TNM Path N, SSF3, 4, 5 Breast (CoC)

[Jim Hofferkamp]

The email below was sent to me last night…

In a case of invasive T2 breast ca, a mastectomy was performed but no LN removed. The rules for classification of the T have been met, so I code a pathologic T of p2, but the pathologic N is pX, correct? I am not having issues with the clinical staging – just the pathologic. I am getting an edit on this – it is the “TNM Path N, SSF3, 4, 5 Breast (CoC) edit. I have 098 coded for SSF3, 000 for SSF4 and SSF5. Is this a known issue with the edit or a coding problem on my part? (I am getting this edit in the NAACCR 16B metafile)

[Kathleen Beaumont]

Jim,

Could you ask the person who sent you this email to provide the values for all of the data items referenced by this edit? A screen shot from the writer’s software (if it displays all of the referenced fields and values) would do. Otherwise, copy/paste from a GenEDITS Plus report.

This edit has 94 lines of code, and it will likely be faster to find the cause of the problem if we can run the edit with the writer’s specific values in the test bench debugger.

Thanks,
Kathleen

[Jim Hofferkamp]

Kathleen,
I think we found the problem. The logic should allow SSF’s 4 and 5 to be 000 when cN is cN0 and pN is pNX.

I believe the fix is pretty straight forward, i’m just hoping we can get it done and tested without causing too much of a delay in the release of v16c.

I’m surprised and concerned that this didn’t show up earlier in testing. I don’t think it would be that uncommon to have a patient with a cN0 and pNX and SSF’s 4 and 5 of 000. The problem is we just don’t have enough 2016 cases to test. I’m just happy it did show up before we released v16c!

[tjanes@fredhutch.org]

Just to comment from a SEER registry perspective, we have been using codes 987 for both SSF4 and SSF5 for the above situation for breast (clinical N0, pathologic NX) because the definition of code 987 was modified slightly for use with TNM. The definition of 987 for SSF4 and 5 = Not applicable: Regional Lymph Nodes not assigned pN0.

However, I do think selecting the correct code for this situation is confusing because all of the definitions for the codes under these SSF’s don’t necessarily fit for TNM. These SSF’s were used previously to derive path N (I+, I-), but we really aren’t deriving path N like we did before, we are directly coding it.

I don’t disagree with allowing 000, but if 987 is also allowed, it may lead to inconsistent coding within a registry, although it may really be insignificant. Maybe the SEER version of the edit will have to be different?

[Jenna Mazreku]

From the perspective of a Central Registry, funded by both SEER and NPCR, we would prefer not to have a separate SEER edit. It would be much better if the standard setters agreed on the codes instead of having two separate edits. We also collect data from COC Facilities, so our edits cannot be in conflict with their requirements also.

We here agree with the use of 000 outlined by Jim.

Thank you,
Jenna

[Jim Hofferkamp]

I talked to Jennifer Ruhl at SEER about this. Below are her comments. We are going to adjust the edit accordingly.

With CS, the instructions were more clear. Code 987 was for when CS Lymph nodes were not coded to 000, in other words, you did not have a cN0 or pN0; however, it could also apply to cNX and pNX. Who knows how this was being used in CS.

It’s obvious that the codes need to be better defined. I know that NAACCR is putting a SSF Structure group (which I volunteered to be on), that is looking at developing the recommended SSF’s (for implementation in 2018) and also revising the existing SSF’s.

Since the instructions are not very clear at this time, I think code 000 and 987 should be allowed for a cN0 and pNX. Code 000 does state that clinical nodes are negative and not examined pathologically. As I stated above, code 987 could apply to pN1 and above or pNX.

I also agree with Jenna that there should be one edit. Could you just go ahead and allow both values for SSF4 and SSF5 for now for everyone? Once we get the instructions updated and better defined, then we can redo the edit. That would probably be for 2018. Tiffany does comment that this could result in a discrepancy in how a registry is coding; however, I don’t think this is going to be a large number of cases.

This issue can go to the new NAACCR group, although the first meeting (or 2 or 3) may be just discussing how to move forward and not really discussing details.

My recommendation: This is based on the fact that this SSF can only be assigned based on pathologic examination, although the pathologic assessment might not meet the criteria for pathologic N.

Code 000

Regional lymph nodes negative on routine hematoxylin and eosin (H and E), no immunohistochemistry (IHC)
OR unknown if tested for isolated tumor cells (ITCs) by IHC studies
Nodes clinically negative (cN0 or cNX), not examined pathologically (pNX)

Code 987

Not applicable: Regional lymph nodes assessed pathologically and not assigned pN0.

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