TNM Potpourri and M&M s. CCRA 43 rd Education Conference Sacramento, CA November 4, 2016

Transcription

1 TNM Potpourri and M&M s CCRA 43 rd Education Conference Sacramento, CA November 4,

2 Overview Review Rules for Classification o Clinical o Pathologic How to Use Clinical information in assigning Pathologic Stage Post therapy - Neoadjuvant scenarios Some Site Specific scenarios, situations & rules M & M s 2

3 RULES FOR CLASSIFICATION 3

4 TNM- Rules for Classification Criteria defined by AJCC in each chapter Must meet criteria to assign stage classification oclinical opathologic 4

5 Clinical- Rules for Classification Assign a clinical stage when Do not assign a clinical stage when Cancer Known or Suspected by MD Dx can be clinical or pathologic Unless chapter rule overrides Diagnostic workup Performed Attempted Unless Patient Situation Precludes workup No diagnosis of cancer No suspicion of cancer Incidental finding of cancer on surgical resection 5

6 Were Clinical Rules for Classification met? CC: Rectal bleeding. PE: No abdominal masses, exam WNL. Colonoscopy: sessile lesion sigmoid colon, biopsies reveal adenocarcinoma. CEA WNL. CT Abdomen/Pelvis. Liver appears normal. No suspicious mesenteric lymph nodes T N M Stage Clin ctx cn0 cm0 99 Cancer known prior to surgery Diagnostic workup performed Rules for classification met 6

7 Were Clinical Rules for Classification met? Patient admit RLQ abdominal pain, elevated white count, fever. Emergent exploratory surgery reveals mass in the appendix in association with appendicitis. Remaining abdominal organs WNL including liver. Pathology revealed adenocarcinoma of appendix invading mesoappendix; 1/3 ileocolonic lymph nodes positive for mets T N M Stage Clin 99 Path pt3 pn1 cm0 3B Cancer unknown prior to surgery Rules for classification not met No Clinical Stage - TNM blank- registry rules require Non blank stage group cm0 presumed in path stage since cancer unknown/suspected 7

8 Pathologic- Rules for Classification Assign a pathologic stage when Do not assign a pathologic stage when Definitive surgical procedure done Which meets AJCC criteria Surgery type varies by primary site Review applicable TNM Chapter Patient did not have surgery Or, surgical procedure does not meet AJCC criteria Generally if no surgery no pathologic stage Some exceptions / special rules 8

9 Were Pathologic Rules for Classification met? Pt with hematuria. Cystoscopy reveals >2cm bladder wall lesion. Biopsies positive for papillary urothelial ca. Imaging negative for LN involvement or distant mets. TURBT reveals papillary urothelial ca with invasion of muscularis propria. All visible tumor debulked. Patient referred for radiation therapy T N M Stage Clin ct2 cn0 cm0 2 Path 99 TURBT does not meet AJCC Bladder rules for pathologic classification TURBT findings used in CLINICAL STAGE TNM blank- registry rules require Non blank stage group 9

10 Were Pathologic Rules for Classification met? Colonoscopy: bx of sigmoid colon mass positive for adenocarcinoma. Sigmoidectomy/Pathology: adenocarcinoma invading into but not through muscularis propria. 0/13 lymph nodes positive. Does sigmoidectomy meet criteria? 2016 T N M Stage Path pt2 pn0 cm0 1 Patient had definitive surgical resection Sigmoidectomy meets AJCC Colon rules for pathologic stage 10

11 Pathologic - Rules for Classification - Special pm1 rule #1: Pathologic stage assignment w/o tumor resection pm1/stage IV rule When Bx on Diagnostic workup confirms mets =pm1 Even if no surgical resection Use pm1 to assign pathologic stage also Path stage assigned even if T & N are clinical Pathologic stage = ct3 cn1 pm1 Stage 4 However, registry data entry requires use of blanks 2016 T N M Stg Group Clin ct3 cn1 pm1 4 Path ct3 cn1 pm1 4 Implied value 11

12 Pathologic Rules for Classification Highest T & N #2 path stage assignment without tumor resection If Biopsy of highest pt and highest pn - can assign path stage Rationale: Surgery would not provide any greater disease extension information HOWEVER: Must have BOTH Must meet AJCC primary site rules for pt or pn w/o surg Not a common scenario References: AJCC Module IV, Lesson 22, slides 2 & 3 Registrars guide to Chapter One, slide 40 TNM Manual page 11, Table

13 USING CLINICAL INFORMATION IN PATHOLOGIC STAGE 13

14 Using Clinical Info in Path Stage Breast bx positive for 1.5cm Infiltrating Ductal ca, Neg PE and H&P. Surgery Lumpectomy w/sentinel LN bx. Pathology: No residual tumor, 0/2 sentinel LNs neg. What is the pathologic T? 2016 T N M Stage Clin ct1c cn0 cm0 1A Path pt1c pn0 cm0 1A Not pt0 - Can include info from diagnostic workup Surgery did not add to nor modify the clinical info Therefore use clinical TS And assign as pt Rules for pathologic classification met by complete tumor resection (=pt) 14

15 pn category pn in PATHOLOGIC STAGE o Assignment of a pn requires microscopic exam of at least one LN o However, when LN(s) Bx in clinical timeframe o Rules allow incorporation of cn information in path stage Assigned as pn not cn 15

16 Using Clinical Info in Path Stage Palpable 2.4cm R breast mass UOQ; axillary fullness but no definite discrete palp LN or mass. Neg H&P Breast bx and Sentinel LN bx: Invasive Ductal Ca with 0/3 sentinel LNs pos. Surgery is Lumpectomy, no lymph node dissection Pathology: Invasive ductal carcinoma 1.8 cm, SBR 6 What is the pt? What is the pn? 2016 T N M Stage Clin ct2 cn0(sn) cm0 2A Path pt1c pn0(sn) cm0 1A pt -Surgical pathology provided more accurate tumor size measurement No LN dissection at surgery, however, had SLNB on DX workup (sn) Any microscopic exam of LN with pt = pn Use cn0 and Assign as pn0(sn) 16

17 Quick Quiz 1 Clinical: Breast bx positive for 1.5 cm infiltrating Ductal Carcinoma ct = ct1c Pathologic: Lumpectomy positive for DCIS only What is your pt? Answer: pt1c o Record invasive component of tumor for T o Unless tumor is only in situ 17

18 Rules for classification - in situ tumor Eureka Case: 1/5/16) 60 yo female with lesion left forearm. No palp LNs. BX: Melanoma in situ. 2/26/16) Skin, left forearm, re-excision previous biopsy site: No residual melanoma in situ. Registrar stage: Correct stage 2016 T N M S Clin ptis cn0 cm0 0 Path ptis cn0 cm0 0 Rules for Classification met for both clinical and pathologic stage Excision of the primary tumor is part of the clinical evaluation Re-excision or wide excision is the definitive surgery -meets AJCC criteria for path stage 18

19 Rules for classification - in situ tumor Eureka Case: 1/5/16: Irreg bordered pigmented lesion left cheek. Neg exam otherwise Bx positive for Melanoma in situ. 2/6/16: L cheek re-excision: highly atypical melanocytes c/w residual melanoma in situ, 5mm to closest margin. Registrar stage: Correct stage 2016 T N M S Clin ptis cn0 cm0 0 Path ptis cn0 cm0 0 Tumor in situ only. Pathologic exam of LN not required Rules allow cn0 in path stage Stage group = 0 19

20 Quick Quiz 2 Clinical Workup Lung RLL 2.2cm mass; biopsy positive for Adenoca Mediastinoscopy: 0/3 hilar nodes positive. 0/4 mediastinal nodes positive CT Chest/Abdomen/Pelvic: Neg MRI Brain: Negative Clinical Stage: ct1b cn0 cm0 Stage 1A Treatment: RLL lobectomy: 1.7cm adenocarcinoma, margins clear. No lymph nodes removed What is the pathologic N - cn0 or pn0 or pnx? 2016 T N M STAGE Pathologic pt1a pn0 cm0 1A 20

21 SOME SITE SPECIFIC Situations, Rules, Examples 21

22 Colon Polypectomy only How to assign Stage Screening colonoscopy: Gross 2.7 cm polyp, sigmoid colon snare polypectomy performed. Additional margin resected at polyp base site. Pathology: Infilt Adenoca arising in mixed adenomatous villous adenoma with invasion beyond lamina propria into submucosa. Polyp base & additional margin free of tumor. What is the Clinical Stage? What is the pathologic Stage? 2016 T N M Stage Clin 99 Path pt1 pnx cm0 99 Clinical stage normally based on colonoscopy with a biopsy (diagnostic only); after some presenting symptoms and MD PE/H&P. No Dx workup in this case which met criteria for ct or cn; screening colonoscopy found polyp within which cancer incidentally found. Polypectomy removed entire tumor meets tumor resection criteria/rules for pathologic classification. No clinical stage in this scenario. 22

23 Colon Polypectomy only How to assign Stage 99 pt1 pnx cm0 99 pt No separate set of definitions for polyps in TNM Tumors arising in polyps use same definitions for T as frank tumors Assign based on depth of invasion pn Currently no rules regarding N category when LN resection is not done for carcinoma in a polyp only Cannot assume nodes negative Assign pnx 23

24 ENDOMETRIAL POLYP 24

25 Endometrial Polyp - Clinical Stage 6/1/16 : Hx Postmenopausal bleeding. Hysteroscopy with D&C: Large endometrial polyp. Polyp removed in its entirety. Per operative note a sharp curette was again used to ensure all polyp tissue and sloughing endometrium removed. Pathology: Uterine polyp, well to moderately differentiated Grade I-II invasive endometrioid adenocarcinoma. Margins negative <0.3mm. 6/17/16 Staging CT chest/abd/pel: negative 2016 T N M Stage Clin ct1 cn0 cm0 1 Tumor in polyp confined to uterus No separate set of definition for polyps Staging workup neg - cn0, cm0 25

26 Endometrial Polyp - Pathologic Stage 7/14/16: TAH-BSO: No suspicious LNs on abdominal exploration; no LN dissection. Pathology: No residual carcinoma. Cervix, endometrium, myometrium, ovaries, fallopian tubes, serosa all negative. Previous endometrial biopsy reviewed-confirming Adenoca confined to endometrial polyp. What is the pt and pn? cn0 is correct 2016 T N M Stage Clin ct1 cn0 cm0 1 Path pt1 ccn0 cm0 1 Low risk for nodal spread in Stage 1 Tumors MD judgement to not perform lymphadenectomy based on risk/benefit ratio appropriate See Chapter 36, page 405, under Pathologic Staging, last sentence: When there are insufficient surgical-pathologic findings, the clinical ct, cn, cm categories should be used on the basis of clinical evaluation. Registry data fields can t accommodate - leave blank - indicates implied value of cn0. cn0 only allowed in path stage for 2016 for in situ tumors-in this case tumor was invasive. staging-for-an-endometrial-polyp AJCC 7 th Edition, Page 405, last sentence under Pathologic Stage 26

27 MELANOMA 27

28 Melanoma Ulceration Ulceration status must be stated Ulceration determined by pathologic exam only - not visual evidence If ulceration status not stated cannot presume it s negative (for TNM) CAUTION: Differs from direction for coding SSF2 If ulceration not mentioned code SSF2 as 000/none Ulceration status needed to assign subcategory a= no ulceration b= ulceration present Effects assignment of T and Stage Group 28

29 Melanoma Example - Ulceration not stated Patient with suspicious mole left calf removed at MD office; P.E. negative for suspicious LNs. H&P neg. Exc Bx Path: Malignant Melanoma Breslow s depth of 1.2mm. Wide excision with lympadenectomy revealed no residual disease and 0/12 LN pos 2016 T N M Stage Clin Path ct2 cn0 cm0 99 pt2 pn0 cm0 99 Ulceration not stated, cannot assign subcategory for ct2 Can t assign stage group 29

30 Melanoma Pathologic Stage IA 1cm purple brown lesion left calf. No palpable LNs. Exc Bx: Malignant Melanoma, Breaslow depth 0.19mm, no ulceration, mitoses <1/mm2, margins negative. Wide excision left calf: no residual melanoma. No LN dissection. What is your Pathologic N? o cn0, pn0, pnx 2016 T N M Stage Clin Path ct1a cn0 cm0 1A pt1a cn0 cm0 1A Pathologic Stage 0 OR 1A - Do not require path eval of LNs to assign stage cn0 is appropriate but in registry software must leave blank In 2016 use of cn0 in path stage only allowed for in situ histology TNM Manual 7 th Edition, page 336, orange stage group table-notes below 34

31 Melanoma Unknown Primary #1 Patient presents with enlarged cervical LN Biopsy confirms metastatic melanoma Complete exam finds no evidence of primary skin lesion or other abnormalities For clinical staging consider the LN to be Regional #2 Patient presents with solitary brain metastasis Biopsy confirms malignant melanoma Work-up revealed no primary skin lesion site and no other disease LDH was normal 2016 T N M Stage Clin ct0 cn1 cm0 3 Path 99 CLINICAL Stage III = Any T >N1 cm0 Ulceration status not needed No path stage-no resection of primary tumor 2016 T N M Stage Clin ct0 cn0 pm1c 4 Path pm1c 4 Path stage uses pm1 rule Ulceration status not needed pt and pn blank (implied ct/cn values) 35

32 THYROID 36

33 Thyroid TNM Site specific rule Clinical Stage: Requires FNA or biopsy confirmation of malignancy If diagnosis not established by FNA or Bx - Cannot assign clinical stage T,N,M-Blank, Stage Group

34 Thyroid TNM Specific Histology must be known Staging tables based on histology and patient age Papillary or Follicular carcinoma Medullary carcinoma Anaplastic carcinoma If histology non-specific (carcinoma nos) cannot assign a specific ct category Assign ctx cn & cm per clinical findings Example ctx cn0 cm0 99 Stage group 99 38

35 LUNG 39

36 Lung Cancer - Occult Clinically inapparent malignancy (un-seen, hidden) Lung cancer evidence in sputum cells or bronchial washings only No evidence of the primary lung mass No evidence of lymph node involvement No evidence of distant mets = Occult Lung Cancer AJCC TNM states occult lung ca = ctx 40

37 Lung ctx cn0 cm0 OC 59yo male w/persistent productive cough. CXR Neg. Sputum cytology reveals carcinoma; IHC indicates lung origin. CT Chest: No evidence primary lung mass. Minimal hilar LAD but not characteristic of tumor involvement. Bronchoscopy: No endobronchial lesions found; brushing and washings positive for squamous cell carcinoma. PET: Neg for lung mass, lymphadenopathy; no signs of distant mets T N M Stage Clin Path ctx cn0 cm0 OC 99 Can you have a pathologic stage with an occult lung cancer? No resection of primary tumor possible - Rules for classification not met NO 41

38 Lung ctx Cannot be assessed 91-yo-male palpable mass right supraclavicular fossa. Biopsy: Adenoca; IHC c/w lung origin. CXR: Indeterminate shadowing RUL characteristic of neoplastic tumor, however, unable to visualize discrete mass. Hilar /mediastinal LAD not apparent. Recommend contrast CT Chest or PET to better define tumor and lymph node status. Patient allergy to contrast medium and pacemaker preclude further imaging Bronchoscopy: No endobronchial lesion. Bronchial forceps random blind bx s anterior segment RUL; pathology positive for adenocarcinoma Patient elects supportive care only What is the T and N? 2016 T N M Stage Clin ctx cn3 cm0 99 Path 99 T cannot be assessed Not ct0 Bronch bx RUL tissue pos+ No Tumor size or other feature to assign T Patient condition precluded better imaging cn3 pos+ supraclavicular node Not an occult tumor 42

39 Lung ct0 Unknown primary #1) 78-year-old male palpable left supraclavicular mass. Biopsy positive for squamous cell carcinoma, lung origin. Complete workup for lung primary negative. Imaging negative. Bronchoscopy negative. No signs distant mets on metastatic workup T N M Stage Clin ct0 cn3 cm0 99 #2) 78-year-old male presents with severe shortness of breath and chest pain. CXR: Left pleural effusion, no lung mass or LAD identified, possible pneumonia. Pleurocentesis: Adenocarcinoma; IHC compatible with lung origin. PET: No primary lung lesion identified. No hilar or mediastinal adenopathy. Left pleural effusion. Lytic lesions 3rd and 4 th posterior ribs c/w bone mets T N M Stage Clin ct0 cn0 cm1a 4 Anatomic site suspected=lung per histology No evidence of the primary tumor =ct0 Not occult- evidence in LNs Case #1 and evidence of distant mets in Case #2 43

40 POST THERAPY NEOADJUVANT STAGE 44

41 Post Therapy/Neoadjuvant - yptnm yp/pathologic Stage: Clinical information ct & cn from diagnostic workup/excluded ypt & ypn based on pathologic resection specimen Can include surgical observations Can include yc post therapy stage information Can include progression/mets identified after neoadjuvant RX M status at diagnosis always assigned -cm0 or cm1 or pm1 If M1 before treatment- stays M1 for yp stage Even if mets no longer detected post therapy Stage Group- If complete response (CR) to post therapy/neoadjuvant treatment stage group cannot be assigned pt0 pn0 cm0 Stage 99 45

42 Post Neoadjuvant Stage DX clinical info excluded 6/8/16: 4.0cm breast mass. Bx positive for Invasive Ductal. Sentinel LN Bx: 0/5 LNs positive 7/5/18: ACT neoadjuvant therapy 10/2/16: Lumpectomy/Path: No residual tumor; benign tissue with treatment related changes. No lymph nodes were resected 2016 T N M Stage Descriptor Clin ct2 cn0(sn) cm0 2A None Path pt0 pnx cm0 99 Y Post Neoadjuvant What is the yptnm? ct2 and cn0(sn) info excluded from post neoadjuvant stage pt0 assigned - based on resection specimen MD clinical judgement- if cn0(sn) no need for further dissection, however = pnx M status at diagnosis always assigned 46

43 Post Neoadjuvant Stage CR 6/8/16: 4.0cm breast mass. Bx positive for Invasive Ductal Ca. Sentinel LN Bx: 1/2 LNs positive 7/5/18: ACT neoadjuvant therapy 10/2/16: Lumpectomy/Path: No residual tumor; benign tissue with treatment related changes. 0/8 axillary LN negative 2016 T N M Stage Descriptor Clin ct2 cn1 cm0 2A None Path pt0 pn0 cm0 99 Y Post Neoadjuvant What is the Stage Group? With complete response (CR) to neoadjuvant therapy No stage group assigned No cancer Registry rules require 99 for stage group 47

44 Post Neoadjuvant Stage residual in situ Clinical: Rectal mass on PE. Imaging confirms involvement of visceral peritoneum; no evidence LN or distant mets. Patient received neoadjuvant radiation. Pathologic: Surgical resection reveals residual carcinoma in situ; all LNs negative on dissection T N M Stage Descriptor Clin ct4a cn0 cm0 2B None Path ptis pn0 cm0 0 Y Post Neoadjuvant Record any residual disease in path stage post neoadjuvant, including in situ If residual disease is in situ, Stage Group = 0 48

45 Post Therapy/Neoadjuvant - yctnm yc/clinical Stage: o Post therapy Info obtained s/p clinical restaging Physical Exam Imaging o Prior to surgery o Currently no registry ability to record/capture a yctnm yc/clinical restaging information o Can be used in yptnm pathologic stage 49

46 yctnm used in yptnm 3/1/16: Patient with 5.2cm invasive ductal breast ca & large palpable axillary LN involved with tumor per MD. 3/15/16 Neoadjuvant therapy began yctnm 6/1/16: Post therapy workup. Breast MRI: tumor size reduced to 2.0cm. Sentinel LN bx: 0/3 LNs pos. 6/18/16: Lumpectomy. No LN dissection. Pathology: residual invasive ductal carcinoma 1.8cm T N M Stage Descriptor Clin ct3 cn1 cm0 3A None Path pt1c pn0(sn) cm0 1A Y Post Neoadjuvant Why pn0 and not pnx since no LNs removed at definitive surgical resection? Diagnostic clinical info excluded from yptnm CAN use yctnm info which showed negative sentinel LNs on biopsy pn0 assigned -microscopic exam of LNs during yctnm 50

47 M & M S 51

48 M & M s Clinical Stage composition may include cm0, cm1 or pm1 Pathologic Stage composition may include cm0, cm1 or pm1 Assign M for each based on oassessment Method ohighest Category 52

49 M1 What to do when: Clinical mets in two or more sites Clinical and Pathologic Mets Have a higher category cm than pm Mets found at surgery Mets found after surgery It s simple, right? 53

50 Clinical mets in two or more sites (same timeframe) Some sites have M subcategories: ocm1, cm1a, cm1b, etc. If cm1a and cm1b present Assign the HIGHER Category ocm1a over cm1 54

51 Clinical and Pathologic mets (same timeframe) If BOTH clinical and pathologic mets - cm1 and pm1 o Assign the pm1 M assigned based on highest assessment method opathologic over Clinical 55

52 Higher category cm than pm - Case Example Diagnostic workup: Adenoca lung invades mediastinum =ct4 Mediastinoscopy biopsies pos+ mediastinal LNs = cn2 Positive/malignant cells in pleural effusion =pm1a Imaging reveals brain mets = cm1b Treatment plan is chemo & radiation Which do we use for our clinical M? When multiple sites of mets, if one pathologically confirmed, take highest category but assign as a pm. Rationale: Other clinically apparent mets likely positive but it would not be reasonable to biopsy every site of clinical mets. cm1b pm1a pm1b pm1b

53 Mets found during Surgery Clinical: CT Abdomen/Pelvis: 7.6cm kidney mass with renal hilar LAD both c/w malignancy. No evidence distant mets. Pathologic: Nephrectomy reveals tumor invades into adrenal gland, 2/6 renal hilar LNs pos for mets. Surgeon observed liver mets-not biopsied T N M Stage What is the pm? Clin ct2a cn1 cm0 2 Path pt4 pn1 cm1 4 Surgical observation of liver mets is new clinical information; but path stage can include surgeons operative findings Incorporate info into pathologic stage Do not go back to change your clinical stage M timeframe has passed 57

54 Mets found after Surgery Are mets found after surgery included in the pathologic stage? YES If they are discovered prior to the start of adjuvant therapy AND within the pathologic 4 month timeframe AND it is clear the mets are not disease progression the pathologic timeframe does include through definitive surgery OR within 4 months of diagnosis so scans, or biopsies after surgery are included in the pathologic stage Donna M Gress, RHIT, CTR 58

55 Mets found after Surgery- Case 1 Is this Mets at diagnosis or disease progression? 11/28/16: CC; Left flank pain. CT Abdomen: 8 cm kidney mass, no evidence regional LAD. Findings c/w renal cell carcinoma. CXR negative. 12/3/15: Admit for left nephrectomy. Per H&P, MD notes metastatic workup has not been done. Nephrectomy Pathology: Renal cell ca, Fuhrman Grade 3, directly invading vena cava above diaphragm. Patient referred to Oncologist. 2/10/16: PET/CT; small scattered lung nodules bilaterally suspicious for mets. T12 lesion characteristic of bony mets. 2/12/16: Biopsy T12: positive for metastatic renal cell ca 2016 T N M Stage What is the pm? Clin ct2 cn0 cm0 3 Path pt3b pnx pm1 4 MD completed staging workup post surgery - METS AT DIAGNOSIS - include pm1 in path stage 59

56 Mets found after Surgery - Case 2 Is this liver mets at diagnosis or disease progression? 5/31/15) Rt hemicolectomy: Adenocarcinoma with 4/21 positive LNs. During intraoperative exploration surgeon states liver and other organs appear normal. 6/11/15) Discharge Summary: Adenoca right colon pt3pn2cm0 7/05/15) Oncology Consult: Pt will complete staging with CEA and CT scans 7/09/15) CT Ch/Ab/Pel: Small lesions suspicious for liver mets right lobe 7/19/15) Oncology Note: CT revealed possible liver mets. Pt is candidate for liver resection and will receive 4 cycles of Folfox/Avastin. 12/9/15) CT Chest/Ab/Pelvis post chemo: Progression in number and size of liver mets. 12/23/15) Oncology Note: Due to progression of liver mets patient is no longer a candidate for liver resection. Answer per CAnswer Forum: Mets at Diagnosis Pathologic stage: pt3 pn2 cm1a Stage IV. 60

57 Mets found after Surgery - Case 2 Rationale per CAnswer Forum Common to complete the staging after the surgical resection Not unusual surgeon could not palpate these liver lesions either due to size or their position in the liver and they were then found on the imaging. Further workup done approx one month post surgery, probably waiting for the patient to heal, and this would be considered in the pathologic staging. Documentation to complete the staging also makes clear this was not disease progression one month after surgery. 61

58 Mets found after Surgery Disease Progression 4/01/16: Colonoscopy revealed circumferential mass right colon. Bx: Adenocarcinoma 4/05/16: CT abdomen revealed fatty liver, no evidence of mets. CXR negative. CEA WNL. 4/12/16: LAR: Mass in right colon identified, resection w/o complication. Abd exploration and palpation of liver WNL; No surface liver mets. Pathology: Adenoca invading thru M.P. into pericolorectal tissues. 1/13 LN pos. 7/16/16: MRI positive for liver mets. 8/20/16: Segmental resection of liver confirmed liver metastasis Why is this disease progression? 2016 T N M Stage Clin ctx cn0 cm0 Path pt3 pn1 cm0 2A Patient had good metastatic workup prior to LAR Surgeon also documents optimal exam of liver intraoperatively and negative for mets MRI liver mets clearly disease progression although within 4 month pathologic timeframe Do not include in pathologic stage 99 62

59 Quick Quiz 3 - Operative Findings from aborted surgery Patient had dx workup for left lung ca =ct1b cn0 cm0, Stage 1A. Treatment plan lobectomy. At surgery multiple tumor nodules & studding noted involving visceral pleura, parietal pleura and parietal pericardium. Biopsies positive for NSCLC. Planned lobectomy was aborted. No tumor resection was done. No LNs resected. What is the Clinical Stage? What is the Pathologic Stage? 2016 T N M Stage Clin ct3 cn0 cm0 2B Path 99 AJCC Chapter 1, page 9, findings from surgical exploration without tumor resection used in clinical stage Whether Visual confirmation OR Bx confirmation No pathologic stage - no resection of primary tumor rules for classification not met 63

60 Questions 64

61 Contact Information Donna M. Hansen, CTR Auditor/Education Training Coordinator California Cancer Registry

62 EXTRA S 66

63 Stage Group Code 99 Assign 99 for Stage Group when Combo of T, N or M not specific enough to assign group T or N are unknown - stage group cannot be assigned Example: pt2, pnx, cm0 Stage Group 99 Standard Setters require non blank stage group orules for classification not met When T, N and M are blank - Stage group must be 99 CoC & NPCR 67

64 When to use 88 TNM not applicable/not defined by AJCC Primary site/histology combination Example: Malignant brain Hematopoietic diseases Sites where Tis (in situ) is not defined/not stageable Example In situ behavior in Thyroid Record 88 is ALL fields T, N, M & Stage Group Both clinical and pathologic stage 68

65 When to use 88 Specific T, N or M category not applicable for site Lymphoma Clinical Stage: o Record 88 for T, N & M o Assign Stage Group per Chapter definitions o If stage group unknown code as 99 Gestational Trophoblastic Tumor No N category for GTT o Record cn/pn as 88 o Assign T, M & Stage group Per chapter definitions Pathologic Stage: o Record 88 for T, N & M, o Assign Stage Group as 99 Stage group 88 will trip a TNM edit 69

66 X OR BLANK 70

67 Use X Only used when Rules for classification have been met Clinical or Pathologic Stage When T or N not able to be assessed By MD Would be documented by MD By Registrar When records are available to stage But results not specific enough to conclusively define T or N 71

68 Use X Clinical Stage Workup insufficient to determine - But assessment was attempted Colonoscopy bx not able to determine depth = ctx Patient health factor precludes more specific testing Unable to test/assess = ctx or cnx o Allergy to radiographic contrast o Implanted medical device precludes testing o Comorbidities preclude procedures LN involvement inconclusive on imaging = cnx o Unclear if negative / Unclear if positive 72

69 Use blanks Only used by Registrars in database o When valid TNM category not able to be entered into registry fields Valid c category not available to record in pathologic stage Using the Blank indicates the implied value o When Rules for Classification have NOT been met No Clinical or Pathologic Stage Note: Stage Group must be 99 o When information not available in records Unknown what workup was done Insufficient records/information available to stage case 73

70 TNM 8 th Edition Quick Look 83 Chapters (57 in 7 th Edition) Some New Sites or Clinical Care Chapters: Myeloid & Lymphoid Leukemia Pediatric Acute Lymphoblastic Leukemia Multiple Myeloma and Plasma cell Disorders Cervical Nodes and Unk Primary Pediatric Lymphoma Nasopharynx Esophagus s/p Neoadjuvant therapy Thymus Merged Sites: Ovary/Fallopian Tube/Primary Peritoneal Split Sites for neuroendocrine histologies: Adrenal Ampulla of Vater Appendix Colon Duodenum Pancreas Small Intestine Stomach Rectum 74

71 TNM 8 th Edition Quick Look Split Sites into separate subsites Pharynx Oropharynx HPV-Mediated ( p16+ ) Oropharynx ( p16(-) ) Nasopharynx Hypopharynx Soft Tissue Sarcoma Abdomen/visceral Head & Neck Retroperitoneal Trunk and Extremity Unusual Histologies Split Sites cont. Thyroid-separated by histology Differentiated & Anaplastic Medullary More Anatomy Illustrations TNM Atlas and Oncoanatomy 8 th Edition Overview by AJCC November 10 th Register on AJCC website 75