Collaborative Staging - American Health Information...

Collaborative Staging

Site-Specific InstructionsProstate

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In this presentation, we are going to take a closer look at the collaborative staging data items for the prostate primary site. Because prostate was not discussed in the AJCC module, this presentation will start with brief overview of anatomy and the staging criteria for the prostate. You will see how the T, N, and M are derived based on the information coded in the Collaborative Stage data items.

Prostate Anatomy

Apex

Base

Henry Gray (1825–1861). Anatomy of the Human Body. 19182

Because staging is based on where the cancer started and what other tissues or organs are involved, it is important to understand where these structures are in relation to the prostate. Notice the base of the prostate is at the top and is close to the vas deferens and seminal vesicles. The apex is at the bottom, closer to the prostatic urethra.

Prostate Lobes

SEER Public Domainhttp://training.seer.cancer.gov/ss_module02_prostate/unit02_sec02_anatomy.html

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For the most part, the prostate is referred to as having two lobes, left and right. There are some smaller components in the middle (anterior, median, posterior) but for staging, the focus is on the involvement of the left or right lobe, or both. Also notice the urethra runs through the middle of the prostate gland. The prostate is enclosed in a capsule. In the CS Extension data item, how much of the prostate in involved - one lobe, one half of one lobe, both lobes, etc. will be recorded. Also, you will see codes that refer to whether the tumor extended through the capsule.

Primary Site and HistologyAll are coded to Prostate, NOS (C61.9)

Almost all prostate cancers are

Adenocarcinomas (8140)

PIN III (8148/2) is not reportable

Transitional cell carcinoma arising in the prostatic urethra is to be coded to C68.0 Urethra and uses the Urethra scheme.

Multiple prostate primaries are VERY RARE4

There are no subsites for prostate cancer, so all are coded to C61.9. Although there are several cells types in the prostate, nearly all prostate cancers start in the gland cells. This kind of cancer is known as adenocarcinoma. AJCC staging applies to adenocarinoma (and its variants) and squamous cell carcinomas. AJCC staging does not apply to sarcomas. The prostate schema should not be used for transitional cell carcinomas (TCC) for both AJCC staging (pg 462) and Collaborate Stage (Note 1) coding. These should be assigned a primary site of C68.0 (urethra) and the Urethra scheme used. Prostate intraepithelial neoplasia grade III (or PIN III) is not reportable. Multiple prostate primaries are VERY RARE. If the patient has a history of prostate cancer, the current condition is most likely a recurrence or progression of disease.

What To Look For

• Prostate-specific antigen (PSA)− Normal findings: 0 - 4.0 ng/ml− PSA >10

• 50% chance of cancer• Look for information regarding metastatic work-up

− An elevated PSA alone (>4) is not enough to report case• You also need a physician statement

• Digital Rectal Exam (DRE)− Bumps, hard places, nodules (clinically apparent)− Changes in size and shape of the prostate (PIN)

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It is necessary to look for certain findings in the medical record because this information will be used to derive the stage. To validate this information from a quality perspective, it is important that this information be well described in the text fields in the abstract. Prostate cancer can often be found early by testing the amount of PSA in the blood or by doing a digital rectal exam. Most men have levels under 4 nanograms per milliliter of blood. Levels < 4 are considered to be within normal limits (WNL). Prostate cancer can cause the level to go up. If the level is between 4 and 10, there is about a 1 in 4 chance of having prostate cancer. If it is above 10, the chance is over 50% and goes up as the PSA level goes up. A very high PSA level might mean that the cancer has spread beyond the prostate and is a clue that you should look for information regarding the metastatic work-up. PSA levels in the 1000’s have been observed. Some men with a PSA below 4 can also have prostate cancer. On the other hand, factors other than cancer can cause the PSA level to go up, such BPH or an infection in the prostate, taking certain drugs, and getting older. Therefore, an elevated PSA alone is NOT enough to report the case. Men with a high PSA need further testing. You must have some other statement from a physician in the medical record indicating that the patient has cancer.

This may be on a physician note or dictation from another clinical exam, a path report from a biopsy, or a radiology report that states the patient has cancer (such as bone mets). The physician will use the results of all of these studies to make the final determination.

Another way prostate cancer is found early is when the doctor performs a digital rectal exam (DRE). Because the prostate gland lies just in front of the rectum, during the exam the doctor can feel if there are any bumps or hard places in the prostate that may indicate cancer. You should look for statements of clinically apparent tumor on physical exam or imaging. This information will used to determine the CS Extension code. Some doctors believe that prostate cancer begins with very small changes in the size and shape of the prostate gland cells. These changes are known as prostatic intraepithelial neoplasia. These changes can be either low-grade (almost normal) or high-grade (abnormal). If there has been a prostate biopsy that showed high-grade PIN (or PIN III), there is a greater chance that there are cancer cells in the prostate. For this reason, these patients will be watched carefully and may need another biopsy. PIN III alone is not reportable. If at any time, this is discovered to be in situ or invasive, then it does become reportable at that time.

Benign Prostatic Hyperplasia (BPH)

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A normal prostate, on the left, does not block the flow of urine from the bladder. An enlarged prostate, on the right, presses on the bladder and urethra and blocks the flow of urine.

What To Look For

• Symptoms of advanced cancer− impotence− blood in the urine − pain in the spine, hips, ribs, or other bones − weakness or numbness in the legs or feet − loss of bladder or bowel control

• These are clues that you should look for information to rule out mets

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Symptoms of advanced prostate cancer could include any of the symptoms listed on the slide. Once again, other diseases also can cause these symptoms. Prostate cancer is the most common cancer in men with the incidence increasing with age. It is rarely diagnosed in men under 40. Most of the time, prostate cancer grows slowly. It is not unusual for the treatment decision to be watch and wait where the patient will have periodic follow-up exams to watch the cancer and wait for it to advance to the point of needing treatment. Autopsy studies show that many older men who died of other diseases also had prostate cancer that neither they nor their doctor were aware of. This is why it is important to review your autopsy reports (if done at your facility) in addition to your other pathology reports.

What To Look For• Biopsy (core needle, TRUS)

− Often done in the doctor’s office− Several samples or chips are taken− H&P, Consult Notes− May be done for other

reasons (other than suspected cancer)• Incidental Finding =• Clinically Inapparent

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If cancer is suspected, a trans-rectal ultrasound (TRUS) with a core needle biopsy may be performed. This is a relatively quick and easy procedure and is usually done in the doctor’s office. This information may be in the office notes that are sent to be added to the record or they may be summarized in the H&P. During this process, they will take several samples (often called chips) around different areas of the prostate. For this reason, we are not to add the size of the cancer contained in these small samples together. And, even still they may miss the cancer altogether and the biopsy will be negative. A prostate biopsy may be done for reasons other than suspected cancer (such as suspected BPH). If there is no indication of cancer (the physical exam and radiology were all negative) and the biopsy returns as cancer, then this is considered an incidental finding or clinically inapparent. This is a factor in the CS Extension data item. Here is a picture of a TRUS biopsy. The transrectal biopsy removes tissue from the prostate by inserting a thin needle through the rectum and into the prostate. This procedure is usually done using transrectal ultrasound to help guide the needle. A transperineal biopsy is another biopsy method, but is not used as much.

What To Look For

TURP

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A transurethral resection of the prostate (TURP) is a surgical procedure to remove tissue from the prostate using a resectoscope (a thin, lighted tube with a cutting tool) inserted through the urethra. This procedure is sometimes done to relieve symptoms before other cancer treatment is given. A TURP may also be done in men who cannot have a radical prostatectomy because of age or illness, although this procedure is being used less frequently.

What To Look For• Coding Gleason Score as the 6th digit grade in the ICD-O-3 morphology code

−See SSF 7-8 for an explanation of Gleason Pattern and Score−Conversion table: FORDS−Example: PD Adenocarcinoma, Gleason Score 3+3 = 6−Record 8140/32 (ICD-O-3 Grade/Differentiation = code 2)

Code Gleason’s Scores Terminology Histologic Grade

1 2, 3, 4 Well Differentiated I

2 5, 6 Moderately Differentiated II

3 7, 8, 9, 10 Poorly Differentiated III10

The tissue from the biopsy (and/or resection) is usually assigned a grade. The system used most often for grading prostate cancer is the Gleason system. Samples from 2 areas of the prostate are each graded from 1 to 5, and the number grades are added to give a Gleason score or sum of between 2 and 10. The lower the number, the more the cells in the sample look like normal prostate cells. A higher score means the samples look less normal and the cancer is likely to grow more quickly. Don’t forget about the conversion table in the FORDS. If there is a discrepancy between the Gleason score and the terminology, the Gleason score has the priority. The columns in this table are listed in priority order. Gleason (1), Terminology (2), Histologic Grade (3). Of course if you have none of the above, the grade will have to be recorded as unknown. This table can be found in the FORDS. Note that this information is for recording the 6th digit of the ICD-O-3 histology code only. Later, you will learn where this information is used for coding several site specific factors. These data items have their own coding instructions that should be applied.

What To Look For

• Most common areas of regional spread − Regional lymph nodes− Direct extension into surrounding organs or tissues

• Seminal vesicles, bladder, rectum, sigmoid colon

• Most common area of distant spread− Bone

• May be identified by any one or more of the following:− Intra-operative exam, surgical resection, laparascopy, − Bone scan, CT, MRI, ProstaScint scan

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In addition to looking for information regarding the prostate, you also need to look for information about areas of involvement outside of the prostate. The most common areas of regional spread are, of course, those organs and tissues that are located next to the prostate. The most common area of distant spread is the bone. The most common procedures used to identify spread beyond the prostate are listed on the slide. Like the bone scan, the ProstaScint scan uses low levels of radioactive material to find cancer that has spread beyond the prostate. This test, however, uses a slightly different process. The advantage of this test is that it finds the spread of prostate cancer to lymph nodes and other organs. And it can tell the difference between prostate cancer and other problems. Doctors are not yet sure how useful this test is and most don’t use it for men who have just been diagnosed with prostate cancer.

Prostate Cancer

AJCC Staging

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Reading Assignment: You should stop and review the prostate chapter in the AJCC manual to familiarize yourself with its contents. Notice that there are two separate definitions of the T category – one for the clinical T and one for the pathologic T. For the clinical T, an important factor is whether the tumor is clinically apparent or not. This will be discussed in detail in the CS discussion and those concepts can be applied to assign the AJCC T category.

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Prostate Diagnostic Procedures

• Digital Rectal Exam (DRE)

• Prostate-specific antigen (PSA)

• Transrectal ultrasound (TRUS)

• CT, MRI, Bone Scan

• Biopsy

• Evaluation for metastases

Diagnostic procedures for prostate cancer include: Digital rectal exam, PSA, Transrectal ultrasound, CT, MRI, Bone scan, Biopsy, and evaluation for metastases. Clinical staging of prostate cancers usually includes a digital rectal exam and usually either a needle biopsy or a transrectal ultrasound biopsy. Since the posterior portion of the prostate gland can be easily palpated, the digital rectal exam is the most effective tool for early detection. Basically, you can use all information before treatment for assigning the clinical stage. Any information gathered after treatment will usually not be used for assigning the clinical stage and will probably be used to determine further treatment. Imaging studies have not proven very useful for prostate cancers, either for the primary or for lymph node involvement. They have a very high false positive rate. Imaging studies are usually not requested for patients with Gleason Scores less than 7-8 and PSA values <20 ng/ml for staging purposes. Therefore, you may find that imaging is not a main source of information for determining stage.

Prostate

• Pathologic T− Usually a total prostatectomy with lymph

node dissection is required− There is no pT1 category

• A few exceptions. A biopsy revealing carcinoma:− in the rectum permits a pT4− in extraprostatic soft tissue permits a pT3− infiltrating the seminal vesicles permits a pT3

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The AJCC pathologic staging criteria requires a total prostatoseminalvesiculectomy, including a lymph node dissection. There are a few exceptions. You should highlight these in your manual (pg 459). If a biopsy proves cancer in any of the areas listed in the highest T categories, that information can be used to assign the pT classification. For example:

•A positive biopsy of the rectum permits a pT4 classification

•A biopsy revealing carcinoma in extraprostatic soft tissue permits a pT3 classification

•A biopsy revealing carcinoma infiltrating the seminal vesicles also permits a pT3 classification. There is no pT1 category. The reason for this is that tumors in the T1 category do not involve enough tissue to assess the highest pT category.

Prostate

• Regional Lymph nodes− Pelvic, NOS− Hypogastric− Obturator− Iliac (external, internal or NOS)− Sacral (lateral, presacral, promontory-

Gerota’s-or NOS

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These are the regional lymph nodes for the prostate. If they were evaluated and were not involved code N0. If there is involvement the code is N1. There are no further subdivisions for positive regional lymph node involvement. Nodal involvement is usually confirmed via biopsy for clinical staging; however, it is possible that this can be determined on imaging. Remember for pathologic staging, a lymph node dissection is required. If the nodes were not dissected, assign NX.

Prostate

• Distant disease− M0− M1 distant mets (NOS)− M1a Non-regional lymph node(s)− M1b Bone(s)− M1c Other site(s) with or without bone mets

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Prostate cancer has more M categories than N categories. There are separate codes to indicate certain circumstances, such as bone mets only. If more than one code applies, assign the highest code. For example, if there are bone mets (M1b) and liver mets (M1c), assign M1c.

Stage Grouping

• You need:− T element− N element− M element

Plus

− PSA− Gleason Score

• Example:− cT1c− cN0− cM0− PSA 4.5− Gleason Score 7

− Stage Group = IIA

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To stage group a prostate cancer, you will need the PSA level and Gleason Score in addition to the TNM element. For example, a case with the following factors will be assigned a stage group IIA: T1c N0 M0 PSA 4.5 Gleason Score 7 This same case, but with a Gleason Score of 5 will be a stage group I. Therefore, obtaining this information (if not recorded in the chart) is important.

Prostate Cancer

Collaborative Staging

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Reading Assignments

• As each data item is being discussed, you should stop and read the information in CSv2 Part II for the prostate and CSv2 Part I, Section 2 for that data item including the associated notes, codes and definitions.

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It is important that you follow along and make notes in your manual. In addition to reading the slides and the instructor’s notes, it is important that you stop and read the related sections in your manual as not every point will be discussed in detail. As we go through each data item, don’t forget the general rules. They still apply. These will not be discussed in detail. Only those things that are specific to the prostate schema will be discussed.

CS – Colon Schema

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CS Lymph Nodes Eval CS Reg LN Pos CS Reg LN Exam CS Mets Eval

Refer to the General RulesRefer to the CS Breast presentation

As we discuss each site specific schema, many of the concepts are the same throughout and do not need to be repeated. The data items listed on this slide will not be discussed again. These data items follow the general rules. For the Eval fields, refer to the clinical and pathologic staging criteria in the AJCC manual for the procedures that qualify for each eval code. Also, for those data items that are discussed, many of the concepts for the general rules will not be repeated. The presentation will focus on those areas specific for the prostate.

CS Tumor Size

• Use the Standard Table

• Tumor Size is found on the pathology report • Prostate rarely has a tumor size reported• Code 999 if size is not stated

• Code the largest dimension of the primary tumor reported− Do not add pieces or chips together− Code size reported prior to treatment

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The tumor size will most often be found on the pathology report for prostate cancers. However, this is rarely recorded. Most of the time you will have to code 999. The tumor size is not needed to derive the stage. If it is reported, then code the largest size reported prior to treatment (chemo, RT, hormones, etc.). Do not add the size of chips or pieces together. Record the largest size of tumor reported by the physician.

CS Extension – Clinical Extension

• Read the NOTES carefully

• Code findings from clinical evaluations only• Imaging• Physical exam / digital rectal exam• Biopsies (prostate or other sites)

• Prostatectomy is EXCLUDED from this data item!• Recorded in SSF 3: CS Extension – Pathologic

Extension

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There are two fields where information regarding extension of tumor will be recorded. These two fields are: CS Extension and Site Specific Factor 3. The CS Extension field is used to describe the extension of the prostate tumor on clinical evaluation only. This includes findings from any imaging report or a physical exam – which will probably include a digital rectal exam. To evaluate extension, they may do a biopsy (ie: of the prostate or rectum). Any information from a biopsy can also be used. What IS EXCLUDED are the findings from a prostatectomy. This information will be recorded in site-specific factor 3. You should highlight the word “clinical” in the data item name. Also, under note 1, highlight “prostatectomy is EXCLUDED from this field and coded only in SSF 3”. There are many errors in this data item because it is a little different than all other sites in that you only record the clinical findings. Be sure to read the notes for this data item…there are lots of them!


Prostate Bladder

Prostate Bladder

Local = Codes 100-300

Extension beyond prostate =

Codes 410-75023

As we did with some of the other site specific schemas, it is often helpful to look at the codes to see if you can determine if the codes can be divided into categories. For prostate, the first division is if the tumor was confined to the prostate OR if it extended beyond the prostate into surrounding tissues or organs. If it is confined to the prostate, it is considered localized and we can start by focusing on codes 100-300. If the tumor extends beyond the prostate then we will need to look more at codes 410-750. Note that in-situ would be coded to 000. In situ does not exist for TNM staging so it will map to TX for TNM staging, but will map to in situ for Summary Staging.


ClinicallyApparent

(visible or palpable)

ClinicallyInapparent

(NOT visible or palpable)

Codes 100-150 Codes 200-240

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The next division is within the local range (codes 100 – 300). One of the major divisions in this range of codes is whether the tumor is clinically inapparent or clinically apparent. Codes 100-150 are used to describe a prostate nodule that is NOT visible on imaging or palpable on exam. Codes 200-240 are used to describe a prostate nodule that IS visible on imaging or palpable on exam.

Clinically Apparent or Inapparent?

• Clinically Inapparent− Tumor is NOT palpable on DRE or visible on imaging− Often discovered when evaluating other conditions

• BPH

• Elevated PSA

− A physician statement of cT1 can be used to indicate clinically inapparent

• Clinically Apparent− Tumor IS palpable on DRE or visible on imaging− Terms “tumor”, “nodule” and “mass” or physician statement may be used

− Terms “firm” and “hypoechoic” alone cannot be used− A physician statement of cT2 can be used to indicate clinically apparent

• In absence of information – use code 30025

Since many patients with early stage cancer are asymptomatic, cancer is frequently identified incidentally when performing a procedure for other reasons. For example, a patient with BPH may undergo a TURP. There was no suspicion of cancer prior to this procedure but on pathologic review of prostate tissue, the cancer is identified. Another common example is the patient may undergo a biopsy or TURP when there is an elevated PSA, but again the nodule could not be palpated. A PSA alone is often not enough to say the patient has cancer, but this may be confirmed when the biopsy is done. In both of these situations, the cancer is considered to be clinically inapparent. The tumor could not be palpated on DRE or seen on imaging. Clinically apparent means that the cancer was visible on imaging or palpable on clinical exam. Usually on a digital rectal exam, there will be a statement describing if there was something palpable in the prostate or not. There are many different words that the physician may use to describe these findings. The terms "tumor", "nodule", "mass" may be used to consider the tumor clinically apparent; however, other terms such as "firm" or "hypoechoic" should not be used unless clinician uses the terms to assign a T category in the clinically apparent range such as T2, T2a, etc. Do not infer inapparent or apparent tumor based on the interpretation of other terms in the DRE or imaging reports. A statement by the physician of involvement is the best source of the tumor being clinically apparent. Also, a statement of T1 for (inapparent) or T2 (for apparent) is sufficient to categorize the case. Throughout the code descriptions for this data item, information regarding a physician’s statement of the cT category has been added. So, if the physician states the tumor is cT1c, and there was no information on how this was derived, then you should assign code 150. For example, work-up was done elsewhere and there is limited information available other than a statement of T1c. This allows the case to be coded using the physician’s statement rather than coding to unknown. If there is no information, including a physician’s statement, on whether the tumor was clinically apparent or not, then assign code 300.


Codes 100-150: clinically inapparent tumor

• Codes 100 -140 − Found incidentally when a

TURP was done− Based on # or % of involvement

• Code 150 − Found incidentally when a biopsy ONLY was done

Image source: TNM interactive, Wiley-Liss.26

The first range of codes (100-150) that we will review are the ones for tumors that clinically inapparent. It is important to keep this division in mind when reviewing these codes. If the tumor is clinically apparent, this range cannot be used. The next piece of information that needs to be determined is whether a TURP was done or a biopsy. If a TURP was done, use codes 100-140. Exactly which code you use depends on how much of the resected tissue was involved with cancer. 5% or less = code 130, more than 5% = code 140. This information is usually found on the pathology report. Use code 100 when the number or percent is not stated. This range also applies if a TURP and a biopsy were done. If there was no clinical evidence of the tumor (clinically inapparent) and they found the cancer when they did a biopsy, then you should use code 150. Often, when a patient has an elevated PSA, they will do a biopsy to rule out cancer. Code 150 should be used when there was a biopsy only

, meaning that they did not do a TURP (either at the same time or later).

Again, each code includes a statement of the T category if that is the only information that is available.


• Codes 200-240: clinically apparent tumor• Use information from the physical exam or

imaging ONLY

• Code 300 – Unknown if clinically apparentImage source: TNM Atlas, 3rd ed., 2nd rev.27

The next range of codes (200-240) for local prostate cancers are for those that are clinically apparent

– meaning that they could feel a nodule on the rectal exam or it was seen on ultrasound or imaging.

Exactly which code you choose is based on how much of prostate is involved. Was there one lobe or less than one half of one lobe involved? Or, are both lobes involved? This note is very important: ONLY the findings from the physical exam or imaging should be used for this range. Often, additional information will be made available when a TURP or biopsy is done. The findings from these procedures are NOT to be included when determining the code in this range. Because we are in the clinical APPARENT range, the information for this code must be based on the findings from the physical exam or imaging that determined that the tumor was apparent. Remember that you want to select the most specific code possible. Therefore, codes 210 and 220 have precedence over code 200. Code 200 has precedence over code 240. Use code 240 if the physician assigns cT2 without a subcategory of a, b, or c. CODE 300 is used for when it is known that the cancer is local but it is unknown if it was clinically or radiographically apparent. An example would be when a diagnosis is made prior to admission for a prostatectomy with no details provided on clinical findings prior to admission.

• Codes 410 – 750• Contiguous extension of primary tumor

− Discontinuous extension coded in CS Mets at Dx


Prostate Bladder

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If there is extension beyond the prostate clinically, regardless of how it was found: biopsy, TURP, imaging, exam, etc., you are going to use the 410-750 range. Select the highest code that appropriately describes the extent of disease. This data item applies to the contiguous extension of ONE tumor only – the primary tumor. “Contiguous” means the direct extension of the tumor into regional tissues or organ(s). An example would be a biopsy that proved direct extension to the bladder (as shown on the slide) or to the sigmoid colon. Discontinuous involvement (or individual or separate areas of mets) will be coded in the CS Mets at Diagnosis data item. An example of distant mets would be a separate tumor in the lung or bone.


• Codes 410-490− Describe extracapsular extension− Extension beyond prostatic capsule

A B CImage source: TNM Atlas, 3rd ed., 2nd rev.

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Codes 410-490 describe extension that is beyond the prostatic capsule (or extracapsular extension). The code you choose depends on whether the extraprostatic extension is on one side of the prostate (A), both sides of the prostate (B), or if it involves the seminal vesicles (C). This is a good example of the type of specific information you need to be looking for in the path report and documenting in your text.

520 Levator prostatae muscle

450 Seminal vesicle

500 Bladder500 Bladder neck520 Ureters

600 Pubic bone

500 External sphincter muscle

700 Cowper's gland

600 Pelvic wall

700 Other bone

700 Penis

520 Skeletal muscle

700 Soft tissue otherthan periprostatic

CS Extension – Clinical ExtensionCodes 500-700

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Codes 500-700 are used when there is direct extension through the prostate capsule into adjacent structures. You may want to highlight “further contiguous

extension” in code 700 which includes soft tissues or other structures not named in the lower codes.

Not shown: 500 Denonvillier’s fascia (between rectum and prostate); rectum 600 Frozen pelvis, NOS 700 Sigmoid colon

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• Code 440

• Microscopic bladder neck involvement

• Code 500

− Bladder neck extension

− Except microscopic bladder neck involvement

Also note that there are two different codes that can be used when the bladder neck is involved. If the involvement is microscopic only, use code 440. For all other bladder neck extension, use code 500. Code 750 should be used if stated as T4 with no additional information to support extension.

Teresa Winslow – public domain

(CS Ext 100-150)

(CS Ext 500-750)(CS Ext 410-490)(CS Ext 200-240)

230 450 70032

Here is another visual of the different stages of cancer. Stage T1: Tumor is microscopic and confined to prostate but is undetectable by a digital rectal exam (DRE) or by ultrasound. Usually discovered by PSA tests or biopsies. These are the clinically inapparent tumors in the range of 100-150. We need to know how it was detected (TURP or biopsy) to determine the exact code. Stage T2: Tumor is confined to prostate and can be detected by DRE or ultrasound/imaging. These are the clinically apparent tumors in the 200-240 range. In this picture there is involvement in both lobes, code 230. Stage T3: The cancer has spread to tissue adjacent to the prostate or to the seminal vesicles, codes 410-490. In this picture there is extracapsular extension and extension to the seminal vesicles, codes 450. Stage T4: Tumors have spread to organs near the prostate, such as the bladder, codes 500-750. This is showing extension to the bladder, bone and rectum, or a code 700 because of the bone involvement.

CS Tumor Size / Extent Eval

• Based on BOTH CS Extension and SSF 3− Code how most extensive disease was

determined from either CS Extension or SSF3

• Warning!− Code structure differs from normal codes− Special circumstances where pathologic staging

applies without a resection− TURP is a clinical staging basis (Eval Code 1)

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The CS Tumor Size/Extent Eval field is used to describe the evaluation method for both the CS Extension and the SSF 3. Since both fields determine the T category, select the eval code that reflects how the most extensive disease was determined. If the prostatectomy determined the most extensive tumor assign code 4. If prostatectomy was performed but the information is not useful for staging, CS Tumor Size/Ext Eval should be assigned based on the information coded in CS Extension - Clinical Extension. According to the AJCC manual, "In general, total prostatoseminal-vesiculectomy, including regional node specimen, and histologic confirmation are required for pathologic T classification”. A simple prostatectomy is acceptable for pathologic T classification when disease is confined to the prostate and margins are negative. And, there are special circumstances where pathologic staging can be done without a resection (Note 3). These examples were discussed in the AJCC section. Later, you will learn that a TURP is coded in the data item “Surgical Procedure of the Primary Site”. This can cause confusion in CS. A common error is that the TURP is coded with an Eval code of 4 (pathological staging basis) because it is considered as surgery to the primary site in a different data item. Remember to keep the rules for each data item separate. Note 5 states that a TURP is a clinical staging basis and should be assigned a code of 1.

Prostate -- CS TS/Ext Eval

•Structure unique to prostate− 0 clinical only

• DRE, TRUS only (no biopsy), imaging− 1 invasive techniques

• Biopsy, TURP, endoscopic exam, TRUS with biopsy− 2 no resection but positive bx of extraprostatic site

• Sites that fall under CS Extension codes 410-750− 3 autopsy (known or suspected at dx)− 4 pathology

• Prostatectomy− 5 pre-op tx, clinical eval− 6 pre-op tx, path eval− 8 autopsy (not suspected at dx)− 9 unknown, not assessed 34

The code structure (for prostate only) differs from the codes for all other sites. This can cause errors in this field if the registrar enters a code 3 out of habit for pathologic staging bases. If a prostatectomy is performed, this is assigned a code 4, not 3. Review Notes 6-9. Let’s look at code 2. In certain circumstances, the prostate staging scheme allows for the assignment of the pathological T based on a biopsy alone even though a resection was not done. The catch is that the biopsy has to be of a site other than the prostate

. These other sites would fall under the CS Extension codes of 410-750. For example, they may do a biopsy of the rectum (code 500) or the soft tissues surrounding the prostate (code 700). Codes 2, 3, and 4 (in red box) generate the “pT”. Note that the description for these codes states “meets the criteria for AJCC pathologic staging”. A biopsy of the prostate would be a code 1.

Codes 5 and 6 in all three eval fields differentiate that the patient received pre-operative neoadjuvant treatment, radiation or systemic therapy, and determines whether clinical or pathology information was used. The intention of the neoadjuvant treatment is to shrink the tumor. Extension and Lymph Node codes assigned after preoperative treatment, in most cases, do not represent the actual farthest extension or lymph node involvement. Code 5 indicates there was preoperative treatment, but the Tumor Size or Extension, whichever is greater, was coded based on clinical information available before treatment was started.

CS LYMPH NODES

• Code only regional nodes• Iliac (excludes common iliac)• Pelvic, NOS• Periprostatic• Sacral, NOS• Regional Lymph Nodes, NOS

• Distant nodes are coded in “CS Mets at DX”

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For this data item we are going to specify whether or not there were positive regional lymph nodes. This does not apply to all sites, but for prostate, this includes contralateral and bilateral lymph node involvement. You may want to highlight that statement in the code 100 box. Any lymph nodes not listed under code 100 are considered distant and are coded in the next data item.

Unknown vs None

• Prostate lymph nodes are inaccessible

• Code 00 if − Isolated, localized, early tumors (AJCC T1 and T2)− No information or no mention AND standard

treatment for local stage was given

• Code 99 if− There is reasonable doubt that the tumor is no longer

localized− Example: Tumor has penetrated through capsule into

surrounding tissues36

The lymph nodes for the prostate are considered to be inaccessible. Therefore, if there is no mention of lymph node involvement and the patient receives standard treatment for local stage, then assign the CS Lymph Nodes as 00, none. If there is reasonable doubt that the tumor is no longer localized, then you should assign 99, unknown.

CS Mets at Dx

Identifies thedistant site(s) of

metastatic involvementat time of diagnosis.

• Distant Lymph Nodes• Distant Sites

40

30

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This field is for metastatic nodules that are separate from the primary tumor. You should review all dictation and reports including pathology and imaging reports for any evidence or statement of metastatic disease. Bone metastases identified after a period of watchful waiting would be considered progression of disease and should not be coded as metastasis at diagnosis. Included in this data item are distant lymph nodes (some of the common ones are listed under codes 11 and 12). The common iliac nodes have their own code (11). All other distant nodes are coded to 12. If a bone scan, or other test, was done that was positive for bone mets, then you would code 30 – metastasis in bone. It has its own code because bone is the most common site of distant mets. Other distant sites (other than bone and distant lymph nodes) are coded to 40 – such as lung, liver, brain, etc. And, there are some combination codes as well. The different metastatic codes are able to map to the various M1 options in TNM staging: M1a, M1b, and M1c, along with M1 NOS when you are unable to assign a, b, or c. Clinical M only requires a history and physical. Extensive testing does not have to be done to assign a clinical M. You can infer a cM0 unless known to be cM1. An example would be a patient diagnosed on needle biopsy with prostate adenocarcinoma, T1c has no complaints of bone pain. In the absence of a bone scan, one would infer a clinical M0.

CS Site Specific Factors 1 & 2Prostate Specific Antigen (PSA)

• Record the highest PSA Lab value prior to diagnostic biopsy or treatment

• Lab values for SSF’s 1 and 2 should be from the same lab report

SSF 1

Code actual lab value

IE: 040, 050, 055, etc.

SSF 2

Code the clinician’sinterpretation of the PSA

value documented in SSF1

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For this data item, we are going to record the highest PSA lab value reported prior to diagnostic biopsy or treatment. Part 1 Section 2 specifies a time frame of 3 months. If there were more than one PSA tests done in the 3 months prior to treatment, then record the highest value from those test within that time frame. Serum PSA is not the same as free PSA or precursor PSA. Do not record values from free or precursor tests in this field. If the report just mentions “PSA”, then assume that is it serum PSA and record that value. Code the actual lab value in SSF 1. If the highest PSA value reported was 5.5, then code 055. There is an implied decimal point between the 2nd and 3rd digits. If the test was not done, then code 000. In SSF 2, you should specify if the value you coded in SSF 1 was elevated (code 010) or within normal limits (020). In general the normal range is – 4.0. So, a value of 5.5 would be elevated. In this example, we would code a 010 in SSF 2. When coding SSF’s 1 and 2, you should be using the same lab report and same lab value to describe both fields.

CS Site Specific Factors 1 & 2

Why record PSA twice? PSA varies by age of patient

Reference Values: Total prostate-specific antigen (PSA) Men younger than 40 < 2.0 ng/mLMen age 40 to 50 < 2.5 ng/mLMen age 51 to 60 < 3.5 ng/mLMen age 61 to 70 < 4.5 ng/mLMen over age 70 < 6.5 ng/mL

PSA varies by the lab methodIn general, PSA levels from 4 to 10 ng/mL are borderline. In general, PSA levels above 10 ng/mL are high.

Recording the exact value and the interpretation helps clarify results of analysis.

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The normal range for the PSA value varies depending on the age of the patient and by the lab method. What might be normal at one facility might not be at another facility. Adding this second SSF helps with the interpretation and analysis of the PSA value. The values listed on this slide are examples of how this can vary. The normal range for tumor markers used by the lab doing the tests should be used. Or, the clinician’s interpretation in the medical record can be used if provided. One recommendation is to discuss this with the labs that provide the majority of this service at your facility and obtain the list of normal range values to avoid coding unknown if possible. If a different lab is used, the values at that particular lab will need to be used to code this SSF. The guidelines in Part I Section 2 state that if there is no interpretation of the PSA value in the record, use code 999. Do not infer a code for this field based on the normal values listed for PSA Value.

CS Site Specific Factor 3 CS Extension – Pathologic Extension

• Record information from the prostatectomy in this data item− This information is excluded from the CS Extension –

Clinical Extension field

• Incidental finding during a prostatectomy for other reasons− Does not affect the coding− Use code for extent of disease found at time of surgery

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SSF 3 is used to record the findings from the prostatectomy. Only include histologic information from a prostatectomy (or autopsy) in this field and only if it was done as part of the first course of treatment – meaning the prostatectomy wasn’t done after the disease had progressed. You may want to highlight this statement in Note 1. If you will remember, findings from the prostatectomy were excluded from the CS Clinical Extension field. In the CS Extension data item, a lot depended on whether or not the tumor was clinically apparent or not. For this data item, this information does not affect or alter the code choice. You should record the highest degree of involvement using all histologic information including the information from the prostatectomy – regardless of why the prostatectomy was performed. Codes 020-099 have been made obsolete, and the codes will no longer be used. Look at code 700. You only code 700 if there was direct extension to the bone reported on the prostatectomy pathology report. If they did a bone scan that showed bone mets, then that information is reported in CS Mets at Dx, not here.

950 No evidence of primary tumor (T0)960 Unknown if prostatectomy done970 No prostatectomy in first course980 Prostatectomy not in first course but performed due

to disease progression985 Autopsy performed but extension unknown990 Prostatectomy done but extension unknown, not

assessed, or not documented

CS Site Specific Factor 3 CS Extension – Pathologic Extension

Special Codes

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There are a few codes in this data item that are not in the Clinical Extension data item, so just beware of that. They are mainly for describing the margins. Because this data items is used to derive the AJCC pT category, this field must be coded. If a prostatectomy was not done or you don’t know if it was done, there are a few special codes to describe the situation. If a prostatectomy was not performed, then use code 970. An example of when you would use 980 would be if the patient was diagnosed and the decided for “watch and wait” as the first course of treatment. Then the patient began to develop further symptoms (progression) so they decide to do a prostatectomy. This is considered second course. Be sure to document this clearly in your text --- that watch and wait was first course, etc. It is rare that this will be recorded because the abstract will usually be completed by the time the progression is known.

CS Site Specific Factor 4

•Initially used to code the PAP (Prostatic Acid Phosphatase) tumor marker (in 2004)

•Then used to code Apex Involvement (2005 – 2009)

•NOW OBSOLETE

•Not required for cases diagnosed on or after 1/1/2010

•Use code 988

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SSF 4 was initially used to code the tumor marker PAP (Prostatic Acid Phosphatase). This data item was changed in 2005 to code Apex Involvement. This data item should be collected for cases diagnosed prior to 2010. For cases diagnosed on or after 1/1/2010, this data item is no longer required to be collected. Code 988 for these cases. This picture shows a cancerous tumor at the apex of the prostate.

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CS Site-Specific Factor 5 and 6: Gleason’s Pattern and Score

• SSF 5 is OBSOLETE

• SSF 6 is OBSOLETE

• Use code 988 (not applicable)

• See SSFs 7-11 to record Gleason information

In CSv2, SSF 5 and 6 has been made obsolete. Old data will be retained, but Gleason information will no longer be coded in these fields. Gleason information is now documented in SSFs 7-11.

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CS Site-Specific Factor 7 Gleason’s Pattern

• Code from needle core biopsy or TURP ONLY

• Record the Gleason’s primary (first number) and secondary patterns (second number)

− Example Gleason 3+2 = 5• 3 is the primary number• 2 is the secondary number• 5 is the score (recorded in SSF 8)• Code 032 in SSF7

• Code the highest or most aggressive pattern

Gleason information has been divided into clinical and pathologic information. In SSF 7 and 8 the clinical information is being recorded. Therefore, ONLY the information from the NEEDLE CORE BIOPSY or TURP should be used to code this data item. The pathologic Gleason information from a prostatectomy/autopsy will be recorded in SSFs 9 and 10. Review Note 2 on how the primary pattern, secondary pattern and score are determined. The Gleason pattern is often written as primary pattern + secondary pattern = score. An example of 3+2=5 is provided. The first number (3) is the primary pattern. The second number (2) is the secondary pattern. The score is these two numbers added together which is 5 and will be coded in SSF8. In this example, a code of 032 should be recorded in SSF7. The first digit in SSF7 is always 0. It is possible that the Gleason information will be written in a variety of other ways as well. The slide after SSF8 provides additional examples that are discussed in Note 2.

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CS Site-Specific Factor 8Gleason’s Score

• Code from needle core biopsy or TURP ONLY

• Record the Gleason’s Score

− Example Gleason 3+2 = 5• 3 is the primary number• 2 is the secondary number• 5 is the score• Code 005 in SSF8

Record the Gleason's score based on the sum of the primary and secondary pattern from the needle core biopsy or TURP ONLY in SSF 8. If multiple needle core biopsies are performed or needle core biopsy and TURP both performed, code the highest or most aggressive score.

CS Site Specific Factor 7 and 8

Value stated Pattern or Score Code Example

One value and it is < 5

Assume it is a primary pattern

Code secondary pattern as a 9

Biopsy: Gleason 4

SSF7 as 049, SSF8 as 004

One value and it is > 5

Assume it is a score Code both patterns as 9

Biopsy: Gleason 7


Value given as x/10

Assume the first number is the score (out of a possible 10)

Code both patterns as 9

Biopsy: Gleason 3/10


Patterns and/or scores for different specimens

Use the pattern with the highest score or most aggressive pattern

Code highest or most aggressive

Biopsy: Gleason 3+3=6

TURP: Gleason 2+3=5


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This slide summarizes how to code certain values stated in the medical record as described in Note 2. Not shown: If there are two numbers, assume that they refer to the two patterns (the first number being the primary and the second number being the secondary) and add them together to obtain the score. An example of this was provided on the previous slide. Gleason 3+2=5 Row 1: If you are only given one Gleason’s value, and it is 5 or less, assume it is the primary pattern and code the secondary pattern as 9. Assign the given Gleason value in SSF8. Example: Biopsy: Gleason 4, code SSF7 as 049, SSF8 as 004. Row 2: If you are given only one value and it is greater than 5, assume the number is a Gleason’s Score and code both patterns as 9. Assign the score in SSF8. Example: Biopsy: Gleason 7, code SSF7 as 099, SSF8 as 007. Row 3: If a Gleason’s value is given as a number with a /10, for example 3/10, assume that the first number is the score, 3 out of a possible 10 and code both patterns as 9. Example: Biopsy: Gleason 3/10, code SSF5 as 099, SSF6 as 003. Row 4: If there is more than one primary and secondary pattern value, the value to be coded is the one based on the specimen with the highest score or most aggressive pattern. Remember that this is based on information from a biopsy and TURP only in SSF7 and 8. And, this is based on prostatectomy (or autopsy) only in SSF9 and 10. Example: Biopsy: Gleason 3+3=6, TURP: Gleason 2+3=5, code SSF7 as 033, SSF8 as 006.

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CS Site-Specific Factor 9 and 10

• Code from Prostatectomy or Autopsy ONLY− SSF 9: Record the Gleason’s primary pattern

and secondary pattern− SSF 10: Record the Gleason’s Score

• Rules of SSF9 and 10 are the same as SSF7 and 8, only the source is different

In SSF 9 and 10, the Gleason’s pathologic information will be recorded. Therefore, ONLY code the information from the PROSTATECTOMY (or autopsy). Code the Gleason’s primary pattern and secondary pattern from the Prostatectomy or Autopsy in SSF 9. Code the Gleason’s score from the Prostatectomy or Autopsy in SSF 10. The rules for SSF9 and 10 are the same as SSF7 and 8. Only the source of the Gleason information is different. If a tertiary pattern is documented in the prostatectomy pathology report, do not include it in either SSF 9 or SSF 10. Record the tertiary pattern in SSF 11.

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CS Site-Specific Factor 11Gleason’s Tertiary

• Code from Prostatectomy or Autopsy ONLY

• Record the specific Gleason’s Tertiary Pattern stated

• High tertiary Gleason pattern− Indicates a worse outcome

Record the tertiary pattern documented on prostatectomy or autopsy only. If a tertiary pattern is documented on needle core biopsy, it should be ignored. If present, a high tertiary Gleason pattern appears to be an indication for a worse outcome. Studies indicate that a Gleason score 7, with tertiary pattern 5, is associated with a worse prognosis than without tertiary pattern 5, and is similar to the prognosis for Gleason score 8-10. The coding structure for SSF 11 is as follows: •Code 010-050 - Pattern 1-5 (record the specific pattern as documented on prostatectomy or autopsy). The tertiary pattern is recorded in the middle digit. •Code 998 - No prostatectomy/autopsy performed •Code 999 – Unknown; Not applicable; Not documented in the patient record

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CS Site-Specific Factor 12 Number of Cores Positive

• Samples taken during the needle core biopsy

• Record the number of positive samples reported in the pathology report

• Code from the procedure with highest number of positive samples− Do not add numbers from

multiple biopsies

During a needle core biopsy, the physician will take several samples (often called chips) around different areas of the prostate. In the pathology report, the samples or chips examined will be counted and the number of samples that contain cancer will be counted. It may also indicate which lobe the positive samples were identified in. In SSF 12, record the number of prostate core biopsies positive for cancer documented by the pathologist in the pathology report. Do not make any assumptions on the number of cores positive based on the number of anatomic locations biopsied because often several cores are submitted per site. If the number of cores positive is not specifically documented, code 991. If multiple needle core biopsy procedures are performed within the timing rule, do not add the positive cores together from the separate procedures. Record the number of cores positive for cancer from the procedure with the highest number positive.

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CS Site-Specific Factor 13 Number of Cores Examined

• Samples taken during the needle core biopsy

• Record the number of samples examinedreported in the pathology report

• Code from the procedure with highest number of positive samples− Do not add numbers from

multiple biopsies

In SSF 13, record the number of prostate core biopsies examined for cancer documented by the pathologist in the pathology report. Do not make any assumptions on the number of cores positive based on the number of anatomic locations biopsied because often several cores are submitted per site. If the number of cores positive is not specifically documented, code 991. If multiple needle core biopsy procedures are performed within the timing rule, do not add the positive cores together from the separate procedures. Record the number of cores positive

for cancer from the procedure with the highest number positive (same procedure used to record SSF 12).

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CS Site-Specific Factor 14Needle Core Biopsy Findings

• Record the findings from the needle core biopsy

• Codes based on the location of the positive samples− whether one or both lobes

are involved

Knowing that the tumor is in one or both lobes is important for treatment planning, especially in clinically INapparent tumors where the clinical extension does not specify the extent of tumor involvement. For example, in a clinically inapparent tumor, the fact that the biopsy is positive is still only a T1c (CS Extension code 150), even if both lobes are involved. This SSF allows for this additional information to be captured. The codes are primarily based on the location of the positive samples - whether one or both lobes are involved. For example, if positive findings were identified in both lobes on a needle biopsy specimen, then code 020 should be recorded.

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CS Site-Specific Factor 15Clinical Staging Procedures Performed

• Based on two procedures: Imaging and DRE

• Imaging includes:− TRUS only− TRUS guided biopsy− erMRI− Others: Doppler U/S, T2-weighted MRI, MRSI, DCE-MRI

• Only use information on staging procedures performed BEFORE a core biopsy or resection

For research purposes, investigators need to determine whether the clinical staging for cases staged as T1c was based on DRE only or on DRE plus imaging. SSF 15 has been added to record information about what clinical staging procedures were performed. Record the procedures used in clinical staging for all

cases, even though the focus in data analysis may only be on T1c. The findings of these clinical staging procedures can be positive or negative, the important information being coded here is what was done, not what the results were.

Procedures used in clinical staging include digital rectal examination (DRE) or imaging techniques including transrectal ultrasound (TRUS) or endorectal coil magnetic resonance imaging (erMRI). There may be others that are not as commonly used. Clinical procedures performed after needle core biopsy or any surgical procedure of the prostate are not included in this field.

Resources

• AJCC Cancer Staging Manual, Seventh Edition

• CDC NPCR Education and Training Series

• Collaborative Staging Manual and Coding Instructions

• ICD-O-3

• SEER Training Website

• TNM Atlas, 3rd ed. 2nd rev., by B. Spiessl et al. Springer Verlag 1992

• NCI Visuals Online

• Gray’s Anatomy 191353

The graphics, coding instructions, and other supportive information were provided by the following resources. Slide 54

This Concludes This Presentation

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Please return to the course content to complete additional case scenarios to reinforce the coding instructions.

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