**Rules for Multiple Tumors**

> **Rule 3a: Simultaneous multiple lesions of the same histologic type
> within the same site (i.e., multi*focal* tumors in a single organ or
> site) are a single primary.** If one lesion has a behavior code of in
> situ /2 and the other lesion has a behavior code of malignant /3, this
> is a single primary whose behavior is malignant /3.
>
> ***Example 1**:* At nephrectomy, two separate, distinct foci of renal
> cell carcinoma are found in the specimen, in addition to the 3.5 cm
> primary renal cell carcinoma. Abstract as a single primary*.*
>
> ***Example 2:*** At mastectomy for removal of a 2 cm invasive ductal
> carcinoma, an additional 5 cm area of intraductal carcinoma was noted.
> Abstract as one invasive primary.
>
> **Rule 3b: If a new cancer of the same histology as an earlier one is
> diagnosed in the same site within two months, this is a single primary
> cancer.**
>
> ***Example:*** Adenocarcinoma in adenomatous polyp (8210) in sigmoid
> colon removed by polypectomy in December 2004. At segmental resection
> in January 2005, an adenocarcinoma in a tubular adenoma (8210)
> adjacent to the previous polypectomy site was removed. *Count as one
> primary.*
>
> **Rule 4: If both sides of a paired organ are involved with the same
> histologic type within two months of the initial diagnosis**
>
> a\. It is one primary if the physician states the tumor in one organ
> is metastatic from the other.
>
> i\. Code the laterality to the side in which the primary originated
>
> ii\. Code the laterality as 4 if it is unknown which in which side the
> primary originated
>
> b\. Code as multiple primaries if the physician states these are
> independent primaries or when there is no physician statement that one
> is metastatic from the other.
>
> ***Exception 1:*** Simultaneous bilateral involvement of the
> **ovaries** with the same histology is one primary and laterality is
> coded '4' when it is unknown which ovary was the primary site.
>
> ***Exception 2:*** Bilateral **retinoblastomas** are a single primary
> with laterality of '4'.
>
> ***Exception 3:*** Bilateral **Wilms** tumors are always a single
> primary with laterality of '4.'
>
> **Rule 5:** If a tumor with the same histology is identified in the
> same site at least two months after the initial/original diagnosis
> **(metachronous)**, this is a **separate primary.**
>
> ***Exception 1*:** This is a single primary only when the physician
> documents that the initial/original tumor gave rise to the later
> tumor.
>
> **Revised April 2005**
>
> ***Example 1**:* Infiltrating duct carcinoma of the upper outer
> quadrant of the right breast diagnosed March 2004 and treated with
> lumpectomy. Previously unidentified mass in left inner quadrant right
> breast noted in July 2004 mammogram. This was removed and found to be
> infiltrating duct carcinoma. Abstract the case as two primaries.
>
> ***Example 2**:* During the workup for a squamous cell carcinoma of
> the vocal cord, a second squamous cell carcinoma is discovered in the
> tonsillar fossa. Abstract as two primaries.
>
> ***Exception 2:*** Effective with cases diagnosed January 1995 and
> later, if an in situ tumor is followed by an invasive cancer in the
> same site more than two months apart, report as two primaries even if
> stated to be a recurrence. The invasive primary should be reported
> with the date of the *invasive* diagnosis. (***Note:*** The purpose of
> this guideline is to ensure that the case is counted as an incident
> case (i.e., invasive) when incidence data are analyzed.)
>
> SEER registries must use the COC data item Type of First Recurrence to
> determine multiple primaries when the first primary is in situ
> followed by an invasive 'recurrence' (according to COC) that has to be
> reported to SEER as a new invasive primary. The principal codes that
> must be reviewed are shown below.
>
> **COC Data Item - Type of First Recurrence**
>
> If the tumor was originally diagnosed as in situ and the recurrence
> code is 16, 17, 26, 27, 36, or 46 then the 'recurrence' must be
> reported as a new case.
>
> 16 Local recurrence of an in situ tumor, NOS
>
> 17 Both local and trocar recurrence of an in situ tumor.
>
> 26 Regional recurrence of an in situ tumor, NOS.
>
> 27 Recurrence of an in situ tumor in adjacent tissue or organ(s) and
> in regional lymph nodes at the same time.
>
> 36 Both regional recurrence of an in situ tumor in adjacent tissue or
> organ(s) and/or regional lymph nodes (26 or 27) and local and/or
> trocar recurrence (16 or 17).
>
> 46 Distant recurrence of an in situ tumor.
>
> ***Exception 3:*** Report as a single primary and prepare a single
> abstract for the first invasive lesion:

-   Multiple invasive adenocarcinomas of the prostate (C619)

-   Multiple invasive bladder cancers (C670 - C679) with histology codes
    8120-8131

> ***Example 1:*** Urothelial bladder tumor removed by transurethral
> resection of the bladder (TURB). At three month check-up, a new
> urothelial tumor is removed. Abstract as one primary of the bladder.
>
> ***Example 2*:** Patient has elevated PSA and a needle biopsy that
> shows adenocarcinoma in the right lobe of the prostate. Patient and
> clinician opt for "watchful waiting." Four months later, PSA is higher
> and patient has a second biopsy, which shows adenocarcinoma in the
> left lobe. Abstract as one primary of the prostate.
>
> **Revised April 2005**

**Table of Rules to Determine Multiple Primaries for Solid Tumors**

+---+---+------+-------+------+---------+---------+---------------------+
| * |   | **   | *     | *    | **Vari  | **T     | **Single vs.        |
| * |   | Tumo | *Site | *His | ables** | iming** | multiple primary**  |
| R |   | rs** | (s)** | tolo |         |         |                     |
| u |   |      |       | gy** |         |         |                     |
| l |   |      |       |      |         |         |                     |
| e |   |      |       |      |         |         |                     |
| * |   |      |       |      |         |         |                     |
| * |   |      |       |      |         |         |                     |
+===+===+======+=======+======+=========+=========+=====================+
| * |   | Si   | NA    | NA   |         | NA      | Single              |
| * |   | ngle |       |      |         |         |                     |
| 1 |   |      |       |      |         |         |                     |
| * |   |      |       |      |         |         |                     |
| * |   |      |       |      |         |         |                     |
+---+---+------+-------+------+---------+---------+---------------------+
| * |   | Si   | NA    | D    |         | NA      | Single              |
| * |   | ngle |       | iffe |         |         |                     |
| 2 |   |      |       | rent |         |         |                     |
| * |   |      |       |      |         |         |                     |
| * |   |      |       |      |         |         |                     |
+---+---+------+-------+------+---------+---------+---------------------+
|   | * | Mult | Same  | Same | Non     | Simul   | Single              |
|   | * | iple |       |      | -paired | taneous |                     |
|   | 3 |      |       |      | or only | or      |                     |
|   | a |      |       |      | one     | sync    |                     |
|   | * |      |       |      | side of | hronous |                     |
|   | * |      |       |      | paired  |         |                     |
|   |   |      |       |      | organ   |         |                     |
+---+---+------+-------+------+---------+---------+---------------------+
|   | * | Mult | Same  | Same | Non     | Simul   | Single              |
|   | * | iple |       |      | -paired | taneous |                     |
|   | 3 |      |       |      | or only | or      |                     |
|   | b |      |       |      | one     | sync    |                     |
|   | * |      |       |      | side of | hronous |                     |
|   | * |      |       |      | paired  |         |                     |
|   |   |      |       |      | organ   |         |                     |
+---+---+------+-------+------+---------+---------+---------------------+
| * |   | Mult | Same  | Same | Both    | Simul   | > Multiple unless   |
| * |   | iple | (     |      | sides   | taneous | > physician states  |
| 4 |   |      | bilat |      | of      | or      | > one is            |
| * |   |      | eral) |      | paired  | sync    | > metastatic.       |
| * |   |      |       |      | organ   | hronous |                     |
|   |   |      |       |      | i       |         | ***Exceptions:***   |
|   |   |      |       |      | nvolved |         |                     |
|   |   |      |       |      |         |         | Bilateral tumors:   |
|   |   |      |       |      |         |         |                     |
|   |   |      |       |      |         |         | Ovary (same         |
|   |   |      |       |      |         |         | histology),         |
|   |   |      |       |      |         |         | retinoblastoma, or  |
|   |   |      |       |      |         |         | Wilms tumor are a   |
|   |   |      |       |      |         |         | single primary      |
+---+---+------+-------+------+---------+---------+---------------------+
| * |   | Mult | Same  | Same |         | Metac   | Multiple unless     |
| * |   | iple |       |      |         | hronous | physician states    |
| 5 |   |      |       |      |         |         | recurrent or        |
| * |   |      |       |      |         |         | metastatic          |
| * |   |      |       |      |         |         |                     |
|   |   |      |       |      |         |         | ***Exceptions:***   |
|   |   |      |       |      |         |         |                     |
|   |   |      |       |      |         |         | 1\. Report as a     |
|   |   |      |       |      |         |         | **singl**e primary: |
|   |   |      |       |      |         |         |                     |
|   |   |      |       |      |         |         | > a\. Invasive      |
|   |   |      |       |      |         |         | > prostate with     |
|   |   |      |       |      |         |         | > histology (8140)  |
|   |   |      |       |      |         |         | >                   |
|   |   |      |       |      |         |         | > b\. Invasive      |
|   |   |      |       |      |         |         | > bladder with      |
|   |   |      |       |      |         |         | > histologies       |
|   |   |      |       |      |         |         | > (8120-8130)       |
|   |   |      |       |      |         |         | >                   |
|   |   |      |       |      |         |         | > c\. Kaposi        |
|   |   |      |       |      |         |         | > sarcoma (9140)    |
|   |   |      |       |      |         |         |                     |
|   |   |      |       |      |         |         | 2\. For all sites:  |
|   |   |      |       |      |         |         | Report as multiple  |
|   |   |      |       |      |         |         | primaries: In situ  |
|   |   |      |       |      |         |         | followed by         |
|   |   |      |       |      |         |         | invasive **even if  |
|   |   |      |       |      |         |         | stated to be        |
|   |   |      |       |      |         |         | recurrence**.       |
+---+---+------+-------+------+---------+---------+---------------------+
| * |   | Mult | Same  | D    | Single  | Simul   | Multiple            |
| * |   | iple |       | iffe | paired  | taneous |                     |
| 6 |   |      |       | rent | or      | or      | ***Exceptions:***   |
| * |   |      |       |      | u       | sync    |                     |
| * |   |      |       |      | npaired | hronous | The following are   |
|   |   |      |       |      | organ   |         | single primaries:   |
|   |   |      |       |      |         |         |                     |
|   |   |      |       |      |         |         | 1.  One histology   |
|   |   |      |       |      |         |         |     is a more       |
|   |   |      |       |      |         |         |     specific        |
|   |   |      |       |      |         |         |     histology than  |
|   |   |      |       |      |         |         |     the other (NOS  |
|   |   |      |       |      |         |         |     and specific).  |
|   |   |      |       |      |         |         |                     |
|   |   |      |       |      |         |         | 2.  Colon:          |
|   |   |      |       |      |         |         |                     |
|   |   |      |       |      |         |         |     a.  (Adeno)     |
|   |   |      |       |      |         |         |         carcinoma   |
|   |   |      |       |      |         |         |         and (adeno) |
|   |   |      |       |      |         |         |         carcinoma   |
|   |   |      |       |      |         |         |         arising in  |
|   |   |      |       |      |         |         |         a polyp.    |
|   |   |      |       |      |         |         |                     |
|   |   |      |       |      |         |         |     b.  Familial    |
|   |   |      |       |      |         |         |         adenomatous |
|   |   |      |       |      |         |         |         polyposis   |
|   |   |      |       |      |         |         |         (FAP) with  |
|   |   |      |       |      |         |         |                     |
|   |   |      |       |      |         |         |        malignancies |
|   |   |      |       |      |         |         |         arising in  |
|   |   |      |       |      |         |         |         polyps.     |
|   |   |      |       |      |         |         |                     |
|   |   |      |       |      |         |         | ```{=html}          |
|   |   |      |       |      |         |         | <!-- -->            |
|   |   |      |       |      |         |         | ```                 |
|   |   |      |       |      |         |         | 3.  Histology       |
|   |   |      |       |      |         |         |     combinations    |
|   |   |      |       |      |         |         |     commonly found  |
|   |   |      |       |      |         |         |     together        |
|   |   |      |       |      |         |         |                     |
|   |   |      |       |      |         |         |     a.  Thyroid     |
|   |   |      |       |      |         |         |         (follicular |
|   |   |      |       |      |         |         |         and         |
|   |   |      |       |      |         |         |         papillary)  |
|   |   |      |       |      |         |         |                     |
|   |   |      |       |      |         |         |     b.  Bladder     |
|   |   |      |       |      |         |         |                     |
|   |   |      |       |      |         |         |       (transitional |
|   |   |      |       |      |         |         |         and         |
|   |   |      |       |      |         |         |         papillary)  |
|   |   |      |       |      |         |         |                     |
|   |   |      |       |      |         |         | 4.  Breast: if two  |
|   |   |      |       |      |         |         |     lesions in one  |
|   |   |      |       |      |         |         |     breast are:     |
|   |   |      |       |      |         |         |                     |
|   |   |      |       |      |         |         |     a.  Lobular and |
|   |   |      |       |      |         |         |         ductal      |
|   |   |      |       |      |         |         |                     |
|   |   |      |       |      |         |         |     b.  Paget       |
|   |   |      |       |      |         |         |         disease and |
|   |   |      |       |      |         |         |         ductal or   |
|   |   |      |       |      |         |         |         intraductal |
+---+---+------+-------+------+---------+---------+---------------------+
| * |   | Mult | Same  | D    | Both    | Simul   | Multiple            |
| * |   | iple |       | iffe | sides   | taneous |                     |
| 7 |   |      |       | rent | of      | or      | ***Exceptions:***   |
| * |   |      |       |      | paired  | sync    | Report as single:   |
| * |   |      |       |      | organ   | hronous |                     |
|   |   |      |       |      |         |         | 1\. If stated to be |
|   |   |      |       |      |         |         | metastatic          |
+---+---+------+-------+------+---------+---------+---------------------+
| * |   | Mult | Same  | D    |         | More    | Multiple            |
| * |   | iple |       | iffe |         | than 2  |                     |
| 8 |   |      |       | rent |         | months  |                     |
| * |   |      |       |      |         | after   |                     |
| * |   |      |       |      |         | or      |                     |
|   |   |      |       |      |         | iginal/ |                     |
|   |   |      |       |      |         | initial |                     |
|   |   |      |       |      |         | tumor   |                     |
+---+---+------+-------+------+---------+---------+---------------------+
| * |   | Mult | Diff  | D    |         | NA      | Multiple            |
| * |   | iple | erent | iffe |         |         |                     |
| 9 |   |      |       | rent |         |         |                     |
| * |   |      |       |      |         |         |                     |
| * |   |      |       |      |         |         |                     |
+---+---+------+-------+------+---------+---------+---------------------+
| * |   | Mult | Diff  | Same |         | NA      | Multiple unless     |
| * |   | iple | erent |      |         |         | stated to be        |
| 1 |   |      |       |      |         |         | metastatic          |
| 0 |   |      |       |      |         |         |                     |
| * |   |      |       |      |         |         | > ***Exception:***  |
| * |   |      |       |      |         |         | > Wilms tumor       |
+---+---+------+-------+------+---------+---------+---------------------+

**SEER PARTICIPANT**

## Item Length: 10

## NAACCR Item #: 40

**NAACCR Name: Registry ID**

**Revised April 2005**

A unique code assigned to each SEER participating registry. The number
identifies the registry sending the record and what population the data
are based on.

  --------------------------------------------------------------------------------
  **Code**     **Participant**   **Area Covered**      **Year SEER **Name**
                                                       Reporting   
                                                       Started**   
  ------------ ----------------- --------------------- ----------- ---------------
  0000001501   Northern          5 counties            1973        San Francisco
               California Cancer                                   Oakland SMSA
               Center                                              

  0000001502   Connecticut       Entire state          1973        Connecticut
               Department of                                       
               Public Health                                       

  0000001520   Karmanos Cancer   3 counties            1973        Metropolitan
               Institute/Wayne                                     Detroit
               State University                                    

  0000001521   Research          Entire state          1973        Hawaii
               Corporation of                                      
               Hawaii                                              

  0000001522   University of     Entire state          1973        Iowa
               Iowa                                                

  0000001523   University of New Entire state          1973        New Mexico
               Mexico                                              

  0000001525   Fred Hutchinson   13 counties           1974        Seattle-Puget
               Cancer Research                                     Sound
               Center                                              

  0000001526   University of     Entire state          1973        Utah
               Utah                                                

  0000001527   Emory University  5 counties            1975        Metropolitan
                                                                   Atlanta

  0000001529   Alaska Native     Native American       1984        Alaska Native
                                 population of Alaska              

  0000001531   Northern          4 counties            1992        San
               California Cancer                                   Jose-Monterey
               Center                                              

  0000001533   University of New Native American       1973        Arizona Indians
               Mexico            population of Arizona             

  0000001535   University of     1 county              1992        Los Angeles
               Southern                                            
               California                                          

  0000001537   Emory University  10 Counties           1978        Rural Georgia

  0000001541   Public Health     California except Los 2000        Greater
               Institute,        Angeles, San                      California
               California        Francisco-Oakland,                
                                 and San-Jose/Monterey             

  0000001542   University of     Entire state          2000        Kentucky
               Kentucky Research                                   
               Foundation                                          

  0000001543   Louisiana State   Entire state          2000        Louisiana
               University HSC                                      

  0000001544   New Jersey        Entire state          2000        New Jersey
               Department of                                       
               Health and Senior                                   
               Services                                            

  0000001551   Cherokee Nation   Native American       1997        Cherokee Nation
               -- Oklahoma       population                        
  --------------------------------------------------------------------------------

######### Terminology Conversion Table

+-------------------------------------------------+--------+----------+
| **Description**                                 | > **G  | **SEER** |
|                                                 | rade** |          |
|                                                 |        | **Code** |
+=================================================+========+==========+
| Differentiated, NOS                             | > I    | 1        |
+-------------------------------------------------+--------+----------+
| Well differentiated                             | > I    | 1        |
+-------------------------------------------------+--------+----------+
|                                                 | > []{  | [        |
|                                                 | .mark} | ]{.mark} |
+-------------------------------------------------+--------+----------+
| Fairly well differentiated                      | > II   | 2        |
+-------------------------------------------------+--------+----------+
| Intermediate differentiation                    | > II   | 2        |
+-------------------------------------------------+--------+----------+
| Low grade                                       | > I-II | 2        |
+-------------------------------------------------+--------+----------+
| Mid differentiated                              | > II   | 2        |
+-------------------------------------------------+--------+----------+
| Moderately differentiated                       | > II   | 2        |
+-------------------------------------------------+--------+----------+
| Moderately well differentiated                  | > II   | 2        |
+-------------------------------------------------+--------+----------+
| Partially differentiated                        | > II   | 2        |
+-------------------------------------------------+--------+----------+
| Partially well differentiated                   | > I-II | 2        |
+-------------------------------------------------+--------+----------+
| Relatively or generally well differentiated     | > II   | 2        |
+-------------------------------------------------+--------+----------+
|                                                 |        |          |
+-------------------------------------------------+--------+----------+
| Medium grade, intermediate grade                | >      | 3        |
|                                                 | II-III |          |
+-------------------------------------------------+--------+----------+
| Moderately poorly differentiated                | > III  | 3        |
+-------------------------------------------------+--------+----------+
| Moderately undifferentiated                     | > III  | 3        |
+-------------------------------------------------+--------+----------+
| Pleomorphic                                     | > III  | 3        |
+-------------------------------------------------+--------+----------+
| Poorly differentiated                           | > III  | 3        |
+-------------------------------------------------+--------+----------+
| Relatively poorly differentiated                | > III  | 3        |
+-------------------------------------------------+--------+----------+
| Relatively undifferentiated                     | > III  | 3        |
+-------------------------------------------------+--------+----------+
| Slightly differentiated                         | > III  | 3        |
+-------------------------------------------------+--------+----------+
| Dedifferentiated                                | > III  | 3        |
+-------------------------------------------------+--------+----------+
|                                                 |        |          |
+-------------------------------------------------+--------+----------+
| High grade                                      | >      | 4        |
|                                                 | III-IV |          |
+-------------------------------------------------+--------+----------+
| Undifferentiated, anaplastic, not               | > IV   | 4        |
| differentiated                                  |        |          |
+-------------------------------------------------+--------+----------+
| Non-high grade                                  |        | 9        |
+-------------------------------------------------+--------+----------+

###### Two-Grade System

Some cancers are graded using a two-grade system, for an example, colon
cancer. If the grade is listed as 1/2 or as low grade, assign code 2. If
the grade is listed as 2/2 or as high grade, assign code 4.

Two-Grade Conversion Table

+----------------+-----------------------------+----------------------+
| **Grade**      | **Differentiation /**       | **SEER Code**        |
|                |                             |                      |
|                | **Description**             |                      |
+================+=============================+======================+
| 1/2, I/II      | Low grade                   | 2                    |
+----------------+-----------------------------+----------------------+
| 2/2, II/II     | High grade                  | 4                    |
+----------------+-----------------------------+----------------------+

# Three-Grade System 

There are several sites for which a three-grade system is used, such as
peritoneum, endometrium, fallopian tube, prostate, bladder and soft
tissue sarcoma. The patterns of cell growth are measured on a scale of
1, 2, and 3 (also referred to as low, medium, and high grade). This
system measures the proportion of cancer cells that are growing and
making new cells and how closely they resemble the cells of the host
tissue. Thus, it is similar to a four-grade system, but simply divides
the spectrum into 3 rather than 4 categories (see Three-Grade Conversion
Table below). The expected outcome is more favorable **Revised April
2005**

for lower grades.

If a grade is written as 2/3 that means this is a grade 2 of a
three-grade system. Do not simply code the numerator. Use the following
table to convert the grade to SEER codes:

**Three-Grade Conversion Table**

+------------------+----------------------------+---------------------+
| > **Grade**      | > **Differentiation /**    | > **SEER Code**     |
|                  | >                          |                     |
|                  | > **Description**          |                     |
+==================+============================+=====================+
| > 1/3, I/III     | > Low grade                | > 2                 |
+------------------+----------------------------+---------------------+
| > 2/3, II/III    | > Intermediate grade       | > 3                 |
+------------------+----------------------------+---------------------+
| > 3/3, III/III   | > High grade               | > 4                 |
+------------------+----------------------------+---------------------+

**Breast Cancer**

**Priority Order for Coding Breast Cancer Grade**

Code grade in the following priority order:

1.  Bloom-Richardson scores 3-9 converted to grade (See following table)

2.  Bloom Richardson grade (low, intermediate, high)

3.  Nuclear grade only

4.  Terminology

    a.  Differentiation (well differentiated, moderately differentiated,
        etc).

5.  Histologic grade

    a.  Grade 1/I/i, grade 2/II/ii, grade 3/III/iii, grade 4/IV/iv

> Breast Grading Conversion Table

+-------+-------------+----------+---------------+-----------+--------+
| **BR  | > **BR      | *        | **            | **H       | **SEER |
| Sco   | > Grade**   | *Nuclear | Terminology** | istologic | Code** |
| res** |             | Grade**  |               | Grade**   |        |
+-------+-------------+----------+---------------+-----------+--------+
| 3-5   | > Low       | 1/3; 1/2 | Well          | I/III;    | > 1    |
|       |             |          | d             | 1/3       |        |
|       |             |          | ifferentiated |           |        |
+-------+-------------+----------+---------------+-----------+--------+
| 6, 7  | > I         | 2/3      | Moderately    | II/III;   | > 2    |
|       | ntermediate |          | d             | 2/3       |        |
|       |             |          | ifferentiated |           |        |
+-------+-------------+----------+---------------+-----------+--------+
| 8, 9  | > High      | 2/2; 3/3 | Poorly        | III/III;  | > 3    |
|       |             |          | d             | 3/3       |        |
|       |             |          | ifferentiated |           |        |
+-------+-------------+----------+---------------+-----------+--------+

**Bloom-Richardson (BR)**

1.  **BR** may **also** be **called**: modified Bloom-Richardson,
    Scarff-Bloom-Richardson, SBR grading, BR grading, Elston-Ellis
    modification of Bloom Richardson score, the Nottingham modification
    of Bloom Richardson score, Nottingham-Tenovus, or Nottingham grade

2.  BR may be expressed in **scores** (range 3-9)

3.  The score is based on three morphologic features of "invasive
    no-special-type" breast cancers (degree of tubule
    formation/histologic grade, mitotic activity, nuclear pleomorphism
    of tumor cells).

4.  Use the Breast Grading Conversion Table to convert the score, grade
    or term into the SEER code

5.  BR may be expressed as a **grade** (low, intermediate, high)

6.  BR grade is derived from the BR score. Note that the conversion of
    low, intermediate, and high for breast is different from the
    conversion used for all other tumors.

4\. For sites/histologies where there is no TNM schema, this field may
be coded 9, not applicable. (See Table 6 in the General Instructions.)

5\. Code 0 includes imaging studies such as standard radiography,
special radiographic projections, tomography, computerized tomography
(CT), ultrasonography, lymphography, angiography, scintigraphy (nuclear
scans), ultrasonography, magnetic resonance imaging (MRI), positron
emission tomography (PET) scans, spiral scanning (CT or MRI) and other
non-invasive methods of examining tissues.

6\. Codes 0-3 are oriented to the AJCC staging basis. In general, Code 1
includes microscopic analysis of tissue that is insufficient to meet the
requirements for pathologic staging in the TNM system. However,
pathologic staging requirements vary by site; for some site schemas,
code 1 may be classified as pathologic. For specific classification
rules, refer to the *AJCC Cancer Staging Manual, sixth edition*. For
example, a total cystectomy is required to pathologically stage a
bladder cancer. Any tissue removed during another procedure, such as a
transurethral resection of a bladder tumor, would not meet the
requirements for pathologic staging and should be coded to 1 in this
field. Code 1 also includes observations at surgery, such as an
exploratory laparotomy in which unresectable pancreatic cancer is
identified, where further tumor extension is not biopsied.

7\. Code 3 is considered pathologic staging across all sites. Use code 3
for a biopsy of tumor extension that meets the requirements for
pathologic staging basis. In other words, according to TNM rules, if the
biopsy documents the highest T category, the biopsy meets the
requirements for pathologic staging basis and the CS Tumor Size/Ext Eval
field should be coded to 3. For example, if a prostate cancer patient
has a biopsy of the rectum that shows microscopic involvement of the
rectal wall (T4), according to the *AJCC Cancer Staging Manual sixth
edition* that patient meets the requirements for pathologic staging in
the T category.

**CS LYMPH NODES**

**Item Length: 2**

## NAACCR Item #: 2830

**NAACCR Name: CS Lymph Nodes**

**Revised April 2005**

Identifies the regional lymph nodes involved with cancer at the time of
diagnosis.

  ---------- -------------------------------- ----------- ----------- -----------
  **Code**   **Description**                  **TNM       **SS77      **SS2000
                                              Mapping**   Mapping**   Mapping**

  00         None; no regional lymph node     N0          None        None
             involvement                                              

             **SITE/HISTOLOGY-SPECIFIC                                
             CODES**                                                  

  80         Lymph nodes, NOS                 NX          RN          RN

  90         Unknown; regional lymph nodes    NX          U           U
             cannot be assessed; not stated                           
             in patient record                                        
  ---------- -------------------------------- ----------- ----------- -----------

**For schemas that do not use the CS Lymph Nodes field:**

  ---------- ------------------------------------------------------------
  **Code**   **Description**

  88         Not applicable
  ---------- ------------------------------------------------------------

**INSTRUCTIONS FOR CODING**

1\. Record the specific regional lymph node chain farthest from the
primary site that is involved by tumor either clinically or
pathologically.

> a\. Regional lymph nodes are listed for each site/histology. In
> general, the regional lymph nodes in the chain(s) closest to the
> primary site have the lower codes. Nodes farther away from the primary
> or in farther lymph node chains have higher codes. Record the highest
> applicable code.
>
> ***Exception:*** The higher codes for \>Regional lymph nodes, NOS=;
> \>Lymph nodes, NOS=; \>Stated as N1, no other information=; \>Stated a
> N2a, no other information=, and so forth, should only be used when
> there is no available information as to the name(s) of the regional
> nodes involved.
>
> ***Example**:* Peribronchial lymph nodes are positive on fine needle
> aspiration biopsy. Contralateral mediastinal mass noted on CT scan but
> not biopsied. Patient chooses radiation therapy as primary treatment.
> Use the code for contralateral mediastinal lymph node involvement as
> it is higher than the code for peribronchial lymph nodes*.*

b\. Record involved regional lymph nodes from the pathology report, if
it is available, when the patient receives no radiation or systemic
treatment prior to surgery.

> c\. This field is to be recorded regardless of whether the patient
> received preoperative treatment.

5\. If a lymph node biopsy was performed, code the number of nodes
removed, if known. If the number of nodes removed by biopsy is not
known, use code 96.

6\. For the following primary sites and histologies, the Regional Nodes
Examined field is always coded as 99.

Brain and Cerebral Meninges

> Hematopoietic, Reticuloendothelial, Immunoproliferative and
> Myeloproliferative Neoplasms

Hodgkin and non-Hodgkin Lymphoma

Other and Ill-Defined Primary Sites

Other Parts of Central Nervous System

Placenta

> Unknown Primary Site

######## CS METS AT DX

**Item Length: 2**

## NAACCR Item #: 2850

**NAACCR Name: CS Mets at Dx**

**Revised April 2005**

Identifies the distant site(s) of metastatic involvement at time of
diagnosis.

+----------+-------------------------------+--------+--------+--------+
| **Code** | **Description**               | **TNM  | **SS77 | **     |
|          |                               | Map    | Map    | SS2000 |
|          |                               | ping** | ping** | Map    |
|          |                               |        |        | ping** |
+----------+-------------------------------+--------+--------+--------+
| 00       | No; none                      | M0     | None   | None   |
+----------+-------------------------------+--------+--------+--------+
| 10       | Distant lymph node(s)         | M1     | D      | D      |
+----------+-------------------------------+--------+--------+--------+
| 40       | Distant metastases except     | M1     | D      | D      |
|          | code 10                       |        |        |        |
|          |                               |        |        |        |
|          | Distant metastasis, NOS       |        |        |        |
|          |                               |        |        |        |
|          | Carcinomatosis                |        |        |        |
+----------+-------------------------------+--------+--------+--------+
|          | **SITE/HISTOLOGY-SPECIFIC     |        |        |        |
|          | CODES WHERE NEEDED**          |        |        |        |
+----------+-------------------------------+--------+--------+--------+
| 50       | \(40\) + (10)                 | M1     | D      | D      |
+----------+-------------------------------+--------+--------+--------+
| 99       | Unknown; distant metastasis   | MX     | U      | U      |
|          | cannot be assessed; not       |        |        |        |
|          | stated in patient record      |        |        |        |
+----------+-------------------------------+--------+--------+--------+

**For schemas that do not use the CS Mets at Dx field:**

  ---------- ------------------------------------------------------------
  **Code**   **Description**

  88         Not applicable
  ---------- ------------------------------------------------------------

**INSTRUCTIONS FOR CODING**

1\. This field represents distant metastases (the TNM M component or
distant stage in Summary Staging) at the time of diagnosis. In other
words, when the patient was diagnosed, tumor had already spread
indirectly (through vascular or lymph channels) to a site remote from
the primary tumor.

> **Note:** The structure of the CS Mets at Dx field is based on the M
> category of TNM. In some schemas, there may be additional items in CS
> Extension or CS Lymph Nodes that map to distant stage in Summary
> Staging (77 and/or 2000) and there may be some items in CS Mets at Dx
> that map to regional stage in Summary Staging. Regardless of where
> such items are recorded, the staging algorithms will properly account
> for the information.

2\. Assign the highest applicable code for metastasis at diagnosis,
whether the determination was clinical or pathological and whether or
not the patient had any preoperative systemic therapy.

2\. Some patients do not have a remission. A change in the treatment
plan indicates a failure to induce remission. If the patient does not
have a remission:

a.  Record the treatment given in an attempt to induce a remission.

b.  Do not record treatment administered after the change in treatment
    plan.

**Other Hematopoietic**

> Record all treatments as described above. The following treatments are
> coded as "other" in Other Treatment even though they do not \"modify,
> control, remove, or destroy proliferating cancer tissue.\" Follow the
> guidelines in the *Abstracting and Coding Guide for the Hematopoietic
> Diseases* to identify treatments. Some examples of "other" treatment
> include:
>
> ***Example 1:* Phlebotomy** may be called blood removal, blood
> letting, or venisection.
>
> ***Example 2:* Transfusions** may include whole blood, RBCs,
> platelets, plateletpheresis, fresh frozen plasma (FFP),
> plasmapheresis, and cryoprecipitate.
>
> ***Example 3:* Aspirin** (also known as ASA, acetylsalicylic acid, or
> by a brand name) is used as a treatment for essential thrombocythemia.

a.  Only record aspirin therapy if it is given to thin the blood for
    symptomatic control of thrombocythemia. Use the following guidelines
    to determine whether aspirin is administered for thinning of blood
    for thrombocythemia rather than for pain control or cardiovascular
    protection:

    i.  Aspirin treatment for essential thrombocythemia is low dose,
        approximately 70-100 mg/day

    ii. The dosage for pain control is approximately 325-1000 mg every
        3-4 hours.

    iii. Cardiovascular protection starts at about 160 mg/day.

**Date Therapy Initiated**

**Item Length: 8**

**NAACCR Item #: 1260**

**NAACCR Name: Date of initial RX\--SEER**

**Revised April 2005**

Record the start date of the first course of therapy. This may be the
start date of any type of treatment for this tumor; surgery,
chemotherapy, radiation therapy, or other types of therapy. Treatment
might be given in a hospital or non-hospital setting. Date fields are
recorded in the month, day, century, year format (MMDDCCYY) with 99 for
unknown day or month and 9999 for unknown year.

Most SEER registries collect the month, day, and year of therapy. The
third and fourth digits (day) are recoded to 99 when the data are
transmitted to SEER.

**Codes for Month**

01 January

02 February

03 March

04 April

05 May

06 June

07 July

08 August

09 September

10 October

11 November

12 December

99 Unknown month

## Codes for Day

01

02

03

..

..

31

99 Unknown day

**Codes for Year**

Code the four-digit year of therapy initiation

Record 9999 for unknown year

**Revised April 2005**

**Special Codes**

00000000 No date, no first course treatment performed

99999999 Unknown date

**Definitions**

> **Cancer-directed therapy**: Treatment administered to the patient in
> an attempt to destroy or modify cancer tissue.
>
> ***Note:*** Surgical procedures coded in the data items Scope of
> Regional Lymph Node Surgery and Surgical Procedure of Other Site are
> not necessarily cancer-directed therapy.

**Coding Instructions**

1.  Code **00000000** if no therapy was given.

    a.  If there was no first course therapy. For example, the patient
        had ONLY biopsy, bypass, or "watchful waiting"

    b.  Autopsy only cases

2.  Code the **start date** of the first therapy. The first therapy may
    be coded in the following data items:

-   Surgery of Primary Site

-   Scope of Regional Lymph Node Surgery

-   Surgical Procedure of Other Site

-   Radiation Therapy

-   Chemotherapy

-   Hormone Therapy

-   Immunotherapy,

-   Hematologic Transplant and Endocrine Procedures

-   Other Therapy

3.  Code the date of **excisional biopsy** as the date therapy initiated
    if it is the first treatment. Code the date of a biopsy documented
    as incisional if further surgery reveals no residual or only
    microscopic residual.

> ***Example:*** Breast core needle biopsy with diagnosis of
> infiltrating duct carcinoma; subsequent re-excision with no residual
> tumor noted. Code the date of the needle biopsy as the excisional
> biopsy date.

4.  Code the date unproven therapy was initiated as the date therapy
    initiated.

5.  If the exact **date** of the first treatment is **unknown**, code
    the date of admission to the hospital for inpatient or outpatient
    treatment.

6.  Code **99999999**

    a.  It is known the patient had first course therapy, but it is
        impossible to estimate the date

    b.  Death certificate only cases

> **Surgery of Primary Site**

**Item Length: 2**

**NAACCR Item #: 1290**

**NAACCR Name: RX Summ\--Surg Prim Site**

Surgery of Primary Site describes a surgical procedure that removes
and/or destroys tissue of the primary site performed as part of the
initial work-up or first course of therapy. Site-specific surgery codes
are included under Appendix C of this manual.

**General Coding Structure** (See Appendix C for site-specific codes)

00 None; no surgical procedure of primary site; diagnosed at autopsy
only

10-19 Site-specific codes. Tumor destruction; no pathologic specimen or
unknown whether there is a pathologic specimen

20-80 Site-specific codes. Resection; pathologic specimen

90 Surgery, NOS. A surgical procedure to the primary site was done, but
no information on the type of surgical procedure is provided.

98 Special codes for hematopoietic, reticuloendothelial,
immunoproliferative, myeloproliferative diseases; ill-defined sites; and
unknown primaries (See site-specific codes for the sites and
histologies), except death certificate only

99 Unknown if surgery performed; death certificate only

**Coding Instructions**

1.  Code 00 if **no surgery** is performed on the primary site or if
    case was diagnosed at **autopsy, and would not be otherwise coded to
    98.**

2.  Use the site-specific coding scheme corresponding to the coded
    primary site.

3.  Code the most **invasive, extensive, or definitive** surgery if the
    patient has multiple surgical procedures of the primary site even if
    there is no tumor found in the pathologic specimen. The codes in the
    range of 00-80 are **listed** in hierarchical but not necessarily
    numerical order. When more than one surgical procedure is performed,
    code the procedure listed furthest down the list within the codes
    10-80.

> ***Example:*** Patient has a needle biopsy of prostate that is
> positive for adenocarcinoma. The patient chooses to have a radical
> prostatectomy. The pathologic examination of the prostatectomy
> specimen shows no residual tumor. Code the radical prostatectomy.

4.  Code an **excisional biopsy,** even when documented as
    **incisional**, when:

    a.  All disease is removed (**margins free**) OR

    b.  All gross disease is removed and there is only **microscopic
        residual at the margin**

> ***Note***: Do not code an excisional biopsy when there is macroscopic
> residual disease.

5.  Code **total removal of the primary site** when a previous procedure
    resected a portion of the site and the current surgery removed the
    rest of the organ. The previous procedure may have been cancer
    directed or non-cancer directed surgery.

> **Revised April 2005**

6.  Code the removal of regional or distant **tissue/organs** when they
    are resected in continuity with the primary site (**en bloc)**.
    Specimens from an en bloc resection may be submitted to pathology
    separately.

> ***Example:*** Code an en bloc removal when the patient has a
> hysterectomy and an omentectomy.

7.  Code surgery for extra-lymphatic lymphoma using the site-specific
    surgery coding scheme (not lymph node scheme) for the primary site.

8.  Code **80** or **90** only when there is no specific information.

9.  Code **98** for the following sites unless the case is death
    certificate only:

    a.  Lymphoma with primary site in lymph nodes (C770-C779) AND
        histology

        i.  9590-9596 OR

        ii. 9650-9719 OR

        iii. 9727-9729

    b.  Hematopoietic, reticuloendothelial, immunoproliferative, or
        myeloproliferative disease

        i.  Primary sites: C420, C421, C423, or C424 AND

        ii. Histologies: 9750, 9760-9764, 9820-9822, 9826, 9831-9920,
            9931-9964, 9980-9989

        iii. Unknown or ill-defined sites (C760-C768, C809)

10. Assign **code 99** for death certificate only (DCO) cases

> b\. If the treatment plan offered multiple treatment options and the
> patient selected treatment that did not include chemotherapy
>
> c\. Patient elects to pursue no treatment following the discussion of
> chemotherapy Discussion does not equal a recommendation.
>
> d\. Only information available is that the patient was referred to a
> clinical oncologist. Referral does not equal a recommendation.
>
> e\. Watchful waiting (CLL)
>
> f\. Patient diagnosed at autopsy
>
> ***Example:*** Patient is diagnosed with multiple myeloma. There is no
> mention of treatment or treatment plans in the medical record.
> Follow-back finds that the patient died three months after diagnosis.
> There are no additional medical records or other pertinent information
> available. Assign code 00 since there is no reason to suspect that the
> patient had been treated.
>
> 5\. Do not code combination of ancillary drugs administered with
> single agent chemotherapeutic agents as multiple chemotherapy. For
> example the administration of 5-FU (antimetabolite) and Leucovorin
> (ancillary drug) is coded to single agent (Code 02).
>
> 6\. Assign **code 82** when the physician would have recommended
> chemotherapy but did not due to patient risk factors, such as:

a.  Advanced **age**

b.  **Comorbid** condition(s) (heart disease, kidney failure, other
    cancer, etc.).

7\. Assign **code 99**

a\. When there is no documentation that chemotherapy was recommended or
performed

b\. Death certificate only.

**Hormone Therapy**

**Item Length: 2**

**NAACCR Item #: 1400**

**NAACCR Name: RX Summ\--Hormone**

**Revised April 2005**

The data item Hormone Therapy records therapy administered as first
course treatment that affects cancer tissue by changing the patient's
hormone balance. See *SEER Self Instructional Manuals for Tumor
Registrars Book 8* for hormone therapy drug codes.

Hormones may be divided into three categories:

1.  Hormones.

2.  Antihormones.

3.  Adrenocorticotrophic agents

**Codes**

00 None, hormone therapy was not part of the planned first course of
therapy; not usually administered for this type and/or stage of cancer;
diagnosed at autopsy only.

01 Hormone therapy administered as first course therapy.

82 Hormone therapy was not recommended/administered because it was
contra indicated due to patient risk factors (comorbid conditions,
advanced age, etc.).

85 Hormone therapy was not administered because the patient died prior
to planned or recommended therapy.

86 Hormone therapy was not administered. It was recommended by the
patient's physician, but was not administered as part of the first
course of therapy. No reason was stated in the patient record.

87 Hormone therapy was not administered. It was recommended by the
patient's physician, but this treatment was refused by the patient, a
patient's family member, or the patient's guardian. The refusal was
noted in the patient record.

88 Hormone therapy was recommended, but it is unknown if it was
administered.

99 It is unknown whether a hormonal agent(s) was recommended or
administered. Death certificate only.

**Coding Instructions**

1.  Assign **code 00** when

    a.  There is no information in the patient's medical record about
        hormone therapy AND

        i.  It is known that hormone therapy is not usually performed
            for this type and/or stage of cancer OR

        ii. There is no reason to suspect that the patient would have
            had hormone therapy.

    b.  If the treatment plan offered multiple treatment options and the
        patient selected treatment that did not include hormone therapy