1. Putting the Puzzle Together: Breast Collaborative Staging Melissa Riddle, RHIT, CTR October 6, 2012

2. Objectives Understand why collaborative staging was created Learn the concepts of collaborative staging for breast cases

3. Collaborative Staging 5yr group effort among all standard setters in North America Designed by and for cancer registrars to code the facts about a cancer case General rules apply to all sites/histologies unless superseded by site-specific rule

4. Collaborative Staging Used for cases diagnosed 1/1/2004 and forward – CSv2 for cases diagnosed 1/1/2010 and forward Derives: – AJCC TNM – SEER Summary Understand SEER Summary and TNM is necessary in order to analyze cases

5. Collaborative Staging Allows both clinical and pathologic information to be used to determine stage – Pathologic information takes precedence

6. Collaborative Staging CS Solution: Mixed or “Best Staged” – Result: more relevant to actual practice – Fewer unstageable cases Registrar records : T elements + c/p N elements + c/p M elements + c/p Site Specific Factors (tumor markers) c/pT c/p N c/p M And Stage Group SS77, SS2000 Computer Derives:

7. Data Elements: CS Tumor Size CS Extension CS TS/Exten Eval CS Lymph Nodes CS LN Eval Regional LN Positive Regional LN Exam CS Mets @ DX CS Mets Eval SSF 1-25

8. Breast CS

9. Collaborative Staging Evaluation Fields: – Code based on the procedure performed Scans Biopsies Surgery – Derives the TNM as clinical or pathologic

10. Breast Evaluation Codes CODEDESCRIPTIONSTAGING 0Physical Exam; Imagingc 1Diagnostic BX; FNAc 3Resection without neoadjuvant TXp 5Neoadjuvant TX; Based on Clinical information c 6Neoadjuvant TX; Resection informationyp 9Unknownc

11. Breast CS Data Items Tumor Size Extension Lymph Nodes Lymph Node Positive/Exam Distant Mets at Diagnosis Site Specific Factors 1-24

12. Tumor Size/Extension

13. Tumor Size Code the specific size of the tumor in mm – Convert any size in cm to mm Pathologic size: – Take pathologic size over clinical – Record the invasive size Example: Invasive Ductal Carcinoma, 0.5cm; DCIS, 2cm Code Tumor Size: 005

14. Tumor Size Special Codes: – 990 Microinvasion; Microscopic focus – 991-995 No specific size: “less than ___cm” – 996 seen on mammogram only but no size given – 997 Paget’s of nipple, no underlying tumor – 998 Diffuse

15. Extension In Situ only: 000 – No invasive disease Invasive cancer without skin involvement: 100 Skin involvement: 200 – Adherence, Attachment, Fixation, Induration & Thickening – Without diagnosis Inflammatory Breast CA

16. CS BREAST: EXTENSION Example: L breast partial mastectomy Path report partial mastectomy: 2cm invasive ductal carcinoma invading into skin CS Extension: 200 (invade skin)

17. Extension Inflammatory Breast CA: – Based on clinical information – Codes based on percentage of breast involved: Code 600: 33% or less Code 725: more than 33% but less than 50% Code 730: more than 50% Code 750*: percentage unknown *Most common code for IBC

18. Regional Lymph Nodes

19. Lymph Nodes Regional Lymph Nodes Only: – Do NOT code cervical or contralateral axillary LN – Includes Levels 1-3 Ipsilateral Axillary LN, internal mammary LN and Supraclavicular LN – Clinical vs. Pathologic If the only information about involved regional LN is from physical exam or imaging- clinical If there are positive LN found on sampling/dissection- pathologic

20. Level 1 & 2 Axilla LN Code 250: – Pathologic involvement LN Code 255: – Clinical involvement moveable LN Code 510: – Clinical involvement fixed/matted LN Code 520: – Pathologic involvement fixed/matted LN Code 600: – Axillary, NOS

21. CS BREAST: LYMPH NODES Example: R breast modified radical mastectomy (MRM) Path from R MRM: 3cm invasive ductal carcinoma; 2/4 R axillary LN involved with metastatic disease CS LN: 250 (pathologic positive movable axillary LN)

22. Reg LN Positive Record all positive pathologic examined regional lymph nodes Example: 3/5 R axillary LN involved with invasive duct carcinomaCODE: 03 Code 95: – Positive LN only on core biopsy or FNA Code 98: – No regional LN were examined pathologically

23. Reg LN Examined Record the total number of pathologically examined regional LN Example: 3/5 R axillary LN involved with invasive duct carcinomaCODE: 05 Code 95: – Regional LN examined by core biopsy or FNA only Code 00: – No regional LN examined pathologically

24. Distant Mets at Diagnosis

25. Distant Mets Code 00: – No evidence of metastatic disease Code 10: – Involvement distant LN: Cervical Contralateral/Bilateral Axillary and/or internal mammary LN Code 40: – Distant met site except distant LN

26. Distant Mets Code 42: – Further contiguous extension: Skin over axilla, contralateral breast, sternum, upper abdomen Code 44: – Involve any of the following: Adrenal gland Bone Contralateral breast- if stated metastatic Lung Ovary Sat nodules skin other than primary breast

27. Distant Mets Code 50: – Distant LN – Distant Sites (listed in codes 40-44) Code 60: – Distant mets, NOS

28. CS BREAST: METS AT DX Example R breast with palpable mass 4cm with fixed R axillary LN mass. CT AB/Pelvis: Innumerable liver mets CS Mets @ DX: 40 (Distant mets other than distant LN)

29. Site Specific Factors

30. Collaborative Staging Site-Specific Factors – Not all 25 SSF are used for every case Breast has the most with 24 to complete – Additional information needed to derive TNM – Prognostic Tumor Markers/Labs – Special Interest/Future Research – Other clinically significant information

31. SSF 1: ER & SSF 2: PR If there is any sample positive, record as positive Do NOT record ER results from Oncotype DX or other multigene test 010- Positive 020- Negative 997- Test ordered results not in chart 999- Unknown

32. SSF 3: Pos Level 1 & 2 LN Based on pathologic information ONLY Code 098: – No pathologically examined LN Code 000: – Negative LN Code 001-089: – Code the exact number of positive LN Code 095: – Positive LN by biopsy or FNA

33. SSF 7: BR Score Priority Order: – BR Score – BR Grade Codes 030-090: – BR Score range of 3-9 Codes 110-130: – BR Grade: Low, Intermediate, High Code 998: – No histologic exam of primary tumor

34. HER 2 SSF 8: IHC test value – Scores 0, 1+, 2+, 3+ SSF 9: IHC interpretation – Record the pathologists interpretation of the test value: positive, negative, equivocal SSF 10: FISH value – Record ratio as given – Code 991: ratio less than 1.00 SSF 11: FISH interpretation – Record the interpretation of the test value

35. HER 2 SSF 14: Other/Unknown test – Statement in medical record on HER2, unknown type of testing performed – Other type of test performed SSF 15: Summary of results – Based on codes in SSF 9, 11, 13 and 14 – Both IHC and FISH/CISH record results of FISH/CISH Except when IHC is performed to clarify equivocal test of FISH/CISH

36. SSF 16: ER, PR & HER2 Identifies Triple negative patients Code Pattern: – First digit: ER – Second digit: PR – Third digit: HER2 Digits: – 0= negative – 1= positive Information unknown on one or more test code 999

37. SSF 16 Example: ER: positive (SSF1: 010) PR: positive (SSF2: 010) HER2: negative (SSF 15: 020) SSF 16 Code: 110 Triple Negative patients code 000

38. SSF 22: Multigene Method Assess: – likelihood of response to chemotherapy – evaluate prognosis or distant recurrence Code 010: Oncotype DX Code 020: MammaPrint Code 030: Other test

39. SSF 23: Multigene Result Record the results of the multigene method: – Oncotype DX: Scores range 0-100 – MammaPrint: Low Risk or High Risk Codes 000-100 – Record actual Oncotype DX score Code 200: Low Risk Code 300: Intermediate Risk Code 400: High Risk

40. SSF 24: Paget’s Disease Record any mention of Paget’s disease – Pathologic takes precedence over clinical info Negative exam of nipple – Interpret as no Paget’s disease Pathology report mentions pagetoid involvement of nipple, Code 020 – Does NOT include pagetoid involvement of ducts or lobules

41. Current Version CSv02.04 http://www.cancerstaging.org/cstage/manuals/coding0204.html Additional Help: http://cancerbulletin.facs.org/forums/

42. The Whole Picture Now you can put these pieces together while using the CS Manual to create a beautiful picture! Always read your notes for CS, they are the little pieces that create the whole!

43. Thank You! Melissa Riddle, RHIT, CTR melissariddlespeaks@ymail.com