This document provides an overview of AJCC TNM staging and coding rules. It begins with learning objectives about understanding TNM staging, the difference between X and blank coding, and demonstrating knowledge through exercises. It then discusses starting the coding process and available resources for help. The rest of the document reviews the general TNM coding rules section by section, including definitions of clinical and pathological staging, timing of data collection, cases involving neoadjuvant therapy, and coding multiple primary tumors. Elements of TNM such as T, N, and M categories are also explained at a high level. The document aims to educate registrars on properly applying TNM staging codes.

1. The Voyage to
Direct Coding of
AJCC TNM...

2. ....and How to Get
There!!
Jayne Holubowsky, CTR
Director, Virginia Cancer Registry
Division of Population Health Data,
Virginia Dept of Health
Kentucky Cancer Registry
30th Annual Advanced Cancer Registrars’
Workshop
September 8, 2016

3. OVERVIEW
Provide information on how to
code AJCC TNM
Provide information regarding
the coding of X vs Blank
Provide exercises to
demonstrate learned information

4. Learning Objectives
Understand the process for TNM
staging
Understand the difference between
X and Blank in TNM Coding
Demonstrate learned information
through exercises

5. TO START WITH.....

6. Where do I even start??
 Make sure YOU know what you need
to make decisions
◦Know the general rules
◦Use resources beside the medical
record
◦Be sure to include text to qualify your
codes
◦Do not be afraid to ask for help

7. OTHER RESOURCES

8. Help from NCRA
The abstract is the basis of all registry functions. It is a tool used to help accurately
determine stage and to aid cancer research; therefore, the abstract must be
complete, containing all the information needed to provide a concise analysis of the
patient’s disease from diagnosis to treatment.
To assist registrars in preparing abstracts, NCRA’s Education Committee has
created a series of informational abstracts. These site-specific abstracts provide an
outline to follow when determining what text to include. The outline has a specific
sequence designed to maximize efficiency and includes eight sections: Physical
Exam/History; X-Rays/Scopes/Scans; Labs; Diagnostic Procedures; Pathology;
Primary Site; Histology; and Treatment. A list of relevant resources is located at the
end of each informational abstract. The sources of information noted in the various
sections below are not all inclusive, but they are the most common. You may need
to do additional research to complete the abstract.
When using the informational abstract, follow the outline and strive to complete all
the sections. Be concise by using phrases, not sentences. Make sure to use text
relevant to the disease process and the specific cancer site and to use NAACCR
Standard Abbreviations. When the abstract is completed, review thoroughly to
ensure accuracy
INFORMATIONAL ABSTRACT
A Guide to Determining What Text to Include

11. Get Ready....??
 What is the TNM Staging Premise?
 What are the general rules?
◦Provide information on where the tables
are located in the manuals
◦Go over the rules one by one
 What you cannot use

12. GENERAL TNM CODING RULES
 TNM Staging Premise
◦ Cancer has a finite length and certain
measurable events along time
continuum
 Mutations of a single cell
 Local growth (increase in size)
 Invasion of organ’s parenchyma
 Invasion of lymphatics within organ

13. Cancer Timeline - continued
 Spread to regional lymph nodes
 Direct invasion of adjacent tissues
 Invasion of blood vessels and spread to distant
organs
◦ Time continuum varies by cancer type
 Marker points defined for each type of cancer
GENERAL TNM CODING RULES

14. GENERAL TNM CODING RULES
 All General Rules are in Chapter 1 of the
AJCC Manual
 Used for ALL sites
 Exceptions or additions in site-specific
chapters
Remember – THERE ARE NO
AMBIGUOUS TERMS IN TNM
STAGING!!

15. Microscopic confirmation • Required for TNM classification
• Rare cases without micro confirm should be analyzed
separately
• Cancers classified by ICD-O-3
• Recommend pathology reporting using CAP cancer protocols
Timing of data eligible for clinical
staging
• Data obtained before definitive tx as part of primary tx or
w/in 4 months, whichever is shorter
• Time frame for collecting clinical stage data also ends when a
decision is made for “watchful waiting” without therapy
Timing of data eligible for pathological
staging
• Data obtained through definitive surgery as part of primary
tx or w/in 4 months, whichever is longer
Timing of data eligible for staging with
neoadjuvant therapy
• Stage in cases w/neoadjuvant tx is: (a) clinical as defined
earlier before initiation of therapy; and, (b) clinical or
pathological using data obtained after completion of neoadj
therapy (ycTNM or ypTNM)
Cases w/uncertainty among T, N, or M
categories
• Assign the lower (less advanced) category of T, N, or M,
prognostic factor or stage grouping
Absence of staging-required
nonanatomic prognostic factor
• Assign stage grouping by the group defined by the lower
(less advanced) designation for that factor
Mult synchronous primary tumors in
single organ
• Stage T by most advanced tumor; use “m” suffix or the
number of tumors in parentheses, e.g., pT3(m)N0 M0 or
pT3(4)N0M0
Synchronous prim tumors in paired
organs
• Stage and report independently
Metachronous prim tumors in single
organ (not recurrence)
• Stage and report independently
T0 staging – unknown primary Stage based on clinical suspicion of primary tumor (e.g., T0
N1 M0 Stg IIA breast cancer)
GENERAL TNM CODING RULES
Adapted from AJCC Cancer Staging Manual, 7th ed, Table 1.3, page 8

16. GENERAL TNM CODING RULES
1. MICROSCOPIC CONFIRMATION
◦ All cases should be confirmed
microscopically
◦ Clinically diagnosed cases should be
reported separately
◦ Cancers are classified by their ICD-O-
3 primary site code

17. GENERAL TNM CODING RULES
2. TIMING – Clinical Staging (cTNM)
◦ All information obtained prior
to initiation of any treatment
or within 4 months of
diagnosis, whichever is
shorter, with no disease
progression
 Treatment decision includes
watchful waiting

18. GENERAL TNM CODING RULES
2. TIMING – Clinical Staging (cTNM) –
continued
◦ May be only common factor for some
sites
◦ Information used includes:
 Symptoms Physical exam
 Endoscopies Biopsy for diagnosis
 Imaging Tumor, Lymph nodes, Distant
sites
 Surgical exploration w/o resection
◦ Application
 Define initial treatment choice
 International population comparison

19. GENERAL TNM CODING RULES
 CLINICAL STAGE
◦ Assigned prior to cancer-directed treatment
◦ Derived from clinical observations
 Specified in each chapter
◦ Ends when 1st cancer directed treatment
starts OR when decision is made not to
treat
◦ Should not be changed based on subsequent
information
◦ Clinicians will use when:
 No surgical treatment
 Adjuvant treatment prior to surgery
 Insufficient information to stage pathologically

20. GENERAL TNM CODING RULES –
POP QUIZ
 A patient is diagnosed with prostate
cancer on June 1. He decides on June 14
that he would prefer active surveillance.
July 1, he goes to his family physician,
complaining of shoulder pain. The
physician orders an x-ray which is done
on July 5 and reveals metastatic disease
in the shoulder.
 Is this a recurrence or is this Stage 4 at
diagnosis?

21. GENERAL TNM CODING RULES
 CLINICAL STAGE – continued
◦ Clinical Stage MUST be reported in CoC-
accredited facilities
◦ Pathology information may be included in
Clinical Staging when there is:
 Biopsy of primary site without resection (cT)
 No pathologic information obtained (cT)
 Biopsy of lymph node(s) w/o pathologic
information about the primary site (cN)
◦ Sentinel node biopsy prior to neoadjuvant tx for breast
CA
 Negative biopsy of metastatic site (cM not pM)

22. GENERAL TNM CODING RULES
 TIMING – Pathological Staging (pTNM)
◦ All information obtained through
completion of 1st course tx or
within 4 months of diagnosis
whichever is longer, with no
neoadjuvant tx or disease
progression

23. GENERAL TNM CODING RULES
 TIMING – Pathological Staging (pTNM) –
continued
◦ Information used
 Clinical TNM
 Pathology from resected tissue (T, N, or M)
 EXCEPTION
◦ If only clinical T, then any LN biopsy = cN
◦ Uses
 Most precise diagnosis
 Adjuvant treatment decisions

24. GENERAL TNM CODING RULES
 PATHOLOGICAL STAGE
◦ Most precise estimate of prognosis
◦ Based on:
 Clinical information acquired before tx
PLUS
 Pathologic examination of surgical
specimen
◦ If primary tumor cannot be removed
◦ Case can be pathologically staged
◦ Specific requirements for pT, pN, pM
◦ Presence of a path report is not
automatically pathological staging

25. GENERAL TNM CODING RULES
 STAGING BASIS
◦ c – Clinical Stage essential to select &
evaluate therapy options
◦ p – Pathological Stage provides most precise
data to estimate prognosis, plan subsequent
therapy & calculate end results
◦ r – Recurrence/Retreatment Stage
Assessment of extent of tumor after recurrence
after disease- free interval when further tx is
planned
◦ a – Autopsy Stage Classification 1st
determined @ autopsy (no previous dx of
cancer)

26. GENERAL TNM CODING RULES
3. CASES WITH NEOADJUVANT
TREATMENT
◦ Cases treated with neoadjuvant
therapy may have a second
staging after treatment
◦
 Should have clinical staging as
baseline
 Post-treatment staging is
labeled yc or yp
◦ Also called intercurrent staging

27. GENERAL TNM CODING RULES
 Post-Therapy Classification – continued
◦ Measures response to neoadjuvant
treatment
 Pt had systemic and/or radiation tx before
surgery
 Case staged at conclusion of therapy
◦ Clinical if no further treatment (ycTNM)
◦ Pathological if resection (ypTNM)
 Stage group notation for no residual cancer
◦ ypT0 ypN0 ycM0
 Should have clinical stage as baseline
◦ Allows assessment of response to therapy
◦ Surgery must meet criteria for pathological staging
 Provides prognostic information
 Helps determine subsequent non-surgical
treatment

28. GENERAL TNM CODING RULES
4. PROGRESSION OF DISEASE
◦ Only information obtained prior to
documented progression of disease is
used for staging
5. UNCERTAINTY ABOUT CATEGORY
◦ If in doubt about correct T, N, or M
value, Stage grouping, or Prognostic
factor, use the less advanced category

29. GENERAL TNM CODING RULES
◦ Uncertain information examples
–Imaging unclear if one node (N1) or two nodes
(N2) are involved
•Use N1 which is lower category
–Colonoscopy states at least in situ
•Use TX since information is unknown
• Cannot assign Tis or T1 as this falsely skews data
–Lung clinical stage group for T2a NX M0
• Use stage group unknown since no information on
nodes
• Cannot assign stage group using N0 as this falsely
skews data

30. GENERAL TNM CODING RULES
6. MISSING PROGNOSTIC FACTOR
◦ If required non-anatomic factor is
not available, stage group case
assuming lowest value for factor
 Example:
T2a, N0, M0 prostate CA but Gleason
score & PSA unknown
Assign Stage Group I (PSA x, Gleason x)

31. GENERAL TNM CODING RULES
 OPTIONAL DESCRIPTORS

32. GENERAL TNM CODING RULES
 Multiple Primary Tumors
7. Simultaneous tumors of same histology in 1
organ
◦ Classify by highest T category
◦ Add suffix of m for multiplicity or # of tumors
 Mastectomy specimen: 1cm IDC UOQ & 23mm IDC LOQ
◦ Use largest tumor (23mm) for staging; assign pT2m or
pT2(2)
8. Simultaneous bilat tumors – classify
separately
◦ Thyroid, ovary, fallopian tube, liver exception
 Multiplicity part of T definitions
◦ Lung exception
 Multiple tumors may be classified in T or M depending on
location

33. GENERAL TNM CODING RULES
9. Metachronous tumors in single
primary
◦ Abstract separately
10.Unknown primary site
◦ No evidence of primary tumor (T0)
◦ Stage according to site suspected by clinician
 Additional Notes from AJCC
◦ Carcinoma in situ
 Must be pathologically determined (pTis)
 Report as clinical AND pathological stage 0

34. ELEMENTS OF TNM
 Descriptors of extent of spread – 3
dimensions
◦ T – Primary tumor & contiguous tumor growth
◦ N – Regional lymph node involvement
◦ M – Distant metastases
 Timing of description – Staging Basis
◦ Clinical
◦ Pathological
 Aggression of cases
◦ Stage grouping

35. ELEMENTS OF TNM - T
T determined by site-specific rules based on size and/or local extension
Clinical assessment of T (cT) based on PE, imaging, endoscopy and
biopsy and surgical exploration w/o resection
Pathologic assessment of T (pT) entails a resection of the tumor or may
be assigned with biopsy only of it assigns the highest T category
pT generally based on resection in single specimen; if resected in >1
specimen, make reasonable estimate of size/extension. Disease-specific
rules may apply
Tumor size should be recorded in whole millimeters. If the size is
reported in smaller units, such as tenths or hundredths of a millimeter, it
should be rounded to the nearest whole millimeter for reporting stage.
Rounding is performed as follows: 1 through 4 are rounded down, 5
through 9 are rounded up.
If not resected, and highest T and N category can be confirmed
microscopically, case may be classified as pT or pN w/o resection
• T Classification Rules
Taken from AJCC Cancer Staging Manual, 7th ed, Table 1.5, page 10

36. ELEMENTS OF TNM - T
 T – TUMOR  Locoregional Spread
◦ Assessment of the primary cancer & any
organs involved by contiguous extension
 Local growth
 Invasion of blood vessels or lymphatics within
organ of origin
 Within a body cavity, tumor seeding of organ
tissues via body fluid
 Direct invasion of adjacent tissues

37. ELEMENTS OF TNM - T
 T Classification: Different Criteria for
Different Cancers
◦ Tumor Size
 Breast, parotid gland, oral cavity
◦ Depth of Invasion
 Colon, bladder, melanoma
◦ Location and extension
 Lung, larynx, pancreas
◦ Other factors
 Tumor multiplicity (thyroid, liver)
 Grade (sarcomas)
 Prognostic factors (prostate, testis)

38. ELEMENTS OF TNM - T
 T Values Range 1-4 – SIZE
◦ Example: Breast
 T1 Less than or equal to 2cm
 T2 Greater than 2cm to 5cm
 T3 Greater than 5cm
 T4 Involving chest wall or skin
Image source: http://www.medinfo.net/imi/tissue-areas/breast-cancer/

39. ELEMENTS OF TNM - T
 T Values Range 1-4 – Invasion
◦ Example: Bladder
 T0 No evidence of primary tumor
 Ta Noninvasive papillary carcinoma
 Tis Carcinoma in situ
 T1 Subepithelial connective tissue
 T2 Muscularis propria
 T3 Perivesical tissue
 T4 Beyond bladder
Image source: http://www.cancerresearchuk.org/cancer-help/type/bladder-cancer/treatment/bladder-cancer-
stage-and-grade /

40. ELEMENTS OF TNM
 T Values Range 1-4 – Extension
◦ Example: Vocal Cord (glottic larynx)
 T1 Limited to cords (normal mobility
 T2 Extends to supra- or subglottis or impaired
cord mobility
 T3 Confined to larynx w/vocal cord fixation;
or, extending to paraglottic space or inner cortex
of thyroid cartilage
 T4a Thru thyroid cartilage; trachea, soft ti of
neck, deep extrinsic muscles of tongue
 T4b Prevertebral space, encasing carotid
artery, invading mediastinal structures
Image source: http://www.oncolex.org/en/Head-and-Neck-cancer/Diagnoses/Larynx/Background/Staging

41. ELEMENTS OF TNM - T
 Tis – Carcinoma In Situ
◦ Primary tumor MUST be removed and
microscopically proven to be non-invasive
(pTis)
◦ May be part of Clinical Stage Group 0
 T0 – No Evidence of Primary Tumor
◦ Tumor in primary site cannot be found

42. ELEMENTS OF TNM - T
 Pathologic Staging – T
◦ Minimal requirement for assigning pT
 Gross resection of primary
 Margins may be microscopically involved
 Must be able to evaluate highest pT category
 If bx documents highest T category, classify as pT
◦ Some sites have specific rules
 Prostate: Radical prostatectomy required
 Bladder: Radical cystectomy required
 Breast: Lumpectomy at a minimum

43. ELEMENTS OF TNM - N
Categorize N by disease-specific rules based on number & location of positive LNs
Minimum expected number & location of LNs to examine for staging defined by disease type
If LN surgery is performed, classify N category as pathologic even if minimum number is not
examined
Pathological assessment f the primary tumor (pT) is necessary to assign pathological
assessment of LNs (pN) except w/unknown primary (T0). If pathological T (pT) is available,
then any microscopic evaluation of LNs is pN
In cases with only clinical T in the absence of pT excision of a single LN or SLN(s) is classified
as clinical nodal status (cN)
Microscopic examination of a single LN or LNs in the highest N category is classified as pN
even in the absence of pathological information on other LNs
Sentinel LN biopsy is denoted with (sn), e.g. pN0(sn); pN1(sn)
LNs with ITC only generally staged as pN0; disease-specific rules may apply (e.g., melanoma)
Direct extension of primary tumor into regional LN is classified as node positive
Tumor nodule with smooth contour in regional LN area are classified as positive LNs
When size is the criterion for N category, stage by size of metastasis, not size of node when
reported (unless specified in disease-specific rules)
• N Classification Rules
Adapted from AJCC Cancer Staging Manual, 7th ed, Table 1.6, page 10

44. ELEMENTS OF TNM - N
 N – Regional LN Involvement
◦ N0 – Regional LNs have been clinically
or pathologically proven to be free of
metastatic dz
◦ N1 – N3
 Increasing involvement of regional lymph
nodes by number, location or size
◦ Subcategories such as N0(i+), N1mi, N2a may be
used

45. ELEMENTS OF TNM - N
 N – Regional LN Involvement - continued
◦N1 – 3 by # of LNs positive
Example: Stomach
◦N1 1-2 regional LNs involved
◦N2 3-4 regional LNs involved
◦N3a 7-15 regional LNs involved
◦N3b 16 or more reg LNs involved
Picture source: http://openi.nlm.nih.gov/detailedresult.php?img=3175221_1471-2407-11-329-2&req=4

46. ELEMENTS OF TNM - N
 N – Regional LN Involvement – continued
◦ N1 – 3 by Location
 Example: Lung
◦ N1 – Peritracheal and perihilar LNs
◦ N2 – Ipsilateral mediastinal and/or subcarinal LNs
◦ N3 – Contralateral mediastinal or hilar LNs; scalene
or supraclavicular LNs
Picture source: http://www.fudahospital.com/zh_asp_new/zt/english/t&t/lung/00016_b.htm

47. ELEMENTS OF TNM - N
 N – Regional LN Involvement – continued
◦N1 – 3 by Size and Number
Example: Renal Pelvis and Ureter
◦N1 Single node, ≤2cm
◦N2 Single node >2 to 5cm or
multiple LNs, all ≤5cm
◦N3 Any metastasis >5cm
Picture source: http://uronotes2012.blogspot.com/2012/07/illustrated-tnm-staging-of-renal-pelvis.html

48. ELEMENTS OF TNM - N
 Pathologic Staging – N
◦ Minimal requirement for assigning pN
 Resection of minimum number of LNs to
assure adequate sampling
 Number varies by primary site
 Exception: sentinel node procedure
EXAMPLE: Lumpectomy for breast cancer with
sentinel LN bx of only Level I nodes=pT_ pN_(sn)
 If recommended # of LNs not removed, still classify
pN
 Pathologic examination of enough LNs to:
 Validate absence of region LN mets (pN0)
 Evaluate highest pN category

49. ELEMENTS OF TNM - N
 Pathologic Staging – N – continued
◦ pN assigned in conjunction with pT
 If removal of primary tumor meets criteria
for pathological T, then not necessary to
have microscopic confirmation of highest
N category
 If highest N category microscopically
proven, then case is pN regardless of
status of T
◦ EXAMPLE: Lung cancer with + FNA of
supraclavicular= pN3 regardless of how
T is determined
 If no removal of primary tumor, then LN
bx or SLN procedure is cN

50. ELEMENTS OF TNM - N
 Pathologic Staging – N – continued
◦Isolated Tumor Cells (ITCs)
 Identified by immunohistochemistry or
molecular techniques, flow cytometry
or DNA analysis
 Definition:
◦ Single tumor cells or small clusters of cells
0.2mm in diameter
 Breast classified as pN0
 Melanoma & Merkel cell carcinoma
classified as pN1

51. ELEMENTS OF TNM - M
• M Classification Rules
Clinical M classification only requires H&P; imaging of distant organ sites not required to assign
cM0; infer status as clinical M0 status unless known clinical M1
“MX” is not a valid category and my not be assigned. Elimination of “MX” is new with
AJCC/UICC, 7th ed
Pathological M classification requires a positive biopsy of the metastatic site (pM)
Pathological M0 (pM0) is not a valid category and may not be assigned. Stage a case with a
negative biopsy of suspected metastatic site as cM0
Case with pathological T and N may be grouped as pathological TNM using clinical M
designator (cM0 or cM1) (e.g., pT1 pN0 cM0 = pathological stage I)
Case with pathological M1 (pM1) may be grouped as clinical and pathological Stage IV
regardless of “c” or “p” status of T and N (e.g., cT1 cN1 pM1 = clinical or pathological Stage
IV)
ITC in metastatic sites (e.g., bone marrow) or circulating or DTCs classified as cM0(i+).
Disease-specific rules may apply

52. ELEMENTS OF TNM - M
 M – Distant Metastases/Systemic
Involvement
◦ Absence or presence of distant metastases
 Blood-borne metastases
◦ Discontinuous from primary site
 Direct distant extension
 Progressive LN involvement
 Seeding w/in cavity

53. ELEMENTS OF TNM - M
 M – Distant Mets/Systemic Involv – continued
◦ Categories
 M0 Absence of metastatic disease
 M1 Presence of at least 1 area of distant
metastasis
◦ Example: Prostate M1 category
 M1a Non-regional lymph nodes
 M1b Bone(s)
 M1c Other site(s)
◦ Notes
 MX Not available in classification
◦ Minimal physical examination results in cM0
◦ pM0 not possible except at autopsy
◦ Classification choices: cM0, cM1, pM1

54. ELEMENTS OF TNM - M
 M – Distant Mets/Systemic Involv – continued
◦ TNM7 Rule: cMx and pMx DELETED
 Inappropriate – clinical assessment of mets can
be based on PE alone
 Makes cases unstageable
 If pathologist does not know clinical M, Mx should
NOT be recorded
 Leave pathological M blank if unknown
◦ If a tissue equivalent to cM1 is biopsied & is negative, it
becomes cM0, NOT pM0
 CTCs and DTCs or bone marrow micrometastasis
are cM0(i+)

55. Blank or X?
 Registry data fields seen on software screen
◦ Clinical T N M Stage Group
◦ Pathological T N M Stage Group
 Use appropriate c or p data fields
◦ Based on what is needed to assign stage correctly
◦ Follows AJCC staging rules
 Do NOT use just elements in that one line
 Match stage assigned by physician
◦ According to AJCC rules

56. Blank or X?
 AJCC defines X for T and N categories
◦ Cannot be assessed
 Cannot use X for other situations
◦ No surgical resection is NOT pTx pNx pM blank Stage 99
 Blank should be used when:
◦ No information is available in chart
◦ Cannot be assigned a valid AJCC value
◦ Patient not eligible for pathologic stage

57. Blank or X?
 Patient had bowel obstruction & went directly to
surgery where colon cancer was found
 Physician assigned pathological stage
◦ pT4a pN2a cM0 Stage IIIC
 How should you record the cStage and pStage?
◦ cTblank cNblank cMblank cStage Blank or 99
◦ pT4a pN2a cM0 pStage 3C
 Cannot assign clinical stage, cancer not known
prior to definitive treatment
◦ AJCC is stage group blank, but CoC requires non-blank
value for clinical stage

58. Blank or X?
Patient had CT chest w/LLL tumor & mediastinal LNs,
mediastinitomy removed 4 LNs confirming N3
disease; concurrent chemoradiation will be given
 Physician assigned clinical stage
◦ T2a N3 M0 Stage IIIB (implied c)
 How would you record cStage & pStage?
◦ cT2a cN3 cM0 cStage 3B
◦ pTblank pNblank pMblank pStage blank
 Biopsy of LNs is part of staging workup, cN
 Cannot assign path stage – no resection of primary
◦ Not stage 99 – implies criteria met but information unknown

59. Blank or X?
Clinical stage of insitu cancer of breast; total
mastectomy, no LN resection
pTis cN0 cM0 Stage 0
pTis cN0 cM0 Stage 0
CAN assign clinical & pathological stage
◦ Rules state in situ assigned pTis cN0 cM0 for
CLINICAL AND PATHOLOGICAL
◦ Rules state both clinical & path stage is 0
◦ Rule put in place because LNs are not usually
resected for in situ cancers
◦ Meets breast criteria for pathological
classification

60. Clinical stage of in situ CA of bladder w/
TURBT and no cystectomy
pTis cN0 cM0 cStage 0
pTblank pNblank pMblank pStage blank or 99
 Cannot assign pathological stage
◦ Bladder criteria of cystectomy has not been met
◦ Common to not find invasive tumor on TURBT
◦ Do NOT use stage 99, path stage criteria not met
 99 implies criteria met but information unknown
◦ Rules state that in situ assigned pTis cN0 cM0
Blank or X?

61. Diagnostic workup includes biopsy of bone showing
mets from breast CA, no resection done; tumor
1.5cm, palp axillary LNs
◦ cT1c cN1 pM1 Stage 4
◦ pTblank pNblank pM1 Stage 4
 pM1 for clinical stage, biopsy done during workup
 pM1 is both clinical & pathological stage IV
according to AJCC rules
◦ Case with pM1 may be grouped as clinical AND
pathological stage IV regardless of c or p status of T and N
Blank or X?

62.  Stage group data fields
◦ Blank indicates:
 No information in medical record; OR
 Criteria not met for pathologic staging
◦ CoC does NOT allow blank for clinical staging
◦ 99 indicates:
 Unknown T or N, stage cannot be assigned
 T, N, or M are not specific enough to assign stage
◦ Example: T2 assigned when T2a or T2b needed to assign stage
 CoC mandates non-blank for clinical stage – use 99
 Do not use 99 if pathological staging criteria not met –
use BLANK
◦ 88 indicates not appleicable
Blank or X?

63.  CoC FORDS Values – Blank, X, 99
◦ Blank indicates:
 No information in medical record
 Do not know if any assessment was performed
 Criteria not met for this stage classification so each
category (T, N, M) is blank
◦ X indicates:
 Not assessed
◦ T cannot be assessed
◦ N cannot be assessed
◦ Does not apply to M
 If patient was examined it can be assigned
◦ Criteria met for this stage classification so each category is
valid value or X
◦ 88 indicates not applicable, not defined by AJCC
Blank or X?

64.  Key points for Blank or X
◦ Does the patient meet criteria for that stage
classification?
 YES – patient meets classification criteria
◦ If physician could not assess T and/or N for the patient, &
◦ Definitive information for T and N not in chart
◦ Use Tx and/or Nx
 Yes – patient meets classification criteria
◦ No information about diagnostic workup or no resection
pathology in chart
 Do NOT use X
◦ Implies physician did not assess or have info on pt’s T and/or N
 DO use blank
◦ Indicates registrar could not find information in chart
Blank or X?

65.  Key Points for Blank & X, continued
◦ Does the patient meet criteria for that stage
classification?
 NO – patient does NOT meet classification criteria
◦ Do NOT use X
 Indicates patient eligible for staging
 Implies physician did not assess or have info on patient’s T
and/or N
◦ Must use BLANKS
 Indicates patient did not meet classification criteria
Blank or X?

66. ELEMENTS OF TNM
 Non-anatomic Factors
◦Also called prognostic factors
 You may recognize them as SSF’s
◦Necessary for staging of some sites
 Number of tumors (thyroid)
 Grade (sarcoma, prostate, bone)
 Depth of invasion (melanoma)
 Risk factors (gestational trophoblastic
tumor)
 Tumor markers (testis, prostate)
 Vascular invasion (testis)

67. ELEMENTS OF TNM
Anatomic stage/prognostic grouping rules
Define separate clinical and pathological group for each case. May combine clinical and
pathological information as a “working stage” in either the pathological or clinical
classification when only partial information is available – this may be necessary for clinical
care.
Minimize use of Tx and Nx; use of “x” for any component makes case unstageable. Case
will not be usable in comparison analyses (exception: any combination of T and N
including Tx and/or Nx with M1 is Stage IV)
For grouping that require a nonanatomic factor, if factor is missing, stage using lowest
category for that factor.
Case with pT and pN and cM0 or cM1 staged as pathological stage group.
Case with cT and cN and pM1 staged as clinical AND pathological stage group.
Carcinoma in situ, stage pTis cN0 cM0 stage as both clinical AND pathological stage 0.

68. ELEMENTS OF TNM
 Stage Grouping
◦ AKA anatomic stage/prognostic groups
 Easily communicated summary of extent of
disease & prognosis
◦ Gathers cases based on anatomic extent
of disease (T, N, M) plus relevant non-
anatomic factors into categories to
facilitate analysis
◦ TNM classification and stage groups,
once established, must remain
unchanged in the medical record

69. ELEMENTS OF TNM
 Stage Grouping - continued
◦ Generally “pure clinical” and “pure pathological”
stage groups defined
 Elements can be combined in a “working stage” while
treatment decisions are being made or when only
partial information is available for either
◦ General concepts
 Stage 0 Carcinoma in situ
 Stage I Confined to primary site
 Stage II Limited to local ext &/or limited reg LN
mets
 Stage III More advance local ext or reg LN involv
 Stage IV Involvement of distant sites

70. ELEMENTS OF TNM
 Stage Grouping - continued
◦ Page 5, 7th ed Cancer Staging Manual:
 “…in clinical medicine, it is often expedient to
combine clinical and pathological T, N, and M
information to define a mixed stage group for
treatment planning. And example of a clinical
situation where such “mixed staging” is used
clinically is a woman with breast cancer who has
had the primary tumor resected providing
pathological T, but for whom there was no lymph
node surgery, requiring use of clinical N. The
mixed stage combining clinical and pathological
information is sometimes referred to as working
stage.
 Continued…

71. ELEMENTS OF TNM
 Stage Grouping - continued
◦ Page 5, 7th ed Cancer Staging Manual -
continued:
 “…However, pure clinical and pathological
stage is still defined for comparative
purposes. In addition, clinical M status (M0
or M1) may be mixed with pathological T and
N information to define pathological stage,
and the same pTis cNo cM0 define both
clinical and pathological stage for in situ
carcinoma. If there is pathological evidence
of metastases (pM1), it may be used with
clinical T and N information to define clinical
Stage IV and pathological Stage IV.

72. OTHER REQUIRED ELEMENTS
 Per memorandum emailed to everyone on June
20th, 2014 SSF’s are NOT going away
“On June 17, the CS Transition Group agreed to continue
collecting Site Specific Factors using the current NAACCR
data layout and definitions at least through 2016. This
approach will continue to use the programming and logic
structure established in Collaborative Stage to collect
those variables. The CS Transition Group felt that this
would be the least disruptive way to proceed for 2016.
The intention is to maintain the SSFs as they are until
there is an opportunity to carefully evaluate the SSFs and
to make decisions on how to structure the collection of
these variables within the NAACCR record layout. In
addition, any changes that will be needed to
accommodate prognostic indicators in the AJCC 8th
edition will be better known in 2016.”

73. OTHER REQUIRED ELEMENTS
 Memorandum - continued
“Excerpt from the SSF Data Structure Task
Force Summary
Option 3: Maintain current CS data structure and
definitions. Standard setters would continue to
specify requirements. Continue to collect required
CS data items in their current CS locations. The
existing CS DLL could continue to be used for site
group determination, valid code definitions and
documentation. Once the AJCC 8th edition is
published, the structure will need to be altered to
accommodate this change.”
Betsy Kohler
Executive Director,
NAACCR Inc.

74. OTHER REQUIRED ELEMENTS
SCHEMA REQUIRED SSF’s
Bladder SSF 2 – Size of Mets in Lymph Nodes
Breast
SSF1 – ERA
SSF2 –
PRA
SSF3 - # Positive Ipsilat Level I-II Lymph Nodes
SSF4 – IHC of
Lymph Nodes
SSF5 –
MOL of
Lymph
Nodes
SSF8 – HER-2 IHC Lab Value
SSF9 – HER-2 IHC
Interpretation
SSF11
– HER-2
Fish Lab
Interpre
tation
SSF13 – HER-2 CISH Lab Value
SSF14 – Result of
Other/ Unknown
HER-2 Test
SSF15
– HER-2
Summar
y Result
of
Testing
SSF16 – Combinations of ER/PR/HER-2 Results
Colon SSF2 – Clinical Assessment of Regional LNs

75. OTHER REQUIRED ELEMENTS
SCHEMA REQUIRED SSF’s
Corpus
Adenosarcoma
SSF2 – Peritoneal Cytology
Corpus
Carcinoma
SSF2 – Peritoneal Cytology
Corpus
Sarcoma
SSF2 – Peritoneal Cytology
Lung SSF1 – Separate Tumor Nodules – Ipsilateral Lung
Prostate
SSF1 – PSA
Lab Value
SSF3 – CS Extension – Pathological Extension
SSF8 –
Gleason
Score on
Needle Core
Bx/TURP
SSF10 – Gleason Score on Prostatectomy/Autopsy

76. OTHER REQUIRED ELEMENTS
 You may continue to collect any SSF your
Cancer Committee deems significant
◦ You can get the list of required SSF’s
from an application in SEER
◦ http://seer.cancer.gov/csreqstatus/application.
html

77. AJCC CODING QUIZ #1
 2.5 cm tumor RUOQ breast. No palpable
axillary nodes. Rest of exam WNL
 Lumpectomy and sentinel node biopsy:
1.8cm duct carcinoma. 0/4 nodes.
What are the T, N, M and Stage Group?

78. AJCC CODING QUIZ #2
 Elevated PSA (8; normal 0 – 2.5)
 DRE: normal prostate
 Needle biopsy: adenoCA, Gleason 3+4
 Pelvic CT: WNL
 Metastatic work up: negative
 Treatment: active surveillance
What are the T, N, M and Stage Group?

79. AJCC CODING QUIZ #3
 TURBT: TCC of bladder dome involv
superficial muscle
 Workup: negative
 No further treatment
What are the T, N, M and Stage Group?

80. SUMMARY
 How To: Direct Coding T, N, M and Stage
1. Determine primary site & histology
 Ask: “Where did it start?” (primary site)
 Ask: “Where did it go? (spread to LNs &/or distant
sites)
 Ask: “How did it get there?”
◦ Direct extension (T)
◦ Lymphatics (N)
◦ Discontinuous mets (M)
 Blood
 Seeding/Nodules
2. Look up site chapter
3. Is histology included in this chapter?

81. SUMMARY
 How To: Direct Coding T, N, M and Stage -
continued
4. Review list of regional LNs
5. Review rules for classification
 Clinical vs Pathological
6. Find staging information in manual
 Look for key words in medical record
 Match key words to lists in staging manual
section for primary site
7. Assign appropriate SSF’s
 Some have impact on Stage Group
8. Determine T, N, M, assign Stage Group

82. SUMMARY
 This is not an easy concept to embrace
 It will take lots of reading
 Most important – ANALYZE!!
◦ Then read again!!
◦ No list to go through to help
◦ Don’t use CS as a crutch
 IF YOU ARE UNSURE – ASK FOR HELP!!!

83. And
FINALLY.....

87. jayne.holubowsky@vdh.virginia.gov
804-864-7873
804-864-7870
Thank you!!!