ACOS Inquiry and Response Selected Inquires CS Tumor Size/Extension Evaluation, CS Lymph Nodes Evaluation, CS Metastasis at Diagnosis Evaluation *

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1 ACOS Inquiry and Response Selected Inquires CS Tumor Size/Extension Evaluation, CS Lymph Nodes Evaluation, CS Metastasis at Diagnosis Evaluation * CS Tumor Size/Extension Evaluation /11/2007: Q: A prostate patient had a positive sextant biopsy and the DRE revealed extracapsular extension. Is the CS Ext Eval code 0, because the furthest ext was being determined by physical exam? A. Yes, code 0 is correct /09/2007: Q: A patient had TURP for benign reasons and incidental foci of adenocarcinoma was found. TURP was coded surgery, 22. Is CS TS/Ext-Eval coded 4, surgical resection performed, even if Note #4, staging basis for TURP is clinical and the CS TS/Ext-Eval should be coded as 1? Software edit will not allow the 4. A. No, Eval code 4 is not correct for a TURP. The AJCC Staging Manual on page 310 clearly explains that a total prostatectomy is required to assign a pathologic T. There is insufficient tissue in a lesser procedure to evaluate the highest T category and surgical margins. That is why Note #4 was placed in the CS Manual on page II-433 to clearly explain this concept, that you must use code 1. Do not confuse coding procedures in the surgery field with the staging definition of a complete surgical resection, especially where site-specific rules /27/2007: Q. If a patient had a prostate needle biopsy for elevated PSA and the physician's physical exam revealed a clinically inapparent disease, is the CS Evaluation code based on the physical exam (0) or the biopsy (1)? A. Code CS Eval code to needle biopsy, /02/2007: Q. For prostate clinical extension 15, is ext/eval coded 0 because the extent was determined by clinical exam? For 22, is ext/eval coded 0 because the extent was determined by clinical exam? For 23, is ext/eval coded 1 because the extent was determined by the fact both lobes were involved by bx? A. The TS/Ext eval field reveals where you obtained your staging information, not necessarily what procedures were performed. The eval codes general rules tell you that 2008 Data Change Training 1 California Cancer Registry

2 you do not assign the highest code, but the code that reflects where the staging information was found. Clinical extension 15, CS Eval code for needle biopsies would be code 1. Codes are used only for clinically inapparent tumor not palpable or visible by imaging and incidentally found microscopic carcinoma in one or both lobes. Codes are used only for clinically/radiographically apparent tumor, i.e., that which is palpable or visible by imaging /23/2008: Q. For a prostate clinical T1c NX M0, clinical ext 15 and the patient had a radical retropubic prostatectomy is the evaluation coded 1 or 4? When is eval code 4 applicable? A. Please see Note 1 for CS TS/Ext Eval on page II-434 of the CS Manual. This evaluates the coding in tumor size, CS-Ext and SSF3. Eval 4 would fit this situation of surgical resection without neoadjuvant therapy. Eval 1 states no surgical resection, which is not appropriate for this case /01/2005: Q. For Prostate CS TS/Ext-Eval, what code is used for clinically inapparent tumors? If palpable/visible on imaging determines codes 10/15, should CS Eval be 0 or 1, for the needle biopsy? A. CS Eval code for needle biopsies would be code /14/2005: Q. If a prostate cancer patient had green light laser vaporization, no specimen was sent to the path lab and the surgery code was 17, no preoperative treatment. Is the CS ext eval coded 4? A. Because there was no specimen resected and no true surgical resection the CS ext eval would be coded either 0 or 1 depending on how extension was determined /21/2006: Q. CS Extension rule 10 on page 29 states "the presence of microscopic residual disease or positive tumor margins does not increase the extension code". However, do positive tumor margins effect CS TS/EXT EVAL? Can we truly code them as "3"? A. Choose the eval based on whether the procedure meets the guidelines for pathologic staging in the AJCC Manual for that particular site /22/2006: Q. Please clarify the difference in responses between I&R 19150, and How do we correctly capture CS TS/Ext Eval information for patients receiving preneoadjuvant treatment when two different sources (reports) are used to determine both tumor size and extension? Determining the correct eval code is confusing when postneoadjuvant operative report and path report info is used to determine extension, however, pre-neoadjuvant info (clinical) is used to determine tumor size. a. Which eval code is correct the eval code corresponding to TS (0) or the eval code corresponding to 2008 Data Change Training 2 California Cancer Registry

3 extension (6)? 2. How do we code TS when the only information available on tumor size is post-neoadjuvant treatment? a. Do we code TS to 999 or to the stated post-neoadjuvant tumor size? A. If the sources for the CS TS/Ext Eval information are different for tumor size and extension, code the one that determines the higher or more extensive involvement. For example, if the tumor size makes it a T3 and the extension makes it a T2, then code the source of the tumor size. You must code the post-operative treatment size/extension if it is more extensive than the clinical information. If it is not, then you code the clinical information. Rule 2b & 2c in CS Extension. As per the answer in 19262, it is better to keep the tumor size and extension the same, either both pre-treatment or both posttreatment. This may mean coding tumor size to 999, if the extension code determines the higher element of involvement, and it was not more extensive after treatment so you are using pre-treatment info, and you do not have a pre-treatment tumor size to correspond to the extension code you are using /10/2005: Q. If a breast cancer pt received neoadjuvant chemo, should the CS Staging be based on the clinical presentation and the eval codes coded to 5 clinical presentation or is the staging changed to pathological and the evaluation code coded to 6? A. Generally, the CS TS/Ext, Lymph Nodes Evaluations on a breast cancer patient receiving neoadjuvant chemotherapy, then surgery will be based on the clinical presentation, code /05/2007: Q. Pt diagnosed with SCC of the lung. An FNA of lung mass showed SCC. PET showed satellite nodules in same lung. CS Tumor Size=999, CS Ext=65. Is TS/Ext Eval 0 (PET Scan) or 1 (FNA)? A. Since you are using the data from the PET Scan to determine the size and extension, code TS/Ext Eval to /17/2008: Q. Pt had a positive cytology for malignant pleural effusion. Ext/evaluation for CS was 1 which derived a pathological T4. Why is the T category pathologic? Is there an exception for pleural effusion when there is a positive cytology? A. As was evident in this case, the evaluation codes are different for the lung schema and this is based on the AJCC Staging Manual 6th Edition p170 and its description of what is used for clinical and pathologic staging. This applies to any diagnostic invasive procedure such as bronchoscopy, mediastinoscopy, thoracentesis, etc, where they yield material for pathologic exam Data Change Training 3 California Cancer Registry

4 /06/2007: Q. For a liver cancer primary, CT identified a 7cm mass in liver with multiple satellite lesions. FNA confirmed hepatocellular carcinoma. For CS Size Ext/Eval, is the code 0 or 1? A. CS TS/Ext-Eval would be 1 based on the fine needle aspiration /17/2006: Q. Is laryngoscopic debulking of a supraglottic mass coded CS TS/Ext-Eval 1 or 3? A. Code CS TS/Ext-Eval to 1, endoscopy /10/2005 Q. A patient was treated with hormone replacement therapy and I-131 for a Hurthle cell adenoma diagnosed in Despite treatment, the benign tumor continued to grow so in 2004, they underwent a resection. Pathology from the resection confirmed the Hurthle cell adenoma along with a new diagnosis of incidental papillary carcinoma (less than 1cm). Does the treatment for the adenoma affect the CS data items such as CS TS/Ext Eval? A. No. The CS EXT/Eval would be coded based on pathological review of the "incidental specimen" regardless of treatment for an adenoma in the same primary site /25/2007 Q. A 3.1cm localized kidney cancer was found on a CT. They did a biopsy, which was positive for clear cell carcinoma, followed by a left renal cryoablation without a pathology specimen. For collaborative staging, do we make the TS/Ext-Eval a 3 for surgery or code a 1 A. Document code 1 in the CS Ext Eval field /07/2006 Q. Patient was diagnosed with rectal adenocarcinoma on colonoscopy biopsy. The colonoscopy showed a fixed lesion extending from 3-15 cm from the anal verge. Vaginal examination showed the rectal tumor had infiltrated into the posterior vaginal wall. They received preoperative chemotherapy and RT. The pathology from the abdominal perineal resection, performed after chemotherapy and RT, demonstrated 2 primary adenocarinomas, in the sigmoid colon and the rectum. The only information regarding the sigmoid lesion was from the pathology report as the sigmoid lesion was never mentioned on the colonoscopy, diagnostic imaging, or physical exam prior to AP resection. Is the CS TS/Ext Eval code for the incidental sigmoid primary a 3 or 6? A. The CS TS/Ext Eval code for the incidental sigmoid primary and for the rectal primary would both be either a 5 or 6, never a 3, because the surgical resection was performed after pre-surgical systemic treatment. A 5 would be used for the rectal ca unless the tumor was more extensive after the pre-surgical systemic treatment, and in that case a 6 would 2008 Data Change Training 4 California Cancer Registry

5 be used. Only the 6 is an option for the sigmoid ca since you have no clinical evidence on which to base the CS Extension. This is decribed on page 31 of the CS Manual, #3d and #3e. CS Regional Lymph Nodes Evaluation /08/2006: Q: A patient was diagnosed at another facility with a positive biopsy. Came to our institution and decided on neo-adjuvant treatment. The breast MRI prior to treatment showed a suspicious lymph node. There was sentinel lymph node mapping biopsy prior to chemotherapy; 4/6 nodes positive. What is the CS Regional Node Eval Code? A.The CS regional lymph node eval would be coded 3, as the sentinel lymph node biopsy was done prior to the chemotherapy being given /15/2007: Q. Can Code 3 be used in the breast schema for CS Reg Nodes Eval if there is a positive FNA of a supraclavicular node? A. FNA of the lymph nodes is coded as 1 per the CS standard tables /06/2006: Q. A patient presented with a 7.5. cm breast cancer and received neoadjuvant treatment. The clinical stage was T3N0M0. After chemotherapy and surgery the stage was yt2yn2amo. How is the CS Regional node Eval Coded? A. Code CS LN Eval as 6 (more extensive after preoperative treatment and surgery) /09/2007: Q. A patient with rectal cancer had no clinical involvement of regional lymph nodes and received neoadjuvant therapy. Resection revealed 5 positive lymph nodes. Is CS Lymph Nodes coded 10 and CS Reg nodes Eval coded 6, based on pathologic evidence after neoadjuvant therapy? A. Yes, code the most extensive involvement. This would be coding the positive nodes with the eval of 6, which indicates this is based on pathologic evidence after neoadjuvant therapy /28/2007: Q. A patient had an open cholecystectomy, primary site is cystic duct. One periductal lymph node was removed, however, celiac nodes were observed to be involved but were not removed. Is CS Lymph Nodes Eval coded 1 or 3? A. The CS Reg nodes eval would be coded to match with the highest level of involvement. For C24.0, cystic duct, the celiac node is a higher code that the periductal 2008 Data Change Training 5 California Cancer Registry

6 node and therefore the eval code would match with this and would be eval 1. This is in rule #1 on page I-43 of the CS Manual /19/2006: Q. Melanoma (skin of nose): A patient had a positive FNA of a submandibular LN, a modified radical neck dissection with 12 lymph nodes removed, all negative. How is CS Regional Node Eval Coded.? A, CS Regional Lymph Eval is coded to 3. CS Metastasis at Diagnosis /16/2007: Q. If a metastatic site had a needle biopsy, is this a code 1 or code 3 for CS mets? A. This would be be a CS Mets Eval code 3, pathologic exam of metastatic tissue /13/2008: Q. #13243 advises using the code which ruled out mets furthest from the primary site. Is the answer the same today, since they have changed the CS manual? A. No, that answer was written in 2004, for a different version of CS. Starting October 31, 2007, the CS Mets at Dx Eval has entirely new rules, which do not include how faar from the primary site a metastasis is, but is based on the M that is derived. * These Inquiry and Response questions and answers are reproduced in unedited format. They are provided for educational purposes. The ACoS Inquiry and Response system is available at: Data Change Training 6 California Cancer Registry

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