1. The Anatomy of Collaborative Staging: Ovary Presentation developed by Collaborative Staging Steering Committee ajcc@facs.org 2005 Update

2. CS Ovary Coding 2005 Structures of Female Pelvis

3. CS Ovary Coding 2005 Ovarian Cancer  Collaborative Stage fields Tumor Size--standard Extension TS/Ext Eval--standard Lymph Nodes LN Eval--standard LN Pos--standard LN Exam--standard Mets at Dx Mets Eval--standard Site-specific Factor 1--CA-125 Site-specific Factors 2-6--not applicable

4. CS Ovary Coding 2005 CS Extension--Notes 1. Ascites  Positive ascites changes stages I and II to IC and IIC.  Disregard negative ascites or ascites, NOS 2. Pelvic organs* coded to 50-65 (FIGO Stage II)  Adnexa, bladder (including serosa), uterine ligaments, cul de sac, fallopian tubes, parametrium, pelvic peritoneum, pelvic wall, rectum, sigmoid colon, ureter, uterus, uterine serosa 5. Abdominal organs* coded to 70-75 (FIGO III)  Abdominal mesentery, diaphragm, gallbladder, infracolic omentum, kidneys, large intestine except rectum and sigmoid, peritoneal surface of liver, omentum, pancreas, pericolic gutter, peritoneum, NOS, small intestine, spleen, stomach, ureters * Involvement may be direct or discontinuous

5. CS Ovary Coding 2005 CS Extension--Notes 6. Liver parenchymal metastases are coded in Mets at Dx. Implants (discontinuous metastases) Other names: seeding, salting, studding, talcum powder appearance 4. Determine whether implants are in pelvis (code 60-64) or abdomen (code 70-73) or unspecified (code 75) 3. Implants outside the pelvis must be microscopically confirmed and coded by size 70Microscopic only 71Macroscopic < 2 cm 72Macroscopic > 2 cm 73Mets outside pelvis, size not stated 75Peritoneal implants, NOS [not stated as pelvic or abdominal]

6. CS Ovary Coding 2005 CS Extension Codes (FIGO I) 10 One ovary, capsule intact, no tumor on surface, negative ascites (FIGO IA) 20 Both ovaries, capsules intact, no tumor on surface, negative ascites (FIGO IB) Source: TNM Atlas, 3rd ed. 2nd rev., by B. Spiessl et al. Springer Verlag 1992.

7. CS Ovary Coding 2005 CS Extension Codes (FIGO IC) One or both ovaries 35 Capsule ruptured 36 Tumor on surface Source: TNM Atlas, 3rd ed. 2nd rev., by B. Spiessl et al. Springer Verlag 1992. 41 One or both ovaries positive ascites or washings

8. CS Ovary Coding 2005 CS Extension Codes 50-52 (FIGO IIA) Extension to or implants on: (negative ascites/washings) 50 Adnexa/tubes, ipsilateral 52 Adnexa/tubes, contralateral 52 Uterus Source: TNM Atlas, 3rd ed. 2nd rev., by B. Spiessl et al. Springer Verlag 1992.

9. CS Ovary Coding 2005 CS Extension Codes 60, 61 (FIGO IIB) Extension to or implants on: (negative ascites) 60 Other pelvic structures* (ipsilateral) 61 Other pelvic structures* (contralateral) * ligaments, mesovarium, pelvic wall, adjacent peritoneum Source: TNM Atlas, 3rd ed. 2nd rev., by B. Spiessl et al. Springer Verlag 1992.

10. CS Ovary Coding 2005 CS Extension Codes 62-64 (FIGO IIC) Tumor confined to pelvis with positive ascites 62 Ipsilateral (50 and/or 60) 63 Contralateral (52 and/or 61) 64 Other pelvic structures Source: TNM Atlas, 3rd ed. 2nd rev., by B. Spiessl et al. Springer Verlag 1992.

11. CS Ovary Coding 2005 CS Extension Code 70-75 (FIGO III) Source: TNM Atlas, 3rd ed. 2nd rev., by B. Spiessl et al. Springer Verlag 1992. 70 Microscopic peritoneal implants (FIGO IIIA) 71 Macroscopic peritoneal implants < 2 cm (FIGO IIIB) 72 Macroscopic peritoneal implants > 2 cm (FIGO IIIC)

12. CS Ovary Coding 2005 Liver Involvement CS Extension codes 70-73: Tumor on capsule or surface of liver (FIGO III) Mets at Dx code 40: Metastasis inside liver (parenchymal) (FIGO IV) Source: TNM Atlas, 3rd ed. 2nd rev., by B. Spiessl et al. Springer Verlag 1992.

13. CS Ovary Coding 2005 CS Lymph Nodes--Notes 1. Code distant nodes in Mets at Dx. 2. If there is a statement that “adnexa palpated” with no mention of lymph nodes, assume lymph nodes are not involved (code 00). 3. If exploratory or definitive surgery with no mention of nodes, assume nodes are negative (00). 4. Regional nodes include bilateral and contralateral involvement of named nodes.

14. CS Ovary Coding 2005 CS Lymph Nodes Source: TNM-Interactive, UICC, 1998 Code 10 1 Hypogastric (internal iliac) Obturator 2 Common iliac 3 External iliac Code 12 4 Lateral sacral Code 20 5 Para-aortic Code 30 6 Inguinal 40 10 + 20 42 [12 or 30] + [10 or 20]

15. CS Ovary Coding 2005 CS Mets at Dx 10Distant nodes, NOS 40Distant metastases except nodes Liver parenchyma Pleural effusion with positive cytology FIGO Stage IVB 50Distant mets plus distant nodes 99Unknown, not assessed, not documented

16. CS Ovary Coding 2005 Site-Specific Factor 1 CA-125  Tumor marker for ovarian cancer; monitors for disease progression  Also called cancer antigen 125 or carbohydrate antigen 125  Normal range < 35 U/ml (SI: < 35 kU/L)  Code the lowest pre-treatment test 000Test not done 010Positive/elevated 020Negative/normal; within normal limits 030Borderline; undetermined whether positive or negative 080Ordered but results not in chart 999Unknown, no information, not documented

17. CS Ovary Coding 2005 Ovarian Cancer Case Study 1: Limited to ovaries  Enlarged right ovary on PE; mass confirmed by ultrasound. No further tests. Laparotomy, RSO, and random biopsies: tumor confined to ovary, capsule intact. All bx and washings negative Tumor size999Size not stated Extension 10One ovary involved, capsule intact TS/Ext Eval 3Based on surgical resection Lymph nodes 00Note 3: expl. surgery, no mention of LN Reg LN Eval 1Based on surgical observation, no bx. Reg LN Pos 98No nodes examined Reg LN Exam00No nodes removed Mets at Dx 00 Inaccessible sites rule--presumed neg. Mets Eval0Based on non-invasive clinical evidence SSF1 999 CA-125 not documented SSF2 - SSF8888Not applicable

18. CS Ovary Coding 2005 Ovarian Cancer Case Study 2: Malignant ascites  Pt had vague abdominal symptoms. Pelvic exam showed right ovary mass. Oophorectomy and Bxs: Adenoca in right ovary and in tumor implants on R fallopian tube. Peritoneal washings positive. Tumor size999Size not stated Extension 62Ipsilat. tube (50) + pos. ascites TS/Ext Eval 3Based on pathology report Lymph nodes 00Note 3: expl. surgery, no mention of LN Reg LN Eval 1Based on surgical observation, no bx. Reg LN Pos 98No nodes removed Reg LN Exam00No nodes examined Mets at Dx 00 Inaccessible sites rule--presumed neg. Mets Eval0Based on non-invasive clinical evidence SSF1 999 CA-125 not documented SSF2 - SSF6888 Not applicable

19. CS Ovary Coding 2005 Ovarian Cancer Case Study 3: Extensive disease  Large pelvic mass on PE. CA-125 highly pos. TAH- BSO and biopsies: cystadenoca in both ovaries and tumor nodules (> 2 cm) on cervix, pelvic sidewall, small intestine, and surface of liver. 0/8 LN pos. Tumor size999Size not stated Extension 72Peritoneal mets > 2 cm TS/Ext Eval 3Based on pathology report Lymph nodes 00No nodes involved Reg LN Eval 3Based on pathology report Reg LN Pos 00No nodes involved Reg LN Exam08Eight nodes examined Mets at Dx 00 Inaccessible sites rule--presumed neg. Mets Eval0Based on non-invasive clinical evidence SSF1 010CA-125 elevated SSF2 - SSF6888Not applicable