The Anatomy of Collaborative Staging: Ovary

Presentation developed byCollaborative StagingSteering Committeeajcc@facs.org

2005 Update

CS Ovary Coding 2005

Structures of Female Pelvis

CS Ovary Coding 2005

Ovarian Cancer

Collaborative Stage fields

• Tumor Size--standard• Extension• TS/Ext Eval--standard• Lymph Nodes• LN Eval--standard• LN Pos--standard• LN Exam--standard• Mets at Dx• Mets Eval--standard• Site-specific Factor 1--CA-125• Site-specific Factors 2-6--not applicable

CS Ovary Coding 2005

CS Extension--Notes1. Ascites

Positive ascites changes stages I and II to IC and IIC.

Disregard negative ascites or ascites, NOS

2. Pelvic organs* coded to 50-65 (FIGO Stage II) Adnexa, bladder (including serosa), uterine

ligaments, cul de sac, fallopian tubes, parametrium, pelvic peritoneum, pelvic wall, rectum, sigmoid colon, ureter, uterus, uterine serosa

5. Abdominal organs* coded to 70-75 (FIGO III) Abdominal mesentery, diaphragm, gallbladder,

infracolic omentum, kidneys, large intestine except rectum and sigmoid, peritoneal surface of liver, omentum, pancreas, pericolic gutter, peritoneum, NOS, small intestine, spleen, stomach, ureters

* Involvement may be direct or discontinuous

CS Ovary Coding 2005

CS Extension--Notes6. Liver parenchymal metastases are coded

in Mets at Dx.

Implants (discontinuous metastases)Other names: seeding, salting, studding, talcum powder appearance

4. Determine whether implants are in pelvis (code 60-64) or abdomen (code 70-73) or unspecified (code 75)

5. Implants outside the pelvis must be microscopically confirmed and coded by size70 Microscopic only71 Macroscopic < 2 cm72 Macroscopic > 2 cm73 Mets outside pelvis, size not stated75 Peritoneal implants, NOS [not stated as pelvic

or abdominal]

CS Ovary Coding 2005

CS Extension Codes (FIGO I) 10 One ovary, capsule intact,

no tumor on surface, negative ascites (FIGO IA)

20 Both ovaries, capsules intact, no tumor on surface, negative ascites (FIGO IB)

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

CS Ovary Coding 2005

CS Extension Codes (FIGO IC) One or both ovaries

35 Capsule ruptured 36 Tumor on surface

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

41 One or both ovaries positive ascites or washings

CS Ovary Coding 2005

CS Extension Codes 50-52 (FIGO IIA) Extension to or implants on: (negative ascites/washings)50 Adnexa/tubes, ipsilateral 52 Adnexa/tubes, contralateral52 Uterus

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

CS Ovary Coding 2005

CS Extension Codes 60, 61 (FIGO IIB) Extension to or implants on: (negative ascites)60 Other pelvic structures* (ipsilateral)61 Other pelvic structures* (contralateral)

* ligaments, mesovarium, pelvic wall, adjacent peritoneum

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

CS Ovary Coding 2005

CS Extension Codes 62-64 (FIGO IIC)Tumor confined to pelvis with positive ascites62 Ipsilateral (50 and/or 60)63 Contralateral (52 and/or 61)64 Other pelvic structures

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

CS Ovary Coding 2005

CS Extension Code 70-75 (FIGO III)

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

70 Microscopic peritoneal implants(FIGO IIIA)

71 Macroscopic peritoneal implants < 2 cm (FIGO IIIB)

72 Macroscopic peritoneal implants > 2 cm (FIGO IIIC)

CS Ovary Coding 2005

Liver InvolvementCS Extension codes 70-73: Tumor on capsule or surface of liver(FIGO III)

Mets at Dx code 40: Metastasis inside liver (parenchymal) (FIGO IV)

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

CS Ovary Coding 2005

CS Lymph Nodes--Notes

1. Code distant nodes in Mets at Dx.2. If there is a statement that “adnexa

palpated” with no mention of lymph nodes, assume lymph nodes are not involved (code 00).

3. If exploratory or definitive surgery with no mention of nodes, assume nodes are negative (00).

4. Regional nodes include bilateral and contralateral involvement of named nodes.

CS Ovary Coding 2005

CS Lymph Nodes

Source: TNM-Interactive, UICC, 1998

Code 101 Hypogastric (internal iliac) Obturator2 Common iliac3 External iliac

Code 124 Lateral sacral

Code 205 Para-aortic

Code 306 Inguinal

40 10 + 2042 [12 or 30] + [10 or 20]

CS Ovary Coding 2005

CS Mets at Dx10 Distant nodes, NOS40 Distant metastases except nodes

Liver parenchymaPleural effusion with positive cytologyFIGO Stage IVB

50 Distant mets plus distant nodes99 Unknown, not assessed, not documented

CS Ovary Coding 2005

Site-Specific Factor 1CA-125

Tumor marker for ovarian cancer; monitors for

disease progression Also called cancer antigen 125 or carbohydrate

antigen 125 Normal range < 35 U/ml (SI: < 35 kU/L) Code the lowest pre-treatment test

000 Test not done010 Positive/elevated020 Negative/normal; within normal limits030 Borderline; undetermined whether positive

or negative080 Ordered but results not in chart999 Unknown, no information, not documented

CS Ovary Coding 2005

Ovarian CancerCase Study 1: Limited to ovaries Enlarged right ovary on PE; mass confirmed by

ultrasound. No further tests. Laparotomy, RSO, and random biopsies: tumor confined to ovary,

capsule intact. All bx and washings negative • Tumor size 999 Size not stated• Extension 10 One ovary involved, capsule intact• TS/Ext Eval 3 Based on surgical resection• Lymph nodes 00 Note 3: expl. surgery, no mention of LN• Reg LN Eval 1 Based on surgical observation, no bx.• Reg LN Pos 98 No nodes examined• Reg LN Exam 00 No nodes removed• Mets at Dx 00 Inaccessible sites rule--presumed neg.• Mets Eval 0 Based on non-invasive clinical evidence• SSF1 999 CA-125 not documented• SSF2 - SSF8 888 Not applicable

CS Ovary Coding 2005

Ovarian CancerCase Study 2: Malignant ascites Pt had vague abdominal symptoms. Pelvic exam

showed right ovary mass. Oophorectomy and Bxs: Adenoca in right ovary and in tumor implants on R fallopian tube. Peritoneal washings positive.

• Tumor size 999 Size not stated• Extension 62 Ipsilat. tube (50) + pos. ascites• TS/Ext Eval 3 Based on pathology report• Lymph nodes 00 Note 3: expl. surgery, no mention of LN• Reg LN Eval 1 Based on surgical observation, no bx.• Reg LN Pos 98 No nodes removed• Reg LN Exam 00 No nodes examined• Mets at Dx 00 Inaccessible sites rule--presumed neg.• Mets Eval 0 Based on non-invasive clinical evidence• SSF1 999 CA-125 not documented• SSF2 - SSF6 888 Not applicable

CS Ovary Coding 2005

Ovarian CancerCase Study 3: Extensive disease Large pelvic mass on PE. CA-125 highly pos. TAH-

BSO and biopsies: cystadenoca in both ovaries and tumor nodules (> 2 cm) on cervix, pelvic sidewall, small intestine, and surface of liver. 0/8 LN pos.

• Tumor size 999 Size not stated• Extension 72 Peritoneal mets > 2 cm• TS/Ext Eval 3 Based on pathology report• Lymph nodes 00 No nodes involved• Reg LN Eval 3 Based on pathology report• Reg LN Pos 00 No nodes involved• Reg LN Exam 08 Eight nodes examined• Mets at Dx 00 Inaccessible sites rule--presumed neg.• Mets Eval 0 Based on non-invasive clinical

evidence• SSF1 010 CA-125 elevated• SSF2 - SSF6 888 Not applicable