Frequently Asked QuestionsCollaborative Staging (CS) FAQs The CS Steering committee receives questions regarding the use of CS System – questions on general rules and how to use rules in specific situations. We have listed some of the questions and answers below by category. Please be sure to visit the Commission on Cancer Inquiry and Response System (I&R) to view additional questions and answers. Question Topics:
Q: What CS Extension code would be used for leiomyosarcoma of the small bowel with focal vascular invasion? A: Use the Small Intestine schema (p. 265). The extension code would be 30, Localized (confined to organ of origin), unless you had more precise information about the level of invasion. Normally blood vessels do not appear in the mucosa, lamina propria, or muscularis mucosae, but are found in the submucosa, muscularis, and deeper structures. Focal invasion of blood vessels within the organ is disregarded for staging and CS coding, but has been shown to possibly affect prognosis. The computer algorithm for leiomyosarcoma of the small bowel would yield a T, N, M and Stage Group of "Not Applicable" since sarcomas are excluded from TNM staging of the small intestine. (9/23/04) Q: Patient with colon cancer had a negative CT scan of the abdomen, pelvis, and chest. The patient also had an observation at surgery indicating negative metastatic involvement of the liver. With regard to CS Mets Eval for colon, the definition in the CS Staging and Coding Manual, p. 45, number one (1) under Instructions for Coding reads "select the CS Mets Eval code that documents the report or procedure from which the information was obtained about metastatic involvement farthest from the primary site--this may not be the numerically highest eval code." A: "Select the code that best explains how the information in the CS Metastases field was determined." The correct Mets Eval code should be 0, not 1 because CT scans document information about metastatic involvement and/or non-involvement farthest from the primary site. (9/23/04) Q: If the patient had a modified radical mastectomy, revealing a 3.0cm invasive ductal carcinoma and DCIS with perineural invasion and lymphatic involvement, does the perineural invasion and lymphatic involvement effect the CS Extension code? A: Perineural invasion and lymphatic involvement do not affect the Extension code. The lymphatics are the tiny lymph channels within the primary organ. Tumor spreads along the path of least resistance and sometimes follows the nerve pathways. As long as the involvement of the nerves or lymphatics does not extend beyond the borders of the primary organ, that type of tumor involvement does not affect the extension code. (9/23/04) Q: Patient had left breast lump with induration of skin and multiple joint pain as noted by the primary physician. Mammogram described a 2-cm breast mass bordering on the UIQ and LIQ with questionable axillary lymph nodes. Path: Excisional biopsy with axillary lymph node dissection revealed 2-cm infiltrating ductal carcinoma, 2/10+ axillary lymph nodes and positive margin. ER/PR positive, Her2Neu negative CXR and bone scan were negative for metastasis. The question is: when doing collaborative staging, does the induration (Extension code 20) take precedence over the path report that does NOT mention any induration (Extension code 10)? If yes, do we answer the TX Ext-Eval as "1" because we used the physical exam? A: The "T" code will be calculated based on the tumor size "*". SS77 and SS2000 consider induration as regional disease. Induration would not be found on a resected breast specimen because there's no more lymph and blood flowing through the tissue. We code the clinical findings in extension, but it also takes tumor size to assign the T category. CS Extension code = 20 , CS Extension Eval Code = 1(May, 2004) Q: Cervix Uteri: If the pelvic exam indicates a tumor to be 4-5cm, and the pelvic CT states the tumor to be approximately 6cm, (and there is no surgical intervention performed), would the tumor size be captured as 060, since CS Tumor Size code 995 is described as "less than 5cm?" A: See General Question #4. "Approximately 6cm" would be coded as 060. None of the codes in the 991-995 range would apply. If the tumor was described as "greater than" 6cm, it would be best to code tumor size as 999 (Unknown). (9/23/04) Q: Cervix Uteri: If the patient has a cone biopsy (invasive to 5mm), then one month later has a radical hysterectomy and lymphadenectomy which shows no residual cervical cancer, but one positive lymph node, can the positive node be included in the Collaborative Stage and the CS Extension code from the cone biopsy? Are they both part of the first course of treatment? A: The cone biopsy would be a diagnostic procedure and the radical hysterectomy and lymphadenectomy would be the definitive first course treatment. Any tissue examined through completion of the first course of treatment can be included in the information used to code (pathologic) CS Extension and CS Lymph Nodes, so you can use both the cone biopsy and the lymph node dissection to code the case. Review the CS Timing rule in the General Instructions section, Instruction 4. (9/23/04) Q: A clinical prostate cancer patient had an unknown clinical apex status. TURP was the only treatment, no prostatectomy performed. What is the code for SSF4 since we cannot use 999? A: Code Site-specific Factor 4 (Prostate Apex Involvement) to 550 "Clinical apex involvement: Unknown and Prostatectomy apex involvement: Unknown. "Prostatectomy apex involvement: Unknown" can be used for cases in which no prostatectomy was performed. (8/05) Q: If a patient was clinically T2c with positive biopsy in the apex and had a prostatectomy that involved right and left lobes and focally the apex, what should be coded for CS SS4? A: Code Site-specific Factor 4 (Prostate Apex Involvement) to 220 which can be used when the apex is involved both clinically and at prostatectomy but it is unknown if this is arising in or extending to the apex. (8/05) Q: Site-specific Factor 4 (Prostate Apex Involvement), how is clinically apparent apex involvement with no prostatectomy coded? A: The new definitions for Site-specific Factor 4 (Prostate Apex Involvement) have been written to allow for both clinical findings as well as findings at prostatectomy. If the tumor is arising in the apex, use code 350. If it cannot be determined if this apical involvement is arising in, or extending to, the apex, use 250. (8/05) Q: If a patient had a cryoprostatectomy as part of first course treatment with no path report, FORDS Surgery Code 14, how is Site-Specific Factor 3 (Pathologic Extension) coded? A: Site-Specific Factor 3 CS Extension – Pathologic is coded 097, "no prostatectomy done". The FORDs Surgery Code would be 13, with no pathology specimen. (8/05) Q: If invasive adenocarcinoma is found in one lobe of the prostate, and the other lobe only indicates high grade PIN (or if it shows adenoca in situ), is the CS Extension-Clinical Extension coded as 23 (involves both lobes) or is the case coded as involving one lobe, since only one lobe showed invasive adenoca? A: Several issues come into play in this question. First, based on SEER rules, high grade PIN would be disregarded, but adenocarcinoma in situ would be a factor in determining whether one or both lobes were involved. Next, was the tumor apparent or inapparent prior to the biopsy? If it was inapparent and diagnosed by needle biopsy, then Extension code would be 15 even if diagnosed in both lobes. If it was apparent and diagnosed by needle biopsy, the code would be 23 if the second lobe was involved with adenocarcinoma in situ, but somewhere in the 20-22 range if the second lobe was involved with PIN III. (9/23/04) Q: If a needle biopsy was done because of elevated PSA, and we don't have any clinical information to confirm whether the case was clinically apparent or inapparent, is the CS Extension coded as 15 (Tumor identified by needle biopsy, e.g., for elevated PSA) or as 30 (Not stated if Stage A or B, T1 or T2, clinically apparent or inapparent)? A: Revised Answer, 10/15/07. In this case, the best code is 30, since there is no clear statement of apparent or inapparent. After consultation with the AJCC curators for genitourinary tumors, a new note has been added to CS Extension to simplify coding in these situations. The new note reads, "A clinically inapparent tumor is one that is neither palpable nor reliably visible by imaging. An apparent tumor is palpable or visible by imaging. Do not infer inapparent or apparent tumor based on the registrar's interpretation of terms in the DRE or imaging reports. A physician assignment of cT1 or cT2 is a clear statement of inapparent or apparent respectively. Code to 30 (which maps to T2 NOS) in the absence of a clear physician's statement of inapparent or apparent. " [Previous answer dated 9/23/04: Code what is known. It is known that the needle biopsy was done because of elevated PSA (Extension code 15). ] Q: Prostate CS Site Specific Factors 1 and 2 What are the main differences between the two? A: SSF 1 for prostate is the actual lab value of the PSA. SSF 2 is the interpretation of that lab value, in other words whether it is normal or elevated. Studies have shown that PSA values are considered elevated at different points for different age groups, so knowing what the actual value is and whether it was considered elevated. (April, 2004) Q: For thyroid, the stage grouping does not allow for a N1 choice. Is it required to specify the N1a or N1b choice for every thyroid case? Or, is it okay to add N1 in the stage group? (April, 2004) A: An N1, NOS option was created and approved by the AJCC. (April, 2004) Q: Lymphomas and International Prognostic Index (IPI) In CS, the same variable is used for Hodgkin and non-Hodgkin lymphomas for the Site Specific Factor 3: IPI Score. At present, it has not been common practice to use the IPI for Hodgkin disease. Some hematologists do not record the IPI for Hodgkin, as they feel it is not applicable, so how should this be handled? A: Easy answer: code 999, not documented. This SSF does not affect stage grouping. (April, 2004) Q: An institution clinically diagnoses a patient with carcinomatosis and the registry enters the case as an unknown primary (C80.9), carcinoma, NOS, stage of disease unknown. Then nine months later, a paracentesis shows serous cystadenocarcinoma. The physician now says that the patient has an ovarian primary. According to SEER and FORDS, it's OK to go back and change the primary site, but can the CS be re-coded based on the new information? A: Yes, primary site, laterality, histology, and stage can be revised when information becomes more complete. Keep in mind, however, that if staging information is updated, it is important to adhere to the timing requirements for the respective staging systems. Most cases that require revision were unknown primaries. (8/05) Q: When a pathology report states tumor size and precedes with "approximately" or "up to" 4.5cm x 1.0cm, should this be captured as 045 or tumor less than 5cm? A: Code as precisely as possible depending on the context of the measurement. "Approximately 4.5cm" should be coded 045. "Up to 4.5cm" would also be coded as 045. For example, if a report stated, "there are four tumors measuring up to 4.5 x 1cm," this statement could be interpreted that to mean that the largest dimension was 4.5 and code accordingly. (9/23/04) Q: On page 25 of the CS Manual Part I for converting tumor size, round down for tenth of mm if between .1 and .4. How do we record a tumor size that is "less than 1.0mm"? A: Be sure that the tumor size is the largest dimension or diameter of the primary tumor and not the depth. Record tumor size as "001" if largest dimension or diameter of tumor is between 0.1 mm and 0.9 mm. (March, 2004) Q: When determining tumor extension, is the information from the gross description or the microscopic description used, where discrepancies exist? A: Generally, the microscopic description takes priority. However, make sure that the microscopic description rules out the contradictory gross impression. In addition, clinical information (imaging or physical examination) may identify more extensive disease that is not biopsied or removed. (9/23/04) Q: When a lymph node(s) is biopsied prior to surgical resection, is that node(s) to be included when calculating nodes examined/evaluated in Collaborative Stage? A: Yes, regional lymph nodes positive and examined are cumulative fields. (See Instructions for Data Items, Regional Nodes Positive, Instruction 4a; and Instructions for Data Items, Regional Nodes Examined, Instruction 4a) (9/23/04) Q: Reg LN Pos / Reg LN Exam. When no regional lymph nodes are pathologically examined, do we use Code 99 "not applicable" as opposed to Code 00 "No nodes examined"? A: When no lymph nodes are pathologically examined the usual pair of codes for Reg LN Pos/Reg LN Exam is 98/00, no nodes examined. (April, 2004) Q: If there is conflicting information, is it correct to follow the "down stage" rule or the Ambiguous Terms listed on p. 20?
A: This is a good philosophical question for all registrars and coders. The term "suspicious for extraprostatic extension" sounds like a clinical finding from the history section of the path report, rather than phrasing that would be used in the gross, micro, or final diagnosis. Normally, extraprostatic extension would be evaluated if the patient had a prostatectomy. On the other hand, if it's a path report from a needle biopsy, it is unlikely that the core biopsy would show extraprostatic extension. If "suspicious for extraprostatic extension" is the only information available, then the overlying instruction in abstracting is "code what you know." This means be conservative and code only that which can be proven. When ambiguous terminology is used, p. 20 of the CS manual indicates that "suspicious for" should be handled as involvement of the stated organ or structure. So in the example, the extraprostatic extension should be coded as 41. (9/23/04) Q: Regarding the output from CS Data: What is the difference in the output data when using a specific code such as (pg 218) LN Code 20 – Multiple ipsilateral nodes listed in code 10 Versus a general code such as LN Code 29 – Stated as 2b, no other information? A: You can see from the rightmost columns on page 218 how the various codes map to N and summary stage. The asterisk indicates that you must know the size of the lymph node in order to properly map codes 20-22. The size of the involved lymph node determines whether the case is N2b or N2c (it can't be N2a because more than one node is involved.). If you don't know the size of the lymph node, you apply the TNM downstaging rule and code N2b. So the output is usually the same. (April, 2004) Q: At the VA, we are in the process of testing the cstage.dll, the Collaborative Staging algorithm, with our VistA Oncology Package. We are happy to report that things are going well so far. How will updates to the staging algorithm be administered? A: The Web site will be updated as changes are defined. Vendors and other interested parties known to the CS Steering Committee will receive e-mail notification of significant updates. (December, 2003) Q: When were Collaborative Staging (CS Version01.00.00) materials released to registry software vendors? A: On August, 2003, the CS Application Program Interface (API), CS Staging and Coding Manual, and the Schema-selection algorithm were released to vendors along with the announcement of the CS Web Page by E-mail list serve announcements. In October, 2003, the CS computer algorithm program and associated files were released to vendors. Updates to the CS algorithm followed in January and April of 2004. (May, 2004) Q: Has there been an assessment done of the comparability between the computed stage in Collaborative Stage versus the stage grouping arrived at through the AJCC TNM 6th edition? A: The CS Task Force has not done any comparability between the two yet, but this may be planned on post implementation. One difference is that the CS generates a single "Best Stage" combining clinical and pathological where AJCC-TNM is pure clinical and/or pure pathological. Also, CS makes some assumptions about T, N, M combinations that are not in the Stage grouping table in TNM. Another difference is in interpretation of unknown status for lymph nodes and distant metastases: the registrar can now make an assumption that nodes and distant mets are negative (N0 M0) rather than unknown (NXMX) in certain situations. Side by side abstracting of cases is necessary to truly compare. This is part of the CS quality improvement plan post-implementation. (April, 2004) Q: Are there any quality assurance processes that are recommended when implementing CS? A: This will be addressed post-implementation by the CS Task Force. (April, 2004)
Revised October 31, 2007 |
