In the Know About Lymph Nodes Fields April
In the Know About Lymph Nodes Fields April Fritz, RHIT, CTR
What We’ll Cover l What’s considered “involvement” l Regional vs. Distant ¡ Reference materials l Nodes Positive/Examined l Scope of Regional LN Surgery l Site-Specific Lymph Nodes Issues ¡ Colon and rectum ¡ Head and Neck ¡ Breast l LN Site-Specific Factors Lymph Nodes Fields 2
What’s in a Name?
Lymph Node Identification Issues Different names for nodes l Anatomic location vs. technical name ¡ Technical name associated with blood vessels l Examples ¡ Lung l Location: perihilar, mediastinal l Technical: azygous, carinal, para-aortic l Surgical: lymph node stations ¡ Breast l Location: intramammary, interpectoral l Technical: axillary, internal mammary, infraclavicular l Surgical: Level I, Level II 23 4 5 6 7 1 8 Lymph Nodes Fields 4
Lymph Node Identification Issues Which nodes get coded where? l Reference: Summary Staging Manual 2000 ¡ List of lymph node synonyms: page 284 l Reference: Hematopoietic Manual Appendix C ¡ List of all lymph nodes with ICD-O-3 codes and AJCC/TNM lymph node region l Reference: Cancer Registry CASEbook ¡ Volume II: Lymphatic System chapter ¡ Site-specific chapters l Reference: AJCC Cancer Staging Manual ¡ REGIONAL if listed under Nodes in Anatomy section l Code as Scope Reg LN Surg ¡ DISTANT if NOT listed under Nodes in Anatomy l Code as Surg Proc/Oth Site code 3 Lymph Nodes Fields 5
Lymph Node Involvement Lymph Nodes Fields 6
Lymph Node Terminology for Carcinomas l Involvement ¡ Fixed ¡ Matted l Not involvement without further MD comment* ¡ ¡ ¡ ¡ ¡ Borderline lymphadenopathy Palpable Shotty * Comment Examples • …suspicious for metastases Significant • Enlarged, clearly involved No clear etiology • Statement of N 1 or higher Rubbery Hard Enlarged Visible swelling
LN Involvement Terms – Exceptions l Mass in … [with no further information] ¡ ¡ Hilum Mediastinum Retroperitoneum Mesentery l Lung ¡ Mass, enlargement, or adenopathy in hilum or mediastinum = involvement l Lymphoma, Kaposi sarcoma ¡ Any positive mention of nodes = involvement “Lymphoma Man” Lymph Nodes Fields 8
Regional Nodes Positive/Examined
Regional Nodes Positive/Examined General Rules l Pathologic information only ¡ Record even if pre-operative treatment l Counts based on total number of regional nodes positive/removed ¡ ¡ ¡ Cumulative through all first course procedures Do not count positive distant lymph nodes Code the exact number in range 01 to 89 If 90 or more nodes, use code 90 If carcinoma in situ, code as 00 or 98 l Priority of node counts ¡ Final dx, synoptic report, microscopic, gross Lymph Nodes Fields 10
Reg Nodes Positive – Specific Rules l Total regional nodes examined by pathologist and found to be involved l Isolated tumor cells ¡ Count as positive only for Merkel cell and cutaneous melanoma Lymph Nodes Fields 11
Reg Nodes Positive – Specific Rules l Special codes ¡ 95 Positive aspiration or core biopsy l Only procedure is FNA (cytology) or core biopsy (tissue) l Positive FNA of single node and all resected nodes are negative ¡ 97 Number unspecified l Number positive is unknown l Any combination of positive aspirated, biopsied, sampled or dissected nodes ¡ 98 No nodes examined l If no nodes removed l Clinical assessment of nodes only l No nodes found in dissection specimen ¡ 99 Unknown, not documented l Unknown whether nodes are positive l Brain, lymphoma, heme-retic, and some other sites l No documentation in the medical record Lymph Nodes Fields 12
Reg Nodes Examined – Specific Rules l Count total regional nodes removed and examined by pathologist l Special codes ¡ 00 No nodes examined l If no nodes in specimen ¡ 95 Aspiration or core biopsy l If only procedure ¡ 96 Lymph node biopsy l If number not known or not stated and procedure is stated as sampling or biopsy or other limited removal of nodes ¡ 97 Lymph node dissection l If number not known or not stated and procedure is stated as LN dissection or lymphadenectomy l Both sampling and dissection, but number unknown Lymph Nodes Fields 13
Lymph Node Procedure Terms l Sampling (code 96) ¡ Removal of a limited number of nodes ¡ Includes lymph node biopsy, berry picking, sentinel lymph node procedure, sentinel node biopsy, selective dissection l Dissection (code 97) ¡ Removal of most or all nodes in lymph node chain(s) that drain the area around the primary tumor ¡ Includes lymphadenectomy, radical node dissection, lymph node stripping Lymph Nodes Fields 14
Reg Nodes Examined – Specific Rules Special codes, cont’d ¡ 98 Procedure not stated l Number not known and procedure not known l Any combination of aspirated, biopsied, sampled or dissected nodes ¡ 99 Unknown l Unknown whether nodes were examined l Brain, lymphoma, hematopoietic, and some other sites l If no documentation in record Lymph Nodes Fields 15
Counting Reg LN Pos/Exam l Count involved and examined nodes ¡ Add 1 to the number of regional lymph nodes positive and examined when l The core biopsy or aspiration is positive for metastases AND l The lymph node dissection does not include the area where the core biopsy or aspiration was done AND l That lymph node was a regional lymph node for primary site Example ¡ Breast cancer: axillary dissection 5/12 nodes positive; FNA of palpable supraclavicular node positive. Nodes Pos 06, Nodes Exam 13 Lymph Nodes Fields 16
Counting Reg LN Pos/Exam l Count involved and examined nodes ¡ Add 1 only to the number of regional lymph nodes examined when l The core biopsy or aspiration is negative for metastases AND l That lymph node was a regional lymph node for the primary site ¡ NOTE: Do not add 1 to regional LN positive because the biopsy/aspiration was negative for metastases. Example ¡ Right upper lobectomy. 3 of 6 hilar lymph nodes positive. Core biopsy of suspicious subcarinal (ipsilateral mediastinal) node negative. Nodes Pos 03, Nodes Exam 07. Lymph Nodes Fields 17
Counting Reg LN Pos/Exam l Do not add to the regional lymph nodes examined or positive when area biopsied/ aspirated is included in the dissection. Example ¡ Oropharynx carcinoma with swollen neck nodes. FNA of level 2 R nodes positive. Pt has right radical neck dissection that finds 5 of 20 nodes positive. Nodes Pos 05, Nodes Neg 20. Lymph Nodes Fields 18
Scope of Regional Lymph Node Surgery
Scope of Regional LN Surgery l Removal, biopsy, aspiration of ¡ Sentinel nodes ¡ Regional nodes l May include procedures that diagnose and/or stage tumor Mediastinoscopic LN Biopsy ¡ Regional node procedures only ¡ Cumulative through first course of treatment l Reflects current surgical practice l Removal of 1 -3 nodes vs. 4 or more nodes ¡ Used for historical comparisons ¡ NOT intended to indicate clinical significance l Codes are hierarchical and cumulative. Lymph Nodes Fields 20
Types of Node Biopsies l FNA ¡ Fine needle aspiration ¡ Cells (cytology) ¡ Use code 95 if only FNA l Core ¡ Wider gauge needle ¡ Tissue (pathology) ¡ Use code 95 if only core l Incisional ¡ Removes part of node ¡ Count if in different chain l Excisional ¡ Removes entire node ¡ Count total 01 -89 Lymph Nodes Fields 21
Scope Reg LN Coding Guidelines l Originally issued mid-year 2012 ¡ Included in FORDS and SEER Program Coding Manual l Use OP report as primary source document ¡ Distinguishes between SLNB and ALND ¡ Supplement with information from path report l Emphasis on correct coding of SLNB for breast and melanoma
Scope of Regional LN Surgery l 0 None ¡ No regional lymph node surgery ¡ No lymph nodes found in the pathologic specimen ¡ Diagnosed at autopsy l 1 Biopsy or aspiration of regional lymph node, NOS ¡ Biopsy or aspiration of regional lymph node(s) only, regardless of the extent of involvement of disease ¡ Review OP report; if additional procedures, use codes 2– 7 ¡ Uncommon for breast cancer
Scope of Regional LN Surgery l 2 Sentinel lymph node biopsy l l l Sentinel node(s) identified by injection of dye or radio label at site of primary tumor Statement in OP report that SLNBx was performed Surgeon may take additional non-sentinel nodes in same procedure, or pathologist may find additional nonsentinel nodes in specimen. Use code 2. If OP report confirms ALND after SLNBx, code as 6. For breast, if > 5 nodes path examined, review OP report to confirm procedure was SLNBx only, not SLNBx with ALND.
Sentinel Lymph Node Biopsy Lymph Nodes Fields 25
Scope of Regional LN Surgery l 3 Number of regional nodes removed unknown or not stated; regional LN removed, NOS ¡ Sampling or dissection of regional lymph node(s) and number of nodes removed unknown/not stated ¡ Procedure is not specified as SLNBx in path ¡ Review OP report to make sure not SLNBx only or SLNBx with reg LN dissection l 4 1– 3 regional lymph nodes removed ¡ Sampling or dissection of regional LN(s) with fewer than four lymph nodes found in specimen ¡ Procedure is not specified as s. SLNBx in path ¡ Code 4 used infrequently ¡ Review OP report to make sure not SLNBx only
Scope of Regional LN Surgery l 5 4 or more regional lymph nodes removed ¡ Sampling or dissection of regional lymph nodes with at least four lymph nodes found in specimen ¡ Procedure not specified as SLNBx in path ¡ If small number of LN removed, review OP report to confirm procedure not SLNBx ¡ If large number LN removed, review OP report to confirm not SLNBx with reg LN dissection in same or separate procedure and code accordingly ¡ For breast ALND generally removes 7– 9 nodes. Review OP report to confirm not SLNBx with ALND. ¡ If failed mapping, review OP report for more extensive dissection of reg LN. Code as 2 if no further dissection or 6 if reg LN dissected during same surg Lymph Nodes Fields 27
Scope of Regional LN Surgery l 6 Sentinel node biopsy and code 3, 4, or 5 at same time, or timing not stated l l SLNBx and reg LN dissection in single surgical event OR SLNBx and reg LN dissection both performed, but timing was not stated in record l 7 Sentinel node biopsy and code 3, 4, or 5 at different times l l If relatively few LN examined, review OP report to confirm if SLNBx only For breast, SLNBx with ALND generally yield 7– 9 LN but may yield fewer. If fewer, review OP report to confirm not just SLNBx only If both SLNB and LN dissection, use code 6 or 7
Scope of Regional LN Surgery l 9 Unknown or not applicable ¡ Unknown whether regional lymph node surgery was performed ¡ Death certificate-only ¡ Use for l l Central nervous system and intracranial gland primaries Lymphomas with a lymph node primary site Unknown or ill-defined primary Hematopoietic, reticuloendothelial, immunoproliferative, or myeloproliferative disease ¡ Review surgically treated cases to confirm code Lymph Nodes Fields 29
Coding Treatment on Abstract The bottom line… Date Surg Prim Site Scope Reg LN Other Reg/Dist 1/12/13 22 Lumpec 2 SLN 1/20/13 23 Re-Exc 5 ALND 0 7 SLN + ALND l 0 Do not rely on registry software to aggregate separate surgeries into correct code Lymph Nodes Fields 30
Site-Specific Lymph Nodes Issues
Colon Issues Lymph Nodes Fields 32
GI Tract – Clin Assessment of Reg LN l Required by COC, SEER, NPCR l Purpose ¡ To handle the TNM mapping when multiple nodes are diagnosed on imaging or physical exam making the case N 2 even though no regional lymph nodes are removed for pathologic examination. l Use imaging and physical exam only ¡ Do not code from surgical observation or node biopsy ¡ Do not use path N classification ¡ Do not apply inaccessible nodes rule l If no diagnostic workup, use code 999 Lymph Nodes Fields 33
Vascular System and Lymph Nodes of Colon All Segments (N 1 -N 2) by number of nodes Colic Epicolic Mesocolic Para/pericolic Rectal Perirectal Tumor deposits without regional node mets (N 1 c) Image source: Mediclip 1998, Williams and Wilkins
Colorectal Regional Lymph Nodes Regional nodes for each segment of colon Cecum Ascending Hepatic flexure Transverse Splenic flexure Descending Sigmoid Regional nodes, NOS including mesenteric, NOS
N 1 Metastasis in 1 to 3 regional nodes N 1 a N 1 b N 1 c N 1 a 1 regional node 2 -3 regional nodes Tumor deposits in subserosa, mesentery, or nonperitonealized pericolic or perirectal tissues without regional nodal metastasis N 1 b Source: UICC TNM-interactive, Wiley-Liss, 1998
TNM Supplement Staging Guidelines l N 1 c (tumor deposits/peritumoral deposits/ satellite nodules) ¡ Discrete, discontinuous tumor foci found in pericolic or perirectal fat or adjacent mesentery (mesocolic fat) away from leading edge of tumor AND no involved regional lymph nodes ¡ May represent discontinuous spread, venous invasion with extravascular spread or totally replaced lymph node ¡ Tumor deposits do not affect T category ¡ No size criterion for tumor deposits
N 2 Metastasis in ≥ 4 regional nodes N 2 a N 2 b N 2 a 4 -6 regional nodes 7 or more regional nodes N 2 b Source: UICC TNM-interactive, Wiley-Liss, 1998
“Mesenteric” Nodes l Inferior mesenteric lymph nodes ¡ Regional for left colon and splenic flexure ¡ Distant for right colon, hepatic flexure and transverse colon l Superior mesenteric lymph nodes ¡ Distant for all segments of colon ¡ Code in CS Mets at Dx l Mesenteric, NOS ¡ Not along a major blood vessel ¡ In mesentery of colon ¡ Code as CS Lymph Nodes 300 Lymph Nodes Fields 39
Head and Neck Issues Lymph Nodes Fields 40
Head and Neck Regional Nodes 1. Submental 2. Submandibular 3. Jugular (deep cervical) 4. Superficial cervical 5. Supraclavicular 6. Prelaryngeal* and paratracheal* 7. Retropharyngeal 8. Parotid 9. Buccal 10. Retroauricular and occipital
Head and Neck Lymph Nodes Level I (* = not shown) Overview A Submental B Submandibular (submaxillary) Level II C Upper deep cervical (upper jugular) * Jugulodigastric (subdigastric) B B Level III A C C F D D Middle deep cervical (mid-jugular) Level IV H H Level V E G E E Lower deep cervical (lower jugular) * Jugulo-omohyoid (supraomohyoid) F Posterior cervical G Posterior triangle * Supraclavicular, NOS H G Level VI J Adapted from: TNM Interactive (CD-ROM), Wiley-Liss H Pre/paralaryngeal and pre/para tracheal (anterior deep cervical) Level VII J Upper mediastinal
Lymph Node Metastases at Diagnosis l Pyriform sinus – 70% l Postcricoid area – 40% l Posterior hypopharynx – 50% l Nasopharynx – 75% l Tonsil – 70% l Base of tongue – 70% l Soft palate – 30 -65% l Pharyngeal wall – 30 -65% l Paranasal sinuses – 20% l Medullary ca of thyroid – 50%
TNM General Guidelines – N l N definitions the same for all head and neck sites except nasopharynx and thyroid l N category by number of lymph nodes involved AND size of lymph node mass: < 3 cm; > 3 ≤ 6 cm; > 6 cm N 1 Single ipsilateral ≤ 3 cm N 2 a Single ipsilateral >3 - ≤ 6 cm N 2 b Multiple ipsilateral ≤ 6 cm N 2 c Bilat/ Contralat ≤ 6 cm Source: AJCC Cancer Staging Atlas (6 th Ed), 2006 N 3 Any node > 6 cm
Head and Neck Lymph Nodes Site-Specific Factors l SSF 1: l SSF 3: l SSF 4: l SSF 5: l SSF 6: l SSF 9: Size of involved node Levels I-III Levels IV-V Levels VI-VII and face Other LN groups Extracapsular extension pathologic Compton, C. C. , Byrd, D. R. , et al. , Editors. AJCC Cancer Staging Atlas, 2 nd Edition. New York: Springer, 2012. ©American Joint Committee on Cancer
SSF 1 – Size of Involved Node l Required by COC, SEER, NPCR (as available) l Code largest size of regional NODE (clin or path), not size of metastasis l Size format same as tumor size with extra codes ¡ 996 Described as less than 6 cm ¡ 997 Described as more than 6 cm
Site-Specific Factors 3 – 6 l Required by COC, SEER l Definitions of levels are the same for all applicable head and neck sites. SSF 3 Levels I – III SSF 4 Levels IV and retropharyngeal nodes SSF 5 Levels VI and VII and facial nodes SSF 6 Other groups as defined by AJCC RP* *RP = retropharyngeal nodes Compton, C. C. , Byrd, D. R. , et al. , Editors. AJCC Cancer Staging Atlas, 2 nd Edition. New York: Springer, 2012. ©American Joint Committee on Cancer
Coding Site-Specific Factors 3 – 6 SSF 3 Levels I – III I II III ___ ___ SSF 4 Levels IV - V, retropharyngeal (RP) ___ IV ___ RP SSF 5 Levels VI – VII, Facial (F) ___ VI ___ VII ___ F SSF 6 Other groups ___ Parapharyngeal (PP), PP PA Parotid (PA), Suboccipital (S) ___ S l Default is 0, not involved. l If any level/chain is involved, code as 1, involved. l Use 999 for Unk if reg LN involved, not stated ¡ Note from Part I Section 2 of the CS manual: “… if regional nodes are known to be positive but level(s) of nodes involved unknown, use code 000 in Site-Specific Factors 3 -6. "
Coding SSF 3 – 6 Example LRND: 2 positive parotid node (< 3 cm with extracapsular exten. ), 1 positive buccal (facial) node (2 cm), and 1 positive 2 cm submandibular node. SSF 3 Levels I – III _1_ I _0_ II _0_ III SSF 4 Levels IV – V, Retropharyngeal (RP) _0_ IV _0_ RP SSF 5 Levels VI – VII, Facial (F) _0_ VI _0_ VII _1_ F SSF 6 Other groups _0_ _1_ Parapharyngeal (PP), PP PA Parotid (PA), Suboccipital (S) _0_ S
SSF 9 Extracapsular Extension— Notes l Fixed and matted imply extracapsular extension l Code extracapsular extension identified pathologically (SSF 9) ¡ ¡ Code regional nodes only Code 000 if nodes are negative Read carefully—codes differ If extracapsular extension not mentioned in path report (SSF 9), use code 010. Pathologic Lymph Nodes 010 No extracapsular extension 030 Macroscopic extracapsular extension pathologically Image source: TNM Interactive (CD-ROM), Wiley-Liss
SSF 9 Extracapsular Extension Pathologic l Required by COC, SEER l Pathologic information ¡ Priority: “macroscopic” over “microscopic” l Macro or micro from final diagnosis l Macro from gross section l Micro from microscopic section l Codes ¡ ¡ ¡ ¡ 000 010 020 030 040 050 997 998 No lymph nodes involved Nodes involved, no extracapsular extension Nodes involved, microscopic extracap exten Nodes involved, macroscopic extracap exten Nodes involved, extracap exten, unk micro/macro Nodes involved, unknown if extracap exten Clin exam of nodes, unk results No clin exam of nodes
Neck Dissections Name of Procedure Nodal Levels Dissected Structures* Additional Preserved Comments * Specific non-lymphatic structures are the spinal accessory (11 th cranial) nerve (SAN), internal jugular vein (IJV), and sternocleidomastoid muscle (SCM) Radical neck I–V plus LN cervical dissection (ND) around tail of parotid None Modified radical ND • Type 1 • Type 2 • Type 3 I–V I–V 1 or more SAN, SCM All Comprehensive ND I–V Varies Standard basic lymphadenectomy procedure Nonstandard term referring to any dissection removing node levels I-V
Neck Dissections Name of Procedure Nodal Levels Structures* Additional Dissected Preserved Comments Selective neck Varies All General term for dissections removal of certain LN groups and preservation of others • Supraomohyoid ND I–III (selective), All sometimes IV • Lateral (jugular) ND II–IV • Anterolateral ND I–IV All • Anterior Compart- VI (selective) All Usually bilateral, ment ND may be unilateral • Posterolateral ND II–V plus All Used for cutaneous suboccipital and scalp malignancies postauricular
Breast Issues What We Didn’t Know…
Regional Lymph Nodes - Breast Other Names for Regional Lymph Nodes Labels 1 i, 1 iii Level I Intramammary, Nodule(s) in axillary fat Level II Rotter’s nodes, Interpectoral Pectoralis minor muscle Level III Infraclavicular, subclavicular Label 2 Internal mammary (parasternal) Source: UICC TNM-interactive, Wiley-Liss, 1998
Regional Lymph Nodes – Clinical l Axillary* nodes ¡ N 1 Movable axillary ¡ N 2 a ¡ N 2 b Fixed, matted axillary Clinically detected IM** without axillary mets ¡ N 3 a ¡ N 3 b ¡ N 3 c Infraclavicular nodes IM and axillary node mets Supraclavicular nodes * Level I, II, intramammary only ** Internal mammary nodes
Regional Lymph Nodes – Pathologic l Axillary* nodes ¡ ¡ p. N 1 mi Micromets (larger than ITCs) p. N 1 a 1 -3 axillary nodes with at least 1 met > 2 mm p. N 1 b IM** detected by SLNB*** only p. N 1 c 1 -3 axillary nodes + IM detected by SLNB ¡ p. N 2 a 4 -9 axillary nodes ¡ p. N 2 b Clinically detected IM without axillary mets ¡ p. N 3 a 10+ axillary nodes or infraclavicular nodes ¡ p. N 3 b Clinically detected IM + axillary node mets ≥ 3 axillary + IM detected by SLNB ¡ p. N 3 c Supraclavicular nodes * Level I, II, intramammary only; ** Internal mammary nodes; *** Sentinel Lymph Node Biopsy
Regional Lymph Nodes – Location Internal Mammary Nodes Definitions Lymphoscintigraphy Mapping of sentinel lymph nodes using radioisotopes to identify nodes for removal by sentinel node biopsy Not clinically apparent Positive only on sentinel node biopsy Clinically apparent Includes ü Imaging (CT, CXR, etc) but not lymphoscintigraphy ü Physical exam (palpable) ü Grossly visible pathologically ü Positive cytology on FNA
Breast Lymph Nodes c. N 1. Ipsilateral movable nodes p. N 1 a. 1 to 3 axillary nodes Adapted from: TNM Atlas, 3 rd ed. 2 nd rev. , by B. Spiessl et al. Springer Verlag 1992.
Breast Lymph Nodes p. N 1 b. Microscopic involvement of internal mammary nodes Adapted from: TNM Atlas, 3 rd ed. 2 nd rev. , by B. Spiessl et al. Springer Verlag 1992.
Breast Lymph Nodes p. N 1 c. 1 -3 axillary nodes and micro involvement of int. mam. nodes Adapted from: TNM Atlas, 3 rd ed. 2 nd rev. , by B. Spiessl et al. Springer Verlag 1992.
Breast Lymph Nodes N 2 a. Ipsilateral fixed axillary nodes p. N 2 a. 4 to 9 axillary nodes (tumor >2 mm) Adapted from: TNM Atlas, 3 rd ed. 2 nd rev. , by B. Spiessl et al. Springer Verlag 1992.
Breast Lymph Nodes c/p N 2 b. Clinically apparent internal mammary nodes Adapted from: TNM Atlas, 3 rd ed. 2 nd rev. , by B. Spiessl et al. Springer Verlag 1992.
Breast Lymph Nodes c/p N 3 a. Infraclavicular nodes with/without axillary nodes Adapted from: TNM Atlas, 3 rd ed. 2 nd rev. , by B. Spiessl et al. Springer Verlag 1992.
Breast Lymph Nodes c/p N 3 b. Int. mam. and axillary c/p N 3 c. Supraclavicular nodes N 3 c N 3 b Adapted from: TNM Atlas, 3 rd ed. 2 nd rev. , by B. Spiessl et al. Springer Verlag 1992.
Reminder – RTF*M l Read the _____ manual! ¡ ¡ ¡ ¡ ¡ Flippin’ Funky Flatulent Fair Fantastic Famous Freakin’ Flashy Fabulous Frustrating ¡ ¡ ¡ ¡ ¡ Funny Factitious Fresh Frangible Fractionated Finite Friendly Far-reaching Fulgent Fuliginous Lymph Nodes Fields 66
Skin and Other Sites Lymph Nodes Fields 67
Merkel Cell – Size of Metastases in LN l Terms not defined in TNM ¡ Micromets (N 1 a) – removed LN dx’d on micro exam ¡ Macromets (N 1 b) – identified by imaging or palpation and micro confirmed l Allows researchers to define micro- and macromets by size l Code structure similar to Tumor Thickness ¡ 000 ¡ 001 -979 ¡ 980 ¡ 998 ¡ 999 No regional nodes involved Size of mets in HUNDREDTHS of mm 9. 80 mm or larger Mets or tumor nests in regional LN, size not assessed No histologic examination of regional LN Lymph Nodes Fields 68 Unknown; not documented
Lymph Node SSFs (3) l Melanoma Skin ¡ Clin Status of LN Mets* l Merkel Cell (all) ¡ ¡ Clin Status of LN Mets* Size of Mets in LN* Extracapsular Extension of Reg LN* ITCs in Reg LN* l Skin ¡ Size of LN* Lymph Nodes Fields 69
Lymph Node SSFs (4) l Testis ¡ Size of Mets in LN* l Scrotum ¡ Size of LN – size of whole node* l Penis ¡ Extranodal Extension of Reg LN* l Kidney Parenchyma ¡ Extranodal Extension of Reg LN* l Bladder ¡ Size of Mets in LN* ¡ Extranodal Extension of Reg LN* Lymph Nodes Fields 70
Testis: Size of Mets in Nodes l Required for deriving N category l Size of mass, not just size of mets l Codes ¡ 000 No LN mets ¡ 010 Mass < 2 cm; no extranodal extension (N 1) ¡ 020 Mass > 2 and < 5 cm; OR pathologic extranodal extension (N 2) ¡ 030 Mass > 5 cm (N 3) ¡ 998 Nodes involved, size of mass unknown ¡ 999 Unknown if performed Lymph Nodes Fields 71
Reminder – Read Source Documents l CS Lymph Nodes ¡ PE, imaging, op report, path report, consults l Nodes Positive/Examined ¡ Path report (final dx, gross, micro), op report l CS Site-specific Factors ¡ As instructed in notes (clinical/pathologic sources) l Scope of Regional LN Surgery ¡ Op report, path report Lymph Nodes Fields 72
SLNB Under Reporting (Breast, Melanoma, and Other Sites) l Identified: NCDB audit 2012 l Confirmed: CDC routine audits and NCI SEER review of DB l Numerous articles in high impact journals Lymph Nodes Fields 73
Action – How to Fix Problem l Coding instructions rewritten l Educational programs, all national agencies l Results? l Recent evaluation of NCI-SEER DB – not a significant improvement Lymph Nodes Fields 74
l I sent out the following via our LCRA Newsbreak on the issue: l Recently the LTR underwent a CDC Re-Abstraction Audit. One of the major errors found had to do with the improper coding of “sentinel lymph nodes” for such sites as breast and melanoma. Please be mindful of the following “Scope of Regional LN Surgery” codes: l · 2: Sentinel lymph node biopsy—this is to be used when only a sentinel LN bx is performed (Excisional removal of generally 1 -3 “Sentinel” LNs) l · 6: Sentinel node biopsy and code 3, 4, or 5 at same time or timing not stated ----codes 6 & 7 are to be used for the removal of sentinel LNs ALONG with REGIONAL LNS either at the SAME TIME or at DIFFERENT TIMES l · 7: Sentinel node biopsy and code 3, 4, or 5 at different times l This is a very serious coding issue which results in the under reporting of “sentinel LN bxs” for sites that utilize this information, such as breast and melanoma. l Please make every effort to make sure you are properly coding and accurately reporting “Sentinel LNs!” Lymph Nodes Fields 75
Head and Neck SSF 7 Upper/Lower Cervical Node Levels l Documents whether involved nodes are above or below level of cricoid cartilage ¡ Lower cervical nodes have worse prognosis l If not obvious, refer to list in Part I, Section 2 of CS User Documentation l If unknown, use code 040 Level of cricoid cartilage Image source: CSv 2 User Documentation, Part I Section 2 Lymph Nodes Fields 76
Lymphoma Surgery Issues l Biopsy/removal of node for diagnosis/ histology ¡ If other nodes also involved, use code 02 in Surg Diagnostic/Staging Proc l Removal of single involved node (Stage I) ¡ Code in Surg Proc of Prim Site Lymph Nodes Fields 77
Head and Neck SSF 1 – Size of Involved Node l Required by COC, SEER, NPCR l Necessary for N category mapping l Code largest size of regional NODE (clin or path), not size of metastasis l Size format same as tumor size with extra choices ¡ 996 Described as less than 6 cm ¡ 997 Described as more than 6 cm Introduction to Head and Neck Sites. In: Greene, F. L. , Compton, C. C. , Fritz, A. G. , et al. , editors. AJCC Cancer Staging Atlas. New York: Springer, 2006: 13 -18. ©American Joint Committee on Cancer Lymph Nodes Fields 78
Head and Neck SSFs 3 – 6 l Required by COC, SEER l Definitions of levels are the same for all applicable head and neck sites. SSF 3 Levels I – III SSF 4 Levels IV and retropharyngeal nodes SSF 5 Levels VI and VII and facial nodes SSF 6 Other groups as defined by AJCC Lymph Nodes Fields 79
Coding Site-Specific Factors 3 – 6 SSF 3 Levels I – III ___ II ___ III SSF 4 Levels IV - V, retropharyngeal (RP) ___ IV ___ RP SSF 5 Levels VI – VII, Facial (F) ___ VI ___ VII ___ F SSF 6 Other groups ___ Parapharyngeal (PP), PP Parotid (PA), Suboccipital (S) ___ PA ___ S l Default is 0, not involved. l If any level/chain is involved, code as 1, involved. Lymph Nodes Fields 80
Lymph Node SSFs (1) l Head and Neck, incl. mucosal melanoma ¡ ¡ Size of Lymph Node* Lymph Node Levels* Upper/Lower Cervical Node Levels Extranodal Extension Path*/Clin l Upper GI, Lower GI, NET Stomach, NET Colon/Rectum, Carcinoid. Appendix ¡ Clinical Assessment of Regional LN* ¡ Histopathological Grading (Appendix)* Lymph Nodes Fields 81
GI Tract – Clin Assessment of Reg LN l Read codes carefully l Code Example (colon) ¡ ¡ ¡ ¡ ¡ 000 Nodes not clinically evident 010 Clin N 1 a (1 node positive clinically) 020 Clin N 1 b (2 -3 nodes positive clinically) 030 Clin N 1 c (tumor deposits without regional nodes Obsolete CSv 02. 04 100 Clin N 1 [NOS] (1 -3 nodes positive clinically) 110 Clin N 2 a (4 -6 nodes positive clinically) 120 Clin N 2 b (7 or more nodes positive clinically) 200 Clin N 2 (4 or more nodes positive clinically) 400 Clinically positive regional nodes, NOS 988 Not applicable: Information not collected Lymph Nodes Fields 82 999 Unknown if nodes are clinically evident
Breast Lymph Node SSFs § SSF 3 Number Pos Ipsilat Axillary LN § SSF 4 Immunohistochemistry of Reg LN § SSF 5 Molecular Studies of Reg LN Say Goodbye – 2014 § § § SSF 17 SSF 18 SSF 19 SSF 20 SSF 24 CTC and method of detection DTC and method of detection Assessment of Pos. Ipsilat. Ax LN Assessment of Pos. Distant Mets Paget Disease
SSF 3 – Number of Positive Ipsilateral Axillary Lymph Nodes l Required by COC, SEER, NPCR l Information needed to assign p. N 1, p. N 2, p. N 3 by number of positive axillary nodes l Applies to positive ipsilateral Levels I and II and intramammary axillary nodes l Same guidelines as for CS Lymph Nodes ¡ Record even if preoperative treatment ¡ Definitions of ITC vs micrometastases ¡ Do not count ITC-only nodes as positive l Same code structure as Reg Nodes Pos ¡ Use code 098 if no nodes were removed or if no nodes found in specimen
SSF 4 – Immunohistochemistry (IHC) of Reg LN Required by COC, SEER, NPCR n Use 000 -009 ONLY when lymph nodes are negative on H&E (code 000 in CS LN) n 000 LN neg on H&E, no IHC done, or unk if IHC done 001 LN neg on H&E, IHC done and negative 002 LN neg on H&E, IHC done and positive for ITCs 009 LN neg on H&E, IHC done and positive, size of mets unk; stated as N 0(i+) If nodes are positive on H&E, use code 987 n If no statement whether IHC tests were done, assume they were not done and code 000 n See also SSF 5, molecular markers n
What are Isolated Tumor Cells? Isolated tumor cells (ITCs) (codes 000, 050) n Epithelial cells inside a lymph node Single tumor cells or small clusters < 0. 2 mm Detected only by immunohistochemical (IHC) or molecular methods ¨ May be verified on “routine” H&E stains ¨ Questionable evidence of malig nant activity (no proliferation or stromal reaction) ¨ Lymph nodes with ITCs only are NOT considered positive lymph nodes. ¨ ¨ ¨
SSF 4 IHC – Immunohistochemistry l IHC stains identify epithelial cells (keratin) l Synonyms ¡ ¡ ¡ Immunohistochemistry Immunocytochemistry Immunochemistry Cytokeratin Pan-CK Pankeratin ‘Keratin cocktail’ Keratin IHC staining AE 1/AE 3 or AE 1/3 (special stains) MNF 116 CAM 5. 2
SSF 5 – Molecular Studies of Regional LN n n Required by COC, SEER, NPCR Not commonly performed If IHC done (SSF 4), molecular studies not done Generic name: RT-PCR; Reverse transcriptase-polymerase chain reaction ¨ Other names: Gene. Search, Taq. Man®, OSNA (one step nucleic acid amplification), Molecular Beacons, Scorpions® and SYBR® Green, Fluorescence Resonance Energy Transfer (FRET), Amplifluor/Sunrise, others
SSF 5 – Molecular Studies of Regional LN n Use codes 000 -002 ONLY when lymph nodes are negative (CS Lymph Nodes codes 000). 000 LN neg on H&E, no RT-PCR done, or unk if RT-PCR done 001 LN neg on H&E, RT-PCR done and negative 002 LN neg on H&E, RT-PCR done and positive for ITCs n n n If nodes are positive, use code 987 If no statement whether molecular tests were done, assume they were not done Isolated tumor cells (ITC): same definition as for CS Lymph Nodes
CS Lymph Nodes l Inaccessible lymph nodes ¡ Nodes within body cavities that cannot be palpated or easily examined ¡ Examples: regional nodes for bladder, kidney, colon, prostate, esophagus, stomach, lung, liver, corpus, ovary (not all-inclusive) l Accessible lymph nodes ¡ Breast, oral cavity, salivary gland, skin, thyroid, etc. ¡ Code regional nodes as negative if general statement in chart ‘remainder of exam negative’ Lymph Nodes Fields 90
CS Inaccessible Nodes Rule l Record regional and distant metastases as NEGATIVE (rather than unknown) when ¡ No mention of LN or mets involvement in PE, Dx testing or surgical exploration AND ¡ Patient receives ‘usual’ treatment to primary AND ¡ Clinically early stage (T 1, T 2, localized) tumors l All three conditions have to be met l Code unknown if reasonable doubt that tumor is not localized Lymph Nodes Fields 91
CS Lymph Nodes – Rules l Regional nodes only ¡ ¡ Site-specific, even for some subsites Distant lymph nodes coded in Mets at Dx Some exceptions Field not used for some sites l Code farthest involved regional nodes clinically or pathologically ¡ If no pre-op tx: path; if pre-op tx: clinical ¡ Priority: pathology report, imaging, physical exam l Direct extension into lymph node ¡ Code as involved node Lymph Nodes Fields 92
CS Lymph Nodes – Rules, cont’d l Special guidelines for head and neck, breast, discontinuous tumor deposits in lower GI tract l Homolateral = ipsilateral = same side l Carcinoma in situ cases ¡ Code CS LN as 000, since biologically tumor cells have not invaded to reach nodes l “Stated as N_, NOS” codes ¡ Use only when no other information in record ¡ If both statement of N and documentation, documentation takes priority Lymph Nodes Fields 93
CS Lymph Nodes – Rules, cont’d l Coding size of metastasis in lymph node ¡ Code from path report if available l Code size of metastasis in node, unless otherwise instructed l If size of metastasis unknown, code size of node l If size described as mass, code size of mass l Isolated tumor cells ¡ Code according to site-specific guidelines l Breast – ITCs are negative l Merkel cell and cutaneous melanoma – ITCs are positive Lymph Nodes Fields 94
CS Nodes Eval – Rules l Linked to CS Lymph Nodes l Code as clinical or pathologic based on intent of procedure and assessment of T ¡ If LN procedure part of workup, staging basis is clinical (codes 0, 1, 5, 9) ¡ If LN procedure part of treatment, code as pathologic (codes 2, 3, 6) l Must have resection of primary site meeting p. T criteria l Document farthest involved regional nodes ¡ May not be highest eval code ¡ Pathologic information takes priority ¡ Document highest N subcategory Lymph Nodes Fields 95
CS Nodes Eval – Rules, cont’d l Most sites use standard table l General structure ¡ 0 Clinical only; no nodes removed ¡ 1 No nodes removed; endoscopy or invasive techniques; surgical observation OR FNA, needle bx; or excisional bx as part of diagnostic workup without removal of primary site sufficient for p. T l bx does not meet criteria for pathologic N ¡ 2 Autopsy (known or suspected dx) Lymph Nodes Fields 96
CS Nodes Eval – Rules, cont’d l. General structure, cont’d ¡ 3 Any microscopic assessment of regional nodes WITH removal of primary site sufficient for p. T OR Positive biopsy of highest N category regardless of T l meets criteria for pathologic N ¡ 5 Pre-op tx and resection; clinical evidence ¡ 6 Pre-op tx and resection; path evidence more extensive ¡ 8 Autopsy (dx not suspected) ¡ 9 Unknown, not assessed; no TNM schema Lymph Nodes Fields 97
CS Nodes Eval – Rules, cont’d l Code 9 ¡ Always 9 for sites without TNM mapping ¡ Avoid 9 if possible when CS Lymph Nodes is 999 l Sentinel nodes ¡ Code as pathologic when tumor size/extension meets criteria for p. T ¡ When no p. T, exam of single LN or sentinel nodes is clinical ¡ Code as pathologic when there is a positive biopsy of node in highest N category Lymph Nodes Fields 98
Idiosyncratic Primary Sites l Lymph nodes coded 988, Not Applicable ¡ ¡ ¡ Placenta (Gestational Trophoblastic Tumor) Brain and Cerebral Meninges Other Parts of Central Nervous System Intracranial Gland Hodgkin and Non-Hodgkin Lymphoma Hematopoietic, Reticuloendothelial, Immunoproliferative and Myeloproliferative Neoplasms ¡ Other and Ill-Defined Primary Sites ¡ Unknown Primary Site Lymph Nodes Fields 99
CS Lymph Nodes – Rules, cont’d Regional Nodes, NOS vs. Distant Nodes l Code named regional nodes as priority l Regional Nodes, NOS (code varies) ¡ Definitely regional, but not named l Multiple LN codes—can’t tell which code to use ¡ In “normal” surgical resection field l Lymph Nodes, NOS (Code 800) ¡ Can’t tell whether regional or distant ¡ Rarely used l When unidentified nodes found in resected primary site specimen ¡ Code as regional nodes, NOS Lymph Nodes Fields 100
Head and Neck Lymph Nodes CS Lymph Nodes—Notes l Contains information about the nodes involved, their general number and laterality l Code ranges vary by primary site l Code any regional LN involvement in this field l Major categories: Single positive ipsilateral node involved Multiple positive ipsilateral nodes Bilateral or contralateral positive nodes Positive regional nodes, NOS l If laterality not specified, assume nodes are ipsilateral l Midline nodes grouped with ipsilateral nodes
Head and Neck Lymph Nodes CS Lymph Nodes – Parotid Example 000 None 100 -190 Single positive ipsilateral node involved 200 -290 Multiple positive ipsilateral nodes 300 -320 Positive ipsilateral nodes, unk. if 1 or > 1 400 -490 Bilateral or contralateral positive nodes 500 -520 Reg nodes, NOS, unk. number and laterality 800 Lymph nodes, NOS Stated as… 000 180 190 290 490 600 700 N 1, no other information N 2 a, no other information N 2 b, no other information N 2 c, no other information N 2, NOS N 3, no other information
Colorectal Cancer Lymph Nodes l Notes 1. Regional nodes only 2. Definition of tumor deposits in adipose tissue l If tumor localized (T 1 or T 2) and no other information about lymph nodes, used code 050 l Code number of tumor deposits in SSF 4 3. Inferior mesenteric nodes are distant for cecum, appendix, ascending, transverse, hepatic flexure Superior mesenteric nodes are distant for all colon sites 4. Codes 100, 200, and 300 take priority over 400 -470 (Stated as __) Lymph Nodes Fields 103
N 2 Metastasis in ≥ 4 nodes - Rectum N 2 b N 2 a Source: UICC TNM-interactive, Wiley-Liss, 1998
GYN Lymph Node SSFs (2) l Corpus (all), Fallopian Tube ¡ Number Pos*/Exam* Pelvic LN ¡ Number Pos*/Exam* Para-Aortic LN l Vagina ¡ Pelvic Nodal Status*/Method of Assessment* ¡ Para-aortic Nodal Status*/Method of Assessment* ¡ Distant Node Status*/Method of Assessment* l Vulva ¡ Regional LN Laterality* Lymph Nodes Fields 105
Corpus, Fallopian Tube Number of Pos/Exam Pelvic Nodes Number of Pos/Exam Para-aortic Nodes l Same code structures as Nodes Pos/Exam with leading 0 Para-aortic Common Iliac Internal iliac Pelvic Sacral External iliac Inguinal Femoral Lymph Nodes Fields 106
Vagina: Lymph Node Status Fields l Code whether nodes are positive l Can be clinical or pathologic l Codes ¡ 000 ¡ 010 ¡ 988 ¡ 999 Negative lymph nodes Positive lymph nodes Not applicable: Information not collected Lymph nodes not examined Unknown; Not documented Lymph Nodes Fields 107
Vagina: Lymph Node Assessment Method Fields l Code how status of pelvic lymph nodes was determined l Use highest applicable code ¡ 010 -020 are clinical ¡ 030 -040 are pathologic l Codes ¡ ¡ ¡ 000 010 020 030 040 Lymph nodes were not assessed Clinical assessment Radiography; Imaging (US, CT, MRI, PET) Incisional biopsy; FNA Lymphadenectomy; Excisional biopsy or resection with microscopic confirmation other than by biopsy Lymph Nodes Fields 108
Vulva SSF 11 – Regional Node Laterality l Required by NPCR l Maintains compatibility with TNM 6 th edition l Codes ¡ 000 ¡ 010 ¡ 020 ¡ 030 ¡ 998 ¡ 999 No involved regional nodes Unilateral - all positive nodes same laterality Bilateral - positive bilateral regional nodes Regional node(s) positive – laterality unknown Lymph nodes not assessed Unknown or no information Lymph Nodes Fields 109
Colorectal Cancer Lymph Nodes Code 050—all segments Tumor deposits without regional node mets Code 110—all segments Colic Epicolic Mesocolic Para/pericolic Lymph Nodes Fields 110
Rectal Cancer Lymph Nodes Code 110—Rectosigmoid Para/pericolic Code 110—Rectum Rectal Perirectal Lymph Nodes Fields 111
Colorectal Cancer Lymph Nodes Code 210—site specific Regional nodes for each segment of colon Cecum Ascending Hepatic flexure Transverse Splenic flexure Descending Sigmoid Code 300—all sites Regional nodes, NOS including mesenteric, NOS Lymph Nodes Fields 112
Regional Nodes Positive/Examined General Rules l Counting nodes (positive or examined) ¡ Regional nodes only! ¡ Do not count positive aspiration or core biopsy of node in same Mets 30 chain removed at surgery ¡ Do count positive aspiration or core biopsy of node in different region LN 600 ¡ If location of biopsied/ aspirated node unknown, do not count LN 600 Lymph Nodes Fields 113
Lymph Node CS Site-Specific Factors not covered in other sessions * required by COC and SEER required by NPCR when available
Head and Neck Lymph Nodes Overview l Regional lymph node information coded in several fields ¡ CS Lymph Nodes field u Nodes involved, their number and laterality ¡ Site-Specific Factor 1 u Size of involved lymph nodes ¡ Site-Specific Factors 3 -6 u Presence or absence of lymph node involvement in each of 7 different levels and other groups defined by AJCC. • Site-specific Factors 9 u Extracapsular extension, pathologic
Breast: When to Use Codes 000, 050 Negative nodes vs Isolated Tumor Cells (ITCs) l Code 000 – No regional lymph node involvement or ITCs detected by immunohistochemistry or molecular methods only l Code 050 – No regional lymph nodes positive but ITCs detected on routine H & E stains Lymph Nodes Fields 116
Breast: When to Use Codes 130, 150 Method of Detecting Micrometastases l Code 130 – Axillary nodes, micrometastases* detected only by immunohistochemistry (IHC) l Code 150 – Axillary nodes, micrometastasis only, detected or verified on routine H & E stains; Micrometastasis, NOS * Micrometastasis: > 0. 2 mm (or > 200 cells) and < 2 mm Lymph Nodes Fields 117
Breast: When to Use Codes 250, 255, 260 l 250 Movable axillary node(s), ipsilateral, positive with > micrometastasis (at least one metastasis > 2 mm) ¡Use when positive nodes are pathologically separate, and size of mets in node is known to be > 2 mm l 255 Clinically positive movable axillary node(s) ¡Use when there is no pathology or when patient has neoadjuvant therapy and only clinical assessment l 260 Stated as N 1, NOS ¡Use when no physical exam or other assessment, only a clinician statement of N 1 Lymph Nodes Fields 118
Breast: When to Use Code 600 l 600 Axillary/regional lymph node(s), NOS; Lymph nodes NOS ¡ Use when size of metastasis in lymph node is not stated ¡ Can be either clinical or pathologic ¡ If stated as fixed/matted, use 510 -520 instead ¡ If stated as movable or not stated as fixed/matted, use 250 -255 instead Lymph Nodes Fields 119
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