CODING STAGE: TNM AND OTHER STAGING SYSTEMS. Liesbet Van Eycken Otto Visser
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1 CODING STAGE: TNM AND OTHER STAGING SYSTEMS Liesbet Van Eycken Otto Visser
2 OVERVIEW PART I Introduction What is stage? Why stage? History and publications of TNM Classification Clinical and pathologic stage Stage group and prognostic grouping PART II How to code TNM and other staging systems? T-, N- and M-categories, examples Other staging systems (extent of disease, Ann Arbor, ) How to assign T, N and M?
3 INTRODUCTION CLASSIFICATION SYSTEMS Classification of tumours: according to primary site according to tumour type (histology) according to grade of differentiation according to specific tumour characteristics such as hormonal status, mutations, etc. according to the anatomic extent of disease (clinically) according to the anatomic extent of disease histopathologically determined according to clinical symptoms according to sex of the patient age of the patient etc. 3 All these factors influence the prognosis of the patient
4 WHAT IS STAGE? How far the cancer has spread in the body at time of diagnosis? Example:
5 Relative survival WHAT IS STAGING? Describing extent of disease A common medical language A way of describing or estimating prognosis Survival of bladder cancer according to stage 100% 80% I III II IV 60% 40% 20% 0% Years after diagnosis
6 WHY STAGE? Sant M , MEPs against cancer
7 CODING PRACTICES FOR STAGE IN EUROPE 2010 Questionnaire: Eurochip with ENCR 86 registries responded (32 countries) 50% response The indicator stage at diagnosis was gathered for at least one cancer site by 81% (using TNM in 39%) % for all cancer sites Availability of stage at diagnosis, cancer treatment delay and compliance with cancer guidelines as cancer registry indicators for cancer care in Europe: Results of EUROCHIP-3 survey. Siesling S, Kwast A, Gavin A, Baili P, Otter R; EUROCHIP-3 Workpackage 5. Int J Cancer Jun 15;132(12): doi: /ijc Epub 2012 Dec 13.
8 THE TNM SYSTEM The most extensive staging system that exists Used all over the world by clinicians and epidemiologists Comparability of data Changes over time in order to incorporate new developments Responsibility? Physician who disposes of the most complete information (clin/path.)
9 HISTORY OF TNM TNM developed by the Frenchmen Pierre Denoix 1968 International Union Against Cancer (UICC): TNM classification of Malignant Tumours 1969 UICC TNM General rules 1974 UICC TNM Classification of Malignant Tumours, 2 nd edition 1978 UICC TNM Classification of Malignant Tumours, 3 rd edition 1982 UICC TNM Classification of Malignant Tumours, revised 3 rd edition 1987 UICC TNM Classification of Malignant Tumours, 4 th edition 1992 UICC TNM Classification of Malignant Tumours, revised 4 th edition 1997 UICC TNM Classification of Malignant Tumours, 5 th edition 2002 UICC TNM Classification of Malignant Tumours, 6 th edition 2009 UICC TNM Classification of Malignant Tumours, 7 th edition 2016 UICC TNM Classification of Malignant Tumours, 8 th edition
10 HISTORY OF TNM Evolution in -Scientific knowledge -Therapeutic possibilities Better registration improved possibilities to analyse subgroups 10 Evolution in TNM-classification - refining/disappearing subgroups - changes within subgroups - changes in stages Some STABILITY over time is a prerequisite only modifications in case of major progress DOCUMENT the moment of adoption of a new version in a cancer registry
11 THE TNM SYSTEM Descriptors: T-, N- and M-categories T = Tumours (extension and/or size) N = Nodes (regional lymph nodes) M = Metastasis (distant metastasis, also non-regional lymph nodes) Staging basis Clinical: all information prior to start of treatment (including surgical exploration before the resection of the primary tumour) Pathological: requires resection of the primary tumour / regional lymph nodes
12 THE TNM SYSTEM STAGE GROUPING Combine T, N and M-category into a Stage = Tumor specific Stage grouping => Stage (8 th edition) Stage 0: (Tis) e.g. Stage 0 breast cancer (Tis) => e.g. bladder Stage 0a (Ta), Stage 0is (Tis) Stage I-III: localized/regional Colon and rectum T2N0M0= stage I Breast T2N0M0 = stage IIA SCC of skin: T2N0M0 = stage II Stage IV: distant metastasis Breast T2N1M1 = stage IV Larynx T4bN0M0 =stage IVB TNM does not mention unknown stage but if T and/or N are unknown it is in general not possible to classify as a specific stage => Avoid missing data as much as possible
13 AVAILABILITY OF CTNM STAGE FOR LUNG CANCER IN BELGIUM,
14
15 STAGING BASIS: PREFIXES ctnm clinical stage: essential to select and evaluate therapy options ptnm pathologic stage: provides most precise data to estimate prognosis and plan further therapy ytnm post-therapy classification, measures response to neoadjuvant treatment rtnm recurrence stage: extent of tumor after recurrence atnm autopsy stage: determined at autopsy, no previous diagnosis of cancer
16 THE TNM SYSTEM PROGNOSTIC GROUPING EXAMPLE: ESOPHAGUS
17 TNM PUBLICATIONS th edition ===================================== Introduction, Lip, oral cavity Breast, Colorectal, cervix, prostate, lung
18 Breast, cervix, colorectal, prostate, lung
19 NICR STAGING TOOL
20 HOW TO CODE TNM AND OTHER STAGING SYSTEMS
21 T-TUMOR DIFFERENT CRITERIA FOR DIFFERENT CANCERS Mostly T1-T4 (ovary T1-T3) Sub classifications (T1a, T1b, etc.) are often used Tumor size Breast, parotid gland, oral cavity Depth of invasion through wall of organ Colon, bladder, melanoma Location and extension Lung, larynx, pancreas Other factors Tumor multiplicity (thyroid, liver) Grade (sarcomas) Prognostic factors (prostate, testis)
22 T-CATEGORIES: SIZE Example: Breast T1 20 mm T2 >20 mm, 50 mm T3 >50 mm T4 involving chest wall and/or skin
23 T-CATEGORIES: DEPTH OF INVASION Example: Bladder T1 subepithelial connective tissue T2 muscularis propria T3 perivesical tissue T4 beyond bladder
24 T-CATEGORIES: EXTENSION Example: Larynx T1 One/both vocal cords, normal mobility T2 Extension to supraglottis T3 Confined to larynx with vocal cord fixation T4a Moderately advanced local disease T4b Very advanced local disease
25 T-CATEGORIES: COMBINATION OF CLARK LEVEL AND BRESLOW DEPTH OF INVASION
26 OTHER T-CATEGORIES Tis carcinoma in situ All epithelial cancers Ta non-invasive papillary carcinoma Bladder, renal pelvis, ureter, urethra Penis T0 no evidence of primary tumor Occult breast carcinoma Accidental finding in a surgical specimen (gall bladder resection because of gall stones) TX primary tumor cannot be assessed It is impossible to assign the highest T-category Do not code TX in case of doubt between 2 consecutive T-categories (code the lower one)
27 N REGIONAL LYMPH NODES LYMPH NODE INVOLVEMENT Absence or presence of metastases in primary lymph node drainage area of cancer
28 N REGIONAL LYMPH NODES N0 Regional lymph nodes have been clinically or pathologically proven to be free of metastatic disease N1-N3 Increasing involvement of regional lymph nodes by number, location or size NX regional nodes cannot be assessed No clinical or pathological investigations have been performed
29 N-CATEGORIES: NUMBER Example: Stomach N1 1-2 regional nodes involved N2 3-6 regional nodes involved N3 7 or more node involved
30 N-CATEGORIES: LOCATION Example: Lung N1 peribronchial and/or hilar and intrapulmonary nodes N2 mediastinal and/or subcarinal nodes N3 contralateral mediastinal, hilar, scalene or supraclavicular nodes
31 N-CATEGORIES: SIZE AND NUMBER Example: Renal pelvis and ureter N1 single node, 2 cm or less N2 single node 2-5 cm or multiple nodes <5 cm N3 any node >5 cm
32 M DISTANT METASTASES: SYSTEMIC INVOLVEMENT Categories M0 absence of metastatic disease M1 presence of at least one distant metastasis M1 subcategory, example: prostate M1a non-regional lymph nodes M1b bone(s) M1c other site(s) In case of multiple metastatic sites: always code to the highest value (M1c) (Not any more available since TNM 7 th edition MX distant metastasis cannot be assessed)
33 OTHER STAGING SYSTEMS Condensed TNM essential TNM Extent of disease Dukes stage (obsolete) FIGO stage (almost equivalent to TNM) Ann Arbor stage (lymphoma) International Prognostic Scoring System (haematological malignancies)
34 ESSENTIAL TNM When T, and/or N, and/or M have not been explicitly recorded in the clinical/pathological records, the cancer registry should attempt to score essential TNM according to the following scheme: T: L (localized) or A (advanced)* N: R- or R+ M: M- or M+ Stage: I: TL R- M- II: TA R- M- III: anyt R+ M- IV: any T any R M+ *Subcategories L1/L2 and A1/A2 are also available
35 EXTENT OF DISEASE (SUMMARY STAGE)
36 EXTENT OF DISEASE: IN SITU
37 EXTENT OF DISEASE: LOCALIZED
38 EXTENT OF DISEASE: REGIONAL
39 EXTENT OF DISEASE: DISTANT
40 EXTENT OF DISEASE: UNKNOWN No investigations were performed No information of the staging procedures is available
41 OTHER STAGING SYSTEMS GYNECOLOGICAL CANCERS
42 OTHER STAGING SYSTEMS - LYMPHOMA
43 HOW TO ASSIGN T, N AND M? Determine primary site and histology Look up site chapter Is histology included in this chapter? Review list of regional lymph nodes Clinical versus pathologic stage Find staging information in the tables Determine T, N, M (Assign stage on the basis of the T, N and M)
44 CODING TNM- EXAMPLE ctnm: T2N0M0 = clinical stage IIA ptnm: T1cN0M0 = stage IA
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