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California Cancer Registry Volume I: Data Standards and Data Dictionary Source: Cancer Reporting in California: Abstracting and Coding Procedures for Hospitals (California Cancer Reporting System Standards, Vol. I), updated May 2007 |
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California Cancer Registry Volume I: Data Standards and Data Dictionary Source: Cancer Reporting in California: Abstracting and Coding Procedures for Hospitals (California Cancer Reporting System Standards, Vol. I), updated May 2007 |
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While Extent of Disease is a detailed description of the spread of the disease from the site of origin, stage is a grouping of cases into broad categories—for example, localized, regional, and distant. In the Stage at Diagnosis field, enter the code that represents the farthest tumor involvement as indicated by all the evidence obtained from diagnostic and therapeutic procedures performed during the first course of treatment or within four months after the date of diagnosis, whichever is earlier. (See Section VI.1 for definitions of first course of treatment and definitive treatment.) Coding must be supported by textual information entered under Diagnostic Procedures (see Section IV.1).
Stage at Diagnosis is not required beginning with cases diagnosed January 1, 1994. Hospitals wishing to do so may continue its use. Cases diagnosed prior to January 1, 1994 must continue to be staged using SEER Summary Staging Guide 1977.
Although Summary Stage is not required by the CCR, it is required by NAACCR and NPCR. It is also used by some of the regional registries and a good many hospital registrars. A new Summary Staging Guide will be used with cases diagnosed on or after January 1, 2001. This document is available from SEER. The rules for using SEER Summary Stage 1977 and SEER Summary Stage 2000 are as follows:
Cancer cases diagnosed before January 1, 2001 should be assigned a summary stage according to SEER Summary Stage Guide 1977.
Cases diagnosed on or after January 1, 2001 should be assigned a stage according to SEER Summary Stage 2000.
Always base coding on the site-specific schemes presented in the Summary Staging Guide for the Cancer Surveillance, Epidemiology and End Results Reporting (SEER) Program, which is available as a separate publication or as Book 6 of the Self Instructional Manual for Tumor Registrars (see Section I.1.6.5). Instructions in sections V.5.8-V.5.11 are provided for guidance only. The codes are:
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0 |
IN SITU |
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1 |
LOCALIZED |
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2 |
REGIONAL, DIRECT EXTENSION ONLY |
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3 |
REGIONAL, LYMPH NODES ONLY |
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4 |
REGIONAL, DIRECT EXTENSION AND LYMPH NODES |
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5 |
REGIONAL, NOS |
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7 |
DISTANT METASTASES OR SYSTEMIC DISEASE (REMOTE) |
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9 |
UNSTAGEABLE (stage cannot be determined from available information) |
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Blank |
NOT DONE |
Terms commonly used to describe stage include:
Invasion. Local spread of a neoplasm by infiltration into or destruction of adjacent tissue.
Microinvasive. The earliest invasive stage. Applied to cervical cancer, describes a small cancer that has invaded the stroma to a limited extent. The FIGO stage is IA. (See sections V.3.4.3 and V.5.9.4).
Direct Extension. A continuous infiltration or growth from the primary site into other tissue or organs (compare to metastasis).
Metastasis. Dissemination of tumor cells in a discontinuous fashion from the primary site to other parts of the body—for example, by way of the circulatory system or a lymphatic system.
Regional. Organs or tissues related to a site by physical proximity. Also applies to the first chain of lymph nodes draining the area of the site.
Physicians sometimes use ambiguous terms to indicate the involvement of tissue or an organ by a tumor. Refer to the SEER Extent of Disease Code Manual, 3rd Edition, for a list of ambiguous terms.
Report the stage of each case at the time of diagnosis. Consider all diagnostic and therapeutic information obtained during the first course of treatment or within four months after the date of diagnosis, whichever is earlier. This time limitation ensures that the stage recorded is based on the same information that was used to plan the patient's treatment. Exclude progression of the disease since the time of the original diagnosis. (See Section VI.1.1 for the analogous rule concerning first course of treatment.)
Example
A patient with lung cancer is staged "regional lymph nodes" by the physician on the basis of positive mediastinal lymph nodes, and radiation therapy is instituted. Four weeks into the treatment course the patient develops neurological symptoms, and further work–up reveals previously unsuspected brain metastases. The treatment plan is changed to take this new manifestation into account. Since the disease has progressed since the time of original diagnosis, the stage would not be changed to distant.
Include pertinent findings from autopsy reports if the patient dies within four months of the diagnosis of the cancer. However, as with other types of information, exclude data about progression of the disease since the time of the original diagnosis.
When a physician has assigned a stage using the TNM, FIGO, Dukes', or any other system, use the information as a guide for coding stage, especially when information in the medical record is ambiguous or incomplete regarding the extent to which the tumor has spread. (For a discussion of TNM, see Section V.7). However, take certain precautions:
Physicians might use different versions of a staging system at the same time, and a specific designation of stage might have different meanings. To determine the corresponding summary stage code, it is essential to know exactly which version a physician is using.
Some staging systems (FIGO for example) use clinical information only, whereas CCR's Stage at Diagnosis includes all information—clinical, surgical, and pathological—that falls into the time period. Use the physician's clinical stage if no pathological information is available.
A field for recording other staging systems, such as Duke's, is available in CNEXT.
Sometimes the stage is stated incorrectly in the medical record due to a typographical, transcription, or similar error. If the stage recorded in one report is clearly contradicted in another, query the physician or the registry's medical consultant. Do not code stage based on information that appears to be inaccurate.
A diagnosis of in situ, which must be based on microscopic examination of tissue or cells, means that a tumor has all the characteristics of malignancy except invasion—that is, the basement membrane has not been penetrated. A tumor that displays any degree of invasion is not classified as in situ. For example, even if a report states "carcinoma in situ of the cervix showing microinvasion of one area," the tumor is not in situ and code 0 is incorrect. However, a primary tumor might involve more than one site (for example, cervix and vagina, labial mucosa and gingiva) and still be in situ, as long as it does not show any invasion.
Certain terms indicate an in situ stage (see also Section V.3.4.2):
AIN (anal intraepithelial neoplasia Grade II-III)**
Bowen's Disease
DCIS (ductal carcinoma in situ)
DIN 3 (ductal intraepithelial neoplasia 3)**
CIN III (cervical intraepithelial neoplasia, grade III)*
Clark's level 1 for melanoma (limited to epithelium)
Confined to epithelium
Hutchinson's melanotic freckle, nos
Intracystic, non infiltrating
Intraductal
Intraepidermal
Intraepithelial
Intrasquamous
Involvement up to but not including the basement membrane
LCIS (lobular carcinoma in situ)
Lentigo maligna
LIN (laryngeal intraepithelial neoplasia)**
Lobular neoplasia, Grade III
No stromal invasion
Non infiltrating
Non invasive
PanIN-III (pancreatic intraepithelial neoplasia III)***
Precancerous melanosis
Preinvasive
Queyrat's erythroplasia
Stage 0
Vaginal intraepithelial neoplasia, Grade III (VAIN III)*
Vulvar intraepithelial neoplasia, Grade III (VIN III)*
* Cases diagnosed January 1992 and later.
** Cases diagnosed January 2001 and later.
***Cases diagnosed January 2004 and later.
If a tumor is staged in situ, the behavior code (see Section V.3.4) is 2.
Localized denotes a tumor that is invasive, but is still confined entirely to the organ of origin. For most sites, the tumor might be widely invasive or have spread within the organ, as long as it does not extend beyond the outer limits of the organ and there is no evidence of metastasis to other parts of the body.
Clinical diagnosis alone is often insufficient for staging a tumor as localized when the primary site and regional lymph nodes are inaccessible, such as with the esophagus, lung, or pancreas. Without confirmation during surgery or an autopsy, it is usually preferable to code the stage as 9 (unstageable). But if the physician has staged the case as localized, or if clinical reports (such as CT scans) provide enough information to rule out spread of disease, stage 1 (localized) may be used. If surgery has been performed, study the operative report for evidence of direct extension or metastasis. If no such evidence has been found, and radiological examination has produced none, classify the tumor as localized.
Invasion of blood vessels, lymphatics, and nerves within the primary site is a localized stage, unless there is evidence of invasion outside the site.
Tumors with more than one focus, or starting point, are considered to be localized unless extension beyond the primary site has occurred. But a tumor that has developed "satellite" nodules—that is, lesions secondary to the primary one—might not be localized. Refer to the Summary Staging Guide for rules about satellite lesions.
Microinvasive, a term used by pathologists to describe the earliest invasive stage, has a precise meaning for cancer of certain sites. Microinvasive cancers are staged as localized, code 1. (Microinvasive squamous cell carcinoma is a common form of cervical cancer, for which ICD-O provides a specific morphology code—8076/3.)
A tumor at the Regional stage has grown beyond the limits of the organ of origin into adjacent organs or tissues by direct extension and/or to regional lymph nodes by metastasis. Neoplasms appearing to be in the regional stage must be evaluated very carefully to make sure they have not spread any farther.
Example: A malignant tumor of the stomach or of the gallbladder often passes through the wall of the primary organ into surrounding tissue. Before coding as regional, make certain that radiological or scan examinations do not reveal metastasis to a lung or bone and that findings during surgery do not include metastasis to the liver or serosal surfaces that are not regional. Also check progress notes and the discharge summary for any mention of metastasis.
Some times a cancer spreads to surrounding organs or tissue with no involvement of regional lymph nodes. Before assigning code 2 to such a case, make sure that tissue adjacent to the original organ is actually involved. The terms "penetrating" and "extension" are sometimes used to describe spreading within an organ, such as the large intestine or bladder, in which case the stage might still be localized (code 1). The Summary Staging Guide lists organs and structures considered to be regional for each site. (Also see Section V.5.3 for interpretation of ambiguous terms.)
If a cancer continues to grow after the onset of local invasion, the regional lymph nodes draining the area usually become involved at some point. Enter code 3 if nodal involvement is indicated but there is no other evidence of extension beyond the organ of origin. Words like "local" and "metastasis" appearing in medical records sometimes cause confusion in coding this stage. Failure to recognize the names of regional lymph nodes might lead to incorrect staging. The Summary Staging Guide and the American Joint Committee on Cancer's Manual for Staging of Cancer (see Section I.1.6.5) contain helpful information about the names of nodes.
Examples: Diagnoses such as "carcinoma of the stomach with involvement of the local lymph nodes" should, lacking further evidence, be considered regional and staged as code 3.
Statements like "carcinoma of the breast with axillary lymph node metastasis" and "carcinoma of the stomach with metastasis to perigastric nodes" indicate metastasis to regional nodes and should be staged as code 3.
Bilateral lymph node metastases are considered regional for primaries on the midline of the body (for example, on the tongue, esophagus, or uterus), and should be coded as 3. But bilateral regional node involvement of primaries that are not on the midline (like the breast) indicates that the cancer has spread to remote tissue (code 7).
Enter code 4 when a tumor has metastasized to regional lymph nodes and also has spread to region al tissue via direct extension, but there is no evidence of metastasis to a distant site or distant lymph nodes.
If available information states only that a cancer has spread regionally, stage as code 5. Also use code 5 for a nodal lymphoma described as regional (sometimes stated in the record as Stage II—see sections V.5.6 and V.7.5).
Enter code 7 for any tumor that extends beyond the primary site by:
Direct extension beyond adjacent organs or tissues specified as regional in the Summary Staging Guide.
Metastasis to distant lymph nodes.
Development of discontinuous secondary or metastatic tumors. (These often develop in the liver or lungs, because all venous blood flows through these organs and the veins are invaded more easily than the thicker walled arteries.)
Code 7 also includes contralateral or bilateral lymph node metastases, if the primary site is not located along the midline of the body (for example, in the breast, lung, bronchus, ovary, testis, kidney). Also included in code 7 are systemic diseases such as leukemia and multiple myeloma.
If information in medical records is insufficient to assign a stage, enter code 9. Code 9 is required when the primary tumor site is not known. For non-analytic cases (class 3), code 9 is appropriate unless the stage at the time of the initial diagnosis is known.
Special rules apply to staging lymph nodes:
For solid tumors, the terms "fixed" or "matted" and "mass in the mediastinum, retroperitoneum, and/or mesentery" (with no specific information as to tissue involved) are considered involvement of lymph nodes. Any other terms, such as "palpable", "enlarged", "visible swelling", "shotty", or "lymphadenopathy" should be ignored; look for a statement of involvement, either clinical or pathological.
For lymphomas, any mention of lymph nodes is indicative of involvement.
For lung primaries, if at mediastinoscopy or x-ray, the description states mass/ adenopathy/ enlargement of any of the lymph nodes listed under code 2 of the EOD -- Lymph Nodes field, assume those lymph nodes are involved. Mediastinal lymph nodes > 1 cm are considered enlarged.
COC Facility Oncology Registry Data Standards (FORDS manual) entry available
NAACCR Data Standards and Data Dictionary entry available
