Esophagus, Esophagus GE Junction, Stomach

Esophagus, Esophagus GE Junction, Stomach
Education and Training Team Collaborative Stage Data Collection System Version v02.03 CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Learning Objectives Understand rationale behind changes and updates
Understand use of codes and reporting Determine proper code use for accurate reporting Understand finding specific documentation SSFs Coding rules CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Outline Overview of the following schemas:
Esophagus Esophagus GE Junction Stomach Review Collaborative Stage data items for schemas Describe changes to schemas in CSv2 This presentation will cover the changes and some information on the following schemas: Esophagus, Esophagus GE Junction and Stomach. We will cover all the changes made in version 2, with focus on v02.03 changes. We will then review the data items for each schema. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Esophagus

ICD-O-3 Topography Based on Landmarks Based on Measurement
Cervical esophagus (C15.0) Thoracic esophagus (C15.1) Upper Thoracic Mid Thoracic Abdominal esophagus (C15.2) Lower Thoracic Upper 1/3 esophagus (C15.3) Proximal third of esophagus Middle 1/3 esophagus (C15.4) Mid third of esophagus Lower 1/3 esophagus (C15.5) Distal esophagus These descriptions represent the use of two different ways the esophagus can be divided anatomically. Assign the primary site code that describes the location of the tumor in the same way the tumor's location is described in the medical record. The terms on the right may also be referred to as proximal esophagus, mid esophagus and distal esophagus. If you have both the landmark and a measurement, the measurement supersedes the landmark. The landmarks usually come from a radiologist and the measurement comes from the GI endoscopist. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Esophagus & Esophagus GE Junction: Histologies
Adenocarcinoma Usually forms in the lower third of the esophagus, near the stomach. Squamous Cell Carcinoma Typically found in the upper two thirds of the esophagus. Histologies Stage Table Assign all ICD-O-3 histology codes to either the Adenocarcinoma or Squamous staging tables There are 2 main types of esophageal cancer: adenocarcinoma or squamous cell carcinoma. Adenocarcinomas are usually found in the lower third of the esophagus. Since the entire esophagus is normally lined with squamous cells, squamous cell carcinoma can occur anywhere along the length of the esophagus. For the location examples described here, these are typical. It is possible to have Adenoca in the upper two thirds and Squamous in the lower third. To determine the final stage, there are histology stage tables (these are extra tables). The final stage will be determined by the T, N, M and the histology. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Esophagus: Adenocarcinoma/Squamous Cell Carcinoma
Effective with AJCC TNM 7th Edition, there are separate stage groupings for squamous cell carcinoma and adenocarcinoma. Since squamous cell carcinoma typically has a poorer prognosis than adenocarcinoma, a tumor of mixed histopathologic type or a type that is not otherwise specified should be classified as squamous cell carcinoma. Applies to both Esophagus and EGJ schema AJCC TNM 7 Stage Squamous AJCC TNM 7 Stage Adenocarcinoma In the 7th edition of TNM, separate staging algorithms were developed for adenocarcinoma and squamous. You will not see these differences when coding the CS data items. This will be determined when the final stage is derived. On the cancer staging website (home of CS), there are extra tables that you can review if you have any questions about how your stage was derived. The histology and staging tables apply to both the Esophagus and EGJ schemas. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Esophagus: The Histologies Stage Table
This is an example of the histologies stage table which gives a breakdown of all the ICD-O-3 histology codes and which histology grouping they will go into. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Esophagus AJCC 7th edition stage derived from: T(CS Extension)
N(CS Lymph nodes) & Regional Nodes Positive M(CS Mets at Dx) Eval codes (for clinical/pathologic staging) Grade Histology (Adenocarcinoma vs Squamous Cell) SSF 1: Clinical assessment of regional lymph nodes For clinical cases SSF 2: Specific Location of tumor For Squamous cell carcinomas only This is a summary of the data items that are needed for staging. T is determined by extension only. N (specifically pathologic N) is determined by CS Lymph nodes and Regional nodes positive. M is CS Mets at Dx, and the eval codes. Grade also factors into the staging. Your histology will also determine which staging table you use, the Adenocarcinoma vs. the Squamous SSF 1 is the Clinical Assessment of Lymph nodes and this is how your clinical N will be derived. If you do not have a pathologic evaluation of the lymph nodes, SSF 1 will be used to determine your N. SSF 2 is the specific location of the tumor. This SSF is needed for staging in the squamous cell table. Code it for all cases though. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Esophagus: High Grade Dysplasia
The terminology preferred by pathologists for carcinoma in situ of the esophagus is high grade dysplasia. This terminology is not reportable to most cancer registries. Therefore, it may be a future issue that early/very low stage esophageal cancer is under-reported as a result of registry reporting terminology. If high grade dysplasia of the esophagus is a reportable cancer, it should be coded as 00 in CS Extension. CS Manual Section I Part 2 Page 33 Version There is still a lot of confusion regarding the terminology “high grade dysplasia” for esophagus. Many pathologists today are using the high grade dysplasia terminology to describe in situ cases; however, “high grade dysplasia” is not a reportable term for the cancer registry. This may result in an underreporting of in situ esophageal lesions. For hospital registrars, they need to discuss this with their cancer committee and determine if they will report the high grade dysplasia. Specifically, they need to discuss this with their pathologists to determine how they are using the terminology. If a facility decides to report high grade dysplasia of the Esophagus, code 00 in CS Extension. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Esophagus: CS Extension
OBSOLETE CODES 600 (v02.00): See codes 610 (v02.03): See codes 615, 720, 725 650 (v02.00): See codes 780 (v02.00): See code 660 800 (v02.00): See codes This is a summary of the obsolete codes for all of versions of CSv2. The newest obsolete code is 610, which is from v02.03. Except for code 610, all of these are data retained. For code 610, this is a data reviewed and changed code. For cases initially coded to 610, you need to go review those cases and reassign the extension code to 615, 720 or 725. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Esophagus: CS Extension-v02.03
Code 130: Stated as T1a Code 165: Stated as T1b Code 815: Stated as T4 [NOS] or invasion of adjacent structures, NOS These are the new codes in v Remember: Only use stated as codes when there is no other information available CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Code 615: Initially in code 610 Tumor invades adjacent structures for cervical and intrathoracic esophagus (upper or middle) Maps to T4a Tumor invades Azygos vein moved to new code Code 720: Initially in code 610 Tumor invades adjacent structures for intrathoracic esophagus: Azygos vein Maps to T4b Code 725: Code 610 was obsoleted. Code 615 is the new 610 with one exception, the Azygos Vein (middle of the original code 610), has been removed and reassigned to code 720. This maps to T4b, while the remainder of the adjacent structures in 615 still map to T41. Code 725 is a combination of the these two new codes and maps to a T4b. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Code 728: Azygos vein (upper/middle esophagus) + Pericardium (middle esophagus) Code 740: Tumor invades adjacent structures + Pericardium (middle esophagus) Code 745: Tumor invades adjacent structures + Pleura (upper esophagus, diaphragm fixed (lower esophagus) These are new combination codes for extension. One note on combination codes. It became necessary as many of the codes needed to be split out to meet the new criteria which was divided between different T’s and a, b, c subsets of T’s (this is what happened with code 610). When that happens, new combo codes are needed to talk about involvement of multiple structures, whereas before the structures were all in the same code CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Esophagus: CS Lymph Nodes
Code 255: any of (100, 200, 220) Cervical (upper) + Celiac (lower) lymph nodes + other named regional lymph nodes (code 100) or scalene/supraclavicular (cervical) and superior mediastinal (upper) We are now into the CS lymph nodes. Code 255 is new and is a combination of 100, 200 or 220. This was added to show that multiple nodal regions from different codes are involved. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Code 260: OBSOLETE v02.03 Code 265: Code 260 minus the following: Common hepatic now Mets at Dx code 15 Splenic now Mets at Dx code 15 Codes 270, 275 and 280: Combination codes Note: Code 260 refers to Mets at Dx codes 15, 55 This should be code 15, 50 (the 55 is a typo) Fixed in v02.04 Code 260, which was specific regional lymph nodes for the cervical, intrathoracic and lower thoracic only, is now obsolete due to two of the descriptions moved to mets at dx. These are the common hepatic (now mets at dx code 15) and the splenic lymph nodes (now mets at dx code 15. Note for code 260 states see Mets at dx codes 15 and 55 (which is a combo code), this should be code 50. This is simply a typo. You can cross out the 55 and put 50. This has been fixed in v02.04. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Code 300: OBSOLETE v02.03 Code 305: Code 300 minus the following: Common hepatic now Mets at Dx code 15 Splenic now Mets at Dx code 15 Codes 310, 320, 330: Combination codes Code 300, which is for all Esophageal subsites is now obsolete due to two of the descriptions moved to mets at dx (same situation as obsoleted code 260). These are the common hepatic (now mets at dx code 15) and the splenic lymph nodes (now mets at dx code 5004) under the cervical esophagus. The remaining lymph nodes are coded in 305. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Code 560: Stated as pathologic N1 Code 600: OBSOLETE v02.03 Stated as clinical N2 (no lymph nodes removed) See code 500 (regional lymph nodes, NOS) Code 700: OBSOLETE v02.03 Stated as clinical N3a (no lymph nodes removed) Only use pathologic “stated as” codes in CS Lymph nodes (560, 610, 710) Code 560 is added for a stated as pathologic N1. Do not use this code if you only have a clinical assessment of the lymph nodes (see SSF 1) For code 600 and 700, these were removed from CS Lymph nodes since they were clinical evaluation. Clinical assessment of lymph nodes should be collected only in SSF 1. The instructions given here are to code 500 when there is clinical assessment only and then record additional information (such as a stated as clinical N1) in SSF 1. The only stated as codes that should be collected in CS Lymph nodes are the pathologic assessments. These would be codes 560, 610 and 710. Once again, the stated as codes should only be used when no other information is available. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Pathologic N derived from CS Lymph Nodes (codes ) and Reg Nodes Pos CS Lymph node eval code 2, 3, 6, 8 N1: Metastasis in regional lymph nodes Regional nodes positive coded 95-99 N2: Metastasis in regional lymph nodes N3: Metastasis in regional lymph nodes Code 500 when number of positive nodes available, but names of nodes not documented Code 800 when unknown if regional or distant ALWAYS defaults to a N1 For lymph node codes , your pathologic N is based on the number of regional nodes positive. For a N1, you have 1-2 positive lymph nodes or codes (which include positive aspiration, positive number but unknown, no nodes examined and unknown if nodes positive), N2 is 3-6 and N3 is Codes should always be used when you have the number of positive lymph nodes. In other words, do not use the stated as codes when the number of positive nodes are available. If you have the number of positive nodes available, but there is no documentation of which ones they are, use code 500. This will provide the correct N based on the number of positive lymph nodes. Use code 800 only when you don’t know if they are regional or not. Code 800 always defaults to a N1, so be very careful about using this code when you have the number of positive nodes available. You may end up with the incorrect N code. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Esophagus: CS Mets at Dx
Codes 11 & 12: OBSOLETE v02.00 Defined as regional in AJCC 7th edition, see CS Lymph node codes 250 and 265 Still mapped as mets at dx for AJCC 6th edition Code 15: Common hepatic and splenic From CS Lymph nodes code 260 CS Mets at Dx did not have many changes, except for the lymph nodes. The specific lymph nodes listed in original codes 11 and 12 were made obsolete in v For AJCC 7th edition, these are now regional. For AJCC 6th edition, they are still coded as distant. The descriptions from codes 11 and 12 were moved over to codes 250 and 265; however, during the validation review, it was discovered that two sets of lymph nodes were moved to regional when they should have stayed distant. These are the common hepatic and splenic nodes, which are now back in mets and coded 15. To make sure that your data is correct, review CS Lymph nodes code 260 to determine if you have any common hepatic or splenic nodes. If so, change your lymph node code another lymph node if other positive nodes (or to 000 if no other positive) and then code mets at dx 15. If you already have metastatic disease, change your mets code to 50 to show distant mets plus distant lymph nodes. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Esophagus SSF 1: Clinical Assessment of Regional Lymph Nodes
Code clinical “stated as” codes in SSF 1 100: Stated as N1 1-2 positive nodes, clinically 200: Stated as N2 3-6 regional nodes positive, clinically 300: Stated as N3 7 or more regional nodes positive, clinically 400: Clinically positive regional nodes positive No other information on clinical status of nodes As you will recall, for CS Lymph nodes, I emphasized that any clinical “stated as” codes for lymph nodes needed to be coded in SSF #1. Here are the codes that you should use for clinical assessment of regional codes. For SSF 1, there are not separate codes for “stated as” codes, they are combined with the actual number of positive regional nodes (if given). Code 400 is used when there is statement of positive clinical lymph nodes, or positive clinical nodes are seen on imaging, and there is no further information to assign one of the N categories. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Esophagus SSF 1: Clinical Assessment of Regional Lymph Nodes
Deriving Clinical N CS Lymph nodes 000, automatically derived CS Lymph nodes use extra table Lymph Nodes Clinical Evaluation AJCC 7 Table CS Lymph nodes CS Lymph nodes eval code 0, 1, 5, 9 N derived from combination of regional nodes positive and SSF 1 For those cases where all you have is clinical information for nodes, your N will be derived from another extra table. This is why it’s important to code SSF 1 as accurately as possible, especially when there is no pathologic information on lymph nodes. For CS Lymph nodes 000 (none) and (which are the stated as codes and other defaults), the extra table is not used. Remember, if you have a clinical only case, codes 560, 610 and 710 should not be used. These are the stated as pathologic codes. For CS Lymph node codes AND CS Lymph node eval 0, 1, 5, 9, your clinical N code will be derived based on the regional nodes positive and SSF 1. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Esophagus SSF 2: Specific Location of Tumor
Staging element for squamous cell tumors Collect for all histologies AJCC definition of location: Position of upper (proximal) edge of tumor in esophagus Location of tumor provides information about extension to adjacent structures Coding a upper thoracic esophagus tumor ICD-O-3: C15.1 (Thoracic esophagus) SSF #2: 020 (Stated as upper thoracic esophagus) This SSF provides you with additional information about the specific location of the tumor. Although it specifically mentions Squamous Cell Carcinoma, this should be collected for all histologies. This type of information is especially important when you have an esophageal primary that extends to adjacent structures. I have provided a simple example here. If you are given information that the tumor is in the upper thoracic, your ICD-O-3 code would be thoracic esophagus, but this SSF would provide you with the additional information that the tumor was located in the upper thoracic. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Esophagus SSF 3: Number of Regional Nodes with Extracapsular Tumor
Tumor involvement of lymph node which spills beyond the wall of the node into surrounding fat Poor prognostic factor Information found in pathology report If extracapsular ext. noted to be negative, code 000 If no mention of extracapsular ext., code 990 If lymph node examination done and results not available, code 997 If no pathologic assessment of lymph nodes, code 998 Extracapsular extension is when the lymph node spills beyond the wall of the node into the surrounding fat. This is an unfavorable prognostic indicator. This information is usually found in the pathology report. For this site specific factor, you are coding the number of regional lymph nodes that are indicated as having extracapsular extension. This number should always be less than or equal to your regional nodes positive. Use code 000 ONLY when extracapsular extension is documented as negative. If you have positive nodes and there is no documentation or mention of extracapsular extension, use code 990. If a lymph node exam was done and you don’t have the results, use code 997. If there is no pathologic exam, in other words you only have a clinical assessment of lymph nodes, code 998. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Esophagus SSF 4: Distance to Proximal Edge of Tumor from Incisors
Measures distance from incisors (teeth) to the uppermost (proximal) point of the tumor Codes : code to nearest centimeter Codes : range codes for when exact distance is not available Code 999: unknown The site of an esophageal primary is defined by its uppermost point (the proximal edge) to the lowermost point (the distal edge). For this SSF, you are recording the distance from the incisors (the teeth) to the uppermost, or proximal edge of the tumor. This information can be found in imaging reports, or an esophagoscopy or a surgical report. Codes are for when you have an exact measure. Record the distance in centimeters. Codes are for when you have a range code, such as “less than 20” or “greater than 30 cm” CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Esophagus SSF 5: Distance to Distal Edge of Tumor from Incisors
Measures distance from incisors (teeth) to the lowermost(distal) point of the tumor Codes : code to nearest centimeter Codes : range codes for when exact distance is not available Code 999: unknown For this SSF, you are recording the distance from the incisors (the teeth) to the lowermost, or distal edge of the tumor. The instructions for SSF 4 apply to this SSF as well. Just remember that SSF #4 is for the uppermost part of the tumor and SSF 5 is for the lowermost part of the tumor. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Esophagogastric Junction

Esophagus & Esophagus GE Junction: Histologies
Adenocarcinoma Usually forms in the lower third of the esophagus, near the stomach. Squamous Cell Carcinoma Typically found in the upper two thirds of the esophagus. Histologies Stage Table Assign all ICD-O-3 histology codes to either the Adenocarcinoma or Squamous staging tables We covered this same slide in the Esophagus section, but this applies to EGJ as well. There are 2 main types of esophageal cancer: adenocarcinoma or squamous cell carcinoma. Adenocarcinomas are usually found in the lower third of the esophagus. Since the entire esophagus is normally lined with squamous cells, squamous cell carcinoma can occur anywhere along the length of the esophagus. For the location examples described here, these are typical. It is possible to have Adenoca in the upper two thirds and Squamous in the lower third. To determine the final stage, there are histology stage tables (these are extra tables). The final stage will be determined by the T, N, M and the histology. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Esophagus GE Junction AJCC 7th edition stage derived from:
T(CS Extension) N(CS Lymph nodes) & Regional Nodes Positive M(CS Mets at Dx) Eval codes (for clinical/pathologic staging) Grade Histology (Adenocarcinoma vs Squamous Cell) SSF 1: Clinical assessment of regional lymph nodes For clinical cases SSF 25: Schema discriminator This is a summary of the data items that are needed for staging and was also covered in the Esophagus section. T is determined by extension only. N (specifically pathologic N) is determined by CS Lymph nodes and Regional nodes positive. M is CS Mets at Dx, and the eval codes. Grade also factors into the staging. Your histology will also determine which staging table you use, the Adeno vs. the Squamous SSF 1 is the Clinical Assessment of Lymph nodes and this is how your clinical N will be derived. If you do not have a pathologic evaluation of the lymph nodes, SSF 1 will be used to determine your N. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Esophagus GE Junction: CS Extension
OBSOLETE CODES 130 (v02.00): Polyps not relevant for schema 140 (v02.03): Polyps not relevant for schema 430 (v02.03): See code 480 600 (v02.03): See codes 570, 605, 615 610 (v02.03): See codes 570, 615 710 (v02.03): See code 810 720 (v02.03): See code 580 820 (v02.03): See code 805 For CS extension in the EGJ schema, these are the obsolete codes. Codes 130 and 140 are now obsolete because there are no polyps in the EGJ schema. Codes 430, 710, 720 and 820, these codes were reassigned to standardize the format for stated as codes. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Esophagus GE Junction: CS Extension-v02.03 New Codes
Explanation 125 Stated as T1a 480 Stated as T3 (previously coded 430) 570 Pericardium, Pleura, Diaphragm (previously coded 600) 580 Stated as T4a (previously coded 720) 605 Code 600 minus organs now listed in codes 570 (also includes transverse colon, including flexures) 615 Combination of codes 570 and 605 805 Stated as T4b (previously coded 820) 810 Stated as T4 [NOS] (previously coded 720) These are the major changes to Esophagus GE Junction for extension. A T1a has now been added. As mentioned in the previous slide, codes 480, 580, 805 and 810 are part of the realignment and standardization of codes. These are automatically converted. New codes 570, 605 and 615 are the result of code 600 being made obsolete. Code 600 had several organs listed which resulted in a mapping of T4a. Pericardium, Pleura and Diaphragm (now in code 570), were removed from code 600 and still map to T4a. For the remaining organs listed in the old code 600 (now code 615), these now map to T4b For code 605, the “transverse colon, including flexures” was inadvertently left off when the change in codes took place. If you have a case where these structures are involved, continue to use code 605. This is where they belong. A release note for this will be on the CS web site and it will be fixed in a future edition of CS. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Esophagus GE Junction: CS Lymph Nodes
Named regional lymph nodes: Code 100: Multiple named lymph nodes Code 400: Celiac lymph nodes Code 450: Paraesophageal/Periesophageal Regional lymph nodes, NOS Code 500: Regional lymph nodes, NOS Lymph nodes, NOS Code 800: Lymph nodes, NOS For EGJ, you have only three codes that specify the named lymph nodes. Code 100 has the most specific lymph nodes. Code 400 is for celiac lymph nodes only and code 450 is for paraesophageal/periesophageal lymph nodes. Like so many other schemas, lymph nodes aren’t always named. If that situation occurs and you have a statement of “regional lymph nodes,” then use code 500. If it is unclear if positive lymph nodes or regional or not, use code 800. As with all other schemas, use of this code will automatically default to the lowest N value, which is N1. All these codes can be used for clinical or pathologic evaluation of lymph nodes. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Esophagus GE Junction: CS Lymph Nodes
Code 610: Stated as pathologic N1 Code 650: OBSOLETE v02.03 Stated as clinical N2 (no lymph nodes removed) See code 500 (regional lymph nodes, NOS) Code 700: OBSOLETE v02.03 Stated as clinical N3a (no lymph nodes removed) Only use pathologic “stated as” codes in CS Lymph nodes (610, 660, 720) Code 610 is added for a stated as pathologic N1. Do not use this code if you only have a clinical assessment of the lymph nodes (see SSF 1) For code 650 and 700, these were removed from CS Lymph nodes since they were clinical evaluation. Clinical assessment of lymph nodes should be collected only in SSF 1. The instructions given here are to code 500 when there is clinical assessment only and then record additional information (such as a stated as clinical N1) in SSF 1. The only stated as codes that should be collected in CS Lymph nodes are the pathologic assessments. These would be codes 610, 660 and 720, . Once again, the stated as codes should only be used when no other information is available. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Pathologic N derived from CS Lymph Nodes (codes ) and Reg Nodes Pos CS Lymph node eval code 2, 3, 6, 8 N1: Metastasis in regional lymph nodes Regional nodes positive coded 95-99 N2: Metastasis in regional lymph nodes N3: Metastasis in regional lymph nodes Code 500 when number of positive nodes available, but names of nodes not documented Code 800 when unknown if regional or distant ALWAYS defaults to a N1 For lymph node codes , your pathologic N is based on the number of regional nodes positive. (We will cover clinical assessment in SSF 1) For a N1, you have 1-2 positive lymph nodes or codes (which include positive aspiration, positive number but unknown, no nodes examined and unknown if nodes positive), N2 is 3-6 and N3 is Codes should always be used when you have the number of positive lymph nodes. In other words, do not use the stated as codes when the number of positive nodes are available. If you have the number of positive nodes available, but there is no documentation of which ones they are, use code 500. This will provide the correct N based on the number of positive lymph nodes. Use code 800 only when you don’t know if they are regional or not. Code 800 always defaults to a N1, so be very careful about using this code when you have the number of positive nodes available. You may end up with the incorrect N code. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Esophagus GE Junction: CS Mets at Dx
Code 10: Distant lymph nodes Code 40: Distant mets (except distant LN’s) Code 50: Distant mets & distant lymph nodes Code 60: Distant mets, NOS Stated as M1 with no other info on Mets Code 99: Unknown if mets The Mets at Dx codes for this schema are fairly straightforward. First code is the distant lymph nodes, then the distant mets, then a combination of distant lymph nodes and distant mets. Code 60 should be used when you have a stated as M1 code or distant mets are mentioned and are not specified. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Esophagus GE Junction: SSF 25 Schema Discriminator
Primary site codes C16.0, C16.1, C16.2 For primary site codes C16.3-C16.9, code 981 for the stomach schema Cases coded to C16.0-automatically go to EGJ schema (use code 010) Before we cover SSF 25, I wanted to remind you that SSF’s 1, 3, 4 and 5 in the EGJ schema are identical to the Esophagus SSF’s, which we covered in the Esophagus section. SSF #2 for EJG schema is obsolete The purpose of SSF #25 is to determine if you need to go into the Stomach schema or the EGJ schema. For all cases in the C16 category, you will need to fill out SSF #25 before your schema is determined. To qualify for the EGJ schema, you must have a primary site code of C16.0, C16.1 and C16.2. For primary site codes C16.3-C16.9, you would code 981 and be directed to the Stomach schema. The purpose of this SSF is to determine exactly where the tumor is located. Once that determination is made, you will know if you are dealing with an EGJ tumor or a stomach tumor CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Stomach CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Stomach AJCC 7th edition stage derived from: T(CS Extension)
N(CS Lymph nodes) & Regional Nodes Positive M(CS Mets at Dx) Eval codes (for clinical/pathologic staging) SSF 1: Clinical assessment of regional lymph nodes For clinical cases SSF 25: Schema discriminator Needed for primary sites C16.0, C16.1 and C16.2 Please review changes to slide and notes/repeated from Esophagus section per comments This is a summary of the data items that are needed for staging and was also covered in the Esophagus GE section . T is determined by extension only. N (specifically pathologic N) is determined by CS Lymph nodes and Regional nodes positive. M is CS Mets at Dx, and the eval codes. SSF 1 is the Clinical Assessment of Lymph nodes and this is how your clinical N will be derived. If you do not have a pathologic evaluation of the lymph nodes, SSF 1 will be used to determine your N. SSF 25 is used to determine whether you have a stomach primary or EGJ junction when your primary site code is C16.0, C16.1 or C16.3 CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Stomach: Histologies Adenocarcinoma, NOS (42.9%)
Signet ring cell carcinoma (15.6%) Adenocarcinoma, Intestinal type (7.2%) Lymphomas (10.1%) NHL, large B-cell diffuse Marginal zone B-cell lymphoma, NOS Others Here is a histology breakdown of some of the most common stomach histologies. Between adenocarcinoma, NOS and adenocarcinoma, intestinal type, over 50% of the histologies are accounted for. Signet ring is almost 16%. What’s interesting is that approx. 10% of our stomach cases are lymphomas. Of course, if you had a lymphoma, your CS would be the lymphoma schema and not the stomach, but I did want to share this. Stomach is one of the most common extralymphatic sites for lymphomas. The data presented here is from the SEER registries for CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Stomach: CS Extension New Codes for Version 2
125: Stated as T1a 170: Stated as T1b 180: Stated as T1 [NOS] (previously340) 390: Stated as T2 480: Stated as T3 555: Stated as T4a (previously 500) 805: Stated as T4b (previously 690) 810: Stated as T4 [NOS] (previously 490) These are the new extension codes that were added for Stomach in v2. Some of these were added in v02.00, some in v02.02 and the remaining ones in v02.03. For the codes that have the comment “converted from in v02.03), this was part of the realignment of codes during the validation project. This was to ensure that all subcategory stated as codes followed the same pattern, a, b, then NOS. Remember: only use the stated as codes when there is no other information available. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Stomach: CS Extension T1a: Invasion of lamina propria or muscularis mucosae T1b: invasion of the submucosa T2: Invasion of the muscularis propria T3: Invasion of the subserosal connective tissue (no invasion of serosa or adjacent structures) T4a: Penetrates the serosa T4b: Invades adjacent structures The T categories for Stomach have been harmonized with the T categories of the esophagus, large and small intestine so they can be compared (AJCC 7th edition, p. 117) The T1 tumors are now divided into invasion of the muscularis mucosae and the submucosa T2 tumors are invasion of the muscularis propria T3 is invasion of the subserosal tissue T4 tumors are now divided into penetration of the serosa (T4a) and invasion of adjacent structures (T4b) CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Stomach: CS Extension Intraluminal extension (T1a and T1b)
Occurring within, or introduced into the lumen AJCC 7th edition: “Intramural (intraluminal) extension is classified by depth of greatest invasion) See Note 1, Ext 3 new codes have “intraluminal extension” as part of their description Code 122 (T1a) Code 165 (T1b) Code 360 (T2) situated within, occurring within, or introduced into the lumen <intraluminal inflammation of the esophagus> Intraluminal extension was introduced into several of the codes because of AJCC 7th edition. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Stomach: CS Extension Code 500 (CSv1), OBSOLETED and divided
Code 505: Invasion of/through serosa If invasion of serosa AND extension to adjacent structures, see codes 610, 650 and 700 Code 551: Invasion of serosa and Extension to adjacent connective tissue Code 555: Stated as T4a (previously in 500) Code 500 was made obsolete. The only difference between code 500 and code 505 is that the stated as T4a information is now collected in it’s own code, which is 555. Several codes throughout CS were obsoleted for this very reason since they wanted to the stated as codes to be separate. Code 551 is a new combination code which includes code 450 (invasion of connective tissue) and the new code 505, invasion of the serosa. The stated as T4a code is now 555. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Stomach: CS Extension Adjacent structures of the Stomach (Ext code 610, T4b) Spleen Transverse Colon Liver Diaphragm Pancreas Abdominal wall Adrenal gland Kidney Small Intestine Retroperitoneum We just covered the codes that will derive a T4a, now we will look at the codes that will derive a T4b. T4b is defined as extension to adjacent organs. This is a listing from the AJCC 7th edition of the adjacent structures of the stomach. If you remember your CSv1 codes, you may notice that two structures are missing. 7th edition AJCC manual, p. 120 CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Stomach: CS Extension OBSOLETE Code 600 (extension to adjacent structures) now divided into: Code 610: All structures in code 600 MINUS Aorta and Celiac Axis Maps to Summary Stage Regional Code 650: Aorta and Celiac Axis Maps to Summary Stage Distant There are now 2 codes used for extension to adjacent structures and that’s because of the two structures that were in the old T4 code for adjacent structures. In CSv1, code 600 included all the sites mentioned on the previous slide, plus Aorta and Celiac axis. Code 600 is obsolete and has been divided into 610 and 650. Adjacent structures mentioned in the AJCC manual are now in code 610 and the Aorta and Celiac Axis are now in code 650. Also, the celiac axis and aorta map to a different summary stage. Both 610 and 650 map to a T4b. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Stomach: CS Lymph Nodes
Left gastric Pancreaticosplenic Pancreatoduodenal Perigastric, NOS Peripancratic Right gastric Superior mesenteric Celiac Hepatic Hepatoduodenal (for lesser curvature only) Regional lymph nodes of the stomach include several groups of nodes that drain the wall of the stomach. Other regional nodal groups follow the main arterial and venous vessels from the aorta and the portal circulation. The nodes listed on the slide are general groups of nodes. You will find more specific names in the CS Lymph Nodes section of the stomach schema in CSv2. When assigning the pathologic N in AJCC 7th Ed. cancer staging, it is important to have adequate nodal dissection. In AJCC 7th Ed. it is suggested that at least 16 regional lymph nodes be assessed pathologically; however pN0 may be assigned on the basis of the actual number of nodes evaluated microscopically. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Code 100: OBSOLETE Includes “see also code 050” No code Will be removed in future version Code 110: Same as code 100 MINUS Superior mesenteric Superior mesenteric coded in Mets at Dx code 10 The change in CS Lymph nodes is fairly minor. During review of the lymph nodes, the superior mesenteric nodes (near the bottom of that long list of nodes from code 100), was in CS Lymph nodes and CS Mets at Dx. Code 100 was obsoleted, the superior mesenteric nodes were removed. Also, note seen in code 100 says to see also code 050. There is no code 050. This will be removed in a future version and can be ignored. Code 110 is the same as 100 EXCEPT for the superior mesenteric nodes, which are coded in CS Mets at Dx, code 10 (which was not changed.) The data for code 100 is retained and review is needed to determine if you have superior mesenteric nodes or not. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Code 600: OBSOLETE v02.03 Stated as N1 See codes 500, 610, SST 1 code 100 Code 650: OBSOLETE v02.03 Stated as N2 See codes 500, 660, SSF 1 code 200 Code 700: OBSOLETE Stated as N3 See codes 500, 750, SSF 1 code 300 We covered this same situation in the esophageal schemas, but the stomach lymph nodes are slightly different. The concept is still the same. You only want to code pathologic “stated as” codes in CS Lymph nodes. Clinical “stated as” codes should be coded in SSF. For the stomach CS lymph nodes, there were no “stated as” clinical codes, unlike the esophagus schemas. They simply had “stated as.” Both clinical and pathologic information would have been collected in these. These are data retained and reviewed cases which need to be reviewed to determine which code to us. For example, cases coded to 600. If the “stated as” code was based on clinical evaluation, then you would code to 500 (regional nodes, NOS) and SSF 1 would be coded to 100. If your “stated as” codes was based on pathologic evaluation, then you would code 610. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Pathologic N derived from CS Lymph Nodes (codes ) and Reg Nodes Pos CS Lymph node eval code 2, 3, 6, 8 N1: Metastasis in regional lymph nodes N2: Metastasis in regional lymph nodes N3a: Metastasis in regional lymph nodes N3b: Metastasis in 16 or more regional lymph nodes Code 500 when number of positive nodes available, but names of nodes not documented Code 800 when unknown if regional or distant ALWAYS defaults to a N1 For lymph codes , your pathologic N is based on the number of regional nodes positive. For a N1, you have positive lymph nodes, N2 is 03-06, N3a is and N3b is 16 or more. Codes should always be used when you have the number of positive lymph nodes. In other words, do not use the stated as codes when the number of positive nodes are available. If you have the number of positive nodes available, but there is no documentation of which ones they are, use code 500. This will provide the correct N based on the number of positive lymph nodes Use code 800 only when you don’t know if they are regional or not. Code 800 always defaults to a N1, so be very careful about using this code when you have the number of positive nodes available. You may end up with the incorrect N code. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Stomach: CS Mets at Dx Common Metastatic Sites
Liver Peritoneal surfaces Malignant peritoneal cytology is classified as metastatic disease Distant lymph nodes Retropancreatic Para-aortic Portal Retroperitoneal Mesenteric The most common metastatic sites from stomach cancer are the liver, peritoneal surfaces, and distant lymph nodes. It is important to note that malignant peritoneal cytology is classified as metastatic disease. Metastasis to the intra-abdominal lymph node groups listed on the slide is coded as distant metastasis for stomach primaries. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

Stomach: CS Mets at Dx Code 10: Distant lymph nodes
Includes Superior mesenteric from old LN code 100 Code 40: Distant mets, INCLUDING positive peritoneal cytology Code 50: Codes Code 60: Distant mets, NOS; Stated as M1 Mets for Stomach is straightforward. Code 10 is for distant lymph nodes, which are listed in the code and also in the AJCC chapter. As a reminder, superior mesenteric nodes are collected in code 10. The positive peritoneal cytology is coded in 40. If you have a negative peritoneal cytology with no other evidence of mets, then you don’t have mets. Then you have the combo code for distant lymph nodes and other distant organs, plus the NOS codes and stated as code. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

CS SSF1: Stomach-Clinical Assessment of Regional Lymph Nodes
Documents clinical assessment of regional lymph nodes prior to treatment When clinically positive nodes stated: 100: 1-2 regional lymph nodes (N1) 200: 3-6 regional lymph nodes (N2) 300: 7 or more regional lymph nodes (N3) 310: 7-15 regional lymph nodes (N3a) 320: 16 or more regional lymph nodes (N3b) CS SSF1 for stomach documents the clinical assessment of regional lymph nodes prior to surgery or neoadjuvant therapy. As you may recall from the discussion of the CS Lymph Nodes data field, the data field SSF1 for stomach is one of the data fields used to correctly map to the clinical N category when involved regional lymph nodes are identified on imaging of the chest, abdomen or pelvis. Diagnostic procedures that clinically assess the involvement of regional lymph nodes of the stomach include CT, MRI, plain radiographs and endoscopic ultrasound (EUS). It is unlikely that a physical exam would show involved regional nodes for the stomach, but it is possible. Endoscopic procedures are excluded; they can only view the inside of the gastrointestinal tract and cannot assess regional lymph nodes. So, looking at the codes, you can see that what we code in this data field is the clinical N category. As stated in the note that precedes the codes for SSF1 for stomach, in the rare instance that the number of clinically positive nodes is stated but a clinical N category is not stated, code 1-2 nodes as 100 (N1), 3-6 nodes as 200 (N2), 7-15 nodes as 310 (N3a), and 16 or more nodes as 320 (N3b). If the number is only described as "more than 7 nodes", code as 300 (N3, NOS). Also included is code 400, which is used when you know that there are clinically positive nodes but the number is not known and there is no documented clinical N category. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

CS SSF2: Stomach Specific Location of Tumor
Clinically significant prognostic factor Identifies specific location of the tumor within the stomach Provides more specificity of tumor location than ICD-O-3 Tumor identified in anterior wall of antrum ICD-O-3: C16:3-Gastric antrum SSF #2: 090- Antrum Anterior wall In SSF2 for the stomach, we code the specific location within the stomach of the primary tumor. Exact location of the tumor is a clinically prognostic factor which factors into survival. This data field provides more specificity on tumor location than the ICD-O-3 topography code does. In the example included here is a tumor identified in the anterior wall of the antrum. For ICD-O-3, our topography code would be gastric antrum. The location of the tumor is identified, but its location in the antrum is not known. SSF #2 provides more specific descriptions for location and by coding 090 for this example, we can document that this tumor was in the antrum, anterior wall. This SSF is not required by any of the standard setters; however, if you choose to collect it, make sure that your primary site codes and SSF #2 do agree with each other. Using our example, a code 040, for Body, Anterior wall, would conflict with the primary site code of C16.3 CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

SSF13: Stomach Carcinoembryonic Antigen (CEA)
Same coding instructions as given for coding CEA values for Colon Code the interpretation of highest lab value of CEA prior to treatment If no documentation of test in record, code 999 Do NOT assume it was not done Code 998 may be done if you know the test was not done on the patient or your facility routinely does not do CEA’s on Stomach cancer patients Code the interpretation of highest lab value of CEA prior to treatment as stated by the clinician in SSF13 for the stomach. Source documents in the patient record for CEA interpretation include clinical laboratory report, sometimes pathology or cytology report, H&P, operative report, consultant report, and discharge summary. This data field is not required by CoC or SEER. However, serum CEA is considered a clinically significant prognostic factor in the AJCC 7th Ed. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

CS SSF14: Stomach Carcinoembryonic Antigen (CEA) Lab Value
Record in nanograms/milliliter highest CEA lab value prior to treatment Needs to be in agreement with SSF #13 If test not done coded for SSF #13, test not done needs to be coded for SSF #14 If coded unknown in SSF #13, unknown needs to be coded in SSF #14 We also code information about CEA in SSF14 for stomach. In this data field record the actual lab value of CEA; that is, record in nanograms/milliliter the highest CEA lab value prior to treatment. SSF’s 13 and 14 are related and the codes should agree with one another. For example, if you code test not done in one, test not done should be coded in the other one. Same with unknown. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

CS SSF15: Stomach CA 19-9 Lab Value
Record in units/milliliter the highest CA 19-9 lab value prior to treatment If no documentation of test in record, code 999 Do NOT assume it was not done Code 998 may be done if you know the test was not done on the patient or your facility routinely does not do CEA’s on Stomach cancer patients Not required by any standard setters May use code 988 Serum Carbohydrate Antigen (CA) 19-9 is a tumor marker in the management of gastrointestinal malignancies. CA 19-9 is produced in excess by adenocarcinomas and released into the blood. In SSF15 for stomach record in units/milliliter the highest CA 19-9 lab value prior to treatment recorded in the medical record. In Canada, the unit of measurement is KiloU/Liter (KU/L). To convert to units/ml, multiply KU/L by Source documents for this information include clinical laboratory report (blood serum) and history and physical. This SSF is not required by any of the standard setters and code 988 may be used. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

CS SSF25: Stomach Involvement of Cardia & Distance from EGJ
Fundus (C16.1) and body (C16.2) of stomach can be assigned to either EsophagusGEJunction or Stomach CSv2 schema SSF25 is schema discriminator field needed for CS algorithm to determine which schema to select when site is C16.1 or C16.2 The fundus (C16.1) and body (C16.2) of the stomach can be assigned to either 2 different CSv2 schemas; the EsophagusGEJunction or Stomach CSv2 schemas. SSF25 is the schema discriminator field needed for the CS algorithm to determine which schema to select when site is C16.1 or C16.2. Since this was covered in more detail in the EGJ portion of the presentation, we will not go over it again. CSv2 Esophagus, EGJ, Stomach August Lecture Version: 1.0

CAnswer Forum Submit questions to CS Forum
Located within the CAnswer Forum Provides information for all Allows tracking for educational purposes Includes archives of Inquiry & Response System CS Forum: CS Web Site: CSv2 Bladder, Kidney & Testis June Lecture Version: 1.0

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Esophagus, Esophagus GE Junction, Stomach

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