Lymph Nodes is 999
OR  Sentinel nodes
Positive biopsy of highest N category regardless  Code as pathologic when tumor size/extension
of T meets criteria for pT
 meets criteria for pathologic N  When no pT, exam of single LN or sentinel nodes
5 Pre-op tx and resection; clinical evidence is clinical
6 Pre-op tx and resection; path evidence more  Code as pathologic when there is a positive
extensive biopsy of node in highest N category
8 Autopsy (dx not suspected)
9 Unknown, not assessed; no TNM schema
Regional Nodes Positive/Examined I-57 I-60
General Rules CS Mets at Dx Rules
 Counting nodes (positive or examined)  Generally used for discontinuous, blood-

 Do not count positive aspiration or core biopsy of borne, or fluid-borne mets and involved
node in same chain removed at surgery
distant lymph nodes
 Do count positive aspiration or core biopsy of
node in different region  Code the farthest documented metastasis
 If location of biopsied/aspirated node unknown,  Usually clinical or inferred
do not count  If no pre-op tx: path when available; if pre-op
tx: clinical
 Priority of node counts
 Final dx, synoptic report, microscopic, gross  Mets at Dx codes (general structure)
 10 Distant lymph nodes
 40 Specific named structures or
carcinomatosis
 50 Distant nodes plus distant mets
 60 Nonspecific distant metastases

I-61
CS Mets at DX
 When to code 00 vs. 99
 Code 00 when


No clinical or pathologic evidence of distant mets and
patient is not treated as if mets are present or suspected
Only history and physical exam needed
New Fields
 Code 99 when
Reasonable doubt that tumor no longer localized
Maps to MX in TNM 6th edition and M0 in 7th edition
 No MX in TNM 7th edition
 Registrar can code Mets at Dx 00 unless distant
mets are identified and classified as cM1 or pM1
 CTCs and DTCs
 Breast only: code as 05
 Code 98
 Lymphoma, heme-retic, and some other sites 26
Lymph-Vascular Invasion (1) Lymph-Vascular Invasion (2)
 Coding instructions  Code structure

 Based on all pathology reports or information 0 – Lymph-vascular invasion not present (absent)/
available Not identified
 Priority given to positive results 1 – Lymph-vascular invasion present/identified
 Includes lymphatic invasion, vascular invasion, or 8 – Not applicable
lymph-vascular invasion 9 – Unknown/Indeterminate
 Do not use for perineural invasion
 Use CAP checklist as primary source
 Other sources may be used in the absence of a checklist

Grade Path Value (1) Grade Path Value (2)
 Does not replace Grade/Differentiation (#440)  Coding instructions

 Record grade specified in Grade Path System  Record grade reported in patient record
 Code structure  Based on same tissue as Grade/Differentiation field
1 Recorded as Grade I or 1  Do not use for site-specific grading systems
2 Recorded as Grade II or 2  Part of the SSF fields
3 Recorded as Grade III or 3  If grade is described as a fraction (x/y)
4 Recorded as Grade IV or 4  This data field is the numerator
Blank No 2-, 3-, or 4-grade system available; unknown  Histologic grade is another name for overall grade or
grade NOS
 Takes priority over a nuclear or architectural grade
Grade Path System (1) Grade Path System (2)
 New item  Coding instructions

 In addition to Grade Differentiation (#440)  Record the grading system in the record
 Record stated grade system; not converted  Based on same tissue as Grade/Differentiation field
 Used in conjunction with “Grade Path Value”  Do not use for site-specific grading systems
 Part of the SSF fields
 Code Structure
 If grade is described as a fraction (x/y)
2 Two-grade system  This data field is the denominator
3 Three-grade system
4 Four-grade system
Blank Not a 2-, 3- or 4-grade system; unknown

Mets at Dx-Metastatic Sites
 4 new fields
 Bone excluding marrow



Lung excluding pleura and pleural fluid
Brain excluding spinal cord and other CNS
Liver
New SSFs
 Code 0 when CS Mets at Dx is 00
 Code structure
0 – No
1 – Yes
8 – Not applicable
9 – Unknown
34
I-76
Site-Specific Factors Site-Specific Factors, cont’d
 25 SSFs
 Based on AJCC 7th edition  SSF data sets
 Some needed for TNM mapping  Breast – 24
 Number of positive axillary nodes, extracapsular extension;  Eyelid, lacrimal gland – 15 to 16
thickness of melanoma  Ocular adnexal lymphoma – 12
 Some tumor markers and lab values  Prostate – 12
 CA 125, CA 19-9, AFP, HCG, KRAS, Ki-67  Head & Neck sites (carcinoma, melanoma) – 9 to 11
 Some prognostic/predictive  Colon and Rectum – 9
 Gleason tertiary pattern; IPI, FLIPI, IPS (lymphomas), HER2  CNS – 9
 Some for future research/special interest  Standards setters have decided which SSFs
 Microsatellite instability (GI cancers), tumor infiltrating
lymphocytes (TILs; Merkel cell) are required
 Some for patient history of other diseases
 History of asbestos exposure (pleural mesothelioma),
retinoblastoma gene mutation

Examples of CSv2 SSFs Site-Specific Factors, cont’d
 SSF1 Melanoma—Thickness
 Actual Breslow depth of invasion  If information regarding SSF is not in
 Required for TNM 6th and 7th staging
 SSF2 Melanoma—Ulceration path report or medical record, Registrar
 Adds ‘a’ or ‘b’ to T1 - T4 is not required to go looking for it
 Required for TNM 6th and 7th staging
 Information may not be available in some facilities
 SSF8, SSF10 Prostate—Gleason Score
 Records actual score for TNM 7th stage grouping
 Not registrar’s role to enforce practice standards
 SSF1 Breast—Estrogen Receptors  Instructions included in schemas on how to code
 Predictive information for response to hormones missing information
 SSF1 Brain—WHO Grade
 Different from ICD-O-3 6th digit grade
 SSF10 Head and Neck sites—HPV Status
 Human papilloma virus (HPV) infection may be risk
factor for oral and other mucosal cancers
CSv2 Schema Changes
Sites with  Schemas for some sites split by morphology

 Head and neck: mucosal melanomas vs. carcinomas
 GIST and neuroendocrine tumors of GI tract separate
Major Changes 
from carcinomas
Liver and intrahepatic bile ducts separate
 Liver (Hepatocellular ca)
 Intrahepatic BD (Cholangioca)
 Esophagus: separate stagings for squamous vs.
adenocarcinoma
39

Schemas Split/Revised CSv2 Coding Issues, continued
 Intrahepatic bile ducts (separate from Liver)  Topography codes split into different schemas
 Liver  Hepatocellular carcinoma  Esophagus schema now includes
 IHB  Cholangiocarcinoma  Gastroesophageal junction (C16.0)
 Stomach fundus (C16.1)
 Extrahepatic bile ducts  Part of stomach body (C16.2)
 Perihilar bile ducts  Extrahepatic bile ducts (C24.0) split into
 Cystic duct  Perihilar (proximal)
 Distal bile duct  Distal bile duct
 Skin  Gallbladder schemas
 Cutaneous Squamous Cell Carcinoma and Other
Cutaneous Carcinoma
 Merkel cell
 Malignant melanoma
Esophagus-Stomach Changes New Schema: Esophagus GE Junction
 Shift of C16.0, parts of C16.1 and C16.2 to  Esophago-gastric Junction

esophagus  Gastroesophageal Junction
 Esophagogastric junction (EGJ) tumors:
 If midpoint (epicenter) within 5 cm of EGJ and also
extends into esophagus, classify and stage as
esophagus
 Stage all others with midpoint in stomach > 5 cm
from EGJ or those within 5 cm of the EGJ with no
extension into esophagus as gastric carcinoma
From Edge et al. Used with permission of the American Joint Committee on Cancer (AJCC), Chicago,
Illinois. The original source for this material is the AJCC Cancer Staging Manual, seventh edition
CSv2 Overview 4/1/2010 43 CSv2 Overview 4/1/2010 44 (2009) published by Springer Science and Business Media LLC, www.springerlink.com.

SSF 25: Involvement of Cardia and
EsophagusGEJunction – CS Extension
Distance from GE Junction
 000 No involvement of esophagus or EGJ Stomach 000 Carcinoma in situ /High-grade dysplasia
 010 Tumor located in Cardia or EGJ EsophGEJ
 020 Esoph or EGJ involved AND tumor midpoint 110 Lamina propria (T1a)
from EGJ ≤ 5 cm EsophGEJ 120 Muscularis mucosae (T1a)
 030 Esoph or EGJ involved AND tumor midpoint 160 Submucosa (T1b)
from EGJ > 5 cm Stomach 200 Muscularis propria (T2)
 040 Esoph or EGJ involved AND tumor midpoint 420 Adventitia (T3)
from EGJ unknown EsophGEJ
 050 Esoph and EGJ not involved but tumor midpoint 450 Adjacent structures (T4a)
from EGJ is ≤ 5 cm Stomach 600 Diaphragm (T4a)
 060 Esoph involved or esoph involvement unknown 610 Pleura, pericardium (T4a)
AND tumor midpoint from EGJ > 5 cm or unknown 700 Adjacent peritoneum (T4a)
AND MD stages case using esoph definitions EsophGEJ 800 Other adjacent structures, e.g. aorta, vertebral
 999 Involvement of esoph not stated, unk or no
info, not documented Stomach
body, trachea (T4b)
 Blank for Stomach cases C16.3-C16.9 Stomach
 Blank for Cardia/EGJ cases C16.0 EsophGEJ
SSF 4 Distance to Proximal Edge

Esophagus – 7th Edition N and M
SSF 5 Distance to Distal Edge
N based on Lymph Nodes Positive  Measure from front teeth
N0 No regional lymph node metastasis  Code in cm (001 – 050/060)
N1 1 to 2 regional lymph nodes  Primary site defined by
N2 3 to 6 uppermost point
N3 >6 [N1 was site dependent]
(proximal edge)
 Cervical (15-20 cm)
M0 No distant Metastasis
 Upper thoracic (20-25 cm)
M1 Distant metastasis [M1a,b were site dependent]
 Middle thoracic (25-30 cm)
 Lower thoracic (30-40 cm)
Anatomical/Prognostic Stage Group Mapping
 Based on histologic type, grade, location within
esophagus and T, N, M
Figure I-2-3. Anatomic Landmarks of Esophagus. From Edge et al. Used with
permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois.
The original source for this material is the AJCC Cancer Staging Manual, seventh
edition (2009) published by Springer Science and Business Media LLC,
www.springerlink.com.

Stomach – CS Extension C24.0 Extrahepatic Bile Ducts
 T1 split into T1a and T1b
 T1a Ext 100, 110, 120, 125
 T1b Ext 130, 140, 160, 170
 T1, NOS Ext 160, 300 (localized), 340
 T2b Subserosa now T3 (Ext 400)
 T3 Perforation of serosa now T4a (Ext 500)
 T4 split into T4a and T4b
 N based on Lymph Nodes Positive

 N1 1 to 2 nodes
 N2 3 to 6 nodes (was N1)
Extrahepatic Bile Ducts. In: Greene, F.L., Compton,
 N3a 7 - 15 nodes (was N2) C.C., Fritz, A.G., et al., editors. AJCC Cancer
Staging Atlas. New York: Springer, 2006: 139-145.
 N3b 16 or more (was N3) ©American Joint Committee on Cancer.
Used with permission of the American Joint
CSv2 Overview 4/1/2010 49 CSv2 Overview 4/1/2010 50 Committee on Cancer (AJCC®), Chicago, Illinois.
SSF 25 Subsite of Extrahepatic

Bile Ducts C24.0 Extrahepatic Bile Ducts
 010 Perihilar bile duct(s);Proximal extrahepatic Perihilar Distal Cystic
bile duct(s); Hepatic duct(s) BDPerihilar BD BD Duct
 020 Stated as Klatskin tumor BDPerihilar schema schema schema
 030 Cystic bile duct; cystic duct CysticDuct
Common bile 
 040 Common bile duct; Common duct, NOS BDDistal
(choledochal) duct
 050 Diffuse involvement; > 1 subsite
involved, subsite of origin not stated BDPerihilar Cystic bile duct 
 060 Subsite of extrahepatic bile ducts not Hepatic bile duct – 
stated, but treated with combined right, left, common
hepatic and hilar resection BDPerihilar
Klatskin tumor 
 070 Subsite of extrahepatic bile ducts
not stated, but treated with pancreatico- Sphincter of Oddi 
duodenectomy BDDistal Extrahepatic bile ?
 999 Subsite not stated and not classifiable duct [NOS]
in codes 050-070 BDPerihilar

Gastrointestinal Stromal Tumor (GIST) GIST Schemas
 Esophagus  T, N, M definitions
What are GISTs?  Stomach common to all GIST sites
 Rare type of soft tissue sarcoma  Small Intestine  TNM7 mapping driven by
 4500-6000 adults (2009) – all sites  Appendix tumor size, not depth of
 Different from carcinomas  Colon invasion
 Develop in muscle layer of gut rather than mucosa T category cut points:
 Rectum 
 Grow outward (exophytic) 2, 5, 10 cm
 Peritoneum
 Described as a distinct entity in 1998  Stage groupings
 Omentum and
 Umbrella term for most mesenchymal tumors of
mesentery different
stomach and intestine
 Most tumors historically called leiomyosarcoma are
now classified as GISTs
GIST CS Extension GIST Site-Specific Factors

 Varies by primary site  Mitotic count
 Very similar to carcinoma schema for same  Kit immunohistochemistry
site (depth of invasion)  Kit gene mutation
 Slight differences in wording  PDGFRA gene mutation
 Elimination of T subcategories (T1a, T1b, …)  Tumor multiplicity
 Carcinoma polyp codes generate error in TNM7
 Location (SSF #) varies by primary site

Mitotic Count Mitotic Count
 Mitotic count: number of cells actively  Usually documented as mitoses per 50 high
dividing power fields (HPF)
 <5 mitoses/high power field – low mitotic rate  Standard magnification is 40X
 >5 mitoses/high power field – high mitotic rate  Also described as ‘per 5 mm2 ’ (square
 Source: pathology report/protocol millimeters)
 Pathologist instructions: scan slide for area of  Site-specific factor code
greatest mitotic activity  Implied decimal between 2nd and 3rd digit
 .8 mitoses/50HPF 008
 5 mitoses/50HPF 050
MITOSIS
Source: www.ncbi.nlm.nih.gov/About/primer/genetics_cell.html.
In the
CSv2 public domain.
Overview 4/1/2010 57 CSv2 Overview 4/1/2010 58
KIT Immunohistochemistry (IHC) KIT Gene Mutation

 Source: pathology report (special immuno-  Source: specialty/reference lab report
fluorescent stain)  C-kit gene regulates cell growth and
 Mutated cells stain brown differentiation
 Confirms diagnosis of GIST  85-90% of GISTs contain oncogenic
 Also known as CD117, mutations of KIT receptor tyrosine kinase
c-kit receptor, SCFR gene
(stem cell factor receptor)  Mutations primarily of exon 11 and 9, and rarely of
exons 13 and 17
 Exon: A segment of a gene that contains
instructions for making a protein
Source: Immunoportal.com. Used with  Specific exon mutation may indicate
permission of image owner, Ole Johnny
Steffensen, Aalesund Norway potential response to targeted therapy drugs
 Imatinib mesylate (Gleevec) and Sutent

PDGFRA Gene Mutation Tumor Multiplicity
 Source: specialty/reference lab report  Source: pathology report
 Platelet-Derived Growth Factor Receptor,  Record presence of anatomically separate,
Alpha polypeptide type multiple GISTs
 A.k.a. CD140A; MGC74795; PDGFR2; Rhe-  Various sizes
PDGFRA  May occur in the setting of neurofibromatosis
 Gene encodes a cell surface tyrosine kinase type 1 or familial GIST syndrome
receptor
 Found in mesenchymal cells
 Mutually exclusive with KIT
 PDGFR regulates cell proliferation, cellular
differentiation, cell growth and development
 30-40% of KIT-negative GISTs contain mutations
of PDGFRA
Testis Investing Layers of Testis

 Mapping requires SSF4 and Lymph-Vascular Parietal peritoneum Source: Medi-Clip: Grant’s Atlas Images I, Thorax and
Abdomen. Williams and Wilkins, 1998.
Extraperitoneal fat
Invasion fields Transverse abd. muscle
 Lymph-vascular invasion Internal abd. oblique m.
 0 Lymph-vascular invasion not present External abd. oblique m. Rectus
Skin and abdominis
(absent)/Not identified muscle
subcutaneous tissues
 1 Lymph-vascular invasion present/Identified
 8 Not applicable Internal spermatic fascia
 9 Unknown if lymph-vascular invasion present; Cremaster muscle
indeterminate External spermatic fascia
Testis
Dartos muscle
Tunica
Scrotal skin vaginalis

Testis – Collaborative Stage Fields Testis – CS Extension
 Tumor Size—standard  Site-Specific Factors  Codes
 Extension  1 Obsolete, see SSF6-7  160 Testis, rete testis; tunica albuginea
 TS/Ext Eval—standard  2 Obsolete, see SSF8-9  200 Tunica vaginalis; surface implants
 Lymph Nodes  3 Obsolete, see SSF 10  300 Localized, NOS
 4 Radical orchiectomy  310 Tunica, NOS
 LN Eval—standard  5 Size of LN mets  460 Epididymis
 LN Pos—standard  6 Preorch AFP Value  500 Spermatic cord, ipsilat; vas deferens
 LN Exam—standard  7 Preorch AFP Interp  600 Dartos muscle, ipsilat; scrotum, ipsilat
 Mets at Dx  8 Preorch HCG Value  700 Scrotum, contralat; ulceration of scrotum
 Mets Eval—standard  9 Preorch HCG Interp  750 Penis
 10 Preorch LDH  800 Further contiguous extension
 11 Persistence of
Elevated Tumor Mkrs
CS Extension Examples CS Extension Examples
160 + LVI 0
300 + LVI 9 into rete testis
limited to testis no vasc/lym invas Ext 700
Ext 500 invades
scrotum
invades with ulceration
spermatic
cord
460 + LVI 1
160 + LVI 1 into epididymis
into tunica albuginea, w/ vasc invas
w/ vasc/lym invas
Source: TNM Atlas
Source: TNM-interactive. Wiley-Liss, 1998
3rd ed. 2nd rev. 1992,
Springer Verlag

Staging Landmarks Testis – Regional Lymph Nodes
Epididymis
Regional lymph
Vas deferens nodes of testis
Skin of Tunica
scrotum albuginea
Tunica Contralateral
vaginalis scrotum
Source: Clinical Anatomy for Medical Students

5th ed., 1995, Little, Brown and Co. Testis Source: Medi-Clip: Grant’s Atlas Images 3,
Perineum, Pelvis and Lower Limb. Williams
and Wilkins, 1998.
CS Regional Lymph Nodes Additional Regional Lymph Nodes

 Code number of positive nodes in Reg LN Pos
Code 100
and size of mass in SSF5.
Lateral aortic (lumbar)
Code 200 4 Retroperitoneal
1
1 Interaortocaval 3 5 Regional nodes, NOS
2 C A
2 Paracaval 6
3 Precaval Code 300 (with previous scrotal/inguinal surgery)
4 Retrocaval Pelvic, NOS
External iliac
Code 100
5 Preaortic Code 400 (with previous scrotal/inguinal surgery)
Inguinal (superficial or deep)
6 Retroaortic
also: peri-/para-aortic
Source: Cancer: PPO, DeVita et al

CS Mets at Dx SSF 4 – Radical Orchiectomy Performed
uro_oncology.asp
www.wockhardthospitals.net/
 Distant lymph nodes (M1a)
 11 (without previous scrotal/inguinal surgery)  Both diagnostic and therapeutic
 Pelvic, NOS 000 Not performed
 External iliac 001 Performed
 12 (without previous scrotal/inguinal surgery 999 Unknown if performed
 Inguinal (superficial or deep)
 13 Other specified distant lymph nodes
Definition
 Distant metastases (M1b) Radical inguinal orchiectomy
 20 Lung  Complete removal of
 25 Lung and distant nodes testicle, epididymis and
 40 Other distant sites; carcinomatosis
spermatic cord to the level
 60 Distant metastasis, NOS
of the internal inguinal ring
CSv2 Overview 4/1/2010 73 CSv2 Overview 4/1/2010 74 www.tc-cancer.com/treatment.html
SSF 6 – Preorchiectomy
SSF 5 – Size of Mets in Lymph Nodes Alpha-Fetoprotein Value
 Size of mass, not just size of mets  Marker for teratocarcinoma, yolk sac or
 Codes embryonal carcinoma. Not found in other
 000 No LN mets histologies
 010 Mass < 2 cm; no extranodal extension (N1)  Also called FP, AFP, alpha-fetoglobulin
 020 Mass > 2 and < 5 cm; OR pathologic  Normal range: < 15 ng/ml in adults
extranodal extension (N2)  Record value prior to orchiectomy in 1st course
 030 Mass > 5 cm (N3)
 Read carefully; value ranges change
 998 Nodes involved, size of mass unknown
 999 Unknown if performed  Examples
 000 0 ng/ml
 001 1-19 ng/ml
 002 20-29 ng/ml
 020 200-299 ng/ml
 120 2000-2999 ng/ml
 200 ≥ 10,000 ng/ml

SSF 7 – Preorchiectomy SSF 8 – Preorchiectomy human
Alpha-Fetoprotein Interpretation Chorionic Gonadotropin Value
 Field information collected in CSv1  Marker for choriocarcinoma or embryonal
 Now preorchiectomy only carcinoma. Not found in other histologies
 Codes  Also called hCG, beta unit hCG, HCG
 000 Within normal limits (S0)  Normal range: 0 ng/ml in adult men
 010 < 1000 ng/ml (S1)  Record value prior to orchiectomy in 1st course
 020 1000 – 10,000 ng/ml (S2)  Read carefully; value ranges change
 030 > 10,000 ng/ml (S3)
 Examples
 997 Ordered, results not in chart
 000 0 ng/ml
 998 Test not done (SX)  001 1-19 ng/ml
 999 Unknown; no information  002 20-29 ng/ml
 020 200-299 ng/ml
 120 2000-2999 ng/ml
 220 20,000-29,999 ng/ml
 250 ≥ 50,000 ng/ml
SSF 9 – Preorchiectomy human SSF 10 – Preorchiectomy LDH

Chorionic Gonadotropin Interpretation Interpretation
 Field information collected in CSv1  Marker for both non-seminomatous and
 Now preorchiectomy only seminomatous advanced disease
 Codes  Also called lactate dehydrogenase, LD, Lactic acid
 000 Within normal limits (S0) dehydrogenase
 Non-specific for testicular cancer; only bulky disease
 010 Above normal and < 5000 mIU/ml (S1)  Normal range: varies by patient age and laboratory
 020 5000 – 50,000 mIU/ml (S2)
 030 > 50,000 mIU/ml (S3)
 Record range prior to orchiectomy
 997 Ordered, results not in chart  Codes
 998 Test not done (SX)  000 Within normal limits (S0)
 010 < 1.5 x N {upper limit of normal} (S1)
 999 Unknown; no information
 020 1.5 to 10 x N (S2)
 030 > 10 x N (S3)
 997 Test ordered, results not in chart
 998 Test not done (SX)
 999 Unknown; no information

SSF 11 – Persistence of Elevated
Calculating the LDH Tumor Markers
Read the lab report to determine the upper limit of  Needed for Stage Group IS
normal and the result. Examples:  Code presence or absence of persistent
Lab A 105 to 333 IU/L elevated tumor markers POST-orchiectomy
Lab B Female: 46-100 IU/L Male: 46-232 IU/L  If markers return to normal post-orch, code 000
Lab C 45 - 90 U/L  Codes
Result is 195  000 No persistence or pre-orch markers were normal;
What is the upper limit of normal? Tumor markers returned to normal post-orch
If result is within normal limits, code 000.  010 Persistence of elevated markers; Markers still
What is 1.5 times that result? (For B, 1.5 x 100 = 150) elevated post-orch; Stated as Stage IS
If result is > normal but < 1.5 x normal, code 010.  999 Unknown if persistence; Not documented
What is 10 times that result? (For B, 10 x 100 = 1000)
If result is > 1.5 x normal but < 10 x normal, code 020.
If result is > 10 x normal, code 030.
SSF Summary CS Coding Instructions

 Number of SSFs 1038  Electronic document
 Average SSF per schema 6.8  Designed for desktop use so it can be easily
accessed
 COC/SEER Required SSFs 673  PDF will allow sticky notes, word search, cross-
 Average required schemas/SSF 4.2 referencing
 Print manual will be available through NCRA
 Top 5 sites Average SSFs 10.2  Part I extensively revised and expanded
 Improvements based on suggestions from users
 Average required by COC/SEER 7.8
and reliability studies
 Part I rules to be cross-referenced in Part II
 Hyperlinks in electronic manual

CS Coding Instructions Part I Summary
 Section 1  Read and understand the CS general rules
 General rules  Refer to the site-specific schema every time—
 Data fields rules do not memorize
 More examples with rules  Read the notes for each data field
 Section 2 – Site-specific notes  Understand the anatomy
 Lymph nodes (head and neck, breast)  Primary site, adjacent structures and regional nodes
 Other problematic data items  Record the most extensive code
 Clinical status of regional lymph nodes (stomach,
colon)
 Greatest size/extension or farthest documented mets
 Lab values and tumor markers  Code the Eval field that documents the field
 Other site-specific factors most important for TNM staging
 Appendices  Understand the inaccessible nodes rule
 Know when to apply it
 Code SSFs as required

Basic Anatomy
The Anatomy of Staging:
Breast Cancer
Pectorialis fascia Pectorialis muscles
Source: Medi-clip: Grant’s Atlas Images I, Thorax

and Abdomen. Williams and Wilkins, 1998.
Image source: usps.gov Breast Cancer CSv2 Coding 2
Breast Sagittal View Breast – Basic Anatomy
Pectoralis
muscle • 50.0 Nipple
Skin • 50.1 Central
Serratus • 50.2 UIQ
anterior
Fatty parenchyma • 50.3 LIQ
muscle • 50.4 UOQ
Chest wall Ducts • 50.5 LOQ
Intercostal Areola • 50.6 Ax. Tail
muscles • 50.8 Overlapping
Nipple • 50.9 Breast, NOS
Ribs
Lobules
Source: UICC TNM-interactive, Wiley-Liss, 1998
Breast Cancer CSv2 Coding 3 Breast Cancer CSv2 Coding 4
Breast Cancer CSv2 Coding 1

ACTUR Training 2010 april@afritz.org
Breast - Orientation Central Portion of Breast (C50.1)
• Quadrants are mirror • Area extending 1 cm. radius around areola

images
12
• Retroareolar
• Clock positions are 11 1 • Subareolar
10 2
same for each breast • Behind nipple
 9:00 Left = 3:00 Right 9 3 • Beneath nipple
 4:00 Left = 8:00 Right • Under/underneath nipple
• Terminology 8 4
 Superior = upper 7 6 5
 Inferior = lower
 Lateral = Outer RIGHT OR LEFT BREAST
 Medial = Inner
Regional Anatomy Breast Cancer – CS Fields
1 Superficial axillary nodes • Collaborative Stage fields

(low axillary, Level I) • Tumor Size—special codes
2 Brachial axillary lymph nodes
3 Interpectoral axillary lymph
6 • Extension
4 5
nodes (Rotter’s nodes, Level II)
2 3 • TS/Ext Eval—standard
4 Deep axillary lymph nodes • Lymph Nodes
(high axillary, apical, Level III) 7 • LN Eval—standard
1
5 Infraclavicular lymph lymph • LN Pos
nodes (subclavicular)
6 Supraclavicular lymph nodes 8 • LN Exam—standard
7 Parasternal lymph nodes • Mets at Dx
(internal mammary nodes) • Mets Eval—standard
8 Paramammary or intramammary • SSFs 1 - 24
lymph nodes (Level I) Adapted from: Pocket Atlas of Human
Anatomy, third edition. H Feneis, Georg
Thieme Verlag, Stuttgart, 1994. Used with
permission.

Breast Cancer – CS Fields Breast Cancer – CS Fields
• Site-Specific Factors  HER2 FIELDS • Site-Specific Factors, continued

 SSF1 ERA • SSF8 HER2: IHC Test Lab Value  SSF16 Combinations of ER, PR, and HER2
 SSF2 PRA • SSF9 HER2: IHC Test  SSF17 Circulating Tumor Cells (CTC) and method of
 SSF3 Pos Axillary LN Interpretation detection
 SSF4 IHC reg LN • SSF10 HER2: Fish Test Lab Value  SSF18 Disseminated Tumor Cells (DTC) and method of
• SSF11 HER2: FISH Test
 SSF5 Molecular studies detection
Interpretation
 SSF6 Size of invasive tumor • SSF12 HER2: CISH Test Lab Value  SSF19 Assessment of Positive Ipsilateral
 SSF7 Nottingham or Bloom- • SSF13 HER2: CISH Test Axillary Lymph Nodes
Richardson (BR) Interpretation  SSF20 Assessment of Positive Distant Metastases
Score/Grade • SSF14 HER2: Result of other or  SSF21 Response to Neoadjuvant Therapy
unknown test  SSF22 Multigene Signature Method
• SSF15 HER2: Summary Result of  SSF23 Result/score of the multigene signature
Testing  SSF24 Paget Disease
CS Tumor Size Tumor Size—General Rules

• Critical part of TNM T1 - T3 categories
• Site-specific (not common) table • Record the largest size reported
• Code invasive tumor size in millimeters  If no pre-op treatment, use path size
• If microinvasion only, code size of largest focus  If pre-op treatment, use pre-op (clinical) size
• If stated as T1, NOS, use code 005  Imaging takes priority over physical exam
• If stated as > 5 cm, use code 051  Record size of invasive component, if given
• Special codes  Special site-specific code 998 takes
 990 Microinvasion; microscopic focus or foci only, precedence over a stated size
no size given; described as < 1 mm; stated as
T1mi, NOS with no other information on size  Do not add pieces together
 991-995 less than y cm, greater than x cm, between x and
y cm, or “Stated as T_, NOS”
• Use if precise size not available
 996 Seen on mammo only but no size given
 997 Paget’s of nipple, no underlying tumor
 998 Diffuse

Nonspecific Tumor Size
Notes Added in Part I – Tumor Size
Descriptions
• 991 Described as “less than 1 cm • If the tumor is multi-focal or there are multiple
Stated as T1b, NOS* tumors being reported as a single primary, code the
• 992 Described as “less than 2 cm,” or “greater size of the largest tumor.
than 1 cm,” or “between 1 cm and 2 cm” • For an incisional biopsy, code tumor size 999 in the
Stated as T1, NOS or T1c, NOS* absence of a clinical size.
• 993 Described as “less than 3 cm,” or “greater
than 2 cm,” or “between 2 cm and 3 cm”
Stated as T2*
* with no other information on size
CS Extension – Notes New CS Extension Codes

1. Changes such as dimpling of the skin, Code Description
tethering, and nipple retraction do not alter  170 Stated as T1 [NOS] *
the classification.  180 Stated as T2 [NOS] *
2. Adherence, attachment, fixation, induration,  190 Stated as T3 [NOS] *
and thickening are clinical evidence of  380 Stated as T4 [NOS] *
extension to skin or subcutaneous tissue;  390 Stated as T4a **
code to 200.  590 Stated as T4b **
3. Fixation, NOS is coded to 300, involvement of  680 Stated as T4c **
pectoralis muscle.  780 Stated as T4d **
 Also code “skeletal muscle, NOS” here
• * with no other information on extension or size
• ** with no other information on extension
16

CS Extension 000, 050, 070 (Tis) CS Size and Extension
000 Carcinoma in situ
Examples that map to T1
050 Paget disease of nipple without underlying tumor
070 Paget disease of nipple without underlying
invasive carcinoma E TS 011 + Ext 300 D
TS 018 + Ext 200
A TS 990 + Ext 100
C
TS 008 + Ext 100
Ext 050, 070 – Paget disease of nipple B TS 005 + Ext 100
Adapted from: AJCC Cancer Staging Atlas,
Springer-Verlag, 2006.
Source: UICC TNM-interactive, Wiley-Liss, 1998
CS Size and Extension CS Extension 400

Examples that map to T2, T3 Extension to chest wall (T4a)
A
TS 031 + Ext 100
Chest wall includes
Ribs
Intercostal muscles
Serratus anterior muscle
Does NOT include

Pectoral muscle (Ext 300)
B
TS 055 + Ext 200
Breast Cancer CSv2 Coding 19 Source: UICC TNM-interactive, Wiley-Liss, 1998


CS Extension 512 CS Extension 514-580, 590, 600
Extensive skin involvement (T4b) Any of the following conditions without a stated
diagnosis of inflammatory carcinoma with or without
dermal lymphatic invasion:
Satellite skin Edema of skin; En cuirasse; Erythema; Inflammation
nodule of skin; Peau d'orange ("pigskin")
514 described as < 33%
Skin ulceration
518 described as > 33% to 50%
520 described as > 50%
580 with amount or percentage
not stated
590 stated as T4b with no other
Edema
information on extension
600 Diagnosis of inflammatory carcinoma
Source: UICC TNM-interactive,
but < 33% of breast involved Wiley-Liss, 1998
Combination Codes CS Extension 612-615, 680

Chest wall and skin involvement (T4c)
• Avoids repeating large amount of text
612 Chest wall plus skin
• 516, 519, 575, 585 involvement < 33% of
• 612, 615 breast
(codes 400 + 512) code
• Example 512
 585—(580) + (512) means patient has one or 615 Chest wall plus skin code 400
more of the conditions in 580 and one or more involvement > 33% of
of the conditions in 512 breast
 such as ulceration of breast (512) AND peau (codes 400 + 520-585)
d’orange with percent of breast involvement
680 Stated as T4c with no
not stated (580)
other information on
extension
Breast Cancer CSv2 Coding 23 Breast Cancer CSv2 Coding 24 Source: UICC TNM-interactive, Wiley-Liss, 1998

CS Extension 725, 730, 750, 780 CS Extension – Notes
Inflammatory carcinoma (T4d)
6. Inflammatory carcinoma (abridged)
 Clinical AND pathologic entity
 Presence of diffuse erythema and edema (peau
d'orange) of breast involving majority of breast skin
“Diffuse dermal
 NOT the same as neglected locally advanced cancer
lymphatic involvement
presenting late in the course of disease.
causing edema and
 May or may not be apparent on skin biopsy
reddening of the skin”
 Primarily a clinical diagnosis. Involvement of dermal
lymphatics alone does not indicate inflammatory
carcinoma in the absence of clinical findings.
 In addition to the clinical picture, a biopsy is still
necessary to demonstrate dermal lymphatic or breast
parenchyma involvement.
Image source: National Cancer Institute
CS Extension – Notes CS TS/Ext Eval, CS Reg Nodes Eval,

CS Mets Eval
7. Recording inflammatory breast carcinoma (IBC)
 A stated diagnosis of inflammatory carcinoma • All standard tables
 Record clinical description* in a narrative field  0 Clinical only (physical exam, imaging, other non-
 Inflammatory carcinoma codes: invasive)
 600 – Dx of IBC involving < 33% of breast skin • Does not meet criteria for pathologic staging
 DO NOT USE CODE 715  1 Invasive techniques, no bx; or needle bx
 725 – Dx of IBC involving 33% to 50% of breast skin • Does not meet criteria for pathologic T or N
 730 – Dx of IBC involving > 50% of breast skin  2 Autopsy (known or suspected dx)
 750 – Dx of IBC only, no clinical description* of skin  3 Surgical resection, no pre-op treatment;
involvement pathologic exam of resected specimen
 780 – Stated as T4d, no other info on extension • Meets criteria for pathologic T, N or M
 If a clinical description* but no statement of  5 Pre-op tx, clinical evidence
inflammatory carcinoma—code to 510, 514, 610 or  6 Pre-op tx, path evidence more extensive
620 as appropriate  8 Autopsy (dx not suspected)
* inflammation, erythema, edema, peau d'orange, etc.  9 Unknown, not assessed

CS Eval Guidelines Regional Lymph Nodes
• CS TS/Ext Eval Other Names for Regional

 Includes information from surgical resection Lymph Nodes
(mastectomy), physical exam, imaging Labels 1i, 1ii, 1iii
Level I Intramammary, Pectoralis
 Unless there is skin or chest wall involvement, minor
assign Eval code based on how size was Nodule(s) in muscle
determined. If there is skin or chest wall axillary fat
involvement (T4 disease), assign Eval code Level II Rotter’s nodes,
based on extension. Interpectoral
• CS Lymph Nodes Eval Level III Infraclavicular,
 Single node biopsy or sentinel node procedure subclavicular
 Clinical if diagnostic (pre-treatment)
 Pathologic if therapeutic Label 2 Internal mammary
(parasternal) Source: UICC TNM-interactive, Wiley-Liss, 1998
CS Lymph Nodes – Notes CS Lymph Nodes – Notes

Code Ranges for Lymph Nodes
• Assume nodes are movable if not stated 000-050 Negative nodes or ITCs only
as fixed or matted 130, 150 Micrometastases
• Assume mets are > 0.2 mm if stated as 250-520 Positive axillary LN; no mention of internal
positive but size of mets not mentioned mammary node status
• Use code 600 if no other information about 600 Positive regional nodes, NOS
710-790 Positive axillary AND internal mammary nodes
positive nodes.
750 Positive infraclavicular nodes
• Axillary nodes defined as ipsilateral Level
800 Positive supraclavicular nodes
I and II, ipsilateral intramammary
 Does not include Level III (infraclavicular or • Clinical evaluation should use only 000, 255, 260,
apical), internal mammary, or ipsilateral 290, 510, 600, 740, 745, 750, 760, 780, 790, 800, 999.
supraclavicular nodes • Codes 130-600 are used for positive axillary nodes
without internal mammary nodes.

What are Isolated Tumor Cells? What is H&E?
• Isolated tumor cells (ITCs) (codes 000, 050)
 Epithelial cells inside a lymph node • Hematoxylin and Eosin
 Single tumor cells or small clusters < 0.2 mm • Hematoxylin
 Detected only by immunohistochemical (IHC) or  Stains nucleus (nucleic
molecular methods acids) of cell blue
 May be verified on “routine” H&E • Eosin
stains  Stains cytoplasm (protein)
 Questionable evidence of malig- pink
nant activity (no proliferation or • Other names for H&E Image source: National Cancer Institute
stromal reaction)  Hematoxylin and eosin;

 Lymph nodes with ITCs only are NOT considered routine/standard stains
positive lymph nodes.
Source: : http://biolog-e.ls.biu.ac.il/synapse/uploads2/Introduction_to_pathology-1.pdf
IHC – Immunohistochemistry Regional Lymph Nodes – Size

• IHC stains identify epithelial cells (keratin) • Micrometastases (codes 130, 150)
• Synonyms  Minimal size (>0.2 to 2 mm)
 Immunohistochemistry  OR more than 200 cells
 Immunocytochemistry  Tumor cells implanted in node with
extravasation, proliferation, and/or
 Immunochemistry stromal reaction
 Cytokeratin  In other words, micromets show
 Pankeratin malignant activity
 Keratin IHC staining  “Occult” metastases
 AE1/AE3 or AE1/3 (special stains)  Positive nodes
 MNF116 • Metastases (codes 250-800)
 CAM 5.2  > 2 mm
 Positive nodes

CS Lymph Nodes When to Use Codes 000, 050
Selecting the Right Code Negative nodes vs Isolated Tumor Cells (ITCs)
 Code 000 – No regional lymph node

How detected involvement or ITCs detected by immuno-
Size of metastasis Size IHC H&E histochemistry or molecular methods only
Isolated tumor cells < 0.2 mm 000 050  Code 050 – No regional lymph nodes
Micrometastasis > 0.2 to 130 150 positive but ITCs detected on routine H & E
< 2 mm stains
Metastasis > 2 mm --- 250–800
(macrometastasis)
When to Use Codes 130, 150 When to Use Codes 250, 255, 260
Method of Detecting Micrometastases
• 250 Movable axillary node(s), ipsilateral,
 Code 130 – Axillary nodes, micrometastases* positive with > micrometastasis
detected only by immunohistochemistry (IHC) (at least one metastasis > 2 mm)
 Use when positive nodes are pathologically separate,
 Code 150 – Axillary nodes, micrometastasis and size of mets in node is known to be > 2 mm
only, detected or verified on routine H & E • 255 Clinically positive movable axillary node(s)
stains; Micrometastasis, NOS  Use when there is no pathology or when patient has
neoadjuvant therapy and only clinical assessment
* Micrometastasis: > 0.2 mm (or > 200 cells) and < 2 mm
• 260 Stated as N1, NOS
 Use when no physical exam or other assessment,
only a clinician statement of N1

When to Use Codes 290, 300 When to Use Codes 510/520, 600
• 290 Clinically stated only as N2, NOS • 510 Fixed/matted ipsilateral axillary nodes
 No physical exam or other assessment, only a clinically; Stated clinically as N2a, NOS
clinician statement of N2  Use when positive nodes are described clinically as
 Use when there is no pathology or when fixed to each other or matted together and there is
patient has neoadjuvant therapy and only • No pathology OR
clinical assessment • Patient had pre-operative radiation or systemic
• 300 Pathologically stated only as N2 NOS therapy
 Use when there is no pathology, or no physical
 No information on which nodes were involved
exam or other assessment, only a clinician
statement of N2a
When to Use Codes 510/520, 600 When to Use Codes 510/520, 600
• 520 Fixed/matted ipsilateral axillary nodes • 600 Axillary/regional lymph node(s), NOS;
clinically with pathologic involvement of Lymph nodes NOS
lymph nodes at least one metastasis > 2mm  Use when size of metastasis in lymph node is not
 Use when positive nodes are described as fixed to stated
each other or matted together AND size of mets is  Can be either clinical or pathologic
known to be > 2 mm  If stated as fixed/matted, use 510-520 instead
 Description of fixation/matting can be by clinician or  If stated as movable or not stated as fixed/matted,
by pathologist in gross exam of specimen use 250-255 instead

Regional Lymph Nodes – Location Sentinel Lymph Node Biopsy
Internal Mammary Nodes Definitions
Lymphoscintigraphy
• Mapping of sentinel lymph nodes using radioisotopes
to identify nodes for removal by sentinel node biopsy
Not clinically apparent (CS LN codes 710, 720, 730)

Positive only on sentinel node biopsy
Clinically apparent (CS LN codes 740, 745, 760)

Includes
 Imaging (CT, CXR, etc) but not lymphoscintigraphy
 Physical exam (palpable)
 Visible nodes on gross pathology
CS Lymph Nodes – N1 Examples CS Lymph Nodes – N2 Examples

Code 250, 255 -- Movable Code 720 -- Microscopic Code 510, 520 Code 740
axillary LN only (N1) IM* nodes AND Fixed/matted Clin pos IM* nodes;
(1-3 pos = pN1a) 1-3 pos axillary LN (pN1c) axillary LN only (N2a) no pos axillary LN (N2b)
(4-9 pos = pN2a)
Code 710 -- Microscopic IM* nodes;

no pos axillary LN (pN1b)
*IM = internal mammary
Microscopic = positive sentinel nodes but not PE or imaging *IM = internal mammary
Breast Cancer CSv2 Coding 47 Adapted from: AJCC Cancer Staging Atlas, Springer-Verlag, 2006. Breast Cancer CSv2 Coding 48 Adapted from: AJCC Cancer Staging Atlas, Springer-Verlag, 2006.

CS Lymph Nodes – N3 Examples CS Mets at DX
Code 750 – Infraclavicular nodes (N3a)
Code 760 – Internal mammary AND 4+ axillary nodes (N3b)
• Mets at Dx codes
 05
CTCs or DTCs in asymptomatic patient
Code 800 – Supraclavicular nodes (N3c)  10
Distant lymph nodes
 40
Distant metastases, NOS; Carcinomatosis
750 800  42
Further skin involvement (axilla, sternum,
contralateral breast, upper abdomen)
 44 Metastases to specific sites (bone, lung, ovary,
+ adrenal, etc.)
760
 50 Distant nodes plus distant mets
 60 Distant metastasis, NOS; Stated as M1, NOS
with/without
axillary nodes
Breast Cancer CSv2 Coding 49 Adapted from: AJCC Cancer Staging Atlas, Springer-Verlag, 2006. Breast Cancer CSv2 Coding 50
CS Mets at DX CS Mets at DX – Guidelines

• Code 00: CTCs and DTCs – M0(i+) • Note 2 paraphrased
 Patient is asymptomatic  Assume no distant metastases (cM0) unless there
 Tumor cells detected microscopically or is documentation of mets clinically (cM1) or by
molecularly biopsy of a metastatic site (pM1)
• In circulating blood (CTC)  Code 00 includes negative physical exam, negative
• In bone marrow imaging, and negative biopsies of distant sites
• In non-regional nodal tissue (DTC)  No pM0
 Tumor cell deposits < 0.2 mm
• Called micrometastases (not same size definition as
for LN)
 CTCs and DTCs may be prognostic for
recurrence or survival

SSF1: ERA – SSF2: PRA SSF1: ERA – SSF2: PRA
• Required by COC, SEER, NPCR

• Guidelines 000 Test not done (not ordered and not performed)
010 Positive/elevated
 Record highest value
• If any sample is positive code as 010 020 Negative/normal; within normal limits
 If neoadjuvant treatment given, code from pre- 030 Borderline; undetermined whether positive
treatment specimens or negative
• If no pre-treatment specimens, code from post- 080 Ordered, but results not in chart
treatment 996 Ordered, results not interpretable
 Code 030 (borderline) rarely used 999 Unknown or no information; Not documented
 Do not code ERA or PRA from multigene test in record
SSF1: ERA – SSF2: PRA SSF3 Number of Positive Ipsilateral

Axillary Lymph Nodes
• Laboratory tests that include ERA and • Required by COC, SEER
PRA • Information needed to assign pN1, pN2, pN3
 Breast profile studies by number of positive axillary nodes
 Hormone receptors • Applies to positive ipsilateral Levels I and II
 Estrogen/Progesterone binding protein
and intramammary axillary nodes
 Estradiol receptor (ER)
 PgR (progesterone receptor) • Same guidelines as for CS Lymph Nodes
 ERICA (estradiol receptor immunocyto-  Record even if preoperative treatment
chemical assay)/PRICA (progesterone receptor  Definitions of ITC vs micrometastases
immunocytochemical assay)  Do not count ITC-only nodes as positive
• Same code structure as Reg Nodes Pos
 DO NOT CODE from OncotypeDX or other  Use code 098 if no nodes were removed or if no
multigene tests nodes found in specimen

SSF4 Immunohistochemistry (IHC) SSF5
of Regional Lymph Nodes Molecular Studies of Regional LN
• Required by COC, SEER • Required by COC, SEER
• Use 000-009 ONLY when lymph nodes are • Not commonly performed
negative on H&E (code 000 in CS Lymph Nodes) • If IHC done (SSF 4), molecular studies not
000 LN neg on H&E, no IHC done, or unk if IHC done done
001 LN neg on H&E, IHC done and negative
002 LN neg on H&E, IHC done and positive for ITCs
• Generic name: RT-PCR; Reverse
009 LN neg on H&E, IHC done and positive, size of transcriptase-polymerase chain reaction
mets unk; stated as N0(i+) • Other names: GeneSearch, TaqMan®, OSNA
(one step nucleic acid amplification), Molecular
• If nodes are positive on H&E, use code 987
Beacons, Scorpions® and SYBR® Green,
• If no statement whether IHC tests were done, Fluorescence Resonance Energy Transfer
assume they were not done and code 000 (FRET), Amplifluor/Sunrise, others
• See also SSF 5, molecular markers
SSF5 SSF6 Size of Invasive Tumor

Molecular Studies of Regional LN
• Use codes 000-002 ONLY when lymph • Required by COC, SEER
nodes are negative (CS Lymph Nodes • Code the phrase that indicates how
codes 000). pathologic tumor size was coded in CS
• If nodes are positive, use code 987 Tumor Size
• If no statement whether molecular tests • “Mixed"
were done, assume they were not done  Tumor with both invasive and in situ
components. Examples:
• Isolated tumor cells (ITC): same
 mixed infiltrating ductal and DCIS
definition as for CS Lymph Nodes  mixed infiltrating ductal and LCIS
• "Pure"
 a tumor containing only invasive or only in situ
carcinoma

SSF7
SSF6 Size of Invasive Tumor
Bloom-Richardson Score/Grade
INV = invasive
• Required by COC, SEER
000 All INV (no IS)
IS = in situ • Many other names (same concept)
010 All IS (no INV)
TS = tumor size  Also called BR, SBR
020 Mixed INV and IS, INV reported  Key words: Bloom, Richardson, Scarff, Elston-
030 Mixed INV and IS, entire size coded (INV size not Ellis, Nottingham, Tenovus
stated) AND minimal IS (< 25%)
040 Mixed INV and IS, entire size coded (INV size not
• May be expressed as
stated) AND extensive IS (25% or more)  Score (range 3-9)
050 Mixed INV and IS, entire size coded (INV size not  Grade (low, intermediate, high) derived from score
stated, IS proportion not stated) • Histologic score features (1-3 points each)
060 Mixed INV and IS, size not known (TS coded 999)
987 Unknown if INV and IS present, unknown if TS
1) extent of tubule formation (% composed of
is mixed or "pure" tumor. tubular structures)
Clinical tumor size coded. 2) nuclear pleomorphism (change in cells)
3) mitotic rate (number of mitoses)
SSF7
• Sum points for extent of tubule formation +  Can convert score into ICD-O-3 grade
nuclear pleomorphism + mitotic rate  Note: conversion of B-R low, intermediate, and
• Code exact score as priority (030 – 090) high is different from conversion used for all
• Code grade if score not stated (110-130) other tumors
 Do not translate grade into numeric score
 110 Low grade; BR grade 1 B-R B-R ICD-O-3 5-yr
 120 Medium/intermediate grade; BR grade 2 Scores Grade Terminology 6th Digit Survival
 130 High grade; BR grade 3 3, 4, 5 1 (lowest) Well differentiated 1 95%
• Other codes 6, 7 2 Moderately 2 75%
 988 Not applicable: information not collected differentiated
for this case 8, 9 3 (highest) Poorly differentiated 3 50%
 998 No histologic examination of primary site Adapted from http://imaginis.com/breasthealth/histologic_grades.asp
(clinical diagnosis)
 999 No grade or score given; no information

SSFs 8-15 HER2 Fields SSFs 8-15 HER2 Fields
• HER2 • 8-9 IHC – Immunohistochemistry
 Human Epidermal growth factor Receptor 2  Most common HER2 test
 Overexpression indicates aggressive behavior,  Special stain done in pathology
likelihood of recurrence  If IHC inconclusive, MD may request FISH test
 Patient may be treated with Herceptin • 10-11 FISH – Fluorescence In Situ Hybridization
• Site-Specific Factors  Fluorescent DNA attaches to HER2 genes
 Required by COC, SEER, NPCR  More expensive, longer to report than IHC
 8-9 HER2: IHC Test Lab Value and Interpretation  Reported as ratio of HER2 receptors to control
 10-11 HER2: Fish Test Lab Value and Interpretation • 12-13 CISH - Chromogenic In Situ Hybridizaton
 12-13 HER2: CISH Test Lab Value and Interpretation  FDA approved 2009; less expensive than FISH
 14 HER2: Result of other or unknown test  Looks for color changes not fluorescence
 15 HER2: Summary Result of Testing  Counts average number of gene copies per cell
IHC – FISH – CISH SSFs 8-15 HER2 Fields

• First field – result • 14 Result of Other or Unknown Test
 IHC 1+, 2+ 3+  Required by COC, SEER
 FISH Ratio (1.00 to 9.87)  Record other HER2 test or unknown type of test
 CISH Mean number of gene copies per cell • 15 Summary Result of Testing
• Second field – interpretation  Summary of SSFs 9, 11, 13, 14
 All three tests  Record final result if multiple tests
• Positive/elevated (amplified)
• Negative/normal (not amplified) • 16 Combinations of ER, PR, and HER2
• Borderline  Summary field that identifies “triple negative”
• Test ordered, results not in chart
• Test not done (not ordered and not performed
patients quickly (code 000)
• Unknown  Results of SSFs 1, 2, 15
___ ___ ___ 0 = negative
ER PR HER2 1 = positive

SSF17 – CTCs and Method of SSF18 – DTCs and Method of
Detection Detection
• CTC Circulating Tumor Cells • DTC Disseminated Tumor Cells
 Small clusters of tumor cells or individual  Small clusters of tumor cells or individual
tumor cells in blood tumor cells in bone marrow
• Method of detection • Method of detection
 Type of test that discovered CTCs  Type of test that discovered CTCs
 Immunocytochemical and molecular assays  Immunohistochemical and molecular assays
• Code structure – 3 digits • Code structure – 3 digits
___ ___ _0__ ___ ___ _0__
Test result Type of test Test result Type of test
0 Negative 0 RT-PCR 0 Negative 0 RT-PCR
1 Positive 1 Immunomagnetic separation 1 Positive 1 Immunhistochemistry
2 Borderline 3 Other type 2 Borderline 3 Other type
4 Unknown test type 4 Unknown test type
 Other codes available  Other codes available
SSF19 – Assessment of Positive SSF19 – Assessment of Positive

Ipsilateral Axillary Nodes Ipsilateral Axillary Nodes
• Codes
• Supplemental information on how number of  000 No positive ipsilateral axillary nodes
positive Level I and II nodes determined for  010 Clinical assessment (only) positive
SSF3, N category and stage group  020 Positive Fine Needle Aspiration (FNA) only
 030 Positive Core biopsy: incisional
• First digit 0 indicates single procedure only
 040 Positive Core biopsy: excisional
• First digit 1 indicates combination of  050 Positive Core biopsy: type not specified
sentinel node biopsy results and lymph  100 Positive SLNB, no ALND
node dissection results  110 Positive SLNB, negative ALND
 120 Positive SLNB, positive ALND
 130 Negative SLNB, positive ALND
 140 No SLNB, positive ALND
 Other codes available
SLNB = sentinel lymph node biopsy(ies)
ALND = axillary lymph node dissection

SSF20 – Assessment of Positive SSF21 – Response to Neoadjuvant
Distant Metastases Therapy
• Records how information about positive • Required by COC, SEER
mets in CS Mets at Dx and site-specific • Code physician statement of response to
Mets at Dx fields was determined pre-operative systemic or radiation therapy
• Code only positive results  Do not infer a response based on medical record
 If Mets at Dx field is 000, SSF20 must be 000 • Codes
• Codes  010 Complete Response (CR)
 000 No positive metastases were identified  020 Partial Response (PR)
 010 Clinical assessment  030 No Response (NR)
 020 Radiography; Imaging (US, CT, MRI, PET)  988 Not applicable: Information not collected
 030 Incisional biopsy; FNA  998 No neoadjuvant therapy
 040 Excisional biopsy or resection with  999 Unknown if response
microscopic confirmation other than by
biopsy
SSF22 – Multigene Signature

Example of an OncotypeDx Report
Method
• Other names
 Oncotype Dx, MammaPrint, genomic profiling,
multigene testing/assay
• Predicts risk of recurrence for node-
negative patients
 May also be useful in predicting recurrence for
node-positive patients
• Tailors treatment specific to person
• Codes (name of test)
 010 Oncotype DX
 020 Mamma Print
 030 Other 76

SSF23 – Result/Score of Multigene
Example of an MammaPrint Report
Signature
• Record result of test named in SSF22
• Codes
 001-099 Actual score
Oncotype DX results
 100 100+
 200 Low risk of recurrence
(good prognosis)
MammaPrint results
 205 High risk of recurrence
(poor prognosis)
 Other codes available
77
SSF24 – Paget Disease Breast – Related CS Fields

• Paget disease of nipple does not always • CS Tumor Size • CS Lymph Nodes
• CS Extension • CS Nodes Eval
get captured in ICD-O-3 code or stage • CS TS/Ext Eval • Reg LN Pos
information • SSF6 Size of invasive • Reg LN Exam
tumor •
• Codes
•
SSF3 # Pos Ax LN
SSF4 IHC
 000 Paget disease absent/not mentioned • CS Mets at DX • SSF5 Molecular studies
 010 Paget disease present • CS Mets Eval • SSF19 Assess Pos Ax LN
 988 Not applicable: Information not collected • SSF 17-18 CTC, DTC
 999 Unknown or no information • SSF20 Assess Pos
Distant Mets
• SSF1 ERA • SSF16 Combination of markers

• SSF2 PRA • SSF21 Neoadj Tx Response
• SSF7 BR Score • SSF22-23 Multigene method/result
• SSF8-15 HER2 fields • SSF24 Paget disease

Breast Case # 1
HISTORY AND PHYSICAL
Date: March 01, 2010
CHIEF COMPLAINT: Abnormal mammogram right breast
HISTORY OF THE PRESENT ILLNESS: The patient is a 64 year old Caucasian female who
had a mammogram and ultrasound performed, which revealed a suspicious spiculated lesion in
the right breast at the 3 o’clock position. The patient’s last mammogram prior to the most recent
was, I believe, a couple of years ago. The patient herself denies any symptoms referable to the
breast whatsoever. The patient has a past history of having a mastectomy performed in 1998 for
breast cancer. She did not receive any adjuvant treatment and I presume this is a lymph node
negative malignancy, although I do not have any final pathology on this. She was administered
five years of hormonal treatment. The patient now comes in for further recommendations.
IMPRESSION: Indeterminate lesion, right breast. Rule our malignancy.
PLAN: The patient will undergo an ultrasound-guided core biopsy today and further
recommendations will be based upon the results of the biopsy. I will see her March 6th for
biopsy result and discuss further recommendations at that time.
HISTORY AND PHYSICAL #2
Date: April 24, 2010
History of Present Illness:

The patient is here for recheck after having a re-excision of the lumpectomy margins on April
13th. The patient is very disappointed that we were not able to proceed with the MammoSite
catheter radiation, but I do not feel that there was enough space between the skin surface and the
balloon, and also was very concerned with her wound healing at the time of the repeat
lumpectomy. Her Oncotype DX came back with a score of 34 putting her at high risk, that is,
24% at 10 years. She has started radiation therapy today. She will be referred for an oncology
consult.
PROGRESS REPORT
Date: March 15, 2010
The patient is a very nice 64 year old Caucasian female who has a history of carcinoma of the
left breast treated with mastectomy in the past. The patient presented with a new lesion in the
right breast on imaging. This was biopsied and proven to be consistent with a carcinoma. This
was an ER and PR positive carcinoma about 1.4 centimeters in size. The patient is to proceed
with breast conservation at her request. We will place a temporary MammoSite balloon catheter
and radiate. If things go well with the MammoSite, she will receive partial breast radiation. We
will get the patient scheduled at the earliest time possible.
CSv2 Training Materials Page 1 of 5

Breast Case # 1
RADIOLOGY REPORT
Procedure: Diagnostic Mammography Unilateral Digital

Date: February 13, 2010
Reason for Exam: History of Breast Cancer
BC Mammo Diagnost Unilat Digital: UNILATERAL RIGHT DIGITAL DIAGNOSTIC

MAMMOGRAM WITH MEDIOLATERAL SPOT COMPRESSION. COMPARISON IS
MADE TO MAMMOGRAM DATED 2/16/2007.
The tissue of the right breast is predominantly fatty. There is a 2.0 cm irregular mass with a
spiculated margin in the right breast at 3 o’clock anterior depth. The mass is confirmed on
additional views. No other significant masses or calcifications are seen in the breast.
IMPRESSION: HIGHLY SUGGESTIVE OF MALIGNANCY

The 2.0 cm irregular mass in the right breast likely represents carcinoma and is indeterminate.
An ultrasound and biopsy are recommended.
Procedure: Right Breast Ultrasound. Mass in breast on mammogram.
CLINICAL INFORMATION: 64 year old female with spiculated mass on diagnostic

mammogram.
Transverse and longitudinal real time imaging through the right breast at the 3 o’clock position
shows a 1.1 x 1.1 x 1.4 cm irregular hypoechoic mass corresponding to the mammographic
abnormality. This is highly suspicious for a cancer. The borders are irregular and there is a
posterior shadowing. No additional masses are seen in the area.
IMPRESSION: Suspicious irregular hypoechoic mass in the right breast at 3 o’clock position
corresponding to the mammographic abnormality. This area should be biopsied to confirm a
histologic diagnosis.
BIRADS IV- Suspicious abnormality – patient will be scheduled for a needle core biopsy.
US CORE BIOPSY
DATE: MARCH 01, 2010
FINAL REPORT: ULTRASOUND GUIDED CORE BIOPSY RIGHT BREAST:

This procedure was performed for the 1.4 cm mass located in the middle depth at 3 o’clock as
described on the previous ultrasound. The mass was localized and a small incision was made in
the breast. An 18 gauge biopsy needle was placed into the mass guided by ultrasound. Once the
needle was in the mass, three core specimens were obtained at different sites within the mass
using guided by ultrasound. Post procedure images of the breast show partial removal of the
mass. Awaiting pathology results. A surgical consult is recommended.

Breast Case # 1
OPERATIVE REPORT
PROCEDURE #1
Date: 03/23/2010
PREOPERATIVE DIAGNOSIS: Carcinoma of the right breast.
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE:
1. Ultrasound guided needle localization for right lumpectomy
2. Right axillary sentinel lymph node localization and biopsy
FINDINGS OF OPERATION: Negative sentinel nodes on frozen section evaluation. These

nodes were hot with counts about 164 and were stained blue.
SPECIMEN:
1. Sentinel nodes right axilla.
2. Right lumpectomy with a long suture margin to the lateral margin, short suture marking
to superior margin.
COMPLICATIONS: None.
PROCEDURE #2
Date: 04/12/2010
Operation: Reoperative Segmental Resection
Specimen: Inferior and anterior margin with a suture marking of new margin.
Brief History: 64 Caucasian female s/p sentinel node biopsy few weeks ago. Anterior and
inferior margins were close, here for re-excision. Patient interested in Mammosite catheter
radiation. Planned as part of procedure.
Procedure: Lumpectomy performed by excising the anterior and inferior margin sharply with
electrocautery. Unfortunately, the superficial margin that is the anterior margins was not
anywhere near even 7mm. I didn’t think it wise to place the Mamma site balloon catheter for
fear of having radiation close to the skin. Wound irrigated, layers closed. Patient taken to
recovery room in stable condition.

Breast Case # 1
PATHOLOGY REPORT
REPORT #1
Date Specimen Collected: 3/01/2010
Date Specimen Reported: 03/02/2010 S07-2378
Clinical History: History of left mastectomy, mass right breast 3 o’clock
FINAL DIAGNOSIS: RIGHT BREAST, 3’OCLOCK, NEEDLE CORE BIOPSY:

INFILTRATING MAMMARY CARCINOMA, INTERMEDIATE GRADE, NOTTINGHAM
SCORE 3+2+1=6. NO MICROCALCIFICATIONS ENCOUNTED.
Gross Description: Received in formalin labeled Breast Case 1 and “right breast biopsy” are
multiple cores of fibrofatty tissue from minute to 1.5 x 0.1 cm which are filtered and submitted
in total in cassette A1.
Microscopic Description: Microscopic examination performed. E-cadherin stains show strong

membrane positivity in tumor cells.
HORMONE RECEPTOR STATUS: ESTROGEN RECEPTOR (IHC): POSITIVE.

PROGESTERONE RECEPTOR (IHC): NEGATIVE. HER-2/NEU ONCOGEN (FISH):
PENDING, SEE ADDENDUM REPORT.
ADDENDUM DIAGNOSIS: RIGHT BREAST, HER-2/NEU (FISH): NOT AMPLIFIED: The
HER-2/cen-17 ratio = 1.3
IMPRESSION: This lady would appear to have a T1 primary breast carcinoma, ER positive,
and is interested in breast conservation. She was not interested in reconstructive surgery to her
left breast at this particular juncture. Following a discussion of local management options, she
wished to consider the option of partial breast radiotherapy. She appears to be a good candidate
for postoperative hormonal adjuvant therapy and may be a candidate for systemic chemotherapy,
depending on the remainder of her clinical features. Her surgical management will likely consist
of a wide local excision and sentinel lymph node biopsy. MammoSite catheter insertion could be
entertained if appropriate at that particular time. Should her sentinel lymph node biopsy prove
positive, an axillary dissection would likely be necessary. I will plan to arrange for Radiation
Oncology consultation next week and I will plan to see her back approximately two weeks
postoperative to make additional management plans.
REPORT #2
Date Specimen Collected: 03/23/2010
S07-3272
Date Specimen Reported: 03/25/2010
Source: A. Sentinel node right breast. B. Right Lumpectomy
FINAL DIAGNOSIS
A. Lymph Node, Right Axilla, Sentinel nodes (6): Negative for malignancy.
B. Right Breast Lumpectomy: Infiltrating mammary carcinoma (1.5 x 1.5 x 0.9 cm.).
Intermediate grade. Nottingham score 3+2+1=6
Breast Case # 1
Ductal carcinoma in situ (High grade, comedo pattern) present.
DCIS extends to anterior margin. Nearest margin (anterior) less than 1 mm. No
vascular/lymphatic invasion.
Hormone Receptor Status (See 07-2378): Estrogen Receptor (IHC): Positive. Progesterone
Receptor (IHC): Negative. HER-2/neu (FISH): negative
TNM Stage: T1c N0 MX
Gross Description:
A. Received fresh “sentinel node right”, 2.5 cm adipose tissue with six lymph nodes identified
from 0.5 x 0.2 x. 0.2 cm to 1.7 cm.
B. “Right Lumpectomy” is 5.5 x 5 x 2.7 cm ovoid fibrofatty breast tissue. There is a 1.5 x 1.5 x
0.9 cm firm tumor nodule focally approaching the anterior margin. Other margins clear.
Microscopic Description: Microscopic examination performed.
Breast: Complete Excision
MACROSCOPIC:
Specimen Type: Excision
Lymph Node Sampling: Sentinel lymph node(s) only
Specimen Size: 5.5 x 5 x 2.7
Laterality: Right
Tumor Site: Not Specified
MICROSCOPIC:
Size of Invasive Component: 1.5 x 1.5 x 0.9 cm
Histological Type: Ductal carcinoma in situ, Invasive ductal carcinoma
Histological Grade: 3+2+1=6 Grade II
TNM Staging: T1c Tumor more than 1.0 cm but not more than 2.0 cm in greatest dimension
N0 No Regional Lymph Node mets (ie, none greater than 0.2 mm,), no
additional examination for isolated tumor cells
MX Cannot be assessed
Margins: Margins(s) involved by invasive carcinoma. Anterior margin.
Margins(s) involved by DCIS. Anterior margin.
Venous/Lymphatic (Large/Small Vessel) Invasion: Absent
Microcalcifications: Not identified
Hormone Receptor Study: Ordered

CSv2 ANSWER WORKSHEET
FIELD# FIELD NAME CODE AND RATIONALE/DOCUMENTATION

1 Patient Name -
CANCER IDENTIFICATION
2 Primary Site
3 Histology
4 Behavior
5 Grade
6 Grade system type
7 Grade system value
8 Lymph-vascular invasion
STAGE OF DISEASE AT DIAGNOSIS
9 CS Mets at Dx - Bone
10 CS Mets at Dx - Lung
11 CS Mets at Dx - Liver
12 CS Mets at DX - Brain
COLLABORATIVE STAGING
13 CS Tumor Size
14 CS Extension
15 CS Tumor Size/Ext Eval
16 CS Lymph Nodes
17 CS Lymph Nodes Eval
18 Regional Nodes Positive
19 Regional Nodes Examined
20 CS Mets at Dx
21 CS Mets Eval
22 CS Site-Specific Factor 1
CSv2 Education and Training Page 1 of 1

BREAST SCHEMA CSv2 1
03/10/2010
CS Tumor Size
 Note 1: See part I for information on timing and rules for coding this field.
 Note 2: Code the specific tumor size as documented in the medical record. If the ONLY information regarding
tumor size is the physician's statement of the "T" category, assign code 990 (T1mi), 991 (T1b), 992 (T1 or T1c),
or 995 (T2). If the physician's statement of the "T" category is T1a, NOS with no documentation of tumor size,
code tumor size as 005. If the physician's statement of the "T" category is T3, NOS with no documentation of
tumor size OR a statement only specifying that the tumor size is greater than 5 cm, code tumor size as 051.
 Note 3: For tumor size, some breast cancers cannot be sized pathologically.
 Note 4: When coding pathologic size, code the measurement of the invasive component. For example, if there
is a large in situ component (e.g., 4 cm) and a small invasive component see Site-Specific Factor 6 to code more
information about the reported tumor size. If the size of invasive component is not given, code the size of the
entire tumor and record what it represents in Site-Specific Factor 6.
 Note 5: Microinvasion is the extension of cancer cells beyond the basement membrane into the adjacent tissues
with no focus more than 0.1 cm in greatest dimension. When there are multiple foci of microinvasion, the size of
only the largest focus is used to classify the microinvasion. (Do not use the sum of all the individual foci.)
Code Description
000 No mass/tumor found
001-988 001 - 988 millimeters (code exact size in millimeters)
989 989 millimeters or larger
Microinvasion; microscopic focus or foci only, no size given; described as less than 1 mm
990
Stated as T1mi, NOS with no other information on size
Described as "less than 1 cm"
991
Stated as T1b, NOS with no other information on size
Described as "less than 2 cm," or "greater than 1 cm," or "between 1 cm and 2 cm"
992
Stated as T1, NOS or T1c, NOS with no other information on size
993 Described as "less than 3 cm," or "greater than 2 cm," or "between 2 cm and 3 cm"
Described as "less than 5 cm," or "greater than 4 cm," or "between 4 cm and 5 cm"
995
Stated as T2 with no other information on size
996 Mammographic/xerographic diagnosis only, no size given; clinically not palpable
997 Paget Disease of nipple with no demonstrable tumor
998 Diffuse
Unknown; size not stated
999
Not documented in patient record
CS Extension
 Note 1: See Part 1 for what information this field is based on including timing rules.
 Note 2: Changes such as dimpling of the skin, tethering, and nipple retraction are caused by tension on
Cooper's ligament(s), not by actual skin involvement. They do not alter the classification.
 Note 3: Consider adherence, attachment, fixation, induration, and thickening as clinical evidence of extension to
skin or subcutaneous tissue, code '200'.
 Note 4: Consider "fixation, NOS" as involvement of pectoralis muscle, code '300'.
 Note 5: If extension code is 000, then Behavior code must be 2; if extension code is 050 or 070, then behavior
code may be 2 or 3; and, if extension code is 100, then behavior code must be 3.
 Note 6: Inflammatory Carcinoma. AJCC includes the following text in the 7th edition Staging Manual,
"Inflammatory carcinoma is a clinicopathologic entity characterized by diffuse erythema and edema (peau
d'orange) of the breast, often without an underlying palpable mass. These clinical findings should involve the
03/10/2010
majority of the skin of the breast. Classically, the skin changes arise quickly in the affected breast. Thus the
term of inflammatory carcinoma should not be applied to a patient with neglected locally advanced cancer of the
breast presenting late in the course of her disease. On imaging, there may be a detectable mass and
characteristic thickening of the skin over the breast. This clinical presentation is due to tumor emboli within
dermal lymphatics, which may or may not be apparent on skin biopsy. The tumor of inflammatory carcinoma is
classified T4d. It is important to remember that inflammatory carcinoma is primarily a clinical diagnosis.
Involvement of the dermal lymphatics alone does not indicate inflammatory carcinoma in the absence of clinical
findings. In addition to the clinical picture, however, a biopsy is still necessary to demonstrate cancer either
within the dermal lymphatics or in the breast parenchyma itself."
 Note 7: For Collaborative Staging, the abstractor should record a stated diagnosis of inflammatory carcinoma,
and also record any clinical statement of the character and extent of skin involvement in the text area. Code 600
should be used if there is a stated diagnosis of inflammatory carcinoma and a clinical description of the skin
involvement is less than one-third (33%) of the skin of the breast. Code 725 should be used if there is a stated
diagnosis of inflammatory carcinoma and a clinical description of the skin involvement is greater than or equal to
one-third (33%) and less than or equal to one half (50%) of the skin of the breast. Code 730 should be used if
there is a stated diagnosis of inflammatory carcinoma and a clinical description of the skin involvement in more
than 50% (majority or diffuse) of the skin of the breast. Cases with a stated diagnosis of inflammatory carcinoma
but no such clinical description should be coded 750. A clinical description of inflammation, erythema, edema,
peau d'orange, etc. without a stated diagnosis of inflammatory carcinoma should be coded 510, 514, 610, or
620, depending on described extent of the condition.
TNM 7 TNM 6 SS77 SS2000

Code Description
Map Map Map Map
In situ: noninfiltrating; intraepithelial
000 Intraductal WITHOUT infiltration Tis Tis IS IS
Lobular neoplasia
Paget Disease of nipple (WITHOUT underlying
050 Tis Tis ** **
tumor)
Paget Disease of nipple (WITHOUT underlying
070 Tis Tis ** **
invasive carcinoma pathologically)
Confined to breast tissue and fat including nipple
100 and/or areola ^ * L L
Localized, NOS
Stated as T1 [NOS] with no other information on
170 T1NOS T1NOS RE RE
extension or size
180 T2 T2 RE RE
extension or size
190 T3 T3 RE RE
extension or size
Invasion of subcutaneous tissue
Local infiltration of dermal lymphatics adjacent to
200 primary tumor involving skin by direct extension ^ * RE RE
Skin infiltration of primary breast including skin of
nipple and/or areola
Attached or fixation to pectoral muscle(s) or
underlying tissue
300 ^ * RE RE
Deep fixation
Invasion of (or fixation to) pectoral fascia or muscle
380 T4NOS T4NOS RE RE
extension
Stated as T4a with no other information on
390 T4a T4a RE RE
extension
Invasion of (or fixation to):
Chest wall
400 T4a T4a RE RE
Intercostal or serratus anterior muscle(s)
Rib(s)
03/10/2010
OBSOLETE DATA RETAINED V0200

Extensive skin involvement, including:
Satellite nodule(s) in skin of primary breast
Ulceration of skin of breast
Any of the following conditions described as
involving not more than 50% of the breast, or
510 ERROR T4b RE RE
amount or percent of involvement not stated:
Edema of skin
En cuirasse
Erythema
Inflammation of skin
Peau d'orange ("pigskin")
Extensive skin involvement, including:
512 Satellite nodule(s) in skin of primary breast T4b T4b RE RE
Ulceration of skin of breast
involving less than one-third (33%) of the breast
WITHOUT a stated diagnosis of inflammatory
carcinoma WITH or WITHOUT dermal lymphatic
infiltration
514 T4b T4b RE RE
Edema of skin
En cuirasse
Erythema
516 (514) + (512) T4b T4b RE RE
involving one third (33%) or more but less than or
equal to half (50%) of the breast WITHOUT a stated
diagnosis of inflammatory carcinoma WITH or
WITHOUT dermal lymphatic infiltration:
518 T4b T4b RE RE
Edema of skin
En cuirasse
Erythema
519 (518) + (512) T4b T4b RE RE
involving more than 50% of the breast
infiltration:
520 T4b T4b RE RE
Edema of skin
En cuirasse
Erythema
575 (520) + (512) T4b T4b RE RE
Any of the following conditions with amount or
percent of breast involvement not stated and
infiltration:
580 T4b T4b RE RE
Edema of skin
En cuirasse
Erythema
585 (580) + (512) T4b T4b RE RE
03/10/2010
Stated as T4b with no other information on

590 T4b T4b RE RE
extension
Diagnosis of inflammatory carcinoma
WITH a clinical description of inflammation,
600 erythema, edema, peau d'orange, etc., involving T4b T4d RE RE
less than one-third (33%) of the skin of the breast,
WITH or WITHOUT dermal lymphatic infiltration
610 ERROR T4c RE RE
(400) + (510)
612 Any of (512-514) + (400) T4c T4b RE RE
615 Any of (520-585) + (400) T4c T4b RE RE
620 ERROR T4c RE RE
(400) + (520)
Stated as T4c with no other information on
680 T4c T4c RE RE
extension
710 erythema, edema, peau d'orange, etc., involving not ERROR T4d RE RE
more than 50% of the skin of the breast,
Inflammatory carcinoma, NOS
715 erythema, edema, peau d'orange, etc., involving not T4b T4d RE RE
more than one-third (33%) of the skin of the breast,
OBSOLETE DATA CONVERTED V0102
Diagnosis of inflammatory
WITH a clinical diagnosis of inflammation,
erythema, edema, peau d'orange, etc., of not more
than 50% of the breast,
720 WITH or WITHOUT dermal lymphatic infiltration ERROR ERROR ERROR ERROR
NOTE: Code 720 has been combined with code
710.
Any cases coded to 720 should be re-coded to
code 710.
erythema, edema, peau d'orange, etc., involving
725 T4d T4d RE RE
one-third (33%) or more but less than or equal to
half (50%) of the skin of the breast,
730 erythema, edema, peau d'orange, etc., involving T4d T4d RE RE
more than 50% of the skin of the breast,
03/10/2010

erythema, edema, peau d'orange, etc., but percent
of involvement not stated,
WITH or WITHOUT dermal lymphatic infiltration.
If percentage is known, code to 600, 725, or 730.

750 T4d T4d RE RE
WITHOUT a clinical description of inflammation,
erythema, edema, peau d'orange, etc.,

Stated as T4d with no other information on
780 T4d T4d RE RE
extension
950 No evidence of primary tumor T0 T0 U U
Unknown extension
999 Primary tumor cannot be assessed TX TX U U
 For Extension codes 100, 200, and 300 ONLY, the T category is assigned based on value of CS Tumor Size as
shown in the Extension Size Table for this site.
 ^ For Extension codes 100, 200, and 300 ONLY, the T category is assigned based on value of CS Tumor Size as
shown in the Extension Size Table for this site.
 ** For codes 050 and 070 ONLY, summary stage is assigned based on the value of Behavior Code ICD-O-3 as
shown in the Extension Behavior Table for this site.
CS Tumor Size/Ext Eval

Code Description Staging
Basis
0 Does not meet criteria for AJCC pathologic staging: c
No surgical resection done. Evaluation based on physical examination,

imaging examination, or other non-invasive clinical evidence. No autopsy
evidence used.
No surgical resection done. Evaluation based on endoscopic examination,

diagnostic biopsy, including fine needle aspiration biopsy, or other invasive
techniques, including surgical observation without biopsy. No autopsy
evidence used.
2 Meets criteria for AJCC pathologic staging: p
No surgical resection done, but evidence derived from autopsy (tumor was
suspected or diagnosed prior to autopsy)
03/10/2010
3 Either criteria meets AJCC pathologic staging: p
Surgical resection performed WITHOUT pre-surgical systemic treatment or

radiation
OR surgical resection performed, unknown if pre-surgical systemic
treatment or radiation performed
AND Evaluation based on evidence acquired before treatment,
supplemented or modified by the additional evidence acquired during and
from surgery, particularly from pathologic examination of the resected
specimen.
No surgical resection done. Evaluation based on positive biopsy of highest

T classification.
5 Does not meet criteria for AJCC y-pathologic (yp) staging: c
Surgical resection performed AFTER neoadjuvant therapy and tumor

size/extension based on clinical evidence, unless the pathologic evidence
at surgery (AFTER neoadjuvant) is more extensive (see code 6).
6 Meets criteria for AJCC y-pathologic (yp) staging: yp
Surgical resection performed AFTER neoadjuvant therapy AND tumor

size/extension based on pathologic evidence, because pathologic
evidence at surgery is more extensive than clinical evidence before
treatment.
8 Meets criteria for autopsy (a) staging: a
Evidence from autopsy only (tumor was unsuspected or undiagnosed prior

to autopsy)
9 Unknown if surgical resection done c
Not assessed; cannot be assessed
Unknown if assessed
CS Lymph Nodes
 Note 1: Code only regional nodes and nodes, NOS, in this field. Distant nodes such as cervical (excluding
supraclavicular) or contralateral axillary are coded in the field Mets at DX.
 Note 2: If the pathology report indicates that nodes are positive but size of the metastases is not stated, assume
the metastases are greater than 0.2 mm and code the lymph nodes as positive in this field. Use code 600 in the
absence of other information about regional nodes.
 Note 3: In a physical exam if palpable nodes are not described as fixed, assume that nodes are movable.
 Note 4: Codes 130-600 are used for positive axillary nodes. Axillary lymph nodes refer to level I and level II
ipsilateral axillary lymph nodes and ipsilateral intramammary nodes only. It does not include ipsilateral level III
axillary lymph nodes which are also known as infraclavicular or apical nodes and are coded in 750 or higher.
Axillary does not include internal mammary or ipsilateral supraclavicular lymph nodes.
 Note 5: If no lymph nodes were removed for evaluation (Reg Nodes Eval code 0 or 1) or if it is unknown if lymph
nodes were removed (Reg Nodes Eval code 9), or if neoadjuvant therapy was given and clinical lymph node
involvement is AS extensive or MORE extensive than pathologic lymph node involvement (Reg Nodes Eval code
5), then use only the following codes for clinical evaluation of regional nodes: 000, 255, 260, 290, 510, 600, 740,
745, 750, 760, 780, 790,800, and 999. Do not use codes 290 and 510 when Reg Nodes Eval 2, 3, 6, or 8.
 Note 6: Isolated tumor cells (ITC) are defined as single tumor cells or small clusters not greater than 0.2 mm,
usually detected only by immunohistochemical (IHC) or molecular methods but which may be verified on H and E
stains. ITCs do not usually show evidence of malignant activity (e.g., proliferation or stromal reaction). Lymph
nodes with ITCs only are not considered positive lymph nodes. If the record only states N0(i+), code to 000 and
see CS SSF-4.
03/10/2010
 Note 7: Unless nodes are stated to be fixed or matted, assume that they are moveable.

Code Description
Map Map Map Map
None; no regional lymph node involvement, or
ITCs detected by immunohistochemistry or
000 ^ * NONE NONE
molecular methods ONLY. (See Note 6 and Site-
specific Factors 4 and 5.)
None; no regional lymph node(s) but with (ITCs)
050 N0(i+) N0(i+) NONE NONE
detected on routine H and E stains. (See Note 6)
Axillary lymph node(s), ipsilateral, micrometastasis
ONLY detected by immunohistochemical (IHC)
130 means ONLY (at least one micrometastasis N1mi N1mi RN RN
greater than 0.2 mm or more than 200 cells and all
micrometastases less than or equal to 2 mm)
Axillary lymph node(s), ipsilateral, micrometastasis
ONLY detected or verified on H&E (at least one
micrometastasis greater than 0.2 mm (or more
150 than 200 cells) and all micrometastases less than N1mi N1mi RN RN
or equal to 2 mm)
Micrometastasis, NOS
Movable axillary lymph node(s), ipsilateral, positive
250 with more than micrometastasis (i.e., at least one ^^ ** RN RN
metastasis greater than 2 mm) (See Note 7.)
Clinically movable axillary lymph node(s),
255 ipsilateral, positive (clinical assessment because of N1 N1 RN RN
neoadjuvant therapy or no pathology)(See Note 7.)
260 Stated as N1, NOS N1 ** RN RN
OBSOLETE DATA RETAINED V0200-
280 ERROR ** RN RN
Stated as N2, NOS
Clinically stated only as N2, NOS (clinical
290 assessment because of neoadjuvant therapy or no N2NOS ** RN RN
pathology)
Pathologically stated only as N2 NOS; no
300 ^^ ** RN RN
information on which nodes were involved
OBSOLETE DATA RETAINED V0200-
Fixed/matted ipsilateral axillary nodes, positive with
500 more than micrometastasis (i.e., at least one ERROR ** RN RN
metastasis greater than 2 mm)
Fixed/matted ipsilateral axillary nodes, NOS
Fixed/matted ipsilateral axillary nodes clinically
(clinical assessment because of neoadjuvant
510 therapy or no pathology) ^^ ** RN RN
Stated clinically as N2a, NOS (clinical assessment
because of neoadjuvant therapy or no pathology)
Fixed/matted ipsilateral axillary nodes clinically
520 with pathologic involvement of lymph nodes at ^^ ** RN RN
least one metastasis greater than 2mm
Axillary/regional lymph node(s), NOS
600 ^^ ** RN RN
Lymph nodes NOS
Internal mammary node(s), ipsilateral, positive on
sentinel nodes but not clinically apparent (no
710 N1b N1b RN RN
positive imaging or clinical exam)
WITHOUT axillary lymph node(s), ispilateral
03/10/2010

720 ^^ ** RN RN
positive imaging or clinical exam)
WITH axillary lymph node(s), ispilateral
730 positive imaging or clinical exam) N1b N1b RN RN
UNKNOWN if positive axillary lymph node(s),
ispilateral
Internal mammary node(s), ipsilateral, clinically
740 apparent (on imaging or clinical exam) N2b N2b RN RN
WITHOUT axillary lymph node(s), ispilateral
apparent (on imaging or clinical exam) and
745 N2b N2b RN RN
ispilateral
Infraclavicular lymph node(s)(subclavicular) (level
750 N3a N3a D RN
III axillary nodes) (apical), ispilateral
apparent (on imaging or clinical exam)
WITH axillary lymph node(s), ipsilateral, codes 150
760 N3b N3b RN RN
to 600
WITH or WITHOUT infraclavicular (level III axillary
nodes) (apical) lymph nodes
770 apparent (on imaging or clinical exam) ERROR N2b RN RN
ispilateral
780 ERROR N3a D RN
(750) + (770)
790 Stated as N3, NOS N3NOS N3NOS RN RN
800 Supraclavicular node(s), ispilateral N3c N3c D D
Unknown; not stated
999 Regional lymph node(s) cannot be assessed NX NX U U
 For code 000 ONLY, the N category is assigned based on the coding of Site-Specific Factors 4 and 5 using the
IHC MOL Table for this site.
 ^ For code 000 ONLY, the N category is assigned based on the coding of Site-Specific Factors 4 and 5 using the
IHC MOL Table for this site.
 ** For codes 250, 260, 280, 290, 300, 500, 510, 520, 600, and 720 ONLY, the N category is assigned based on
the values of Site-Specific Factor 3 (Number of Positive Ipsilateral Axillary Lymph Nodes) and CS Reg Nodes
Eval. If the Eval code is 2 (p), 3 (p), 6 (y), or 8 (a), the N category is determined by reference to the Lymph
Nodes Pathologic Evaluation Table. If the Eval code is 0 (c), 1(c), 5(c), or 9 (c), the N category is determined by
reference to the Lymph Nodes Clinical Evaluation Table. If the Eval field is not coded, the N category is
determined by reference to the Lymph Nodes Positive Axillary Node Table.
 ^^ For codes 250, 260, 280, 290, 300, 500, 510, 520, 600, and 720 ONLY, the N category is assigned based on
the values of Site-Specific Factor 3 (Number of Positive Ipsilateral Axillary Lymph Nodes) and CS Reg Nodes
Eval. If the Eval code is 2 (p), 3 (p), 6 (y), or 8 (a), the N category is determined by reference to the Lymph
Nodes Pathologic Evaluation Table. If the Eval code is 0 (c), 1(c), 5(c), or 9 (c), the N category is determined by
reference to the Lymph Nodes Clinical Evaluation Table. If the Eval field is not coded, the N category is
determined by reference to the Lymph Nodes Positive Axillary Node Table.
03/10/2010
CS Lymph Nodes Eval

 Note 1: 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.
 Note 2: In the 7th edition of the AJCC manual, the clinical and pathologic classification rules for the N category
were changed to reflect current medical practice. The N is designated as clinical or pathologic based on the
intent (workup versus treatment) matching with the assessment of the T classification. When the intent is workup,
the staging basis is clinical, and when the intent is treatment, the staging basis is pathologic.
A. Microscopic assessment including biopsy of regional nodes or sentinel nodes if being performed as part
of the workup to choose the treatment plan, is therefore part of the clinical staging. When it is part of the workup,
the T category is clinical, and there has not been a resection of the primary site adequate for pathologic T
classification (which would be part of the treatment).
B. Microscopic assessment of regional nodes if being performed as part of the treatment is therefore part of
the pathologic staging. When it is part of the treatment, the T category is pathologic, and there has been a
resection of the primary site adequate for pathologic T classification (all part of the treatment).
 Note 3: Microscopic assessment of the highest N category is always pathologic (code 3).
 Note 4: If lymph node dissection is not performed after neoadjuvant therapy, use code 0 or 1.
 Note 5: Only codes 5 and 6 are used if the node assessment is performed after neoadjuvant therapy.
Code Description Staging Basis

Does not meet criteria for AJCC pathologic staging:
0 No regional lymph nodes removed for examination. Evidence based on physical c

examination, imaging examination, or other non-invasive clinical evidence. No
autopsy evidence used.
Does not meet criteria for AJCC pathologic staging based on at least one of the
following criteria:
No regional lymph nodes removed for examination. Evidence based on endoscopic

examination, or other invasive techniques including surgical observation, without
1 c
biopsy. No autopsy evidence used.
OR
Fine needle aspiration, incisional core needle biopsy, or excisional biopsy of regional
lymph nodes or sentinel nodes as part of the diagnostic workup, WITHOUT removal
of the primary site adequate for pathologic T classification (treatment).
Meets criteria for AJCC pathologic staging:
2 p
No regional lymph nodes removed for examination, but evidence derived from
autopsy (tumor was suspected or diagnosed prior to autopsy).
Meets criteria for AJCC pathologic staging based on at least one of the following
criteria:
Any microscopic assessment of regional nodes (including FNA, incisional core

needle bx, excisional bx, sentinel node bx or node resection), WITH removal of the
3 p
primary site adequate for pathologic T classification (treatment) or biopsy
assessment of the highest T category.
OR
Any microscopic assessment of a regional node in the highest N category,
regardless of the T category information.
Does not meet criteria for AJCC y-pathologic (yp) staging:
5 Regional lymph nodes removed for examination AFTER neoadjuvant therapy AND c
lymph node evaluation based on clinical evidence, unless the pathologic evidence at
surgery (AFTER neoadjuvant) is more extensive (see code 6).
03/10/2010
Meets criteria for AJCC y-pathologic (yp) staging:
6 Regional lymph nodes removed for examination AFTER neoadjuvant therapy AND yp
lymph node evaluation based on pathologic evidence, because the pathologic
evidence at surgery is more extensive than clinical evidence before treatment.
Meets criteria for AJCC autopsy (a) staging:
8 a
Evidence from autopsy; tumor was unsuspected or undiagnosed prior to autopsy.
Unknown if lymph nodes removed for examination
9 c
Unknown if assessed
Reg LN Pos
 Note 1: Record this field even if there has been preoperative treatment.
 Note 2: Lymph nodes with only isolated tumor cells (ITCs) are NOT counted as positive lymph nodes. Only
lymph nodes with metastases greater than 0.2mm (micrometastases or larger) should be counted as positive. If
the pathology report indicates that nodes are positive but size of the metastases is not stated, assume the
metastases are > 0.2mm and code the lymph nodes as positive in this field.
 Note 3: Record all positive regional lymph nodes in this field. Record the number of positive ipsilateral regional
level I-II axillary nodes separately in the appropriate Site-Specific Factor field.
Code Description
00 All nodes examined negative.
01-89 1 - 89 nodes positive (code exact number of nodes positive)
90 90 or more nodes positive
95 Positive aspiration or core biopsy of lymph node(s)
97 Positive nodes - number unspecified
98 No nodes examined
Unknown if nodes are positive; not applicable
99
Reg LN Exam
Code Description
01-89 1 - 89 nodes examined (code exact number of regional lymph nodes examined)
90 90 or more nodes examined
95 No regional nodes removed, but aspiration or core biopsy of regional nodes performed
Regional lymph node removal documented as sampling and number of nodes
96
unknown/not stated
Regional lymph node removal documented as dissection and number of nodes
97
unknown/not stated
Regional lymph nodes surgically removed but number of lymph nodes unknown/not
98 stated and not documented as sampling or dissection; nodes examined, but number
unknown
Unknown if nodes were examined; not applicable or negative
99
03/10/2010
CS Mets at DX
 Note 1: Do not code involvement of supraclavicular (transverse cervical) lymph nodes in CS Mets at DX (see CS
Lymph Nodes).
 Note 2: Cases in which there are no distant metastasis as determined by clinical and/or radiographic methods
are designated cM0 (use code 00), and cases in which one or more distant metastases are identified by clinical
and/or radiographic methods are designated cM1. A case is classified as clinically free of metastases (cM0)
unless there is documented evidence of metastases by clinical means or by biopsy of a metastatic site
(pathologic).

Code Description
Map Map Map Map
00 No; none M0 M0 NONE NONE
No clinical or radiographic evidence of distant
metastasis, but deposits of molecularly or
microscopically detected tumor cells in circulating
05 M0(i+) M0 NONE NONE
blood, bone marrow or other non-regional nodal
tissue that are 0.2mm or less in a patient without
symptoms or signs of metastases.
Distant lymph node(s)
Cervical, NOS
Contralateral/bilateral axillary and/or internal
10 M1 M1 D D
mammary
Other than above
Distant lymph node(s), NOS
Distant metastases except distant lymph node(s)
40 (code 10) M1 M1 D D
Carcinomatosis
Further contiguous extension:
Skin over:
Axilla
42 M1 M1 D D
Contralateral (opposite) breast
Sternum
Upper abdomen
Metastasis:
Adrenal (suprarenal) gland
Bone, other than adjacent rib
Contralateral (opposite) breast - if stated as
44 metastatic M1 M1 D D
Lung
Ovary
Satellite nodule(s) in skin other than primary
breast
(10) + any of [(40 to 44)]
50 M1 M1 D D
Distant lymph node(s) plus other distant metastases
Distant metastasis, NOS
60 M1 M1 D D
Stated as M1, NOS
Unknown if distant metastasis
99 Distant metastasis cannot be assessed M0 MX U U
03/10/2010
CS Mets Eval
 Note: This item reflects the validity of the classification of the item CS Mets at DX only according to the
diagnostic methods employed.
Staging
Code Description
Basis
Does not meet criteria for AJCC pathologic staging of distant metastasis:
0 Evaluation of distant metastasis based on physical examination, imaging c

examination, and/or other non-invasive clinical evidence. No pathologic
examination of metastatic tissue performed or pathologic examination was
negative.
Does not meet criteria for AJCC pathologic staging of distant metastasis:
Evaluation of distant metastasis based on endoscopic examination or other

1 c
invasive technique, including surgical observation without biopsy. No
pathologic examination of metastatic tissue performed or pathologic
examination was negative.
Meets criteria for AJCC pathologic staging of distant metastasis:
2 No pathologic examination of metastatic specimen done prior to death, but p

positive metastatic evidence derived from autopsy (tumor was suspected
or diagnosed prior to autopsy).
Meets criteria for AJCC pathologic staging of distant metastasis:
Specimen from metastatic site microscopically positive WITHOUT pre-

surgical systemic treatment or radiation
3 p
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.
Does not meet criteria for AJCC y-pathologic (yp) staging of distant
metastasis:
5 c
Specimen from metastatic site microscopically positive WITH pre-surgical
systemic treatment or radiation, BUT metastasis based on clinical
evidence.
Meets criteria for AJCC y-pathologic (yp) staging of distant metastasis:
6 yp
systemic treatment or radiation, BUT metastasis based on pathologic
evidence.
Meets criteria for AJCC autopsy (a) staging of distant metastasis:
8 a
Evidence from autopsy based on examination of positive metastatic tissue
AND tumor was unsuspected or undiagnosed prior to autopsy.
9 Unknown if assessed c
03/10/2010
CS Site-Specific Factor 1
Estrogen Receptor Assay (ERA)
 Note 1:
A. In cases where ER and PR are reported on more than one tumor specimen, record the highest value (if
any sample is positive, record as positive).
B. If neoadjuvant therapy is given, record the assay from tumor specimens prior to neoadjuvant therapy.
C. If neoadjuvant therapy is given and there are no ER or PR results from pre-treatment specimens, report
the findings from post-treatment specimens.
 Note 2: In general, ER/PR is only done on one sample. In cases where it is done on more than one sample,
there is not necessarily any reason to think that the most accurate is the test done on the "largest" tumor
specimen. Clinically, treatment will be based on any positive test - in other words, given the benefit and minimal
toxicity of hormonal therapy, most patients will be given the "benefit of the doubt" and given hormonal therapy if
any ER test is positive.
 Note 3: The most recent interpretation guidelines for ER/PR do not allow for a borderline result. Therefore, code
030 will rarely be used. If 1% or greater cells stain positive, the test results are considered positive. If less than
1% stain positive, the results are considered negative.
 Note 4: If the patient is ER positive and node negative a multigene test such as OncotypeDX may be performed
in which case another ER/PR test will be done. Do not record the results of that test in this field. Record only
the results of the test which made the patient eligible to be given the multigene test.
Code Description
000 Test not done (test was not ordered and was not performed)
020 Negative/normal; within normal limits
030 Borderline; undetermined whether positive or negative
080 Ordered, but results not in chart
996 Ordered, results not interpretable
999 Unknown or no information
Progesterone Receptor Assay (PRA)
 Note 1:
A. In cases where ER and PR are reported on more than one tumor specimen, record the highest value (if
any sample is positive, record as positive).
B. If neoadjuvant therapy is given, record the assay from tumor specimens prior to neoadjuvant therapy.
C. If neoadjuvant therapy is given and there are no ER or PR results from pre-treatment specimens, report
the findings from post-treatment specimens.
 Note 2: In general, ER/PR is only done on one sample. In cases where it is done on more than one sample,
there is not necessarily any reason to think that the most accurate is the test done on the "largest" tumor
specimen.
 Note 3: The most recent interpretation guidelines for ER/PR do not allow for a borderline result. Therefore, code
030 will rarely be used. If 1% or greater cells stain positive, the test results are considered positive. If less tha
1% stain positive, the results are considered negative.
 Note 4: If the patient is ER positive and node negative a multigene test such as OncotypeDX may be performed
in which case another ER/PR test will be done. Do not record the results of that test in this field. Record only
the results of the test which made the patient eligible to be given the multigene test.
03/10/2010
Code Description
080 Ordered, but results not in chart
996 Ordered, results not interpretable
Number of Positive Ipsilateral Level I-II Axillary Lymph Nodes
 Note 1: Only include the number of positive ipsilateral level I and II axillary lymph nodes and intramammary
lymph nodes in this field beginning with CS version 2. Intramammary are not the same as internal mammary.
 Note 2: Record this field even if there has been preoperative treatment.
 Note 3: Lymph nodes with only isolated tumor cells (ITCs) are NOT counted as positive lymph nodes. Only
lymph nodes with metastases greater than 0.2 mm (micrometastases or larger) should be counted as positive. If
the pathology report indicates that nodes are positive but size of the metastases is not stated, assume the
metastases are greater than 0.2 mm and code the lymph nodes as positive in this field.
 Note 4: This field is based on pathologic information only. If no ipsilateral axillary nodes were removed for
examination, or if an ipsilateral axillary lymph node drainage area was removed but no lymph nodes were found,
code 098.
 Note 5: The general coding instructions in Part I for Regional Nodes Positive also apply to this field (although the
codes in Regional Nodes Positive are 2 digits rather than 3). When positive ipsilateral axillary lymph nodes are
coded in this field, the number of positive ipsilateral axillary lymph nodes must be less than or equal to the
number coded in Regional Nodes Positive (i.e., the number of positive ipsilateral axillary nodes will always be a
subset of the number of positive regional nodes.)
Code Description
000 All ipsilateral axillary nodes examined negative
095 Positive aspiration of lymph node(s)
098 No axillary nodes examined
099 Unknown if axillary nodes are positive; not applicable
03/10/2010
Immunohistochemistry (IHC) of Regional Lymph Nodes
 Note 1: Use codes 000-009 only to report results of IHC on otherwise histologically negative or that have only
ITCs on routine H and E stains., i.e., only when CS Lymph Nodes is coded 000. Otherwise code 987 in this field.
usually detected by immunohistochemical (IHC), H and E (see code 050 of CS Lymph Nodes), or molecular
methods (RT-PCR: Reverse Transcriptase Polymerase Chain Reaction) (see CS Site-Specific Factor 5). ITCs
do not usually show evidence of malignant activity (e.g., proliferation or stromal reaction.) If both IHC and H and
E report positive ITC findings, record as 002 or 009 depending on whether size of clusters was given.
 Note 3: If it is unstated whether or not tests were done for IHC assume they were not done.
 Note 4: If the record states N0(i+) and no other information, code to 009.
Code Description
000 Regional lymph nodes negative on routine H and E, no IHC studies or
Unknown if tested for ITCs by IHC studies
Nodes clinically negative, not examined pathologically
001 Regional lymph nodes negative on routine H and E, IHC studies done, negative for
tumor
002 Regional lymph nodes negative on routine H and E, IHC studies done, positive for ITCs
(tumor cell clusters not greater than 0.2mm)
009 Regional lymph nodes negative on routine H and E, positive for tumor detected by IHC,
size of tumor cell clusters or metastases not stated;
stated as N0(i+) with no further information
888 OBSOLETE DATA CONVERTED V0200
See code 987
Not applicable
CS Lymph Nodes not coded 000
987 Not applicable
Molecular Studies of Regional Lymph Nodes
 Note 1: Use codes 000-002 only to report results of molecular studies (RT-PCR: Reverse Transcriptase
Polymerase Chain Reaction) on otherwise histologically negative lymph nodes on routine H and E stains, i.e.,
only when CS Lymph Nodes is coded 000. Otherwise code 987 in this field.
detected by immunohistochemical (IHC) (see CS Site_Specific Factor 4) or by H and E (CS Lymph Nodes code
050) or molecular methods (RT-PCR: Reverse Transcriptase Polymerase Chain Reaction). ITCs do not usually
show evidence of malignant activity (e.g., proliferation or stromal reaction.)
 Note 3: If it is not stated whether molecular tests were done, assume they were not done.
Code Description
000 Regional lymph nodes negative on H and E, no RT-PCR molecular studies done or
unknown if RT-PCR studies done
Nodes clinically negative, not examined pathologically
001 Regional lymph nodes negative on H and E, RT-PCR molecular studies done, negative
for tumor
002 Regional lymph nodes negative on H and E, RT-PCR molecular studies done, positive
for tumor
03/10/2010

See code 987
Not applicable
987 Not applicable
Size of Tumor--Invasive Component
 Note 1: Record the code that indicates how the pathological tumor size was coded in CS Tumor Size.
 Note 2: For this field, "mixed" indicates a tumor with both invasive and in situ components. Such a "mixed"
tumor may be a single histology such as mixed infiltrating ductal and ductal carcinoma in situ or combined
histology such as mixed infiltrating ductal and lobular carcinoma in situ. "Pure" indicates a tumor that contains
only invasive or only in situ tumor.
 Note 3: This information is collected for analytic purposes and does not affect the stage grouping algorithm.
Different codes in this field may explain differences in outcome for patients in the same T category or stage
group.
Example:
Patient 1 has a "mixed" (see Note 2) tumor measuring 2.5 cm with extensive areas of in situ tumor, and the size
of the invasive component is not stated. This would be coded 025 in CS Tumor Size, and would be classified as
T2. It would be coded 040 in Site-Specific Factor 6.
Patient 2 has a purely invasive tumor measuring 2.5 cm. This would also be coded 025 in CS Tumor Size and
would also be classified as T2. However, it would be coded 000 in Site-Specific Factor 6.
Patient 1's tumor would probably have a better survival than Patient 2's tumor, since it would more likely be a T1
lesion if the true dimensions of the invasive component were known.
Code Description
000 Entire tumor reported as invasive (no in situ component reported)
010 Entire tumor reported as in situ (no invasive component reported)
020 Invasive and in situ components present, size of invasive component stated and coded
in CS Tumor Size
030 Invasive and in situ components present, size of entire tumor coded in CS Tumor Size
because size of invasive component not stated
AND in situ described as minimal (less than 25%)
AND in situ described as extensive (25% or more)
AND proportions of in situ and invasive not known
060 Invasive and in situ components present, unknown size of tumor (CS Tumor Size coded
999)
See code 987
Unknown if invasive and in situ components present, unknown if tumor size represents
mixed tumor or a "pure" tumor. (See Note 2.)
Clinical tumor size coded.
987 Unknown if invasive and in situ components present, unknown if tumor size represents
mixed tumor or a "pure" tumor. (See Note 2.)
Clinical tumor size coded.
03/10/2010
Nottingham or Bloom-Richardson (BR) Score/Grade
 Note 1: BR may also be called: modified Bloom-Richardson, Scarff-Bloom-Richardson, SBR grading, BR
grading, Elston-Ellis modification of Bloom Richardson score, the Nottingham modification of Bloom Richardson
score, Nottingham-Tenovus, or Nottingham grade.
 Note 2: Code the tumor grade using the following priority order: a). Bloom-Richardson scores 3-9; b). Bloom
Richardson grade (low, intermediate, high).
 Note 3: BR score may be expressed as a range, 3-9. The score is based on three morphologic features of
"invasive no-special-type" breast cancers (degree of tubule formation/histologic grade, mitotic activity, nuclear
pleomorphism/nuclear grade of tumor cells). If a report describes any of the factors with words (low,
intermediate, high) rather than numbers, do NOT attempt to translate these words into a score/number.
Code Description
030 Score of 3
040 Score of 4
050 Score of 5
060 Score of 6
070 Score of 7
080 Score of 8
090 Score of 9
110 Low Grade, BR grade 1, score not given
120 Medium Grade, BR grade 2, score not given
130 High Grade, BR grade 3, score not given
988 Not applicable:
Information not collected for this case
998 No histologic examination of primary site
999 Neither BR grade nor BR score given
Unknown or no information
HER2: IHC Test Lab Value
 Note 1: Record the results of only the ImmunoHistoChemical (IHC) test for Human Epidermal growth factor
Receptor 2 (HER2) in this field. The test determines whether there are additional copies of the HER2/neugene in
the tumor cells compared to the normal number.
 Note 2: If the test was done but the actual score is not stated, code 998.
Code Description
000 Score 0
001 Score 1+
002 Score 2+
003 Score 3+
988 Not applicable:
997 Test ordered, results not in chart
03/10/2010
HER2: IHC Test Interpretation
 Note 1: Record the results of only the ImmunoHistoChemical (IHC) test for Human Epidermal growth factor
Receptor 2 (HER2) in this field.
Code Description
988 Not applicable:
HER2: Fish Test Lab Value
 Note 1: Record the results of only the Fluorescence In Situ Hybridization (FISH) test for Human Epidermal
growth factor Receptor 2 (HER2) in this field. The test determines whether there are additional copies of the
HER2/neugene in the tumor cells compared to the normal number. The results are reported as a ratio between
the number of copies of the HER2/neugene and the control.
 Note 2: Record the actual ratio if given. Enter the stated ratio to two decimal places. Use a trailing zero if
needed. Example: a ratio of 1.8 is entered as 180. Ratio of 5.64 is entered as 564.
 Note 3: If the test was done but the actual ratio is not stated, code 998.
Code Description
100-986 Ratio of 1.00 to 9.86 (enter exact ratio to two decimal places)
987 Ratio of 9.87 or greater
988 Not applicable:
03/10/2010
HER2: FISH Test Interpretation
 Note: Record the interpretation of only the Fluorescence In Situ Hybridization (FISH) test for Human Epidermal
growth factor Receptor 2 (HER2) in this field.
Code Description
010 Positive/elevated; amplified
020 Negative/normal; within normal limits; not amplified
030 Borderline; equivocal; undetermined whether positive or negative
988 Not applicable:
HER2: CISH Test Lab Value
 Note 1: Record the results of only the Chromogenic In Situ Hybridization (CISH) test for Human Epidermal
growth factor Receptor 2 (HER2) in this field. The test determines whether there are additional copies of the
HER2/neugene in the tumor cells. The results are reported as the mean number of copies of the HER2/neugene
on either 30 or 60 tumor cells.
 Note 2: Record the actual mean if given. Enter the stated mean to two decimal places. Use a trailing zero if
needed. Example: a mean of 1.8 is entered as 180. A mean of 5.64 is entered as 564.
 Note 3: If the test was done but the actual mean is not stated, code 998.
Code Description
100-986 Mean of 1.00 to 9.86 (enter exact mean to two decimal places)
987 Mean of 9.87 or greater
988 Not applicable:
03/10/2010
HER2: CISH Test Interpretation
 Note: Record the interpretation of only the Chromogenic In Situ Hybridization (CISH) test for Human Epidermal
growth factor Receptor 2 (HER2) in this field.
Code Description
988 Not applicable:
HER2: Result of other or unknown test
 Note: If the Human Epidermal growth factor Receptor 2 (HER2) test wasn't a FISH test or IHC test OR it is
unknown which HER2 test was performed, record the results here.
Code Description
030 Borderline; equivocal; undetermined whether positive or negative
988 Not applicable:
03/10/2010
HER2: Summary Result of Testing
 Note 1: The summary of the results of the IHC, FISH, or other/unknown Human Epidermal growth factor
Receptor 2 (HER2) test is recorded here. This variable can be derived from the results of CS Site-Specific
Factors 9,11,13,14.
 Note 2: If both an IHC and a gene-amplification test (FISH, CISH, etc.) were given, record the result of the gene-
amplification test in this field. However, if the gene-amplification test was given first and the result was
borderline/equivocal and an IHC was done to clarify these equivocal results, take the result of the IHC.
Code Description
988 Not applicable:
Combinations of ER, PR, and HER2
 Note 1: There is an interest in triple negative breast cancer. This field could be derived from SSF 1, 2, and 15.
 Note 2: ER: the first digit is 0 for negative and 1 for positive for ER.
 Note 3: PR: the second digit is 0 for negative and 1 for positive for PR.
 Note 4: HER2: the third digit is 0 for negative and 1 for positive for HER2.
Code Description
000 ER Negative, PR Negative, HER2 Negative (Triple Negative)
001 ER Negative, PR Negative, HER2 Positive
010 ER Negative, PR Positive, HER2 Negative
011 ER Negative, PR Positive, HER2 Positive
100 ER Positive, PR Negative, HER2 Negative
101 ER Positive, PR Negative PR, HER2 Positive
110 ER Positive, PR Positive, HER2 Negative
111 ER Positive, PR Positive, HER2 Positive
988 Not applicable:
999 One or more tests were unknown if performed
One or more tests had unknown or borderline results
03/10/2010
Circulating Tumor Cells (CTC) and method of detection
 Note: The immunomagnetic separation test takes precedence over RT-PCR test.
Code Description
010 Positive, RT-PCR test
020 Positive, immunomagnetic separation (IMS) test
030 Positive, other test type
040 Positive, unknown test type
110 Negative/normal, RT-PCR test
120 Negative/normal, immunomagnetic separation (IMS) test
130 Negative/normal, other test type
140 Negative/normal, unknown test type
210 Borderline, undetermined if positive or negative, RT-PCR test
220 Borderline, undetermined if positive or negative, immunomagnetic separation (IMS) test
230 Borderline, undetermined if positive or negative, other test type
240 Borderline, undetermined if positive or negative, unknown test type
988 Not applicable:
Disseminated Tumor Cells (DTC) and method of detection
 Note: The immunohistochemical test takes precedence over RT-PCR test.
Code Description
010 Positive, RT-PCR test
020 Positive, immunohistochemical separation (IHC) test
030 Positive, other test type
040 Positive, unknown test type
110 Negative/normal, RT-PCR test
120 Negative/normal, immunohistochemical separation (IHC) test
130 Negative/normal, other test type
140 Negative/normal, unknown test type
210 Borderline, undetermined if positive or negative, RT-PCR test
220 Borderline, undetermined if positive or negative, immunohistochemical separation
(IHC) test
230 Borderline, undetermined if positive or negative, other test type
240 Borderline, undetermined if positive or negative, unknown test type
988 Not applicable:
03/10/2010
Assessment of Positive Ipsilateral Axillary Lymph Nodes
 Note: Includes ipsilateral level I and II axillary plus intramammary. Code the assessment used for the number of
positive axillary lymph nodes SSF3 (Number of positive axillary lymph nodes).
Code Description
000 No ipsilateral axillary lymph nodes were positive
010 Only clinical assessment showed positive nodes
020 Positive Fine Needle Aspiration (FNA) only
030 Positive Core biopsy: incisional
040 Positive Core biopsy: excisional
050 Positive Core biopsy: type not specified
100 Positive sentinel lymph node biopsy(ies) and no lymph node dissection
110 Positive sentinel lymph node biopsy(ies) and negative lymph node dissection
120 Positive sentinel lymph node biopsy(ies) and positive lymph node dissection
130 Negative sentinel node biopsy(ies) AND positive lymph node dissection
140 No sentinel node biopsy AND positive lymph node dissection
988 Not applicable:
998 Nodes positive, but method of assessment unknown
Assessment of Positive Distant Metastases
 Note 1: This Site-Specific Factor evaluates how the information regarding positive metastasis in CS metastasis
and CS metastasis to the bone, lung, liver, and brain were determined. If distant metastasis is coded as 00 - no
positive metastasis, this field must also be coded to 000.
 Note 2: Code to the highest code if multiple assessments. See part I for tests to be included.
Code Description
000 No positive metastases were identified
010 Clinical assessment
020 Radiography; Imaging (US, CT, MRI, PET)
030 Incisional biopsy; FNA
040 Excisional biopsy or resection with microscopic confirmation other than by biopsy
988 Not applicable:
03/10/2010
Response to Neoadjuvant Therapy
 Note: The registrar should look in the medical record for a specific statement as to the response to neoadjuvant
therapy. The registrar should not try to interpret or infer a response based on the medical record.
Code Description
010 Complete Response (CR)
020 Partial Response (PR)
030 No Response (NR)
988 Not applicable:
998 No neoadjuvant therapy
999 Unknown if response
Unknown or no information
Multigene Signature Method
Code Description
010 Oncotype DX
020 Mamma Print
030 Other
988 Not applicable:
Code the result/score of the multigene signature
Code Description
001-099 Actual score
100 100+
200 Low risk of recurrence (good prognosis)
205 High risk of recurrence (poor prognosis)
988 Not applicable:
03/10/2010
Paget Disease
 Note: Record any mention of Paget disease, whether clinical or pathological, giving priority to the pathologic
assessment. Interpret a negative exam of the nipple as Paget disease not present. Code unknown when no
examination of the nipple, clinical or pathologic, is available in the medical record.
Code Description
000 Paget disease absent
010 Paget disease present
988 Not applicable:

1 Patient Name - Breast Case 1
2 Primary Site C508 New cancer: >5 years following L breast cancer
3 Histology 8500
4 Behavior 3
5 Grade 2
6 Grade system type
7 Grade value
8 Lymph-vascular invasion 0
9 CS Mets at Dx - Bone 0
10 CS Mets at Dx - Lung 0
11 CS Mets at Dx - Liver 0
12 CS Mets at DX - Brain 0
13 CS Tumor Size 015
14 CS Extension 100
15 CS Tumor Size/Ext Eval 3
16 CS Lymph Nodes 00
17 CS Lymph Nodes Eval 3
18 Regional Nodes Positive 00
19 Regional Nodes Examined 06
20 CS Mets at Dx 00
21 CS Mets Eval 00
22 CS Site-Specific Factor 1 ERA 010 IHC +
23 CS Site-Specific Factor 2 PRA 020 IHC -
24 CS Site-Specific Factor 3 # AX LN 000
25 CS Site-Specific Factor 4 IHC - ITC 000 Node -, unknown if test done
26 CS Site-Specific Factor 5 RT – ITC 000 Node - , unknown if test done
27 CS Site-Specific Factor 6 Which TS 000 Conflicting info. Size of invasive comp stated as 015
28 CS Site-Specific Factor 7 SBR 060 3+2+1
29 CS Site-Specific Factor 8 IHC HER2 Result 998 Assume test not done
30 CS Site-Specific Factor 9 IHC HER2 Interp 998 Assume test not done
31 CS Site-Specific Factor 10 FISH HER2 Res 130
32 CS Site-Specific Factor 11 FISH HER2 Interp 020 Not amplified
33 CS Site-Specific Factor 12 CISH HER2 Res 998 Assume test not done
34 CS Site-Specific Factor 13 CISH HER2 Interp 998 Assume test not done
35 CS Site-Specific Factor 14 Other HER2 Interp 998
36 CS Site-Specific Factor 15 Summary HER2 020
37 CS Site-Specific Factor 16 Comb ER,PR,HER2 100 ER+,PR-,HER2-
38 CS Site-Specific Factor 17 CTCs 998 Assume test not done
39 CS Site-Specific Factor 18 DTCs 998 Assume test not done
40 CS Site-Specific Factor 19 Ax LN Assess 000 No ispilateral axillary nodes were positive
41 CS Site-Specific Factor 20 Dist Mets Assess 000
42 CS Site-Specific Factor 21 Neoadj Response 998
43 CS Site-Specific Factor 22 Multigene Method 010 OncogeneDx
44 CS Site-Specific Factor 23 Multigene Score 034 Score = 34%
45 CS Site-Specific Factor 24 Paget 000 No mention in pathology report
46 CS Site-Specific Factor 25 Not Applicable 988

Rational for specific data elements:

Passageways of Head and Neck
The Anatomy of Staging:

Head and Neck
Cancers
Presentation developed by
April Fritz, RHIT, CTR
A.Fritz and Associates, LLC
Reno, NV
april.fritz@nih.gov
18. TNM Staging: Head and Neck Cancers 1 Head and Neck CSv2 Coding 2
Head and Neck Issues Head and Neck Groups
• So many structures, so close together A. Lip and oral cavity (C00 – C05.0)
• So many names and synonyms B. Pharynx
• So many staging schemes • Oropharynx (C05.1, C05.2, C10)
• Nasopharynx (C11)
TNM Chapters 6 • Hypopharynx (C12.9, C13)
Summary Stage Sites 22 C. Larynx (C32)
Collaborative Staging v2 58 D. Thyroid (C73.9)
Others
• Determining the correct primary site is
VERY important! • Salivary glands (C07)
• In CS, site-specific factors are the same for • Paranasal sinuses (C31)
all head and neck sites. • Maxillary (C31.0)
• Ethmoid (C31.1)
• Nasal cavity and middle ear (C30)
Head and Neck CSv2 Coding 3 Head and Neck CSv2 Coding 4
Head and Neck Cancers CSv2 Coding 1

TNM Supplement Guidelines Head and Neck Cancer – CS Fields
• Tumor involving two sites Collaborative Stage Site-Specific Factors
• Classify to site in which greater part of tumor Fields (in general) 1. SSF1 Size of LN
is located • Tumor Size—standard 2. OBSOLETE
• Consider only invasive component if tumor as • Extension 3. SSF3 Levels I-III
associated carcinoma in situ • TS/Ext Eval—standard 4. SSF4 Levels IV-V,
• Extension • Lymph Nodes Retrophar
• Superficial • LN Eval—standard 5. SSF5 Levels VI-VII, Facial
 spread limited to mucosa • LN Pos—standard 6. SSF6 Other H&N nodes
 not sufficient for T4
• LN Exam—standard 7. Upper/Lower Cervical
• Deep Node Levels
 muscles, bones or other deep structures (vertical or • Mets at Dx
horizontal invasion) • Mets Eval—standard 8. Extracaps Exten Clinical
9. Extracaps Exten Path
10. HPV Status
11. Measured Thickness
(Depth)
What’s New in CSv2? Mucosal Melanomas
• New Schemas • TNM mapping very different

• Pharyngeal Tonsil • No T1 or T2 equivalent codes
• Mucosal Melanoma • Ext 105 Confined to mucosa = T3
 Lip and Oral Cavity • Further involvement
 Pharynx  500-600 range moderately advanced = T4a
 Nasal Cavity and Accessory Sinuses Examples: Deep soft tissues, skin of face, maxillary
 Larynx cartilage
• Schema Discriminator  800 range very advanced = T4b
 Nasopharynx Examples: Brain, dura, cranial nerves, encasing internal
 Pharyngeal Tonsil carotid artery
• New criteria for anaplastic carcinoma of • Depth of invasion collected in SSF
thyroid • Not used in TNM mapping
• Stage III and IV only
7 Head and Neck CSv2 Coding 7 Head and Neck CSv2 Coding 8

Head and Neck – Tumor Size Required Head and Neck – CS Extension
 Lip  Other Mouth  Nasal Cavity • General format
• Upper  Buccal Mucosa  Middle Ear • 000 In situ
• Lower  Salivary Glands  Sinus
• 100 Lamina propria/submucosa
• Other • Parotid • Maxillary
 Tongue • Submandibular • Ethmoid • 300 Localized, NOS
• Base • Other Salivary • Other * • 400-590 Adjacent structures (T3)
• Anterior  Pharynx  Larynx • 600-690 Mixed T3-T4 (site specific)
 Gum • Oropharynx • Glottic • 700-800 Adjacent structures (T4)
• Upper • Anterior Epiglottis • Supraglottic
• 950 No evidence of primary tumor
• Lower • Nasopharynx • Subglottic
• Other • Hypopharynx • Other
 Floor of Mouth • Other Pharynx *
 Palate
• Hard • Thyroid is NOT included
• Soft * no TNM staging
ABC requires Tumor Size for TNM
XYZ Tumor Size not a factor in TNM
CS TS/Ext Eval, CS Reg Nodes Eval, CS When to Code TS/Ext Eval

Mets Eval for Size versus Extension
• All standard tables • Accessible sites
• General structure • Code for size when
•0 clinical only  Tumor is localized and size determines the T category
•1 invasive techniques, no bx; or needle bx (T1 vs T2 vs T3)
 does not meet criteria for pathologic T or N • Code for extension when
•2 autopsy (known or suspected dx)  Tumor involves involves structures that map to T4
•3 pathology
 meets criteria for pathologic T, N or M
• Inaccessible sites
• 5 pre-op tx, clinical eval • Code for extension because size is not a factor
• 6 pre-op tx, path eval in TNM mapping
• 8 autopsy (dx not suspected)
• 9 unknown, not assessed

Head and Neck Regional Nodes Head and Neck Lymph Nodes
Overview Level I (* = not shown)
A Submental
B Submandibular (submaxillary)
1. Submental Level II
C Upper deep cervical (upper jugular)
2. Submandibular
B * Jugulodigastric (subdigastric)
3. Jugular (deep cervical) B Level III
A
4. Superficial cervical C D Middle deep cervical (mid-jugular)
5. Supraclavicular C Level IV
E Lower deep cervical (lower jugular)
6. Prelaryngeal* and F
D
H H * Jugulo-omohyoid (supraomohyoid)
paratracheal* Level V
E
7. Retropharyngeal F Posterior cervical
8. Parotid G E H G Posterior triangle
* Supraclavicular, NOS
9. Buccal G
Level VI
10. Retroauricular and H Pre/paralaryngeal and pre/paratracheal
occipital (anterior deep cervical)
J
Level VII
Adapted from: TNM Interactive (CD-ROM), J Upper mediastinal
Wiley-Liss
Lymph Node Levels Lymph Node Metastases at Diagnosis
• Pyriform sinus – 70%

I Submental and submandibular • Postcricoid area – 40%
II Upper jugular • Posterior hypopharynx – 50%
III Middle jugular
IV Lower jugular and • Nasopharynx – 75%
supraclavicular • Tonsil – 70%
V Superficial cervical (along • Base of tongue – 70%
spinal accessory nerve)
VI Anterior compartment • Soft palate – 30-65%
(prelaryngeal and • Pharyngeal wall – 30-65%
paratracheal) • Paranasal sinuses – 20%
VII Upper mediastinal
• Medullary ca of thyroid – 50%
VII
Image source: voice-center.com (The Voice Center, Norfolk, VA)

General Guidelines – N Head and Neck Lymph Nodes
CS Overview
• Lymph Node fields definitions the same for all
sites except nasopharynx and thyroid • Regional lymph node information coded in
• N category mapping by size of lymph node several fields
mass: < 3 cm; > 3 < 6 cm; > 6 cm • CS Lymph Nodes field
• N category mapping by number of lymph  nodes involved, their number and laterality
nodes involved • Site-Specific Factor 1
 size of involved lymph nodes
• SEER rule: if laterality of lymph nodes is
• Site-Specific Factors 3-6
not stated, assume they are ipsilateral  presence or absence of lymph node involvement in each
• "Fixed" and "matted" are considered of 7 different levels and other groups defined by AJCC.
involvement. • Site-Specific Factor 7
 presence of extracapsular extension
• "Enlarged," "palpable," "shotty,” • Site-specific Factors 8-9
“lymphadenopathy" are NOT considered  Extracapsular extension, clinical and pathologic
involvement.
Lymph Nodes—Specific Fields Head and Neck Lymph Nodes

CS Lymph Nodes—Notes
• CS LN: Which nodes, number and laterality
• SSF1: Size of involved node • Contains information about the nodes involved,
• SSF3: Levels I-III their general number and laterality
• SSF4: Levels IV-V • Code ranges vary by primary site
• SSF5: Levels VI-VII and face • Code any regional LN involvement in this field
• SSF6: Other LN groups • Major categories:
• SSF7: Upper and lower Single positive ipsilateral node involved
cervical node levels Multiple positive ipsilateral nodes
• SSF8: Extracapsular Bilateral or contralateral positive nodes
Positive regional nodes, NOS
extension clinical
• If laterality not specified, assume nodes are
• SSF9: Extracapsular
ipsilateral
extension pathologic
• Midline nodes grouped with ipsilateral nodes
Image source: AJCC Cancer Staging Manual, 6th edition

Head and Neck Lymph Nodes Head and Neck Lymph Nodes
CS Lymph Nodes – Example CS Lymph Nodes—N Categories
• Parotid Gland Example—Parotid Gland When to Code
000 None 000 N0 100-700 vs. 800
100-190 Single positive ipsilateral node involved 180 N1, no other information
200-290 Multiple positive ipsilateral nodes Codes 100 - 700
190 N2a, no other information • Nodes are definitely
300-320 Positive ipsilateral nodes, unk. if 1 or > 1 290 N2b, no other information regional
400-490 Bilateral or contralateral positive nodes 490 N2c, no other information
500-520 Regional nodes, NOS, unk. number and 600 N2, NOS Code 800
laterality • Can’t tell whether
700 N3, no other information regional or distant
800 Lymph nodes, NOS nodes
• Rarely used
Site-Specific Factor 1 Site-Specific Factors 3-6

Size of Involved Node—Notes
• Required by COC, SEER • Definitions of levels are the same for all
• Code size of NODE, not size of metastasis applicable head and neck sites.
• Code largest diameter measured clinically or
pathologically SSF 3 Levels I-III
• Code regional nodes only SSF 4 Levels IV and V and retropharyngeal
• Size format same as tumor size with extra choices nodes
• 996 Described as less than 6 cm SSF 5 Levels VI and VII and facial nodes
• 997 Described as more than 6 cm SSF 6 Other groups as defined by AJCC
Site-Specific Factor 2
Extracapsular Extension
• OBSOLETE—Data now collected in SSFs 8-9

Coding Site-Specific Factors 3-6 Coding SSF 3-6 Example
LRND: 2 positive parotid node (< 3 cm with extra-
SSF 3 Levels I-III ___ ___ ___ capsular exten.), 1 positive buccal (facial) node (2 cm),
I II III and 1 positive 2 cm submandibular node.
SSF 4 Levels IV-V, ___ ___ ___
SSF 3 Levels I-III _1_ _0_ _0_
retropharyngeal (RP) IV V RP
I II III
SSF 5 Levels VI-VII, ___ ___ ___
Facial (F) VI VII F SSF 4 Levels IV-V, _0_ _0_ _0_
Retropharyngeal (RP) IV V RP
SSF 6 Other groups ___ ___ ___
Parapharyngeal (PP), PP PA S SSF 5 Levels VI-VII, _0_ _0_ _1_
Parotid (PA), Suboccipital (S) Facial (F) VI VII F
SSF 6 Other groups _0_ _1_ _0_
• Default is 0, not involved. Parapharyngeal (PP), PP PA S
• If any level/chain is involved, code as 1, involved. Parotid (PA), Suboccipital (S)
Site-Specific Factor 7 Table I-2-3 Example

Upper/Lower Cervical Node Levels Lymph Nodes of the Head and Neck Showing
Level and Site-Specific Factor Positions
• Documents whether involved nodes are
Name Level SSF7 Code SSF3-6 Position
above or below level of cricoid cartilage
• Lower cervical nodes have worse prognosis
• If not obvious, refer to list in Part I, Section 2
of CS User Documentation -- --
• If unknown, use code 040 -- --
-- --
Level of cricoid cartilage

Note 1. Look for a statement of upper or lower cervical nodes or that the
involved nodes are above or below the lower border of the cricoid cartilage and
code appropriately. If no further information, use code 40 in SSF 4.
Head and Neck CSv2 Coding 27 Image source: CSv2 User Head and Neck CSv2 Coding 28
Documentation, Part I Section 2

Site-Specific Factors 8-9 Site-Specific Factor 8
Extracapsular Extension—Notes Extracapsular Extension Clinically
• Code extracapsular extension identified • Clinical information
clinically (SSF 8) and/or pathologically (SSF 9) • Physical exam may show
• Code regional nodes only  matted mass of nodes
• Code 000 if nodes are negative • Imaging studies may show
 amorphous spiculated margins on nodes
• Read carefully—codes differ  involvement of internodal fat
• If extracapsular extension not mentioned in  loss of normal oval to round shape
PE/Imaging (SSF 8) or path report (SSF 9), use code • Codes
010. • 000 No lymph nodes involved
• 010 Nodes involved, no extracapsular extension
• 020 Nodes involved, extracapsular extension
Pathologic Lymph Nodes • 030 Nodes involved, unk if extracapsular exten.
010 No extracapsular extension • 988 Not applicable: no node involvement
030 Macroscopic extracapsular • 997 Clin exam of nodes, unk results
extension pathologically • 998 No clin exam of nodes
• 999 Unknown; not documented; not assessed
Head and Neck CSv2 Coding 29 Image source: TNM Interactive (CD-ROM), Wiley-Liss Head and Neck CSv2 Coding 30
Site-Specific Factor 9 Coding SSF 1-9 Example

Extracapsular Extension Pathologic LRND: 2 positive parotid node (< 3 cm with extra-
• Required by COC, SEER capsular exten.), 1 positive buccal (facial) node (2 cm),
• Pathologic information and 1 positive 2 cm submandibular node.
• Priority: “macroscopic” over “microscopic” SSF 1 Size of node 993 Described as < 3 cm
 Macro or micro from final diagnosis
SSF 2 [obsolete]
 Macro from gross section
 Micro from microscopic section SSF 3 Levels I-III 100 Level 1 only
• Codes SSF 4 Levels IV-V, RP 000 All nodes neg
SSF 5 Levels VI-VII, F 001 Facial nodes only
• 000 No lymph nodes involved
SSF 6 Other groups 010 Parotid nodes only
• 010 Nodes involved, no extracapsular extension
SSF 7 Upper/Lower 010 All above cricoid cartilage
• 020 Nodes involved, microscopic extracap exten
SSF 8 Clin extracap ext 999 Unknown if clin involved
• 030 Nodes involved, macroscopic extracap exten
• 988 Not applicable: no node involvement SSF9 Path extracap ext 040 Extracap exten, unk if
• 997 Clin exam of nodes, unk results micro or macro
• 998 No clin exam of nodes Computer derived N: pN2b
• 999 Unknown; not documented; not assessed

Site-Specific Factor 10 Site-Specific Factor 10
HPV Status HPV Status
• Required by COC, SEER for some H&N sites • Codes
• 000 HPV test neg; not pos for any HPV types; Negative, NOS
• Human papilloma virus (HPV) infection may be • 010 LOW RISK pos (all pos type(s) low risk)
risk factor for oral and other mucosal cancers • 020 HIGH RISK pos, spec type(s) other than 16 or 18*
• Highest risk strains for cancer are types 16 and 18 • 030 HIGH RISK pos for HPV 16 WITHOUT pos results
for HPV 18 or pos of HPV 18 unknown* ^
• Code results from any tissue, not just primary • 040 HIGH RISK pos for HPV 18 WITHOUT pos results for
site HPV 16 or pos of HPV 16 unknown* ^
• 050 HIGH RISK pos for HPV 16 AND HPV 18 * ^
• Many codes—read carefully • 060 HIGH RISK positive, NOS, type(s) not specified
• 070 Positive, NOS, risk and type(s) not stated
• 988 Not applicable: Information not collected
• 997 Test ordered, results not in chart
• 998 Test not done (not ordered and not performed), including
no pathologic specimen available for HPV testing
• 999 Unknown or no information; Not documented
* WITH or WITHOUT positive results for low risk type(s)
^ WITH or WITHOUT positive results for other high-risk types
Site-Specific Factor 11 Related CS Fields for Head & Neck

Measured Thickness (Depth)
• Required by COC, SEER where listed in schema • CS Lymph Nodes
• CS Tumor Size • CS Reg Nodes Eval
• Not in all schemas • CS Extension • Reg LN Pos
• All H&N melanomas require thickness for T mapping • CS TS/Ext Eval • Reg LN Exam
• Measurement different from skin melanomas • SSF11 Measured • SSF1 Size of LN
• Codes thickness (depth) • SSF3 Levels I-III
• 000 No mass/tumor found • SSF4 Levels IV-V, Retrophar
• 001-979 Exact thickness in tenths of mm • CS Mets at Dx • SSF5 Levels VI-VII, Facial
• 980 98.0 millimeters or larger • Mets Eval • SSF6 Other H&N nodes
• 987 Not applicable: in situ carcinoma • SSF7 Upper/lower cervical LN
• 988 Not applicable: Information not collected • SSF10 HPV status • SSF8 Extracaps exten clin
• 990 Microinvasion; Microscopic focus or foci • SSF9 Extracaps exten path
only; no depth given
• 998 No surgical specimen
• 999 Not documented in patient record; Unknown

Anatomical References
for TNM Staging LIP AND
and Coding of ORAL CAVITY
Head and Neck
Cancers
18. TNM Staging: Head and Neck Cancers 37 18. TNM Staging: Head and Neck Cancers 38
Lip and Oral Cavity Lip and Oral Cavity

• Lip
• T category by size of primary • Assign to lip (C00._) if more than 50% of tumor is
• T1 < 2 cm located on vermillion surface.
• T2 > 2 and < 4 cm
• T3 > 4 cm • Oral Cavity
• T4 Direct invasion of other structures (bone, • Tumor that extends to oropharynx via mucosa is
muscle) classified only by size.
• T4a (lip) cortical bone, floor of mouth, skin of face
• T4b (oral cavity) adjacent structures: cortical bone, • Tongue
deep muscle of tongue, maxillary sinus, skin of face • Anterior 2/3 = mobile tongue
• T4b masticator space, pterygoid plates, skull base, • Base (root) of tongue in oropharynx
encasing internal carotid artery

Head and Neck – CS Extension Lip and Oral Cavity Structures
• Muscles of the tongue
• Used in shaping the mouth for speech, chewing
and swallowing
• Intrinsic musculature Hard palate
• Muscles within the tongue (no bony attachment) Gum
• Also called lingual
• Used to curl sides of tongue upward Tongue
• When mentioned as involved, code in Ext 200 range (T1-T3) Lips
(Ant. 2/3)
• NOT part of T4 category in TNM
Gum
• Extrinsic musculature
• Muscles anchoring the tongue in the mouth Floor of
• Attached to mandible, hyoid bone, styloid process of mouth
temporal bone, or palate
• When mentioned as involved, code in CS Extension 700-750
(T4) range (except sites: floor of mouth and submandibular
gland)
• When involved, map to T4 in TNM
Not shown: Cheek Mucosa, Retromolar Trigone
Structures of the Mouth CS Extension Codes – Lip

ORAL CAVITY OROPHARYNX
Lip
Gum/gingiva Soft palate 200 Musculature 750 Tongue

Hard palate 100 Skin of lip
Uvula
100 Labial mucosa
Tonsillar pillar 510 Gum
Commissure
775 Floor of mouth
of lips
Tonsil
535 Cortical bone
Retromolar
Posterior wall
trigone
of oropharynx
Not shown: 300 Localized, NOS
Tongue 500 Cheek mucosa
Not shown: 760 Skin of face/neck
Base of tongue 800 Further contiguous extension

CS Extension Codes – Gum/Gingiva CS Extension Codes – Mobile Tongue
Not shown: 100 Mucoperiosteum (stroma) Upper Gum Only
740 Nasal cavity

500 Lip, labial 200 Intrinsic muscles
650 Hard palate of tongue
mucosa
650 Soft palate
Lower Gum Only
535 Maxilla 600 Soft palate
500 Mucosa
of tongue (not shown) 500 Lower
500 Floor of gingiva 500 Base of tongue
mouth 500 Floor of
720 Deep muscles
535 Mandible of tongue mouth
750 Extrinsic muscles
535 Mandible of tongue
Not shown: 300 Localized, NOS
500 Buccal mucosa Not shown: 300 Localized, NOS
550 Subcutaneous soft tissue of face 400 Tumor crosses midline
600 Tonsils, lateral pharyngeal wall 800 Further contiguous extension
805 Skull
760 Skin of face
805 Further contiguous extension
CS Extension Codes – Floor of Mouth CS Extension Codes – Hard Palate

745 Nasal cavity
500 Mobile tongue 535 Palatine bone
100 Mucoperiosteum
500 Upper gum (stroma)
500 Soft palate
500 Lower 500 Base of tongue

gingiva
535 Mandible 620 Deep muscles
of tongue
530 Sublingual
gland 600 Epiglottis
530 Submaxillary 600 Vallecula Not shown: 300 Localized, NOS
gland and ducts Not shown: 300 Localized, NOS
400 Tumor crosses midline
500 Buccal mucosa
550 Subcutaneous soft tissue
535 Maxillary bone
760 Skin of undersurface of chin/neck
745 Maxillary sinus, sphenoid bone, pterygoid bone

Three Subsites of Pharynx
PHARYNX Nasopharynx
Oropharynx
Hypopharynx
Three Subsites of Pharynx from back Subsites of Oropharynx
• C01.9 Base of tongue

• C05.1 Soft palate
Nasal cavity
Nasopharynx • C05.2 Uvula
• C09.1 Tonsillar fossa
• C09.2 Tonsillar pillar
Oropharynx Base of tongue • C09.9 Tonsil, NOS
• C10.0 Vallecula
• C10.2 Lateral wall
Hypopharynx • C10.3 Posterior wall
• C10.9 Oropharynx, NOS
Postcricoid area
Esophagus

Structures of the Mouth Pharynx, NOS: Waldeyer’s ring
ORAL CAVITY OROPHARYNX
 Lymphoid tissue in nasopharynx and
Lip oropharynx
Gum/gingiva • No TNM staging for pharynx, NOS
Soft palate
• Lymphomas are coded with lymphoma schema
Hard palate
Uvula
Tonsillar pillar
Commissure
of lips Nasopharynx
Tonsil adenoids
Retromolar
Posterior wall Oropharynx
trigone
of oropharynx
Lingual tonsils
Tongue Palatine tonsils
Not shown:
Base of tongue
CS Extension Codes – Soft Palate CS Extension Codes – Tonsil and

and Uvula Other Oropharynx (1)
670 Nasal cavity
150 Confined to one:
700 Palatine bone
Anterior wall
650 Hard palate
500 Upper gum Lateral wall
740 Nasopharynx Posterior wall Tonsillar
pillar
200 Two or more subsites Tonsil
700 Mandible 720 Tongue
involved Posterior
300 Localized, NOS wall of
Not shown: oropharynx
300 Localized, NOS 730 Larynx
500 Buccal mucosa Definitions
600 Lateral pharyngeal wall Anterior wall Base of tongue and vallecula
700 Maxilla Lateral wall Tonsil, tonsillar fossa, tonsillar
710 Pterygoid muscle pillars and glossotonsillar sulci
740 Maxillary sinus
Posterior wall Mucosa at back of throat

CS Extension Codes – Tonsil and CS Extension Codes – Base of
Other Oropharynx (2) Tongue and Lingual Tonsil
500 Anterior 2/3

700 Hard palate of tongue
500 Upper gum 710 Nasopharynx, NOS
600 Soft palate
400 Soft palate, uvula
500 Floor 200 Intrinsic muscles
of mouth 500 Lower of tongue
500 Base of tongue gingiva
700 Mandible 700 Extrinsic muscles
500 Floor of 750 Extrinsic muscles
of tongue of tongue
mouth
708 Prevertebral
530 Sublingual
fascia/muscle
gland 640 Epiglottis
Not shown: 650 Larynx
710-720 Mandible 610 Vallecula
630 Pyriform sinus Not shown: 300 Localized, NOS
510 Any 150-500 with fixation 400 Tumor crosses midline
610 Soft tissue of neck 610 Lateral pharyngeal wall
800 Further contiguous extension 780 Skin
Nasopharynx Structures CS Extension Codes – Nasopharynx (1)

C11.0 Superior wall
C11.1 Posterior wall 105 Confined to one:
C11.2 Lateral wall Posterior superior wall
Lateral wall
C11.3 Anterior wall
Inferior wall
C11.8 Overlapping lesion of nasopharynx 200 Two or more subsites involved
C11.9 Nasopharynx, NOS 305 Localized, NOS
Superior wall Posterior wall
(roof)
(roof)
Lateral wall
Lateral wall Nasopharynx
Nasopharynx
Lateral wall
Lateral wall Superior surface
Superior surface of soft palate
of soft palate

CS Extension Codes – Nasopharynx (2) Hypopharynx Sites
• C12.9 Pyriform sinus
605 Skull 700 Brain; • C13.0 Postcricoid region
cranial nerves • C13.1 Hypopharyngeal aspect of
aryepiglottic fold
500 Nasal Cavity
Lateral wall • C13.4 Posterior wall
• C13.9 Hypopharynx, NOS
400 Soft palate Lateral wall
Superior surface
400 Oropharynx
of soft palate
710 Hypopharynx
Not shown:
585 Pterygopalatine fossa
565 Any 10-50 with fixation
620 Paranasal sinus
710 Infratemporal fossa; orbit
CS Extension Codes – Hypopharynx (1) CS Extension Codes – Hypopharynx (2)

100 Confined to one:
Postcricoid area
Pyriform sinus
Posterior 400 Oropharynx
pharyngeal wall
200 Two or more Hypopharyngeal
surface of
adjacent subsites aryepiglottic fold
involved (not fixed) Pyriform sinus Not shown:
300 Localized, NOS Posterior 420 100 with fixation
pharyngeal wall 450 Any 200, 300, or 400
640 Prevertebral
Hypopharynx Postcricoid area with fixation
fascia/muscle
550 Fixation of hemilarynx 500 Larynx
or larynx
620 Thyroid 560 Esophagus
Esophagus 650 Carotid artery
800 Further contiguous 600 Soft tissues
extension of neck

Subsites of Larynx
Supraglottis
LARYNX Epiglottis
False cords Pyriform sinus
Ventricle Glottis
Subglottis
True cords
Front of Larynx from behind Larynx – View from Above
Epiglottis
Thyrohyoid
membrane
Arytenoid cartilage
Thyroid cartilage Left Right

Vocal cords Vocal cords
abducted adducted
Trachea to breathe to speak

Structures of Glottis and Supraglottis CS Extension Codes – Glottic Larynx (1)
Supraglottic/Glottic
300 Epiglottis
Epiglottis
130 True vocal cords, NOS
Anterior 110 One cord
commissure 120 Both cords
True vocal cords 300 False vocal cords
False vocal cords

300 Aryepiglottic fold
Aryepiglottic
fold 300 Arytenoid
Arytenoid 300 Subglottis Not shown:

Posterior 350 Impaired vocal cord mobility
400 Limited to larynx with fixation
commissure 450 Localized, NOS
CS Extension Codes – Glottic Larynx (2) CS Extension Codes – Supraglottic

Larynx (1)
700 Oropharynx
100 Confined to one subsite (normal vocal cord mobility)
200 Involves more than one subsite in supraglottis
600 Base of tongue 230 Involves glottis, no fixation
Not shown: 390 Involves subglottis, no fixation
600 Vallecula
600 Pyriform sinus;
Not shown:
postcricoid
250 Impaired vocal cord mobility
680 Cricoid cartilage 600 Hypopharynx 400 Limited to larynx with fixation
800 Further 450 Localized, NOS
contiguous 600 Pre-epiglottic
extension tissues Epiglottis
710 Esophagus, False vocal cords

700 Thyroid cervical
700 Soft tissues of neck 700 Trachea

Aryepiglottic fold
Arytenoid

CS Extension Codes – Supraglottic CS Extension Codes – Subglottic
Larynx(2) Larynx
Not shown: 100 Subglottis (normal vocal cord mobility) (T1)
625 Code 60 with 700 Oropharynx
fixation 300 Involves adjacent region of larynx; no fixation (T2)
650 Postcricoid 660 Deep base 400 Limited to larynx with fixation (T3)
of tongue
690 Cricoid cartilage
450 Localized, NOS
800 Further 320 Vallecula
contiguous 600 Base of tongue; hypopharynx; postcricoid area;
extension pyriform sinus; vallecula (T4)
650 Hypopharynx
650 Pre-epiglottic tissues

680 Thyroid/cricoid cartilage; other tissues beyond (T4)
700 Oropharynx; cervical esophagus; soft tissues of
230 Glottis neck; strap muscles; thyroid gland; trachea; skin (T4)
700 Esophagus
700 Thyroid
800 Further contiguous extension (T4)
700 Soft tissues of neck 730 Trachea
Major Salivary Glands
Masseter muscle
SALIVARY GLANDS
Sublingual
gland
Parotid gland
Submaxillary gland

Salivary Gland Guidelines CS Extension Codes for Major
Salivary Glands
• MAJOR salivary glands
• Schemas for parotid, submandibular, 100 Confined to gland of origin
400 Other major salivary gland involved
salivary gland other 420 Skin overlying gland (p)
• Tumor Size more important than Extension Parotid gland

400 Masseter muscle (p)
• Lymph node scheme same as other head 700 Facial nerve (p)
and neck sites (p) Parotid only
750 Jugular vein (p)
(s) Submaxillary 750 Facial artery
only and vein(s)
• MINOR salivary gland 400 Stylohyoid muscle
• Code and stage minor salivary gland cancers 400 Digastric muscle
Not shown:
according to the site of origin 400 Mylohyoid muscle (s) 300 Localized, NOS
Submaxillary gland
• Example: adenoid cystic carcinoma of 450 Periosteum of mandible
500 Cortex of mandible
minor salivary gland in hard palate Not shown: 760 Base of skull
800 Further contiguous extension 405 Spinal accessory nerve
Code primary as C05.0 hard palate
• IfNeck
Head and no site
CSv2 of77origin is described, use C06.9
Coding Head and Neck CSv2 Coding 78
Paranasal Sinuses
Frontal sinuses
PARANASAL SINUSES
Ethmoid and
sphenoid
Ohngren’s sinuses
line
Maxillary
sinuses

Maxillary Sinus – Ohngren’s Line CS Extension Codes – Maxillary Sinus
 Divides maxillary sinus into 100 Confined to maxillary sinus
300 Localized, NOS
Infrastructure (anterior and inferior) (T2)  Ohngren’s line divides maxillary sinus into
• Hard palate; middle nasal meatus; nasal 400 Infrastructure (anterior and inferior)
cavity; palatine bone • Hard palate; middle nasal meatus; nasal cavity; palatine
bone
Suprastructure (superior and posterior) (T3) 600 Suprastructure (superior and posterior)
• Anterior ethmoid sinus; floor of orbit; posterior wall of
• Anterior ethmoid sinus; floor of orbit;
maxillary sinus
posterior wall of maxillary sinus 660 Ethmoid sinus; pterygoid sinus
680 Anterior orbit; frontal sinus; sphenoid sinus; eye
675 Base of skull
710 Soft palate
750 Brain; cranial nerves; dura; nasopharynx
Nasal Cavity and Ethmoid Sinuses Extension Codes – Nasal Cavity

C30.0 Ethmoid sinus
Nasal cavity subsites: right and 000 In situ; non-invasive (Tis)
left 100 Invasive tumor confined to site of origin
Meatus (superior, middle, inferior); Nasal
chonchae (superior, middle, inferior); Septum;
Tympanic membrane (T1)
300 Localized, NOS (T1)
400 Extending to adjacent connective tissue within
nasoethomoidal complex; Nasolacrimal duct (T2)
600 Adjacent organs/structures including: Bone of
skull; Choana; Frontal sinus; Hard palate;
Nasopharynx (T3)
650 Cribiform plate (T3)
660 Maxillary sinus (T3)
Nasal cavity subsites: septum, floor,
lateral wall, and vestibule

Extension Codes – Nasal Cavity Extension Codes – Ethmoid Sinuses
000 In situ; non-invasive; intraepithelial
670 Medial wall or floor of the orbit (T3) 120, 160 Confined to one ethmoid sinus (or NOS) without
700 Tumor invades: Anterior orbital contents; Skin of bone involvement (T1)
nose; Skin of cheek; 220, 260 Confined to one ethmoid sinus (or NOS) WITH
Minimal extension to: Anterior cranial fossa; bony invasion (involvement of perpendicular plate of
Pterygoid plates; Sphenoid or frontal sinuses ethmoid bone or ethmoid air cells) (T1)
(T4a) 300 Localized, NOS (T1)
760 Tumor invades: Orbital apex; Dura; Brain; Middle 320 Confined to both ethmoid sinuses without bone
cranial fossa; Cranial nerves (other than V2), involvement (T2)
nasopharynx, or clivus (T4b) 340 Confined to both ethmoid sinuses (or NOS) WITH
bony invasion (involvement of perpendicular plate of
ethmoid bone or ethmoid air cells) (T2)
400 Extension to nasal cavity with/without bony invasion
(involvement of perpendicular plate of ethmoid bone
or ethmoid air cells) (T2)
Floor; Lateral wall; Nasal vestibule; Septum; Turbinates
Extension Codes – Ethmoid Sinuses Middle Ear

620 Base of skull, NOS (T3) C30.1
630 Cribriform plate (T3) External ear Middle ear
640 Medial wall or floor of orbit; orbital plate (T3)
650 Maxillary sinus (T3)
660 Palate (T3)
700 Anterior orbital contents; Frontal sinus; Maxillary
nerve; Minimal extension to anterior cranial fossa;
Pterygoid plates; Skin of external nose or cheek;
Sphenoid sinus (T4a)
720 (660) + (700) (T4a)
760 Brain; Clivus; Cranial nerves other than the
maxillary nerve; Dura; Middle cranial fossa; Internal
Nasopharynx; Orbital apex or roof (T4b) ear
780 (660) + (760) (T4b)
800 Further contiguous extension (T4)

Thyroid Gland
THYROID GLAND
CS Extension - Thyroid (1) CS Extension - Thyroid (2)

000 In situ (CIS) 500 Parathyroid; Recurrent laryngeal or
100 Single invasive tumor confined to thyroid vagus nerve
T4a
200 Multiple foci confined to thyroid 520 Cricoid cartilage; esophagus; larnynx;
300 Localized, NOS SCM muscle
400 Into thyroid capsule but not beyond 550 Trachea
450 Minimal extrathyroid extension including 600 Thyroid cartilage; fixed to adjacent
strap muscles (T3) tissues
480 Pericapsular soft/ 620 Major blood vessels; carotid artery,
T4b
connective tissue (T3) jugular vein, thyroid artery/vein
700 Bone; skeletal muscle
800 Further contiguous extension;
mediastinal tissues; prevertebral fascia
Code 450
Minimal
extension
Head and Neck CSv2 Coding 91 Source: TNM-Interactive, UICC, 1998 Head and Neck CSv2 Coding 92

CS Extension Codes CS Lymph Nodes
550 Trachea • 000 No regional lymph node involvement

600 Thyroid cartilage 450 Strap muscle • 120 Level VI nodes
• 130 Cervical nodes, levels I – V; cervical, NOS
520 Sternocleido- 620 Carotid artery
mastoid muscle
• 150 Supraclavicular; Level VII nodes (superior
mediastinum)
620 Jugular
• 500 Regional nodes, NOS
vein • 800 Lymph nodes, NOS
• 999 Unknown; not stated
700
Bone 520 Esophagus
Source: Medi-clip: Grant’s Atlas Images 4, Head

and Neck. Williams and Wilkins, 1998.
Site-specific Factor 1
Solitary vs. Multifocal
• 000 None
• 001 Solitary tumor
• 002 Multifocal tumor
• 999 Insufficient
information; not Code 001
documented in
patient record
Code 002
Head and Neck CSv2 Coding 95
Source: TNM-Interactive, UICC, 1998

Head & Neck Case # 2
DISCHARGE SUMMARY
Date of Admission: 11/12/2010

Date of Discharge: 11/21/2010
Admission Diagnosis: Status Post Resection of Laryngeal Cancer.
Procedures Performed: Total laryngectomy, bilateral modified radical neck dissection, pectoralis
flap on 11/12/2010.
Indications: This is a 65-year-old female, who had been seen and evaluated with findings of a
laryngeal cancer that necessitated resection, as mentioned above.
Hospital Course: Ms. XX was admitted and observed in the ICU setting on postoperative day 1.
This was after undergoing the mentioned procedures above. For complete operative details,
please refer to a separately dictated note. . . .
Discharge Medications: 1. She is to go back on her previous medications. 2. Pain medicine to be

used as needed.
RADIOLOGY REPORT # 1
Date: 10/19/2010
CT Soft Tissue of the Neck w/o Contrast (including thorax)
Addendum: 10/22/2010 – these is soft tissue density thickening/mass density along the left of the
airway at the level of the epiglottis. There is asymmetry at the false vocal cords with some
prominence of the right false vocal cord.
Clinical History: Swelling in head and neck.
Procedure/Results: Noncontrast images were obtained of the neck and chest at the request of the
ordering physician. Technical note is made that lack of intravenous contrast makes visualization
of soft tissue structures in the neck difficult. The visualized paranasal sinuses are clear. The
salivary glands are normal in size and symmetric with no significant abnormalities, the vascular
structures in the neck show no obvious abnormalities with this noncontrast study. There are
several normal sized lymph nodes scattered in the neck bilaterally with no evidence of pathologic
enlargement. The thyroid gland is normal. The airway is patent with no obvious laryngeal mass
noted. Within the chest, the lungs demonstrate emphysematous change bilaterally, predominantly
in the apices. There is a calcified granuloma in the superior segment of the right lower lobe and a
second in the right lower lobe near the diaphragm. A 6 mm noncalcified nodule is noted in the
right middle lobe. Follow-up recommendations in this patient would include a CT in 12 months
if there is no increased risk for malignancy. If there is an increased risk, a CT in 6-12 and 18-24
months is recommended. The heart and mediastinum show no significant abnormalities.
Atherosclerotic calcification is noted at the aortic arch. In the upper abdomen, a single

hypodensity is noted in the medial segment of the left hepatic lobe which is too small to
characterize. No other significant findings are noted.
Impression: 1. Normal sized lymph nodes are identified involving the neck in this patient with a
history of swelling; 2. Noncalcified pulmonary nodule in the right middle lobe with follow-up
recommended as detailed above.
RADIOLOGY REPORT # 2
Date: 10/31/2010
PET CT of the Whole Body
Clinical History: 65 year-old female with squamous cell carcinoma.
After the administration of 16 mCi FDG, whole body attenuation corrected positron emission
tomography was obtained from the base of the skull to the proximal thighs (5 to 8 beds).
Coronal, sagittal, transaxial and MIP images were displayed. A noncontrast CT scan was
obtained for attenuation correction and anatomical localization purposes. PET CT fusion images
were also generated. Standard uptake values were obtained as needed. The glycemia at the time
of injection was 86mg/d1.
Findings: Whole body positron emission tomography demonstrates multiple areas of intense
increased uptake of FDG. These areas include the laryngeal region which demonstrates
heterogeneous uptake with SUV max as high as 7.5. This probably corresponds to patient’s
primary laryngeal carcinoma. This is also multiple bilateral hypermetabolic lymphadenopathy
affecting cervical chains bilaterally (deep and superficial as well as posterior triangle). The most
intense hypermetabolic lymphadenopathy is the right midcervical region with SUV max of 80.
No evidence of any hypermetabolic activity in the lungs. The small 0.6 cm nodule seen in right
middle lobe does not show any FDG metabolism. However, it is too small for the FDG PET
resolution. There was atherosclerosis seen in the aorta and major vessels. There is otherwise,
normal excretion of the kidneys and bladder.
Impression:
1. Hypermetabolic large laryngeal lesion that is compatible with patient’s primary laryngeal
cancer.
2. Hypermetabolic metastatic cervical lymphadenopathy bilaterally more pronounced on the

right side.
3. No evidence of distant metastatic disease.
OPERATIVE REPORT

Date: 11/12/2010
Preoperative Diagnosis: Laryngeal Cancer with Cervical Metastasis Bilaterally and Base of
Tongue Extension.
Procedures performed:
1. Total laryngectomy with right modified neck dissection and base of tongue resection.
2. Left modified neck dissection.
3. Pectoralis myofascial flap reconstruction.
Specimens: 1. Right neck contents. 2. Left neck contents. 3. Larynx.
Indications: This is a 65-year-old female who had been seen and evaluated for hoarseness x 3
months, upon evaluation with an initial scope and a panendoscopy with biopsies. This was
confirmed to be squamous cell carcinoma, invasive.
Procedure: Informed consent was obtained prior to the procedure. On the date of the surgery, the
patient was identified and brought to the operating room and placed on the table in supine
position. General endotracheal tube anesthesia as well as an A-line and a Foley was placed and
the table turned to 90 degrees to face the operating surgeon. A nasogastric feeding tube was then
placed, confirmed and secured at the membranous columella. The area of the neck bilaterally, as
well as the chest were prepped and draped in the usual fashion for the above-mentioned
procedures. . . . Attention was initially turned to the left side. On this side a modified neck
dissection was planned and at the end the internal jugular and the accessory muscles were
preserved. . . . Attention was then turned to the contralateral side. This was treated in a similar
manner up to the point where metastatic nodes were identified with significant extension into the
lateral skull base area. At this juncture it was necessary to suture ligate the external carotid
branch of the carotid artery as the mass was completely adherent. The mass was also adherent to
the hypoglossal nerve; however, this was carefully dissected off and saved. Dissection superiorly
was, therefore, continued carefully to the superior extent of the mass which was at the skull base.
Once all the structures mentioned on the contralateral side were preserved the mass was removed
en bloc. On this side the neck dissection resulted in sacrifice of internal jugular vein and
sternocleidomastoid muscle. Accessory nerve was preserved. Once this was done, attention was
turned to the total laryngectomy portion. Initial dissection was done by identifying the trachea
and dissecting the thyroid gland off of the anterior tracheal wall by dividing the isthmus. All
surrounding tissue was also removed. An incision was then made at the second ring and
dissected circumferentially, sparing the putty wall. . . . Attention was then turned to dissecting
the laryngeal structure off of the surrounding strap muscles. Once this was done the thyroid
cornu was identified and constrictor musculature was dissected off of the lateral attachments.
This was initially done on the left side and subsequently on the right. Once this was completed
the hyoid bone was skeletonized, working medially to laterally, and the larynx was entered
through the left side. This was done by making a small incision and, with complete visualization,
entering the piriform sinus wall, conserving as much mucosa as necessary and as possible with
no signs of involvement by the tumor. The larynx was therefore entered on the left side and
dissection carried out in inferiorly and around onto the right side. At the superior extent, the
tumor was easily visible and the tongue base could be palpated. The right tongue base was found
to be full with indications of potential tumor involvement. Dissection was therefore extended to
this point, after which the larynx was brought out en bloc. . . . At this point margins were taken at
the tongue base and these were found to be negative. Once this was completed and all frozen
sectioning back with negative results closure was begun by fashioning a pectoralis myocutaneous
myofascial flap from the right-hand side. . . . In brief, a small stomal inclusion incision was made
on the skin included within the apron incision and the inferior residual trachea was freed from
surrounding fascia and tunneled outward. The stoma was then secured with 4-0 chromic sutures.
The superior end of the stoma was left for closure with the incision. The pectoralis flap was then
used to provide closure, particularly on the right side where the carotid sheath had been
extensively dissected. This flap was tacked down with 3-0 Vicryls. Once this was completed
closure of all incisions was done over Hemovac drains. This was done in a layered manner using
Vicryl stitches. Overall skin was closed using staples. The remaining superior aspect of the
stoma was then closed using Vicryl. . . . The patient tolerated the procedure well.
PATHOLOGY REPORT # 1
Date: 10/24/2010
Clinical Diagnosis: Laryngeal Lesion.
Specimen: 1-2. Biopsies of Supraglottic Mass of the Larynx
Final Diagnosis: Invasive Poorly Differentiated Squamous Cell Carcinoma.
Gross: Received fresh are multiple fragments of rubbery, tan to pink tissue measuring 1 x 0.8 x
0.2 cm. Invasive squamous carcinoma. 2. Received in formalin are multiple fragments of
rubbery, lobulated, pink to dark brown tissue measuring 1 x 0.3 cm.
PATHOLOGY REPORT # 2
Date: 11/12/2010
Procedure:
1. Total laryngectomy with right modified neck dissection and base of tongue resection.
2. Left modified neck dissection. 3. Pectoralis myofascial flap reconstruction.
Clinical Diagnosis: Squamous Cell Carcinoma of the Larynx.
Specimen:
1. Left anterior lobe level V node.
2. High left jugular node.
3. Left modified neck dissection (stitch is high level II).
4. Right modified neck dissection - 2A, 2B, 3, 4, and 5 (short
superior, long lateral).
5. Left base of tongue.
6. Left mid tongue base.

7. Right tongue base.
8. Right mid tongue base.
9. Mid tongue base.
10. Total larynx and base of tongue.
11. Re-excision of base of tongue - suture on left.
12. Right lateral tongue.
Final Diagnosis:
1. Left anterior lobe level V node: one lymph node with metastatic squamous cell
carcinoma
2. High left jugular node: one lymph node with metastatic squamous cell carcinoma
3. Left modified neck dissection: metastatic squamous cell carcinoma to 5 (including

extranodal extension), of 12 lymph nodes (3 of 10 in the high level and 2 of 2 in the
lower portion)
4. Right Modified Neck Dissection: metastatic squamous cell carcinoma to 7 lymph nodes
(including extranodal invasion) of level II; 2 of 2 level III; 1 of 1 level IV; and 2
(including extranodal invasion) of 4 level V lymph nodes
5. Left base of tongue
6. Left mid base of tongue
7. Right tongue base
8. Right mid tongue base
9. Mid tongue base
10. Laryngectomy with base of tongue: deeply infiltrating poorly differentiated squamous
cell carcinoma of the epiglottis with no carcinoma identified in resection margins
11. Re-excision of base of tongue - suture on left
12. Right lateral tongue
P.S.: Specimens 1-4 and 10 positive for carcinoma; Specimens 5-9, 11 and 12 no cancer
seen.
Gross:
1. Received fresh, labeled left anterior lobe level V node, is a 0.7 x 0.5 x 0.3 cm lymph node.
Bisected and entirely submitted following frozen section.
2. Received in formalin, labeled high left jugular node, is a 0.6 x 0.3 x 0.3 cm rubbery, firm, tan
to pink lymph node. Bisected and entirely submitted.

3. Received in formalin, labeled left modified neck dissection without stitch at level 2, is an8.5 x
5.5 x 3 cm tissue with orientation, stitch is high at level 2. Specimen is divided in half. . . .
Lymph nodes are identified and entirely submitted . . .
4. Received in formalin is a right modified neck dissection labeled 2A, 2B, 3, 4, 5. The specimen
has orientation, short: suture superior, long suture lateral. Specimen includes some fatty tissue.
Part of the sternocleidomastoid. The jugular vein looks unremarkable. . . . Lymph nodes are
identified and entirely submitted . . .
5. Received fresh is a 1.9 x 0.6 x 0.6 cm rubbery, pink-tan piece of tissue.
6. Received fresh is a 1.2 x 0.6 x 0.6 cm piece of rubbery, pink to tan tissue.
7. Received fresh are two pieces of rubbery, lobulated, tan-pink tissue measuring together 1.5 x 1
x 0.4 cm.
8. Received fresh is a 1.8 x 0.4 x 0.3 cm piece of rubbery, tan to yellow tissue.
9. Received fresh are two fragments of rubbery, pink-tan tissue measuring together 1.5 x 1.5 x
0.5 cm.
10. Received in formalin is a 7 cm from proximal to distal, 6 cm from right to left, 5.2 cm from
anterior to posterior larynx. In the epiglottis there is a 2.2 x 2.5 cm ulcerated infiltrative lesion
that occupies and destroys almost the entire epiglottis. The tumor extends inferiorly into the
anterior commissure and the medial parts of the left and right true vocal cords. The lesion is at
3.5 cm from the distal margin (which contains tracheal cartilage). The tumor is widely separated
from the mucosal margins of the laryngeal portion of the specimen. The tumor on cut surface is
firm and light gray. The tumor invades superior to the thyroid cartilage 6 mm anteriorly, but is
clearly separated from anterior resection margins.
11. Received in formalin is a 6 cm in length x 1.5 x 0.7 cm fragment indicated as tongue. The
specimen has orientation with a short suture indicating the left side. Surgical margin is inked
black.
Microscopic:
10. The grossly described tumor which destroys the epiglottis is a poorly differentiated squamous
cell carcinoma. It infiltrates deeply. No tumor is identified in the resection margins (a right
superolateral section has fragmented margin on the slide; the tumor was clearly separated from
that connective tissue margin grossly). Thus no carcinoma is identified in the margins of the
specimen.


1 Patient Name -
2 Primary Site
3 Histology
4 Behavior
5 Grade
6 Grade system type
7 Grade system value
8 Lymph-vascular invasion
9 CS Mets at Dx - Bone
10 CS Mets at Dx - Lung
11 CS Mets at Dx - Liver
12 CS Mets at DX - Brain
13 CS Tumor Size
14 CS Extension
15 CS Tumor Size/Ext Eval
16 CS Lymph Nodes
17 CS Lymph Nodes Eval
18 Regional Nodes Positive
19 Regional Nodes Examined
20 CS Mets at Dx
21 CS Mets Eval

SUPRAGLOTTIC LARYNX SCHEMA CSv2 1
03/10/2010
CS Tumor Size
 Note 1: Code the specific tumor size as stated in the medical record. Use code 992, 994, or 995 if the
physician's statement about T value is the ONLY information available about the size of the tumor. (Refer to the
CS Extension table for instructions on coding extension.)
Code Description
000 No mass/tumor found
001-988 001 - 988 millimeters (code exact size in millimeters)
990 Microscopic focus or foci only, no size of focus given
991 Described as "less than 1 cm"
996 Described as "greater than 5cm"
999 Unknown; size not stated
CS Extension
 Note 1: Use code 450 for localized tumor ONLY if no information is available to assign codes 100 through 400.
 Note 2: Use code 685, 735, 810, or 815 if the physician's assignment of T category is the ONLY information
available about the extent of the tumor.

Map Map Map Map
000 In situ; noninvasive; intraepithelial Tis Tis IS IS
100 Invasive tumor with normal vocal cord mobility confined to: T1 T1 L L
Supraglottis (one subsite):
Aryepiglottic fold
Arytenoid cartilage
Corniculate cartilage
Cuneiform cartilage
Epilarynx, NOS
False cords
Ventricular bands
Ventricular cavity
Ventricular fold
Infrahyoid epiglottis
Laryngeal cartilage, NOS
Laryngeal (posterior) surface of epiglottis
Suprahyoid epiglottis (including tip, lingual {anterior} and
laryngeal surfaces)
Stated as T1 with no further information on extension
200 Tumor involves more than one subsite of supraglottis T2 T2 L L
as listed in code 100
WITHOUT fixation of larynx or NOS
230 Tumor involves glottis WITHOUT fixation of larynx or NOS T2 T2 L L
250 Involvement of any structures in supraglottic larynx (code 100) T2 T2 L L
and larynx with impaired vocal cord mobility
03/10/2010
300 OBSOLETE DATA RETAINED V0200 ERROR T2 L L

Tumor involves adjacent region(s) of larynx
320 Tumor involves regions outside supraglottis, including: T2 T2 RE RE
Mucosa of base of tongue
Vallecula
Medial wall of pyriform sinus
WITHOUT fixation of larynx or NOS
350 OBSOLETE DATA RETAINED V0200 T2 T2 L L
Impaired mobility split between codes 250 and 360, improved
mapping
Impaired vocal cord mobility
360 Involvement of any structures in code 320 with impaired vocal cord T2 T2 RE RE
mobility
375 Stated as T2 with no other information on extension T2 T2 L L
390 Involvement of subglottis WITHOUT vocal cord fixation T3 T3 L L
395 390 + 320 T3 T3 RE RE
(Subglottis + any structure in code 320 WITHOUT vocal cord
fixation)
400 Involvement of any structures in supraglottis (code 100), glottis, T3 T3 L L
and subglottis WITH vocal cord fixation
450 Localized, NOS T1 T1 L L
520 Paraglottic space WITHOUT vocal cord fixation T3 T3 RE RE
600 OBSOLETE DATA RETAINED V0200 ERROR T2 RE RE
Improved mapping, see code 320
Tumor involves region outside the supraglottis
WITHOUT fixation, including:
Medial wall pyriform sinus
Mucosa of base of tongue
Vallecula
620 OBSOLETE DATA RETAINED V0200 ERROR T3 RE RE
Code 600 WITH fixation
625 Involvement of any structures in codes 320 or 520 WITH vocal cord T3 T3 RE RE
fixation
650 Hypopharynx, NOS T3 T3 RE RE
Postcricoid area
Pre-epiglottic tissues
660 Deep base of tongue T3 T3 RE RE
670 OBSOLETE DATA CONVERTED V0200 ERROR ERROR ERROR ERROR
See code 690
Cricoid cartilage
680 Minor thyroid cartilage erosion (e.g., inner cortex) T3 T3 RE D
685 Stated as T3 with no other information on extension T3 T3 RE RE
690 Cricoid cartilage T4a T4a RE RE
695 690 + 680 T4a T4a RE D
(Cricoid cartilage + Minor thyroid cartilage erosion)
700 Extension to/through: T4a T4a D D
Esophagus
Oropharynx
Soft tissues of neck
Thyroid cartilage (except minor erosion, see code 680)
Thyroid gland
03/10/2010

Strap muscle(s)
Omohyoid
Sternohyoid
Sternothyroid
Thyrohyoid
Skin
Deep extrinsic muscle of tongue
Trachea
735 Stated as T4a with no other information on extension T4a T4a RE RE
800 Further contiguous extension, including: T4b T4b D D
Mediastinal structures
Prevertebral space
Carotid artery (encased)
810 Stated as T4b with no other information on extesnion ERROR T4b D D
815 Stated as T4 NOS with no other information on extension T4NOS T4NOS RE RE
950 No evidence of primary tumor T0 T0 U U
999 Unknown extension TX TX U U
Primary tumor cannot be assessed
CS Tumor Size/Ext Eval

Basis
No surgical resection done. Evaluation based on physical examination,
imaging examination, or other non-invasive clinical evidence. No autopsy
evidence used.
No surgical resection done. Evaluation based on endoscopic examination,
diagnostic biopsy, including fine needle aspiration biopsy, or other invasive
techniques, including surgical observation without biopsy. No autopsy
evidence used.
No surgical resection done, but evidence derived from autopsy (tumor was
suspected or diagnosed prior to autopsy)
3 Either criteria meets AJCC pathologic staging: p
Surgical resection performed WITHOUT pre-surgical systemic treatment or
radiation
OR surgical resection performed, unknown if pre-surgical systemic
treatment or radiation performed
AND Evaluation based on evidence acquired before treatment,
supplemented or modified by the additional evidence acquired during and
from surgery, particularly from pathologic examination of the resected
specimen.
No surgical resection done. Evaluation based on positive biopsy of highest
T classification.
03/10/2010

Surgical resection performed AFTER neoadjuvant therapy and tumor
size/extension based on clinical evidence, unless the pathologic evidence
at surgery (AFTER neoadjuvant) is more extensive (see code 6).
Surgical resection performed AFTER neoadjuvant therapy AND tumor
size/extension based on pathologic evidence, because pathologic
evidence at surgery is more extensive than clinical evidence before
treatment.
8 Meets criteria for autopsy (a) staging: a
Evidence from autopsy only (tumor was unsuspected or undiagnosed prior
to autopsy)
9 Unknown if surgical resection done c
Unknown if assessed
CS Lymph Nodes
 Note 1: For head and neck schemas, this field includes all lymph nodes defined as Levels I-VII and Other by
AJCC. The complete definitions are provided in the General Instructions.
 Note 2: For head and neck schemas, additional information about lymph nodes (size of involved nodes,
extracapsular extension, levels involved, and location of involved nodes above or below the lower border of the
cricoid cartilage) is coded in Site-Specific Factors 1, 3-9.
 Note 3: If laterality of lymph nodes is not specified, assume nodes are ipsilateral. Midline nodes are considered
ipsilateral.
 Note 4: For head and neck cancers, if lymph nodes are described only as "supraclavicular", try to determine if
they are in Level IV (deep to the sternocleidomastoid muscle, in the lower jugular chain) or Level V (in the
posterior triangle, inferior to the transverse cervical artery) and code appropriately. If the specific level cannot be
determined, consider them as Level V nodes.
 Note 5: The description of lymph nodes has been standardized across the head and neck schemas. All lymph
node levels and groups listed here are considered regional nodes for AJCC staging. Summary Stage 1977 and
Summary Stage 2000 divide these nodes into regional and distant groups.
 Note 6: Level III nodes have been moved from code 100 in CSV1 to code 110. Level IV nodes have been
added to code 120.

Map Map Map Map
000 None; no regional lymph node involvement N0 N0 NONE NONE
100 Single positive ipsilateral regional node: ^ * RN RN
Level II node- Upper jugular
Jugulodigastric (subdigastric)
Upper deep cervical
Level VI node –
Anterior compartment group
Laterotracheal
Paralaryngeal
Paratracheal - above suprasternal notch
Perithyroidal
Precricoid (Delphian)
Pretracheal - above suprasternal notch
Recurrent laryngeal
Cervical, NOS
Deep cervical, NOS
Internal jugular NOS:
Regional lymph node, NOS
03/10/2010
110 Single positive ipsilateral regional node: ^ * D RN

Level I
Level IA - Submental
Level IB - Submandibular (submaxillary), sublingual
Level III - Middle jugular
Middle deep cervical Retropharyngeal
120 Single positive ipsilateral regional node: ^ * D D
Level IV - Lower jugular
Jugulo-omohyoid (supraomohyoid)
Lower deep cervical
Virchow node
Level V node - Posterior triangle group
Level VA - Spinal accessory
Level VB - Transverse cervical, supraclavicular (see Note 4)
Level VII node - Superior mediastinal group
(for other mediastinal nodes see CS Mets at DX)
Esophageal groove
Paratracheal - below suprasternal notch
Pretracheal - below suprasternal notch
Other groups:
Facial:
Buccinator (buccal)
Mandibular
Nasolabial
Parotid:
Infraauricular
Intraparotid
Periparotid
Preparotid
Parapharyngeal
Retroauricular (mastoid) Suboccipital
180 Stated as N1, no other information N1 N1 RN RN
190 Stated as N2a, no other information N2a N2a RN RN
200 Multiple positive ipsilateral nodes listed in code 100 ^ * RN RN
210 Multiple positive ipsilateral nodes, any listed in code 110 ^ * D RN
(WITH or WITHOUT nodes listed in code 100)
220 Multiple positive ipsilateral nodes, any listed in code 120 ^ * D D
(WITH or WITHOUT nodes listed in code 100 or 110)
290 Stated as N2b, no other information N2b N2b RN RN
300 Regional lymph nodes listed in code 100: ^ * RN RN
Positive ipsilateral node(s), not stated if single or multiple
310 Regional lymph nodes listed in code 110: ^ * D RN
320 Regional lymph nodes listed in code 120: ^ * D D
400 Regional lymph nodes listed in code 100: ^ * RN RN
Positive bilateral or contralateral nodes
410 Regional lymph nodes, any listed in code 110: ^ * D RN
(WITH or WITHOUT nodes listed in code 100)
420 Regional lymph nodes, any listed in code 120: ^ * D D
(WITH or WITHOUT nodes listed in code 100 or 110
490 Stated as N2c, no other information N2c N2c RN RN
500 Regional lymph nodes as listed in code 100: ^ * RN RN
Positive node(s), not stated if ipsilateral, or bilateral, or contralateral,
AND not stated if single or multiple
03/10/2010
510 Regional lymph nodes, any listed in code 110: delete any ^ * D RN
520 Regional lymph nodes, any listed in code 120: delete any ^ * D D
600 Stated as N2NOS N2NOS N2NOS RN RN
700 Stated as N3, no other information N3 N3 RN RN
800 Lymph nodes, NOS, no other information ^ * RN RN
999 Unknown; not stated NX NX U U
Regional lymph nodes cannot be assessed
 ^ For codes 100-120, 200-220, 300-320, 400-420, 500-520, and 800 ONLY, the N category for AJCC 7th Edition
staging is assigned based on the value of Site-Specific Factor 1, Size of Lymph Nodes, using the extra table
Lymph Nodes Size Table, for this site.
 * For codes 100-120, 200-220, 300-320, 400-420, 500-520, and 800 ONLY, the N category for AJCC 6th Edition
staging is assigned based on the value of Site-Specific Factor 1, Size of Lymph Nodes, using the extra table
Lymph Nodes Size Table, for this site.
CS Lymph Nodes Eval

 Note 1: 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.
 Note 2: In the 7th edition of the AJCC manual, the clinical and pathologic classification rules for the N category
were changed to reflect current medical practice. The N is designated as clinical or pathologic based on the
intent (workup versus treatment) matching with the assessment of the T classification. When the intent is workup,
the staging basis is clinical, and when the intent is treatment, the staging basis is pathologic.
A. Microscopic assessment including biopsy of regional nodes or sentinel nodes if being performed as part
of the workup to choose the treatment plan, is therefore part of the clinical staging. When it is part of the workup,
the T category is clinical, and there has not been a resection of the primary site adequate for pathologic T
classification (which would be part of the treatment).
B. Microscopic assessment of regional nodes if being performed as part of the treatment is therefore part of
the pathologic staging. When it is part of the treatment, the T category is pathologic, and there has been a
resection of the primary site adequate for pathologic T classification (all part of the treatment).
 Note 3: Microscopic assessment of the highest N category is always pathologic (code 3).
 Note 4: If lymph node dissection is not performed after neoadjuvant therapy, use code 0 or 1.
 Note 5: Only codes 5 and 6 are used if the node assessment is performed after neoadjuvant therapy.

Basis
No regional lymph nodes removed for examination. Evidence based on
physical examination, imaging examination, or other non-invasive clinical
evidence. No autopsy evidence used.
1 Does not meet criteria for AJCC pathologic staging based on at least one c
of the following criteria:
No regional lymph nodes removed for examination. Evidence based on
endoscopic examination, or other invasive techniques including surgical
observation, without biopsy. No autopsy evidence used.
OR
Fine needle aspiration, incisional core needle biopsy, or excisional biopsy
of regional lymph nodes or sentinel nodes as part of the diagnostic workup,
WITHOUT removal of the primary site adequate for pathologic T
classification (treatment).
03/10/2010

No regional lymph nodes removed for examination, but evidence derived
from autopsy (tumor was suspected or diagnosed prior to autopsy).
3 Meets criteria for AJCC pathologic staging based on at least one of the p
following criteria:
Any microscopic assessment of regional nodes (including FNA, incisional
core needle bx, excisional bx, sentinel node bx or node resection), WITH
removal of the primary site adequate for pathologic T classification
(treatment) or biopsy assessment of the highest T category.
OR
Any microscopic assessment of a regional node in the highest N category,
regardless of the T category information.
Regional lymph nodes removed for examination AFTER neoadjuvant
therapy AND lymph node evaluation based on clinical evidence, unless the
pathologic evidence at surgery (AFTER neoadjuvant) is more extensive
(see code 6).
Regional lymph nodes removed for examination AFTER neoadjuvant
therapy AND lymph node evaluation based on pathologic evidence,
because the pathologic evidence at surgery is more extensive than clinical
evidence before treatment.
8 Meets criteria for AJCC autopsy (a) staging: a
Evidence from autopsy; tumor was unsuspected or undiagnosed prior to
autopsy.
9 Unknown if lymph nodes removed for examination c
Unknown if assessed
Reg LN Pos
 Note: Record this field even if there has been preoperative treatment.
Code Description
00 All nodes examined negative.
95 Positive aspiration or core biopsy of lymph node(s)
99 Unknown if nodes are positive; not applicable
03/10/2010
Reg LN Exam
Code Description
01-89 1 - 89 nodes examined (code exact number of regional lymph nodes examined)
90 90 or more nodes examined
95 No regional nodes removed, but aspiration or core biopsy of regional nodes performed
96 Regional lymph node removal documented as sampling and number of nodes
unknown/not stated
97 Regional lymph node removal documented as dissection and number of nodes
unknown/not stated
98 Regional lymph nodes surgically removed but number of lymph nodes unknown/not
stated and not documented as sampling or dissection; nodes examined, but number
unknown
99 Unknown if nodes were examined; not applicable or negative
CS Mets at DX
 Note: Supraclavicular and transverse cervical lymph nodes are coded in CS Lymph Nodes because they are
categorized as N rather than M in AJCC TNM.
Map Map Map Map
00 No; none M0 M0 NONE NONE
10 Distant lymph node(s) M1 M1 D D
Mediastinal
Distant lymph node(s), NOS
40 Distant metastases except distant lymph M1 M1 D D
node(s)(code 10)
Carcinomatosis
50 (10) + (40) M1 M1 D D
Distant lymph node(s) plus other distant metastases
60 Distant metastasis, NOS M1 M1 D D
Stated as M1, NOS
99 Unknown if distant metastasis M0 MX U U
Distant metastasis cannot be assessed
03/10/2010
CS Mets Eval
 Note: This item reflects the validity of the classification of the item CS Mets at DX only according to the
diagnostic methods employed.

Basis
0 Does not meet criteria for AJCC pathologic staging of distant metastasis: c
Evaluation of distant metastasis based on physical examination, imaging
examination, and/or other non-invasive clinical evidence. No pathologic
examination of metastatic tissue performed or pathologic examination was
negative.
1 Does not meet criteria for AJCC pathologic staging of distant metastasis: c
Evaluation of distant metastasis based on endoscopic examination or other
invasive technique, including surgical observation without biopsy. No
pathologic examination of metastatic tissue performed or pathologic
examination was negative.
2 Meets criteria for AJCC pathologic staging of distant metastasis: p
No pathologic examination of metastatic specimen done prior to death, but
positive metastatic evidence derived from autopsy (tumor was suspected
or diagnosed prior to autopsy).
3 Meets criteria for AJCC pathologic staging of distant metastasis: p
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.
5 Does not meet criteria for AJCC y-pathologic (yp) staging of distant c
metastasis:
systemic treatment or radiation, BUT metastasis based on clinical
evidence.
6 Meets criteria for AJCC y-pathologic (yp) staging of distant metastasis: yp
systemic treatment or radiation, BUT metastasis based on pathologic
evidence.
8 Meets criteria for AJCC autopsy (a) staging of distant metastasis: a
Evidence from autopsy based on examination of positive metastatic tissue
AND tumor was unsuspected or undiagnosed prior to autopsy.
9 Not assessed; cannot be assessed c
Unknown if assessed
03/10/2010
Size of Lymph Nodes
 Note: Code the largest diameter, whether measured clinically or pathologically, of any involved regional lymph
node(s). Do not code the size of any nodes coded in CS Mets at DX.
Code Description
000 No involved regional nodes
001-979 001-979 millimeters (code exact size in millimeters)
981-988 OBSOLETE DATA CONVERTED V0200
See code 980
981-988 millimeters
See code 980
989 millimeters or larger
990 Microscopic focus or foci only, no size of focus given
991 Described as "less than 1cm"
992 Described as "less than 2cm" or "greater than 1cm" or "between 1cm and 2cm"
997 Described as "more than 6cm"
999 Regional lymph node(s) involved, size not stated
Unknown if regional lymph node(s) involved
OBSOLETE - Extracapsular Extension, Lymph Nodes for Head and Neck
Levels I-III, Lymph Nodes for Head and Neck
 Note: Site-Specific Factors 3-6 are used to code the presence or absence of lymph node involvement in each of
7 different levels and other groups defined by AJCC. The definitions of the levels are the same for all applicable
head and neck sites. One digit is used to represent lymph nodes of a single level, with the three digits of Site-
Specific Factor 3 representing lymph nodes of, respectively, Levels I-III; the digits of Site-Specific Factor 4
representing lymph nodes of Levels IV and V and the retropharyngeal nodes; the digits of Site-Specific Factor 5
representing lymph nodes of Levels VI and VII and the facial nodes; and the digits of Site-Specific Factor 6
representing the remaining Other groups as defined by AJCC. In each digit, a code 1 means Yes, the nodes are
involved.
Code Description
000 No lymph node involvement in Levels I, II, or III
100 Level I lymph node(s) involved
010 Level II lymph node(s) involved
001 Level III lymph node(s) involved
110 Level I and II lymph nodes involved
101 Level I and III lymph nodes involved
011 Level II and III lymph nodes involved
03/10/2010
111 Level I, II and III lymph nodes involved

999 Unknown if regional lymph node(s) involved, not stated
Levels IV-V and Retropharyngeal Lymph Nodes for Head and Neck
involved.
Code Description
000 No lymph node involvement in Levels IV or V or retropharyngeal
100 Level IV lymph node(s) involved
010 Level V lymph node(s) involved
001 Retropharyngeal nodes involved
110 Level IV and V lymph nodes involved
101 Level IV and retropharyngeal nodes involved
011 Level V and retropharyngeal nodes involved
111 Level IV and V and retropharyngeal lymph nodes involved
Levels VI-VII and Facial Lymph Nodes for Head and Neck
 Note 1: Site-Specific Factors 3-6 are used to code the presence or absence of lymph node involvement in each
of 7 different levels and other groups defined by AJCC. The definitions of the levels are the same for all
applicable head and neck sites. One digit is used to represent lymph nodes of a single level, with the three digits
of Site-Specific Factor 3 representing lymph nodes of, respectively, Levels I-III; the digits of Site-Specific Factor 4
involved.
 Note 2: Facial nodes including buccinator, mandibular, and nasolabial lymph nodes.
Code Description
000 No lymph node involvement in Levels VI or VII or facial nodes
100 Level VI lymph node(s) involved
010 Level VII lymph node(s) involved
001 Facial lymph node(s) involved
110 Level VI and VII lymph nodes involved
101 Level VI and facial nodes involved
011 Level VII and facial nodes involved
03/10/2010
111 Level VI and VII and facial lymph nodes involved

Parapharyngeal, Parotid, and Suboccipital/Retroauricular Lymph Nodes, Lymph Nodes
for Head and Neck
involved.
Code Description
000 No involvement of any group:
Parapharyngeal lymph nodes
Parotid (preauricular, periparotid, and/or intraparotid) lymph nodes
Suboccipital/retroauricular lymph nodes
100 Parapharyngeal lymph node(s) involved
010 Parotid (preauricular, periparotid, and/or intraparotid) lymph node(s) involved
001 Suboccipital/retroauricular lymph node(s) involved
110 Involvement of two groups:
Suboccipital lymph nodes
111 Involvement of three groups:
03/10/2010
Upper and Lower Cervical Node Levels
 Note 1: AJCC requires that nodes be designated as involving upper or lower levels within the neck. The
boundary between upper and lower levels is the lower border of the cricoid cartilage.
 Note 2: Nodes in Levels I, II, and III are upper level nodes. Nodes in Level IV and VII are lower level nodes.
Level VA nodes are upper level nodes, and Level VB are lower level nodes. Level VI nodes span both upper and
lower levels. Nodes included in "Other groups" (Facial, Parotid, Parapharyngeal, Retropharyngeal,
Retroauricular, and Suboccipital) are all upper level nodes.
 Note 3: Code the location of nodal involvement in relation to the lower border of the cricoid cartilage of all
involved nodes, whether assessed clinically or pathologically, as stated by a physician.
 Note 4: If there is no physician statement of upper and/or lower level nodal involvement, assign levels I, II, III,
and VA nodes to upper level. Assign level IV, VB, and VII to lower level. If Level V (A and B not specified) and/or
Level VI nodes are involved with no further information about location, use code 040.
 Note 5: A description of "mid neck" requires clarification with the physician. Code 040, unknown level, if "mid
neck" is the only information available.
Code Description
000 No lymph nodes involved
010 Upper level lymph nodes involved (all involved nodes above the lower border of the
cricoid cartilage)
020 Lower level lymph nodes involved (all involved nodes below the lower border of the
cricoid cartilage)
030 Upper and lower level lymph nodes involved (all involved nodes both above and below
the lower border of the cricoid cartilage)
040 Unknown level lymph nodes involved (unable to determine if involved nodes above or
below the lower border of the cricoid cartilage)
988 Not applicable:
999 Unknown if regional lymph node(s) involved, not stated Not documented in patient
record
Extracapsular Extension Clinically, Lymph Nodes for Head and Neck
 Note 1: Code the status of extracapsular extension accessed clinically for any involved regional lymph node(s)
coded in the CS Lymph Nodes field. Do not code extracapsular extensio in any nodes coded in CS Mets at DX in
this field.
 Note 2: If nodes are involved clinically, and documentation of physical examination or imaging is available
without a statement of extracapsular extension, use code 010.
 Note 3: If the only documentation is a reference to clinically involved nodes with no reference to extracapsular
extension, use code 030.
 Note 4: If there is no information about clinical assessment of nodes, use code 999.
 Note 5: Clinical assessment can be by physical examination or imaging. According to AJCC, "ECS can be
diagnosed clinically by a matted mass of nodes adherent to overlying skin, adjacent soft tissue, or clinical
evidence of cranial nerve tissue. Radiologic signs of ECS include amorphous, spiculated margins of a metastatic
node and stranding of the perinodal soft tissue in previously untreated patients."
Code Description
000 No lymph nodes involved clinically
010 Nodes involved clinically, no extracapsular extension clinically
020 Nodes involved clinically, extracapsular extension clinically (nodes described as fixed or
matted)
03/10/2010
030 Nodes involved clinically, unknown if extracapsular extension

988 Not applicable:
997 Clinical examination of lymph nodes performed, unknown results
998 No clinical examination of lymph nodes
999 Unknown if regional lymph node(s) involved clinically, not stated Regional lymph nodes
cannot be accessed Not documented in patient record
Extracapsular Extension Pathologically, Lymph Nodes for Head and Neck
 Note 1: Code the status of extracapsular extension assessed pathologically of any involved regional lymph
node(s) coded in the CS Lymph Nodes field. Do not code extracapsular extension in any nodes coded in CS
Mets at DX in this field.
 Note 2: If nodes are involved pathologically but there is no statement of extranodal extension in the pathology
report, use code 010.
 Note 3: Code "microscopic" or "macroscropic" extranodal extension as stated in the final diagnosis. If not stated
in the final diagnosis, code "microscopic" if extranodal extension is described only in the microscopic section of
the pathology report and "macroscopic" if extranodal extension is described in the gross section of the pathology
report.
 Note 4: "Macroscopic" extension takes priority over "microscopic" extension.
 Note 5: Use code 040 if pathologic extracapsular extension is described with no further information and the
pathology report is not available for review.
 Note 6: Use code 050 if nodes involved pathologically with no further information about extracapsular extension.
Code Description
000 No lymph nodes involved pathologically
010 Nodes involved pathologically, no extracapsular extension pathologically
020 Nodes involved pathologically, MICROSCOPIC extracapsular extension pathologically
030 Nodes involved pathologically, MACROSCOPIC extracapsular extension pathologically
040 Nodes involved pathologically, extracapsular extension pathologically, unknown if
microscopic or macroscopic
050 Nodes involved pathologically, unknown if extracapsular extension
988 Not applicable:
997 Pathologic examination of lymph nodes performed, results not available
998 No pathologic examination of lymph nodes
999 Unknown if regional lymph node(s) involved pathologically, not stated
03/10/2010
HPV (Human Papilloma Virus) Status
 Note 1: There is evidence that human papilloma virus (HPV) plays a role in the pathogenesis of some cancers.
 Note 2: Record the results of any HPV testing performed on pathologic specimens from the primary tumor or a
metastatic site, including regional nodes. HPV testing may be performed for prognostic purposes; testing may
also be performed on metastatic sites to aid in the determination of the primary site.
 Note 3: The highest risk HPV types are types 16 and 18. Other high risk types are 31, 33, 35, 36, 45, 51, 52,
56, 58, 59, 68, 26, 53, 66, 67, 69, 70, 73, 82, 85 Low risk types are 6, 11, 32, 34, 40, 42, 44, 54, 61, 62, 64, 71,
72, 74, 81, 83, 84, 87, 89. The HPV vaccine is designed to protect against types 16 and 18 (associated with
cervical cancer) and types 6 and 11 (associated with genital warts).
 Note 4: High risk may be abbreviated "hrHPV" or "HR-HPV".
 Note 5: Some tests for HPV, such as a hybrid capture test, only report negative or positive for high risk HPV
without identifying types; use codes 025 and 050, respectively to report those test results.
Code Description
000 HPV test negative; not positive for any HPV types
Negative, NOS
010 LOW RISK positive (all positive type(s) are low risk)
020 HIGH RISK positive, specified type(s) other than types 16 or 18,
WITH or WITHOUT positive results for low risk type(s)
030 HIGH RISK positive for HPV 16 WITHOUT positive results for HPV 18 or positivity of
HPV 18 unknown,
WITH or WITHOUT positive results for other high-risk types,
040 HIGH RISK positive for HPV 18 WITHOUT positive results for HPV 16 or positivity of
HPV 16 unknown,
050 HIGH RISK positive for HPV 16 AND HPV 18,
060 HIGH RISK positive, NOS, type(s) not specified
070 Positive, NOS, risk and type(s) not stated
988 Not applicable:
998 Test not done (test was not ordered and was not performed), including no pathologic
specimen available for HPV testing
CSv2 WORKSHEET

1 Patient Name - Head Neck #2
2 Primary Site C321 Epiglottis (laryngeal surface) - Path 2
3 Histology 8070 Squamous cell carcinoma - Path 2
4 Behavior 3 Malignant
5 Grade 3 Poorly differentiated - Path 2
6 Grade system type Numeric grade system not used
7 Grade value Numeric grade system not used
8 Lymph-vascular invasion 9 Not documented - Path 2
9 CS Mets at Dx - Bone 0 No metastasis identified - PET
10 CS Mets at Dx - Lung 0 No metastasis identified
11 CS Mets at Dx - Liver 0 No metastasis identified
12 CS Mets at DX - Brain 0 No metastasis identified
13 CS Tumor Size 025 2.2x2.5 cm tumor - Path 2
14 CS Extension 660 Extension into base of tongue - Op, Path 2
15 CS Tumor Size/Ext Eval 3 Tumor resected
16 CS Lymph Nodes 420 Multiple positive bilateral nodes in code 120 - Path 2
17 CS Lymph Nodes Eval 3 Lymph node dissection
18 Regional Nodes Positive 19 19 nodes positive - Path 2
19 Regional Nodes Examined 28 28 nodes removed - Path 2
20 CS Mets at Dx 00 No indication of metastatic disease
21 CS Mets Eval 0 Clinical evaluation
22 CS SSF1, Size of Nodal Met 999 Size of largest node not stated - Op, Path 2
23 CS SSF2, OBSOLETE 988 Factor not applicable
24 CS SSF3, Node Levels I, II, III 011 Levels 2, 3 involved - Path 2
25 CS SSF4, Nodes IV,V, Other 110 Levels 4, 5 involved - Path 2
26 CS SSF5, Nodes VI, VII, Other 000 Levels not involved
27 CS SSF6, Node Levels Other 000 Levels not involved
28 CS SSF7, Upper/Lower Nodes 030 Upper and lower level nodes involved - Path 2
29 CS SSF8, Clinical Extracap Ext 010 Nodes involved clinically, extracap not stated - PET
30 CS SSF9, Pathologic Extracap Ext 040 Extracap extension path, unknown micro/macro - Path 2
31 CS SSF10, HPV Status 998 HPV status not reported, assume not done for exercise
32 CS Site-Specific Factor 11 988
CSv2 WORKSHEET
Rationale for specific data elements:
Example – #2, Determine on which side of epiglottis tumor arises

#16, code 4XX if any bilateral involvement of nodes
#29, Code extracapsular invasion not present if nodes clinically positive but
extracapsular invasion not mentioned
#30, Code extracapsular lymph node involvement

New TNM

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New TNM

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The TNM System

Why a New Edition? 7th Edition Goals

 Challenges to cancer staging  Improve clinical utility

What’s New in TNM7 3 What’s New in TNM7 4

What’s New in TNM 7? 1

New Look: Staging At-A-Glance Summary of Changes

What’s New in TNM7 7 What’s New in TNM7 8

What’s New in TNM 7? 2

Survival graph from

What’s New in TNM7 9 What’s New in TNM7 10

Chapter 1 Rules Changes

Revised and expanded  Tumor size rounding

What’s New in TNM7 11 What’s New in TNM7 12

What’s New in TNM 7? 3

What’s New in TNM7 13 What’s New in TNM7 14

Clinical Classification Rules Modified Pathologic Staging Rules Modified

What’s New in TNM7 15 What’s New in TNM7 16

What’s New in TNM 7? 4

 Also called intercurrent staging (‘y’  New terminology

 yc – Clinical staging after neoadjuvant  If grouping requires non-anatomic factor

What’s New in TNM7 17 What’s New in TNM7 18

Prognostic Factors Prognostic Factors – Examples

What’s New in TNM 7? 5

Few or Minor Modifications Major Modifications

 Head and Neck  Biliary  Esophagus

What’s New in TNM7 23 What’s New in TNM7 24

What’s New in TNM 7? 6

 Shift of C16.0, parts of C16.1 and C16.2 to  Esophago-gastric Junction

Esophagus – 7th Edition Esophagus – 7th Edition

What’s New in TNM 7? 7

T1 Lamina propria, submucosa  T

Colon-Rectum – 7th Edition Colon-Rectum – 7th Edition

T1 – T3 Unchanged N1 Metastasis in 1 to 3 regional lymph nodes

What’s New in TNM 7? 8

Changes from TNM 6 Changes from colon

What’s New in TNM7 33 What’s New in TNM7 34

Appendix – 7th Edition Carcinoids (NET) – 7th Edition

What’s New in TNM 7? 9

Lung – 7th Edition Lung – 7th Edition

What’s New in TNM 7? 10

Breast – 7th Edition Breast – 7th Edition

What’s New in TNM7 43 What’s New in TNM7 44

What’s New in TNM 7? 11

What’s New in TNM 7? 12

Summary The Details

 New chapters and revisions to existing  AJCC Cancer Staging Manual

What’s New in TNM7 51 What’s New in TNM7 52

What’s New in TNM 7? 13

 Dr. Leslie Sobin

What’s New in TNM 7? 14

How to Clinically  T Primary tumor and contiguous

Staging Basis General Rules for Staging

 Clinical (c)  Chapter 1 TNM Manual

Clinical TNM Staging 3 Clinical TNM Staging 4

How to Clinically TNM Stage a Case 1

1. MICROSCOPIC CONFIRMATION 2. TIMING

Clinical TNM Staging 5 Clinical TNM Staging 6

General Rules for Staging Posttherapy Classification

3. CASES WITH NEOADJUVANT TREATMENT  yTNM

Clinical TNM Staging 7 Clinical TNM Staging 8

How to Clinically TNM Stage a Case 2

4. PROGRESSION OF DISEASE 6. MISSING PROGNOSTIC FACTOR

Additional Chapter 1 Notes Additional Chapter 1 Notes