Presentation developed by April Fritz RHIT CTR 2016 cp Indicators for TNM Currently in registry software TNM data elements are mutually exclusive Clinical T N M Stage Pathologic T N M Stage ID: 581225
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Slide1
c/p Indicators for T, N, M
Presentation developed byApril Fritz, RHIT, CTRSlide2
2016 c/p Indicators for TNM
Currently in registry software, TNM data elements are mutually exclusive Clinical T ___ N ___ M ___ Stage ___
Pathologic T ___ N ___ M ___ Stage ___
No way to document “mixed stage”
Per AJCC website
“This discrepancy between registry software data items and AJCC staging classification rules causes a dilemma for registrars when abstracting the T, N, and M data items and results in inconsistent coding practices and data loss.” Slide3
2016 c/p Indicators for TNM
2016 c/p indicators enable complete documentation of clinical and/or pathologic stagingAllow necessary ‘p’ values within the clinical staging data elements
Allow necessary ‘c’ values within the pathologic staging data elementsSlide4
2016 c/p Indicators for TNM
Per AJCC website“This implementation will allow registrars to comply with AJCC rules while abstracting, thus reducing stage assignment confusion and increasing registrar confidence in assigning AJCC stage, increasing data integrity, and reducing the time and resources registrars and AJCC and
CoC
staff currently spend addressing these issues.
“The
CoC
would like to whole-heartedly thank registrars for their persistence in reporting this issue to AJCC and National Cancer Data Base (NCDB) and in pursuing answers to your questions.”Slide5
Examples of 2016 Indicators
Previous Value
Value for 2016 +
cT1
c1
cT2a
c2A
cT3b
c3B
cT4d
c4DcTXcXcN0i+c0I+cN1ac1AcN2ac2AcM0c0cM1cc1C
Previous ValueValue for 2016 +pTispISpTapApT1mip1MIpT1a1p1A1pT4cp4CpNXpXpN1cp1CpM1ap1A
[Blank] allowed in each data fieldSlide6
Example 1
DCIS of breast diagnosed on core biopsy; excisional biopsy with clear margins. No nodes palpable or removed.Clin T:
pIS
N: c0 M: c0 Stage 0
Path
T:
pIS
N: c0 M: c0 Stage 0
Per AJCC rules (Chapter 1), mixed stage allowed
In situ must be
pT in clinicalNodes cannot be involved so are not removed (cN0 in pathologic)Distant sites cannot be involved by in situ tumorSlide7
Example 2
Patient with obstructive urinary symptoms had TURP. Path report shows Gleason 2+2 adenocarcinoma in half of chips. DRE: no abnormalities. Patient chose active surveillance.Clin
T: c1B N: c0 M: c0 Stage I
Path
T: Blank N: Blank M: Blank Stage 99
Per AJCC rules (prostate chapter), case does not meet path staging criteria
All pathologic stage fields should be blank
TURP findings used for clinical T
Missing PSA information grouped in lowest categorySlide8
Example 3
Woman elects TAH-BSO for menorrhagia. Otherwise asymptomatic. Path report shows FIGO grade 2 endometrioid adenocarcinoma penetrating to inner half of myometrium. No nodes in specimen.Clin
T: Blank N: Blank M: Blank Stage 99
Path
T: p1A N:
pX
M: c0 Stage 99
Per AJCC rules, tumor not known prior to definitive treatment
Clinical stage fields should be blank
No nodes examined, so cannot path stage caseSlide9
Example 4aPatient evaluated for back pain; CT spine shows 8 cm mass in kidney, no involved nodes, and multiple osteolytic lesions along spine. Core needle biopsy of kidney mass confirms adenocarcinoma. No resection of primary.
Clin T: c2A N: c0 M: c1 Stage 4
Path T: Blank N: Blank M: Blank Stage 99
Per AJCC rules
No resection = no path staging (all fields blank)
No special rule for cM1; cannot carry over to path stage 4.Slide10
Example 4b
Patient fell at home and broke hip. Tissue from hip repair shows metastatic adenocarcinoma. CT abd/pelv shows 8 cm mass in kidney, but no involved nodes. No resection of primary. Patient discharged to long-term skilled care facility.
Clin
T: c2A N: c0 M: p1 Stage 4
Path T: Blank N: Blank M: p1 Stage 4
Per AJCC rules
pM1 stage-grouped as clinical AND pathologic Stage 4 regardless of c/p status of T and N
Leave
pT
,
pN blank if no resectionSlide11
General Rules Chapter 1Based on anatomic extent of:“T” tumor by size and contiguous extension
“N” regional draining lymph nodes defined by number or location of positive LNs“M” presence/absence distant metastasisSlide12
RulesAll cases should be micro confirmed
Histo or cytologyIncluding clinical TNMIf cTNM done w/o path, pull them from studiesTiming when data eligible for
Clinical staging
Pathologic staging
Staging with neoadjuvant therapySlide13
Clinical Staging - MacroscopicTiming:
Before ANY treatment starts – OR whichever isWithin 4 months diagnosis date SHORTERInformation used:
Symptoms Physical exam
Endoscopies Biopsy for diagnosis
Imaging (tumor, lymph nodes, or distant sites)
Surgical exploration w/o resection
May be ONLY common factor of some sites
Uses
Define initial treatment choice
International population comparisonSlide14
Pathologic Staging - MicroscopicTiming:
Thru completion surgery(ies) – OR whichever Within 4 months diagnosis date
is LONGER
Information used:
Information from c)TNM
Pathology from resected tissue (T, N, or M)
EXCEPTION: IF only clinical T, THEN sentinel LN = c)N
NO p)M0 (would require autopsy), only p)M1
Uses
Most precise prognosis
Adjuvant treatment decisionsSlide15
Other StagingPost-Therapy Stage
Result after Neoadjuvant therapy - y)P staging at surgical resectionPatient treated with systemic therapy or RT WITHOUT surgery – y)C staging after therapyNot possible in USA registries software
Allows these cases to be removed when treatment or survival evaluations
Retreatment Stage
Stage of recurrence AFTER disease-free interval
May be needed for clinical trial enrollment
Autopsy Stage
No diagnosis of cancer prior to deathSlide16
RulesProgression of disease: only info BEFORE progression used for stagingUncertainty (T, N, M, group stage, or modifying factor): use lower/lesser definition
Nonanatomic factor not available: assign case based on lowest factor allowedMultiple simultaneous tumors in one organ? Describe tumor with highest “T”Slide17
pTNMpT = resection of primary tumor enough to satisfy the highest TpN = # LN to evaluate highest pN category
Exception: Sentinel LN surgeryM may be c) or p)If pM1, may be p)TxNxM1Slide18
pTNM w/o ResectionIf biopsied tumor canNOT
be removedANDHighest T OR Highest N OR M1 category can be confirmed pathologicallyTHEN
Criteria for pT OR pN OR
pM
has been metSlide19
pTNM w/o Resection ExamplesRectal biopsy shows prostate cancer = pT4Supraclavicular LN biopsy = lung cancer
pN3BUT violates another rule in AJCC – can’t have pN w/o pTBiopsy of any distant mets = pM1Slide20
Rules for ClassificationSite-specific – read chapterDefines what is needed for cTNM vs pTNM
What tests fit in cTNMWhat must be resected for pTNMTumor only?Entire organ?Where does surgical exploration fit?Slide21
pTNM SurgerySite-specific guidelines for pTNMNot all surgeries, even curative, qualify for pTNM
EX: TURB for bladder (clinical) vs cystectomy (pathologic)Slide22
T for TumorTx – Primary tumor can NOT be assessed
Not enough infoT0 – No evidence primary tumorEX: Tissue from met to prove dx of site, but no lesion found in siteTis – in situT1 – early invasiveT2, T3, T4 –
↑ size, regional
tiss
extension
Tumor size recorded in mm
Doctor may estimate or aggregate if > 1 piece
T usually requires resection of lesion and/or of organ
May be subdivided into a or b or cSlide23
N for Regional NodesNx – Nodes
canNOT be assessedNot enough infoN0 – No evidence LN mets
N1, N2, N3 – based on number or location positive nodes
May be subdivided into a or b or cSlide24
N Cont’dAny LN not listed as regional is distant
Recommended minimal number excised by chapterAny LN examined by path = pN (with tumor resection)Biopsy LN = pN (with tumor resection)Clinical T w/o resection, sentinel LN = cN
Isolated Tumor Cells (ITC) =
N0
usually
Direct extension tumor into regional LN area = + LN
Size of
mets
vs size of LN per chapterSlide25
M (Distant) Metastasis
c)M0 – No distant metsONLY clinical (no pM0)Imaging distant organ sites not requiredM1 – Distant
mets
Clinical OR pathologic
May be subdivided into a or b
No Mx any longer
Removed from CAP protocol & staging forms
Unless there is clinical or pathologic M1, cM = M0
Isolated tumor cells in
mets
sites (ITC)Circulating or disseminated tumor cells (DTC)If not noted in “T” or “N”, it’s distantMxSlide26
Stage GroupStage 0 – in situStage I – confined to primary site
Stage II or III – increasing organ and/or regional LN involvedStage IV – distant metastasisMay be subdivided into a or b
“
Pure” cTNM or pTNM
Working stage – combined c) or p) in midst of workup
Only for tumor conference discussion
Tx or Nx may make unstageable unless “Any T” or “Any N” allowed
If anatomic factor required, may use lowest category if factor not foundSlide27
Mixed Staging YikesPurely p) or c) TNM staging for comparisonsEXCEPTION – cM can be combined with pT pN
No pM0 any longercM0 used when creating p) group stageEXCEPTION – pM can be combined with c or p T,NpTx pNx pM1 = stage IV, cT# cN# pM1 = stage IV
EXCEPTION – In situ
pTis cN0 cM0 can be used for p) AND c) group stage
Computer logic: pTis pNx OR cTx cN0 = Group Stage 0Slide28
X VS Blank“The X category is used when information on a specific component is unknown.”
pg 8 Cancer Staging ManualPer chapters, using X means that element “cannot be assessed”Donna Gress lecture 2013 states BLANK should be used when
No information in chart
Cannot assign a valid AJCC value
Patient not eligible for pathologic stagingSlide29
T0 VS TXTx – primary tumor cannot be assessedT0 – No evidence of primary tumor
A primary tumor was not found by any clinical methodsPer AJCC Q&A, T0 implies you looked for tumor and couldn’t findUsed for cT or pT stagingHistorically only used for pTSlide30
88Not applicableUsed when chapter does not accept histology (EX: carcinoid of lip)
Used when no chapter for stagingCNS, hematopoieticHistorical: used when cT could not be defined (ex. Melanoma must be excised or testicle must be removed to diagnose)Slide31
Brief TNM Staging ExercisesSlide32
Case Study: Lung
CT Chest: large R infrahilar mass with 4.2 cm RLL mass occluding RLL bronchus and narrowing of pulmonary veins. R mediastinal adenopathy. R pleural effusion associated with the large mass. Two smaller lesions L lung at level of hilum.All other workup negative.
Core
bx
: R mediastinal node positive for small cell carcinoma.
1. What is the clinical T?
a. c3 b. c2A c. Blank d. c4
Source: Cancer Case Studies, NCRASlide33
Case Study: Lung
CT Chest: large R infrahilar mass with 4.2 cm RLL mass occluding RLL bronchus and narrowing of pulmonary veins. R mediastinal adenopathy. R pleural effusion associated with the large mass. Two smaller lesions L lung at level of hilum.All other workup negative.
Core
bx
: R mediastinal node positive for small cell carcinoma.
2. What is the pathologic N?
a. c2 b.
pX
c. Blank d. p0
Source: Cancer Case Studies, NCRASlide34
Case Study: Lung
CT Chest: large R infrahilar mass with 4.2 cm RLL mass occluding RLL bronchus and narrowing of pulmonary veins. R mediastinal adenopathy. R pleural effusion associated with the large mass. Two smaller lesions L lung at level of hilum.All other workup negative.
Core
bx
: R mediastinal node positive for small cell carcinoma.
3. What is the clinical M?
a. c1A b. c0 c. Blank d.
cX
Source: Cancer Case Studies, NCRASlide35
Case Study: Rectum
PTA: Biopsy proven carcinoma in rectal mass. Remainder of exam negative.Rectosigmoid colectomy: 5.0 cm moderately differentiated adenocarcinoma extending through muscularis propria to
pericolonic
soft tissue of rectum. Radial margin positive for adenocarcinoma.
7/17 lymph nodes positive for metastatic adenocarcinoma.
1. What is the pathologic T?
a. p4A b. p3 c.
pX
d. p2
Source: Cancer Case Studies, NCRASlide36
Case Study: Rectum
PTA: Biopsy proven carcinoma in rectal mass. Remainder of exam negative.Rectosigmoid colectomy: 5.0 cm moderately differentiated adenocarcinoma extending through muscularis propria to
pericolonic
soft tissue of rectum. Radial margin positive for adenocarcinoma.
7/17 lymph nodes positive for metastatic adenocarcinoma.
2. What is the clinical T?
a. c4A b. c3 c.
cX
d. c2
Source: Cancer Case Studies, NCRASlide37
Case Study: Rectum
PTA: Biopsy proven carcinoma in rectal mass. Remainder of exam negative.Rectosigmoid colectomy: 5.0 cm moderately differentiated adenocarcinoma extending through muscularis propria to
pericolonic
soft tissue of rectum. Radial margin positive for adenocarcinoma.
7/17 lymph nodes positive for metastatic adenocarcinoma.
3. What is the pathologic N?
a. p2B b. p1C c.
pX
d. p2
Source: Cancer Case Studies, NCRASlide38
Case Study: Rectum
PTA: Biopsy proven carcinoma in rectal mass. Remainder of exam negative.Rectosigmoid colectomy: 5.0 cm moderately differentiated adenocarcinoma extending through muscularis propria to
pericolonic
soft tissue of rectum. Radial margin positive for adenocarcinoma.
7/17 lymph nodes positive for metastatic adenocarcinoma.
4. What is the pathologic M?
a. c1A b. Blank c.
pX
d. c0
Source: Cancer Case Studies, NCRASlide39
Case Study: Lymphoma
PE: Night sweats, 35 pound weight loss in 2 months, abdominal pain. Supraumbilical abdominal mass.Imaging: no lymphadenopathy or organomegalyPartial gastrectomy: mass in greater curvature of stomach completely excised
Pathology: Diffuse large B-cell lymphoma confined to stomach wall
1. What is the clinical Stage Group?
a. c1BE b. c1B c.
cX
d. c1ESlide40
Case Study: Lymphoma
PE: Night sweats, 35 pound weight loss in 2 months, abdominal pain. Supraumbilical abdominal mass.Imaging: no lymphadenopathy or organomegalyPartial gastrectomy: mass in greater curvature of stomach completely excised
Pathology: Diffuse large B-cell lymphoma confined to stomach wall
2. What is the pathologic Stage Group?
a. p1BE b. p1B c. 99 d. p1ESlide41
Case Study: Breast
10/17 PE: R breast: marked skin erythema and peau d’orange. 8.0cm by 7.0cm vertical mass above the nipple in the 12 o’clock radial. Palpable 3.0 cm x 2.0 cm right axillary lymph node. No other adenopathy. 10/19 Imaging: no distant metastases
10/20 Excisional biopsy R axillary node confirms metastasis
10/26 R modified radical mastectomy: 6 cm
infil
ductal carcinoma, BR 6/9. 8 axillary nodes negative.
1. What is the clinical T?
a. c3 b. c4B c.
cX
d. c4DSlide42
Case Study: Breast
10/17 PE: R breast: marked skin erythema and peau d’orange. 8.0cm by 7.0cm vertical mass above the nipple in the 12 o’clock radial. Palpable 3.0 cm x 2.0 cm right axillary lymph node. No other adenopathy. 10/19 Imaging: no distant metastases
10/20 Excisional biopsy R axillary node confirms metastasis
10/26 R modified radical mastectomy: 6 cm
infil
ductal carcinoma, BR 6/9. 8 axillary nodes negative.
2. What is the pathologic T?
a. p3 b. p4B c.
pX
d. p4DSlide43
Case Study: Breast
10/17 PE: R breast: marked skin swelling and peau d’orange. 8.0cm by 7.0cm vertical mass above the nipple in the 12 o’clock radial. 3.0 cm x 2.0 cm right axillary lymph node. No other adenopathy. 10/19 Imaging: no distant metastases
10/20 Excisional biopsy R axillary node confirms metastasis
10/26 R modified radical mastectomy: 6 cm
infil
ductal carcinoma, BR 6/9. 8 axillary nodes negative.
3. What is the clinical N?
a.
cX
b. c0 c. c1 d. c1ASlide44
Case Study: Breast
10/17 PE: R breast: marked skin swelling and peau d’orange. 8.0cm by 7.0cm vertical mass above the nipple in the 12 o’clock radial. 3.0 cm x 2.0 cm right axillary lymph node. No other adenopathy. 10/19 Imaging: no distant metastases
10/20 Excisional biopsy R axillary node confirms metastasis
10/26 R modified radical mastectomy: 6 cm
infil
ductal carcinoma, BR 6/9. 8 axillary nodes negative.
4. What is the pathologic N?
a. p2 b. p0 c. p1 d. p1ASlide45
Case Study: Melanoma
Pathology report for skin, left arm, excision: Conventional invasive melanoma originating in a dermal nevus with no adjacent intraepidermal component.- Breslow’s tumor thickness 1.8 mm; Clark’s level III- No epidermal ulceration- Foci suspicious for vascular space invasion- No regression
- High mitotic rate (>40 per 10 HPF)
- Tumor nodule appears completely excised; nearest
inked margin at 0.4 mm
1. What is the clinical T?
a. p2A b. c2A c.
cX
d. p2BSlide46
Case Study: Melanoma
Pathology report for skin, left arm, excision: Conventional invasive melanoma originating in a dermal nevus with no adjacent intraepidermal component.- Breslow’s tumor thickness 1.8 mm; Clark’s level III- No epidermal ulceration- Foci suspicious for vascular space invasion- No regression
- High mitotic rate (>40 per 10 HPF)
- Tumor nodule appears completely excised; nearest
inked margin at 0.4 mm
2. What is the pathologic T?
a. c2A b. c2 c.
pX
d. BlankSlide47
Case Study: Bladder
Transurethral resection of bladder tumor: 0.5 cm papillary tumor at ureteral orifice.PE and Abdominal Ultrasound: within normal limitsPathology: Urothelial carcinoma confined to mucosa; no penetration of basement membrane. 1. What is the clinical T?
a.
pIS
b.
cA
c. Blank d.
cX
Source: Cancer Case Studies, NCRASlide48
Case Study: Bladder
Transurethral resection of bladder tumor: 0.5 cm papillary tumor at ureteral orifice.PE and Abdominal Ultrasound: within normal limitsPathology: Urothelial carcinoma confined to mucosa; no penetration of basement membrane. 2. What is the pathologic T?
a.
pIS
b.
pA
c. Blank d.
pX
Source: Cancer Case Studies, NCRASlide49
Case Study: Prostate
Elderly patient admitted for hip fracture after a fall. Pathology report from hip fracture internal fixation showed metastatic prostatic adenocarcinoma.Patient discharged to nursing home on hormone therapy. 1. What is the clinical M?
a. c1B b. c1 c. p1B d. BlankSlide50
Case Study: Prostate
Elderly patient admitted for hip fracture after a fall. Pathology report from hip fracture internal fixation showed metastatic prostatic adenocarcinoma.Patient discharged to nursing home on hormone therapy. 2. What is the pathologic stage group?
a. 4 b. 4B c. Unknown d. 99Slide51
Take-Home Messages
c/p indicators allow complete classification and stage grouping of cases
In some situations, p information used in c
In fewer situations c information used in p
Use appropriate category according to rules
Use AJCC rules from Chapter 1 and site-specific chapter
Sometimes more than one rule applies
Should reduce confusion and frustration in assigning T, N, M data fields for clinical and pathologic stagingSlide52
Recommendations
Do not change procedures or coding instructions in middle of diagnosis year.Doing so will result in inconsistent data for analysis
Document any rules changes and the effective date in the registry’s procedure manual
Until there are further
written
instructions
,
Follow the guidelines for coding blanks vs. X vs. 0 established by your registry software vendor or state registrySlide53
Recommendations and Reminders
Finish 2015 cases before you start 2016 diagnosesUse consistent rules for entire diagnosis year
New data fields, new c/p indicators, discontinued data items effective for 01/01/2016 diagnoses and forward
Follow your standards setter(s) instructions
Do not try to use new c/p indicators until you receive 2016 vendor software updatesSlide54
Any Questions?