In the Know About Lymph Nodes Fields - PowerPoint Presentation

Slide1

In the Know About Lymph Nodes Fields

April Fritz, RHIT, CTRSlide2

Lymph Nodes Fields

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What We’ll Cover

What’s considered “involvement”

Regional vs. Distant

Reference materialsNodes Positive/ExaminedScope of Regional LN SurgerySite-Specific Lymph Nodes IssuesColon and rectumHead and NeckBreastLN Site-Specific FactorsSlide3

What’s in a Name?

Slide4

Lymph Nodes Fields

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Lymph Node Identification Issues

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7

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4

3

8

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Different names for nodes

Anatomic location vs. technical name

Technical name associated with blood

vessels

Examples

Lung

Location: perihilar, mediastinal

Technical: azygous, carinal, para-aortic

Surgical: lymph node stations

Breast

Location: intramammary, interpectoral

Technical: axillary, internal mammary,

infraclavicular

Surgical: Level I, Level IISlide5

Lymph Nodes Fields

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Lymph Node Identification Issues

Which nodes get coded where?

Reference: Summary Staging Manual 2000

List of lymph node synonyms: page 284Reference: Hematopoietic Manual Appendix CList of all lymph nodes with ICD-O-3 codes and AJCC/TNM lymph node regionReference: Cancer Registry CASEbookVolume II: Lymphatic System chapterSite-specific chapters

Reference: AJCC Cancer Staging Manual

REGIONAL if listed under Nodes in Anatomy section

Code as Scope

Reg

LN

Surg

DISTANT if NOT listed under Nodes in Anatomy

Code as

Surg Proc/Oth Site code 3Slide6

Lymph Node Involvement

Lymph Nodes Fields 6Slide7

Lymph Node Terminology for Carcinomas

InvolvementFixedMattedNot involvement without further MD comment*

Borderline lymphadenopathy

PalpableShottySignificantNo clear etiologyRubberyHardEnlargedVisible swelling* Comment Examples…suspicious for metastasesEnlarged, clearly involvedStatement of N1 or higherSlide8

Lymph Nodes Fields

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LN Involvement Terms – Exceptions

Mass

in … [with no further information]

HilumMediastinumRetroperitoneumMesenteryLungMass, enlargement, or adenopathy in hilum or mediastinum = involvementLymphoma, Kaposi sarcomaAny positive mention of nodes = involvement

“Lymphoma Man”Slide9

Regional Nodes Positive/ExaminedSlide10

Lymph Nodes Fields

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Regional Nodes Positive/Examined

General Rules

Pathologic information only

Record even if pre-operative treatmentCounts based on total number of regional nodes positive/removed Cumulative through all first course proceduresDo not count positive distant lymph nodesCode the exact number in range 01 to 89If 90 or more nodes, use code 90If carcinoma in situ, code as 00 or 98Priority of node countsFinal dx, synoptic report, microscopic, grossSlide11

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Reg Nodes Positive – Specific Rules

Total regional nodes examined by pathologist and found to be involved

Isolated tumor cells

Count as positive only for Merkel cell and cutaneous melanomaSlide12

Lymph Nodes Fields

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Reg Nodes Positive – Specific Rules

Special codes

95 Positive aspiration or core biopsy

Only procedure is FNA (cytology) or core biopsy (tissue)Positive FNA of single node and all resected nodes are negative97 Number unspecified Number positive is unknownAny combination of positive aspirated, biopsied, sampled or dissected nodes98 No nodes examinedIf no nodes removed

Clinical assessment of nodes only

No nodes found in dissection specimen

99 Unknown, not documented

Unknown whether nodes are positive

Brain, lymphoma,

heme-retic

, and some other sites

No documentation in the medical recordSlide13

Lymph Nodes Fields

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Reg Nodes Examined – Specific Rules

Count total regional nodes removed and examined by pathologist

Special codes

00 No nodes examinedIf no nodes examinedIf no nodes in specimen95 Aspiration or core biopsy If only procedure96 Lymph node biopsyIf number not known or not stated and procedure is stated as sampling or biopsy or other limited removal of nodes

97 Lymph node dissection

If number not known or not stated and procedure is stated as LN dissection or lymphadenectomy

Both sampling and dissection, but number unknown

98 00

Slide14

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Lymph Node Procedure Terms

Sampling (code 96)

Removal of a limited number of nodes

Includes lymph node biopsy, berry picking, sentinel lymph node procedure, sentinel node biopsy, selective dissectionDissection (code 97)Removal of most or all nodes in lymph node chain(s) that drain the area around the primary tumorIncludes lymphadenectomy, radical node dissection, lymph node strippingSlide15

Lymph Nodes Fields

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Reg Nodes Examined – Specific Rules

Special codes

, cont’d

98 Procedure not statedNumber not known and procedure not knownAny combination of aspirated, biopsied, sampled or dissected nodes99 UnknownUnknown whether nodes were examinedBrain, lymphoma, hematopoietic, and some other sitesIf no documentation in recordSlide16

Counting Reg LN Pos/Exam

Count involved and examined nodes

Add 1 to the number of regional lymph nodes positive and examined when

The core biopsy or aspiration is positive for metastases ANDThe lymph node dissection does not include the area where the core biopsy or aspiration was done ANDThat lymph node was a regional lymph node for primary siteExampleBreast cancer: axillary dissection 5/12 nodes positive; FNA of palpable supraclavicular node positive. Nodes Pos 06, Nodes Exam 13

Lymph Nodes Fields

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Counting Reg LN Pos/Exam

Count involved and examined nodes

Add 1 only to the number of regional lymph nodes examined when

The core biopsy or aspiration is negative for metastases ANDThat lymph node was a regional lymph node for the primary siteNOTE: Do not add 1 to regional LN positive because the biopsy/aspiration was negative for metastases.ExampleRight upper lobectomy. 3 of 6 hilar lymph nodes positive. Core biopsy of suspicious subcarinal (ipsilateral mediastinal) node negative. Nodes Pos 03, Nodes Exam 07.

Lymph Nodes Fields

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Counting Reg LN Pos/Exam

Do not add to the regional lymph nodes examined or positive when area biopsied/ aspirated is included in the dissection.

Example

Oropharynx carcinoma with swollen neck nodes. FNA of level 2R nodes positive. Pt has right radical neck dissection that finds 5 of 20 nodes positive. Nodes Pos 05, Nodes Neg 20.

Lymph Nodes Fields

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Scope of Regional Lymph Node SurgerySlide20

Lymph Nodes Fields

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Scope of Regional

LN Surgery

Mediastinoscopic

LN Biopsy

Removal, biopsy, aspiration of

Sentinel nodes

Regional nodes

May include procedures that

diagnose and/or stage tumor

Regional node procedures only

Cumulative through first course of treatment

Reflects current surgical practice

Removal of 1-3 nodes vs. 4 or more nodes

Used for historical comparisonsNOT intended to indicate clinical significanceCodes are hierarchical and cumulativeSlide21

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Types of Node Biopsies

FNA

Fine needle aspiration

Cells (cytology)Use code 95 if only FNACoreWider gauge needleTissue (pathology)Use code 95 if only coreIncisionalRemoves part of node

Count if in different chain

Excisional

Removes entire node

Count total 01-89Slide22

Scope Reg LN Coding Guidelines

Originally issued mid-year 2012

Included in FORDS and SEER Program Coding Manual

Use OP report as primary source documentDistinguishes between SLNB and ALNDSupplement with information from path reportEmphasis on correct coding of SLNB for breast and melanomaSlide23

Scope of Regional LN Surgery

0 None

No regional lymph node surgery

No lymph nodes found in the pathologic specimen Diagnosed at autopsy1 Biopsy or aspiration of regional lymph node, NOSBiopsy or aspiration of regional lymph node(s) only, regardless of the extent of involvement of diseaseReview OP report; if additional procedures, use codes 2–7Uncommon for breast cancer Slide24

Scope of Regional LN Surgery

2 Sentinel lymph node biopsy

Sentinel node(s) identified by injection of dye or radio label at site of primary tumor

Statement in OP report that SLNBx was performedSurgeon may take additional non-sentinel nodes in same procedure, or pathologist may find additional non-sentinel nodes in specimen. Use code 2. If OP report confirms ALND after SLNBx, code as 6.For breast, if > 5 nodes path examined, review OP report to confirm procedure was SLNBx only, not SLNBx with ALND.Slide25

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Sentinel Lymph Node BiopsySlide26

Scope of Regional LN Surgery

3 Number of regional nodes removed unknown

or not stated; regional LN removed, NOS

Sampling or dissection of regional lymph node(s) and number of nodes removed unknown/not stated Procedure is not specified as SLNBx in pathReview OP report to make sure not SLNBx only or SLNBx with reg LN dissection4 1–3 regional lymph nodes removed Sampling or dissection of regional LN(s) with fewer than four lymph nodes found in specimenProcedure is not specified as sSLNBx in pathCode 4 used infrequentlyReview OP report to make sure not SLNBx onlySlide27

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Scope of Regional LN Surgery

5 4 or more regional lymph nodes removed

Sampling or dissection of regional lymph nodes with at least four lymph nodes found in specimen

Procedure not specified as SLNBx in pathIf small number of LN removed, review OP report to confirm procedure not SLNBxIf large number LN removed, review OP report to confirm not SLNBx with reg

LN dissection in same or separate procedure and code accordingly

For breast ALND generally removes 7–9 nodes. Review OP report to confirm not

SLNBx

with ALND.

If failed mapping, review OP report for more extensive dissection of

reg

LN. Code as 2 if no further dissection or 6 if

reg

LN dissected during same surgSlide28

Scope of Regional LN Surgery

6 Sentinel node biopsy and code 3, 4, or 5 at

same time, or timing not stated

SLNBx and reg LN dissection in single surgical eventOR SLNBx and reg LN dissection both performed, but timing was not stated in record 7 Sentinel node biopsy and code 3, 4, or 5 at different timesIf relatively few LN examined, review OP report to confirm if SLNBx only For breast, SLNBx with ALND generally yield 7–9 LN but may yield fewer. If fewer, review OP report to confirm not just SLNBx

only

If both SLNB and LN dissection, use code 6 or 7Slide29

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Scope of Regional LN Surgery

9 Unknown or not applicable

Unknown whether regional lymph node surgery was performed

Death certificate-onlyUse for Central nervous system and intracranial gland primariesLymphomas with a lymph node primary siteUnknown or ill-defined primaryHematopoietic, reticuloendothelial, immunoproliferative, or myeloproliferative diseaseReview surgically treated cases to confirm codeSlide30

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Coding Treatment on Abstract

The bottom line…

Date

Surg Prim Site

Scope Reg LN

Other Reg/Dist

1/12/13

22 Lumpec

2 SLN

0

1/20/13

23 Re-Exc

5 ALND

7 SLN + ALND

0

Do not rely on registry software to aggregate separate surgeries into correct codeSlide31

Site-Specific Lymph Nodes IssuesSlide32

Colon Issues

Lymph Nodes Fields 32Slide33

Lymph Nodes Fields

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GI Tract – Clin Assessment of Reg LN

Required by COC, SEER, NPCR

Purpose

To handle the TNM mapping when multiple nodes are diagnosed on imaging or physical exam making the case N2 even though no regional lymph nodes are removed for pathologic examination. Use imaging and physical exam onlyDo not code from surgical observation or node biopsyDo not use path N classificationDo not apply inaccessible nodes ruleIf no diagnostic workup, use code 999Slide34

Vascular System and Lymph Nodes of Colon

Image source:

Mediclip

1998, Williams and Wilkins

All Segments (N1-N2)

by number of nodes

Colic

Epicolic

Mesocolic

Para/

pericolic

Rectal

Perirectal

Tumor deposits without regional node

mets

(N1c)Slide35

Regional nodes for each segment of colon

Cecum

Ascending

Hepatic flexure

Transverse

Splenic flexure

Descending

Sigmoid

Colorectal Regional Lymph Nodes

Regional nodes, NOS

including mesenteric, NOS Slide36

N1 Metastasis in 1 to 3 regional nodes

Source: UICC

TNM-interactive

, Wiley-

Liss

, 1998

N1b

N1a

N1a 1 regional node

N1b 2-3 regional nodes

N1c Tumor deposits in

subserosa, mesentery,

or nonperitonealized

pericolic or perirectal

tissues without regional

nodal metastasisSlide37

TNM Supplement Staging Guidelines

N1c (tumor deposits/peritumoral deposits/ satellite nodules)Discrete, discontinuous tumor foci found in pericolic or perirectal fat or adjacent mesentery (mesocolic fat) away from leading edge of tumor AND no involved regional lymph nodes

May represent discontinuous spread, venous invasion with extravascular spread or totally replaced lymph node

Tumor deposits do not affect T categoryNo size criterion for tumor depositsSlide38

N2 Metastasis in

≥

4 regional nodes

Source: UICC

TNM-interactive

, Wiley-

Liss

, 1998

N2a

N2b

N2a 4-6 regional nodes

N2b 7 or more regional

nodesSlide39

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“Mesenteric” Nodes

Inferior mesenteric lymph nodes

Regional for left colon and splenic flexure

Distant for right colon, hepatic flexure and transverse colonSuperior mesenteric lymph nodesDistant for all segments of colonCode in CS Mets at DxMesenteric, NOSNot along a major blood vesselIn mesentery of colon

Code as CS Lymph Nodes 300Slide40

Head and Neck IssuesLymph Nodes Fields

40Slide41

Head and Neck Regional Nodes

1. Submental

2. Submandibular

3. Jugular (deep cervical)

4. Superficial cervical

5. Supraclavicular

6. Prelaryngeal* and

paratracheal*

7. Retropharyngeal

8. Parotid

9. Buccal

10. Retroauricular and

occipitalSlide42

Head and Neck Lymph NodesOverview

Level I

(* = not shown)

A Submental

B Submandibular (submaxillary)

Level IIC Upper deep cervical (upper jugular)* Jugulodigastric (subdigastric)

Level III

D Middle deep cervical (mid-jugular)

Level IV

E Lower deep cervical (lower jugular)

* Jugulo-omohyoid (supraomohyoid)

Level V

F Posterior cervical

G Posterior triangle

* Supraclavicular, NOSLevel VIH Pre/paralaryngeal and pre/para- tracheal (anterior deep cervical)Level VIIJ Upper mediastinal

Adapted from: TNM Interactive (CD-ROM), Wiley-Liss

J

A

B

B

C

C

D

E

E

F

G

G

H

H

HSlide43

Lymph Node Metastases at Diagnosis

Pyriform sinus – 70%Postcricoid area – 40%Posterior hypopharynx – 50%Nasopharynx – 75%Tonsil – 70%

Base of tongue – 70%

Soft palate – 30-65%Pharyngeal wall – 30-65% Paranasal sinuses – 20%Medullary ca of thyroid – 50%Slide44

TNM General Guidelines – N

N definitions the same for all head and neck sites except nasopharynx and thyroidN category by number of lymph nodes involved AND size of lymph node mass:

< 3 cm; > 3 ≤ 6 cm; > 6 cm

Source: AJCC Cancer Staging Atlas (6

th

Ed), 2006

N1 Single ipsilateral

≤

3 cm

N2a Single ipsilateral >3-

≤

6 cm

N2b Multiple ipsilateral ≤ 6 cmN2c Bilat/ Contralat

≤ 6 cmN3 Any node > 6 cmSlide45

Head and Neck Lymph NodesSite-Specific Factors

SSF1: Size of involved node

SSF3: Levels I-III

SSF4: Levels IV-VSSF5: Levels VI-VII and faceSSF6: Other LN groupsSSF9: Extracapsular extension pathologic

Compton, C.C., Byrd, D.R., et al., Editors. AJCC Cancer Staging Atlas, 2nd Edition. New York: Springer, 2012. ©American Joint Committee on CancerSlide46

SSF1 – Size of Involved Node

Required by COC, SEER, NPCR (as available)

Code largest size of regional NODE (

clin or path), not size of metastasisSize format same as tumor size with extra codes996 Described as less than 6 cm997 Described as more than 6 cmSlide47

Site-Specific Factors 3 – 6

Required by COC, SEERDefinitions of levels are the same for all applicable head and neck sites.

SSF3 Levels I – III

SSF4 Levels IV and V and retropharyngeal nodesSSF5 Levels VI and VII and facial nodesSSF6 Other groups as defined by AJCC

Compton, C.C., Byrd, D.R., et al., Editors. AJCC Cancer Staging Atlas, 2nd Edition. New York: Springer, 2012. ©American Joint Committee on Cancer

RP*

*RP = retro-pharyngeal nodesSlide48

Coding Site-Specific Factors 3 – 6

SSF3 Levels I – III ___ ___ ___

I II III

SSF4 Levels IV - V, ___ ___ ___ retropharyngeal (RP) IV V RPSSF5 Levels VI – VII, ___ ___ ___ Facial (F) VI VII FSSF6 Other groups ___ ___ ___ Parapharyngeal (PP), PP PA S Parotid (PA), Suboccipital (S)

Default is 0, not involved.

If any level/chain is involved, code as 1, involved.Use 999 for Unk if reg LN involved, not stated Note from Part I Section 2 of the CS manual: “… if regional nodes are known to be positive but level(s) of nodes involved unknown, use code 000 in Site-Specific Factors 3-6."Slide49

Coding SSF 3 – 6 Example

LRND: 2 positive parotid node (< 3 cm with extra-capsular exten.), 1 positive buccal (facial) node (2 cm), and 1 positive 2 cm submandibular node.

SSF3 Levels I – III

_1_ _0_ _0_ I II IIISSF4 Levels IV – V, _0_ _0_ _0_ Retropharyngeal (RP) IV V RPSSF5 Levels VI – VII, _0_ _0_ _1_ Facial (F) VI VII F

SSF6 Other groups _0_

_1_ _0_ Parapharyngeal (PP), PP PA S Parotid (PA), Suboccipital (S)Slide50

SSF 9 Extracapsular Extension— Notes

Fixed and matted

imply extracapsular extension

Code extracapsular extension identified pathologically (SSF 9)Code regional nodes onlyCode 000 if nodes are negativeRead carefully—codes differIf extracapsular extension not mentioned in path report (SSF 9), use code 010.

Pathologic Lymph Nodes

010 No extracapsular extension

030 Macroscopic extracapsular

extension pathologically

Image source: TNM Interactive (CD-ROM), Wiley-LissSlide51

SSF9 Extracapsular Extension Pathologic

Required by COC, SEERPathologic informationPriority: “macroscopic” over “microscopic”

Macro or micro from final diagnosis

Macro from gross sectionMicro from microscopic sectionCodes 000 No lymph nodes involved 010 Nodes involved, no extracapsular extension 020 Nodes involved, microscopic extracap exten030 Nodes involved, macroscopic extracap exten 040 Nodes involved, extracap exten, unk micro/macro050 Nodes involved, unknown if extracap exten997 Clin exam of nodes, unk results998 No clin exam of nodesSlide52

Neck Dissections

Name of Procedure Nodal Levels Structures* Additional

Dissected Preserved Comments

* Specific non-lymphatic structures are the spinal accessory (11th cranial) nerve (SAN), internal jugular vein (IJV), and sternocleidomastoid muscle (SCM)Radical neck I–V plus LN None Standard basic cervical dissection (ND) around tail of lymphadenectomy parotid procedureModified radical ND I–V 1 or more • Type 1 I–V SAN • Type 2 I–V SAN, SCM

• Type 3 I–V All

Comprehensive ND I–V Varies Nonstandard term referring to any dissection removing node levels I-V Slide53

Neck Dissections

Name of Procedure Nodal Levels Structures* Additional

Dissected Preserved Comments

Selective neck Varies All General term for dissections removal of certain LN groups and preservation of others • Supraomohyoid ND I–III (selective), All sometimes IV • Lateral (jugular) ND II–IV

• Anterolateral ND I–IV All

• Anterior Compart- VI (selective) All Usually bilateral, ment ND may be unilateral • Posterolateral ND II–V plus All Used for cutaneous suboccipital and scalp malignancies postauricularSlide54

Breast Issues

What We Didn’t Know…Slide55

Regional Lymph Nodes - Breast

Pectoralis minor muscle

Source: UICC

TNM-interactive

, Wiley-Liss, 1998

Other Names for Regional

Lymph Nodes

Labels 1i, 1ii, 1iii

Level I Intramammary,

Nodule(s) in

axillary fat

Level II Rotter’s nodes,

Interpectoral

Level III Infraclavicular,

subclavicularLabel 2 Internal mammary

(parasternal)Slide56

Axillary* nodes N1 Movable axillary

N2a Fixed, matted axillaryN2b Clinically detected IM** without axillary mets

N3a Infraclavicular nodes

N3b IM and axillary node metsN3c Supraclavicular nodes * Level I, II, intramammary only** Internal mammary nodesRegional Lymph Nodes – ClinicalSlide57

Axillary* nodes pN1mi Micromets

(larger than ITCs)pN1a 1-3 axillary nodes with at least 1 met > 2 mmpN1b IM** detected by SLNB*** onlypN1c 1-3 axillary nodes + IM detected by SLNB

pN2a 4-9 axillary nodes

pN2b Clinically detected IM without axillary metspN3a 10+ axillary nodes or infraclavicular nodes pN3b Clinically detected IM + axillary node mets ≥ 3 axillary + IM detected by SLNBpN3c Supraclavicular nodes * Level I, II, intramammary only; ** Internal mammary nodes; *** Sentinel Lymph Node BiopsyRegional Lymph Nodes – PathologicSlide58

Internal Mammary Nodes Definitions

Lymphoscintigraphy

Mapping of sentinel lymph nodes using radioisotopes

to identify nodes for removal by sentinel node biopsy

Not clinically apparent

Positive only on sentinel node biopsy Clinically apparent Includes

Imaging (CT, CXR,

etc

) but not lymphoscintigraphy

Physical exam (palpable)

Grossly visible pathologically

Positive cytology on FNA

Regional Lymph Nodes – LocationSlide59

Breast Lymph Nodes

cN1. Ipsilateral movable nodes

pN1a. 1 to 3 axillary nodes

Adapted from: TNM Atlas, 3rd ed. 2nd rev., by B. Spiessl et al. Springer Verlag 1992.Slide60

Breast Lymph Nodes

Adapted from: TNM Atlas, 3rd ed. 2nd rev., by B. Spiessl et al. Springer Verlag 1992.

pN1b. Microscopic involvement

of internal mammary nodesSlide61

Breast Lymph Nodes

Adapted from: TNM Atlas, 3rd ed. 2nd rev., by B. Spiessl et al. Springer Verlag 1992.

pN1c. 1-3 axillary nodes and micro

involvement of int. mam. nodesSlide62

Breast Lymph Nodes

N2a. Ipsilateral fixed axillary nodes

pN2a. 4 to 9 axillary nodes (tumor >2 mm)

Adapted from: TNM Atlas, 3rd ed. 2nd rev., by B. Spiessl et al. Springer Verlag 1992.Slide63

Breast Lymph Nodes

Adapted from: TNM Atlas, 3rd ed. 2nd rev., by B. Spiessl et al. Springer Verlag 1992.

c/p N2b. Clinically apparent

internal mammary nodesSlide64

Breast Lymph Nodes

c/p N3a. Infraclavicular nodes

Adapted from: TNM Atlas, 3rd ed. 2nd rev., by B. Spiessl et al. Springer Verlag 1992.

with/without axillary nodesSlide65

Breast Lymph Nodes

Adapted from: TNM Atlas, 3rd ed. 2nd rev., by B. Spiessl et al. Springer Verlag 1992.

c/p N3b. Int. mam. and axillary

c/p N3c. Supraclavicular nodes

N3c

N3bSlide66

Lymph Nodes Fields

66

Reminder – RTF*M

Read the __________ manual!

Flippin’

FunkyFlatulentFairFantasticFamousFreakin’FlashyFabulousFrustrating

Funny

Factitious

Fresh

Frangible

Fractionated

Finite

Friendly

Far-reaching

Fulgent

FuliginousSlide67

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Skin and Other SitesSlide68

Lymph Nodes Fields

68

Merkel Cell – Size of Metastases in LN

Terms not defined in TNM

Micromets (N1a) – removed LN dx’d on micro exam

Macromets (N1b) – identified by imaging or palpation and micro confirmedAllows researchers to define micro- and macromets by sizeCode structure similar to Tumor Thickness000 No regional nodes involved001-979 Size of mets in HUNDREDTHS of mm

980 9.80 mm or larger

990 Mets or tumor nests in regional LN, size

not assessed

998 No histologic examination of regional LN

999 Unknown; not documentedSlide69

Lymph Nodes Fields

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Lymph Node SSFs

(3)

Melanoma Skin

Clin Status of LN Mets*Merkel Cell (all)Clin Status of LN Mets*Size of Mets in LN* Extracapsular Extension of Reg LN*ITCs in Reg LN*SkinSize of LN*Slide70

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70

Lymph Node SSFs

(4)

Testis

Size of Mets in LN*ScrotumSize of LN – size of whole node*PenisExtranodal Extension of Reg LN*Kidney ParenchymaExtranodal Extension of Reg LN*BladderSize of Mets in LN*Extranodal Extension of Reg LN*Slide71

Lymph Nodes Fields

71

Testis: Size of Mets in Nodes

Required for deriving N category

Size of mass, not just size of mets

Codes

000 No LN mets

010 Mass

<

2 cm; no extranodal extension (N1)

020 Mass > 2 and

<

5 cm; OR pathologic

extranodal extension (N2)

030 Mass > 5 cm (N3)

998 Nodes involved, size of mass unknown999 Unknown if performedSlide72

Lymph Nodes Fields

72

Reminder – Read Source Documents

CS Lymph Nodes

PE, imaging, op report, path report, consults

Nodes Positive/ExaminedPath report (final dx, gross, micro), op reportCS Site-specific FactorsAs instructed in notes (clinical/pathologic sources)Scope of Regional LN SurgeryOp report, path reportSlide73

SLNB Under Reporting (Breast, Melanoma, and Other Sites)Identified: NCDB audit 2012

Confirmed: CDC routine audits and NCI SEER review of DBNumerous articles in high impact journals

Lymph Nodes Fields

73Slide74

Action – How to Fix ProblemCoding instructions rewritten

Educational programs, all national agenciesResults?Recent evaluation of NCI-SEER DB – not a significant improvement

Lymph Nodes Fields

74Slide75

Lymph Nodes Fields

75

I sent out the following via our LCRA Newsbreak on the issue:

Recently the LTR underwent a CDC Re-Abstraction Audit. One of the

major errors found

had to do with the improper coding of “sentinel lymph nodes” for such sites as breast and melanoma.  Please be mindful of the following “Scope of Regional LN Surgery” codes:·  2: Sentinel lymph node biopsy—this is to be used when only a sentinel LN bx is performed (Excisional removal of generally 1-3 “Sentinel” LNs)·  6: Sentinel node biopsy and code 3, 4, or 5 at same time or timing not stated ----codes 6 & 7 are to be used for the removal of sentinel LNs ALONG with REGIONAL LNS either at the SAME TIME or at DIFFERENT TIMES·  7: Sentinel node biopsy and code 3, 4, or 5 at different timesThis is a very serious coding issue which results in the under reporting of “sentinel LN bxs” for sites that utilize this information, such as breast and melanoma.

Please make every effort to make sure you are properly coding and accurately reporting “Sentinel LNs!”Slide76

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Head and Neck SSF7

Upper/Lower Cervical Node Levels

Documents whether involved nodes are above or below level of cricoid cartilage

Lower cervical nodes have worse prognosisIf not obvious, refer to list in Part I, Section 2 of CS User DocumentationIf unknown, use code 040

Image source: CSv2 User Documentation, Part I Section 2

Level of cricoid cartilageSlide77

Lymph Nodes Fields

77

Lymphoma Surgery Issues

Biopsy/removal of node for diagnosis/ histology

If other nodes also involved, use code 02 in Surg Diagnostic/Staging Proc

Removal of single involved node (Stage I)Code in Surg Proc of Prim SiteSlide78

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78

Head and Neck

SSF1 – Size of Involved Node

Required by COC, SEER, NPCR

Necessary for N category mappingCode largest size of regional NODE (clin or path), not size of metastasisSize format same as tumor size with extra choices996 Described as less than 6 cm997 Described as more than 6 cm

Introduction to Head and Neck Sites. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer Staging Atlas. New York: Springer, 2006: 13-18. ©American Joint Committee on CancerSlide79

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79

Head and Neck SSFs 3 – 6

Required by COC, SEER

Definitions of levels are the same for all applicable head and neck sites.

SSF 3 Levels I – III SSF 4 Levels IV and V and retropharyngeal nodesSSF 5 Levels VI and VII and facial nodes

SSF 6 Other groups as defined by AJCC

Slide80

Lymph Nodes Fields

80

Coding Site-Specific Factors 3 – 6

SSF 3 Levels I – III ___ ___ ___

I II III

SSF 4 Levels IV - V, ___ ___ ___ retropharyngeal (RP) IV V RPSSF 5 Levels VI – VII, ___ ___ ___ Facial (F) VI VII F

SSF 6 Other groups ___ ___ ___

Parapharyngeal (PP), PP PA S

Parotid (PA), Suboccipital (S)

Default is 0, not involved.

If any level/chain is involved, code as 1, involved.Slide81

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81

Lymph Node SSFs

(1)

Head and Neck, incl. mucosal melanoma

Size of Lymph Node*Lymph Node Levels*Upper/Lower Cervical Node LevelsExtranodal Extension Path*/ClinUpper GI, Lower GI, NET Stomach, NET Colon/Rectum, CarcinoidAppendixClinical Assessment of Regional LN*Histopathological Grading (Appendix)*Slide82

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GI Tract – Clin Assessment of Reg LN

Read codes carefully

Code Example (colon)

000 Nodes not clinically evident010 Clin N1a (1 node positive clinically)020 Clin N1b (2-3 nodes positive clinically)030 Clin N1c (tumor deposits without regional nodes Obsolete CSv02.04100 Clin N1 [NOS] (1-3 nodes positive clinically)110 Clin N2a (4-6 nodes positive clinically)120 Clin N2b (7 or more nodes positive clinically)

200 Clin N2 (4 or more nodes positive clinically)

400 Clinically positive regional nodes, NOS

988 Not applicable:  Information not collected

999 Unknown if nodes are clinically evident Slide83

Breast Lymph Node SSFs

SSF3 Number Pos Ipsilat Axillary LN

SSF4 Immunohistochemistry of Reg LN

SSF5 Molecular Studies of Reg LNSay Goodbye – 2014

SSF17 CTC and method of detection

SSF18 DTC and method of detection

SSF19 Assessment of Pos. Ipsilat. Ax LN

SSF20 Assessment of Pos. Distant Mets

SSF24 Paget DiseaseSlide84

SSF3 – Number of Positive Ipsilateral Axillary Lymph Nodes

Required by COC, SEER, NPCR

Information needed to assign pN1, pN2, pN3

by number of positive axillary nodesApplies to positive ipsilateral Levels I and II and intramammary axillary nodesSame guidelines as for CS Lymph NodesRecord even if preoperative treatmentDefinitions of ITC vs micrometastases Do not count ITC-only nodes as positiveSame code structure as Reg Nodes PosUse code 098 if no nodes were removed or if no nodes found in specimenSlide85

Required by COC, SEER, NPCR

Use 000-009 ONLY when lymph nodes are

negative on H&E (code 000 in CS LN)

000 LN

neg

on H&E, no IHC done, or unk if IHC done 001 LN neg on H&E, IHC done and negative 002 LN neg

on H&E, IHC

done and positive

for ITCs

009 LN

neg

on H&E, IHC

done

and positive, size of mets unk; stated as N0(i+)If nodes are positive on H&E, use code 987

If no statement whether IHC tests were done, assume they were not done and code 000See also SSF 5, molecular markersSSF4 – Immunohistochemistry (IHC) of Reg LN Slide86

Isolated tumor cells (ITCs) (codes 000, 050)

Epithelial cells inside a lymph node

Single tumor cells or small clusters

<

0.2 mmDetected only by immunohistochemical (IHC) or molecular methodsMay be verified on “routine” H&E

stains

Questionable evidence of

malig

-

nant

activity (no proliferation or

stromal reaction)

Lymph nodes with ITCs only are NOT considered positive lymph nodes. What are Isolated Tumor Cells? Slide87

SSF4 IHC – Immunohistochemistry

IHC stains identify epithelial cells (keratin)

Synonyms

Immunohistochemistry Immunocytochemistry ImmunochemistryCytokeratinPan-CKPankeratin‘Keratin cocktail’Keratin IHC stainingAE1/AE3 or AE1/3 (special stains)MNF116CAM 5.2Slide88

Required by COC, SEER, NPCR

Not commonly performed

If IHC done (SSF 4), molecular studies not done

Generic name: RT-PCR; Reverse transcriptase-polymerase chain reaction

Other names: GeneSearch,

TaqMan®, OSNA (one step nucleic acid amplification), Molecular Beacons, Scorpions® and SYBR® Green, Fluorescence Resonance Energy Transfer (FRET), Amplifluor/Sunrise, others

SSF5 – Molecular Studies

of Regional LNSlide89

Use codes 000-002 ONLY when lymph nodes are negative (CS Lymph Nodes codes 000).

000 LN

neg

on H&E,

no RT-PCR done

, or unk if RT-PCR done 001 LN neg on H&E, RT-PCR done and negative 002 LN neg on H&E, RT-PCR done and positive for ITCs

If nodes are positive, use code 987

If no statement whether molecular tests were done, assume they were not done

Isolated tumor cells (ITC): same definition as for CS Lymph Nodes

SSF5 – Molecular Studies

of Regional LNSlide90

Lymph Nodes Fields

90

CS Lymph Nodes

Inaccessible lymph nodes

Nodes within body cavities that cannot be palpated or easily examined

Examples: regional nodes for bladder, kidney, colon, prostate, esophagus, stomach, lung, liver, corpus, ovary (not all-inclusive)Accessible lymph nodesBreast, oral cavity, salivary gland, skin, thyroid, etc.Code regional nodes as negative if general statement in chart ‘remainder of exam negative’Slide91

Lymph Nodes Fields

91

CS Inaccessible Nodes Rule

Record regional and distant metastases as NEGATIVE (rather than unknown) when

No mention of LN or

mets involvement in PE, Dx testing or surgical explorationANDPatient receives ‘usual’ treatment to primaryANDClinically early stage (T1, T2, localized) tumors

All three conditions have to be met

Code unknown if reasonable doubt that tumor is not localizedSlide92

Lymph Nodes Fields

92

CS Lymph Nodes – Rules

Regional nodes only

Site-specific, even for some subsites

Distant lymph nodes coded in Mets at DxSome exceptionsField not used for some sitesCode farthest involved regional nodes clinically or pathologicallyIf no pre-op tx: path; if pre-op tx: clinicalPriority: pathology report, imaging, physical examDirect extension into lymph nodeCode as involved nodeSlide93

Lymph Nodes Fields

93

CS Lymph Nodes – Rules

, cont’d

Special guidelines for head and neck, breast, discontinuous tumor deposits in lower GI tract

Homolateral = ipsilateral = same sideCarcinoma in situ casesCode CS LN as 000, since biologically tumor cells have not invaded to reach nodes“Stated as N_, NOS” codesUse only when no other information in recordIf both statement of N and documentation, documentation takes prioritySlide94

Lymph Nodes Fields

94

CS Lymph Nodes – Rules

, cont’d

Coding size of metastasis in lymph node

Code from path report if availableCode size of metastasis in node, unless otherwise instructedIf size of metastasis unknown, code size of nodeIf size described as mass, code size of massIsolated tumor cellsCode according to site-specific guidelinesBreast – ITCs are negativeMerkel cell and cutaneous melanoma – ITCs are positiveSlide95

Lymph Nodes Fields

95

CS Nodes Eval – Rules

Linked to CS Lymph Nodes

Code as clinical or pathologic

based on intent of procedure and assessment of TIf LN procedure part of workup, staging basis is clinical (codes 0, 1, 5, 9)If LN procedure part of treatment, code as pathologic (codes 2, 3, 6)Must have resection of primary site meeting pT criteriaDocument farthest involved regional nodes

May not be highest

eval

code

Pathologic information takes priority

Document highest N subcategorySlide96

Lymph Nodes Fields

96

Most sites use standard table

General structure

0 Clinical only; no nodes removed

1 No nodes removed; endoscopy or invasive techniques; surgical observation OR FNA, needle bx; or excisional bx as part of

diagnostic workup without removal of primary

site sufficient for

pT

bx does not meet criteria for pathologic N

2 Autopsy (known or suspected dx)

CS Nodes Eval – Rules

, cont’d

Slide97

Lymph Nodes Fields

97

General structure

, cont’d

3 Any microscopic assessment of regional nodes

WITH removal of primary site sufficient for pT OR Positive biopsy of highest N category regardless of Tmeets criteria for pathologic N5 Pre-op

tx

and resection; clinical evidence

6 Pre-op

tx

and resection; path evidence more

extensive

8 Autopsy (dx not suspected)

9 Unknown, not assessed; no TNM schema

CS Nodes Eval – Rules

, cont’d Slide98

Lymph Nodes Fields

98

CS Nodes Eval – Rules

, cont’d

Code 9Always 9 for sites without TNM mappingAvoid 9 if possible when CS Lymph Nodes is 999Sentinel nodesCode as pathologic when tumor size/extension meets criteria for pTWhen no pT, exam of single LN or sentinel nodes is clinicalCode as pathologic when there is a positive biopsy of node in highest N categorySlide99

Lymph Nodes Fields

99

Idiosyncratic Primary Sites

Lymph nodes coded 988, Not Applicable

Placenta (Gestational Trophoblastic Tumor)

Brain and Cerebral MeningesOther Parts of Central Nervous SystemIntracranial Gland Hodgkin and Non-Hodgkin LymphomaHematopoietic, Reticuloendothelial, Immunoproliferative and Myeloproliferative NeoplasmsOther and Ill-Defined Primary SitesUnknown Primary SiteSlide100

Lymph Nodes Fields

100

CS Lymph Nodes – Rules

, cont’d

Regional Nodes, NOS vs. Distant Nodes

Code named regional nodes as priorityRegional Nodes, NOS (code varies)Definitely regional, but not namedMultiple LN codes—can’t tell which code to useIn “normal” surgical resection fieldLymph Nodes, NOS (Code 800)Can’t tell whether regional or distantRarely usedWhen unidentified nodes found in resected primary site specimenCode as regional nodes, NOSSlide101

Head and Neck Lymph NodesCS Lymph Nodes—Notes

Contains information about the nodes involved, their general number and laterality

Code ranges vary by primary site

Code any regional LN involvement in this fieldMajor categories: Single positive ipsilateral node involved Multiple positive ipsilateral nodes Bilateral or contralateral positive nodes Positive regional nodes, NOSIf laterality not specified, assume nodes are ipsilateralMidline nodes grouped with ipsilateral nodesSlide102

Head and Neck Lymph NodesCS Lymph Nodes – Parotid Example

000 None

100-190 Single positive ipsilateral node involved 200-290 Multiple positive ipsilateral nodes 300-320 Positive ipsilateral nodes, unk. if 1 or > 1 400-490 Bilateral or contralateral positive nodes 500-520 Reg nodes, NOS, unk. number and laterality 800 Lymph nodes, NOS Stated as… 000 N0 180 N1, no other information

190 N2a, no other information

290 N2b, no other information 490 N2c, no other information 600 N2, NOS 700 N3, no other informationSlide103

Lymph Nodes Fields

103

Colorectal Cancer Lymph Nodes

Notes

1. Regional nodes only

2. Definition of tumor deposits in adipose tissueIf tumor localized (T1 or T2) and no other information about lymph nodes, used code 050Code number of tumor deposits in SSF4 3. Inferior mesenteric nodes are distant for

cecum, appendix, ascending, transverse, hepatic flexure

Superior mesenteric nodes are distant for all colon sites

4. Codes 100, 200, and 300 take priority over 400-470 (Stated as __)Slide104

N2 Metastasis in ≥

4 nodes - Rectum

Source: UICC

TNM-interactive

, Wiley-

Liss

, 1998

N2a

N2bSlide105

Lymph Nodes Fields

105

GYN Lymph Node SSFs

(2)

Corpus (all), Fallopian Tube

Number Pos*/Exam* Pelvic LNNumber Pos*/Exam* Para-Aortic LNVaginaPelvic Nodal Status*/Method of Assessment*Para-aortic Nodal Status*/Method of Assessment*Distant Node Status*/Method of Assessment*VulvaRegional LN Laterality*Slide106

Lymph Nodes Fields

106

Corpus, Fallopian Tube

Number of Pos/Exam Pelvic Nodes

Number of Pos/Exam Para-aortic Nodes

Same code structures as Nodes Pos/Exam with leading 0

Para-aortic

Common Iliac

Internal iliac

Sacral

External iliac

Inguinal

Femoral

PelvicSlide107

Lymph Nodes Fields

107

Vagina: Lymph Node Status Fields

Code whether nodes are positive

Can be clinical or pathologic

Codes000 Negative lymph nodes010 Positive lymph nodes988 Not applicable: Information not collected998 Lymph nodes not examined

999 Unknown; Not documentedSlide108

Lymph Nodes Fields

108

Vagina: Lymph Node Assessment Method Fields

Code how status of pelvic lymph nodes was determined

Use highest applicable code

010-020 are clinical030-040 are pathologicCodes000 Lymph nodes were not assessed010 Clinical assessment020 Radiography; Imaging (US, CT, MRI, PET)

030 Incisional biopsy; FNA

040 Lymphadenectomy; Excisional biopsy or

resection with microscopic confirmation

other than by biopsySlide109

Lymph Nodes Fields

109

Vulva SSF11 – Regional Node Laterality

Required by NPCR

Maintains compatibility with TNM 6

th editionCodes000 No involved regional nodes010 Unilateral - all positive nodes same laterality 020 Bilateral - positive bilateral regional nodes 030 Regional node(s) positive – laterality unknown 998 Lymph nodes not assessed 999 Unknown or no information Slide110

Lymph Nodes Fields

110

Colorectal Cancer Lymph Nodes

Code 050—all segments

Tumor deposits without regional node

mets

Code 110—all segments

Colic

Epicolic

Mesocolic

Para/

pericolicSlide111

Lymph Nodes Fields

111

Rectal Cancer Lymph Nodes

Code 110—Rectosigmoid

Para/

pericolic

Code 110—Rectum

Rectal

PerirectalSlide112

Lymph Nodes Fields

112

Code 210—site specific

Regional nodes for each segment of colon

Cecum

Ascending

Hepatic flexure

Transverse

Splenic flexure

Descending

Sigmoid

Colorectal Cancer Lymph Nodes

Code 300—all sites

Regional nodes, NOS including mesenteric, NOS Slide113

Lymph Nodes Fields

113

Regional Nodes Positive/Examined

General Rules

LN 600

LN 600

Mets 30

Counting nodes (positive or examined)

Regional nodes only!

Do not count positive aspiration

or core biopsy of node in same

chain removed at surgery

Do count positive aspiration

or core biopsy of node

in different region

If location of biopsied/

aspirated node unknown,

do not countSlide114

Lymph Node CS Site-Specific Factors

not covered in other sessions

* required by COC and SEER

required by NPCR when availableSlide115

Head and Neck Lymph NodesOverview

Regional lymph node information coded in several fields

CS Lymph Nodes field

Nodes involved, their number and laterality Site-Specific Factor 1 Size of involved lymph nodesSite-Specific Factors 3-6 Presence or absence of lymph node involvement in each of 7 different levels and other groups defined by AJCC. Site-specific Factors 9Extracapsular extension, pathologicSlide116

Lymph Nodes Fields

116

Breast: When to Use Codes 000, 050

Negative nodes vs Isolated Tumor Cells (ITCs)

Code 000 – No regional lymph node involvement or

ITCs detected by immuno-histochemistry or molecular methods only Code 050 – No regional lymph nodes positive but ITCs detected on routine H & E stainsSlide117

Lymph Nodes Fields

117

Breast: When to Use Codes 130, 150

Method of Detecting Micrometastases

Code 130 – Axillary nodes, micrometastases* detected only

by immunohistochemistry (IHC) Code 150 – Axillary nodes, micrometastasis only, detected or verified on routine H & E stains; Micrometastasis, NOS* Micrometastasis: > 0.2 mm (or > 200 cells) and

<

2 mmSlide118

Lymph Nodes Fields

118

Breast: When to Use Codes 250, 255, 260

250 Movable axillary node(s), ipsilateral,

positive with > micrometastasis

(at least one metastasis > 2 mm)Use when positive nodes are pathologically separate, and size of mets in node is known to be > 2 mm255 Clinically positive movable axillary node(s)Use when there is no pathology or when patient has neoadjuvant therapy and only clinical assessment 260 Stated as N1, NOS

Use when no physical exam or other assessment, only a clinician statement of N1Slide119

Lymph Nodes Fields

119

Breast: When to Use Code 600

600 Axillary/regional lymph node(s), NOS;

Lymph nodes NOS

Use when size of metastasis in lymph node is not statedCan be either clinical or pathologicIf stated as fixed/matted, use 510-520 insteadIf stated as movable or not stated as fixed/matted, use 250-255 instead