**THE SEER PROGRAM**

**CODING AND STAGING MANUAL 2004**

**Fourth Edition**

CANCER STATISTICS BRANCH

SURVEILLANCE RESEARCH PROGRAM

DIVISION OF CANCER CONTROL AND POPULATION SCIENCES

NATIONAL CANCER INSTITUTE

NATIONAL INSTITUTES OF HEALTH

PUBLIC HEALTH SERVICE

US DEPARTMENT OF HEALTH AND HUMAN SERVICES

***Effective Date: Cases diagnosed January 1, 2004***

**NIH Publication Number 04-5581**

**U.S. Department of Health and Human Services**

**National Institutes of Health**

**National Cancer Institute**

**The SEER Coding and Staging Manual 2004**

**Fourth Edition**

Editor

Carol Hahn Johnson, BS, CTR

Acknowledgements

Margaret "Peggy" Adamo, RHIT, CTR, SEER, NCI

Patricia Andrews, MPH, CTR, Louisiana Tumor Registry

Jack Cunningham, CTR, Georgia Center for Cancer Statistics

Lois Dickie, CTR, New Mexico Tumor Registry

Lynda L. Douglas, CTR, Northern California Cancer Center

Cynthia Dryer, BA, CTR, State Health Registry of Iowa

April Fritz, BA, RHIT, CTR, SEER NCI

Lea G. Guidry, RHIA, CTR, Acadiana Tumor Registry

Karen Ledford, RHIA, CTR, Centers for Disease Control

Nancy Lozon, BS, CTR, Metropolitan Detroit Cancer Surveillance System

Jeannine Maxwell, BS, CTR, Alaska Native Tumor Registry

SuAnn McFadden, CTR, Utah Cancer Registry

Donna Morrell, CTR, Los Angeles Cancer Surveillance Program

Patrick Nicolin, BA, CTR, Metropolitan Detroit Cancer Surveillance
System

Steven Peace, BS, CTR, SEER, NCI

Jean Pirkey, CTR, Connecticut Tumor Registry

Linda D. Rego, BA, CTR, Hawai'i Tumor Registry

Lynn Ries, MS, SEER, NCI

Frances Ross, BA, CTR, Kentucky Cancer Registry

Mary Streeter, RHIT, CTR, Georgia Center for Cancer Statistics

Nancy Sullivan, RHIA, Seattle-Puget Sound

Cheryl Tatum, BA, CTR, California Cancer Registry

**Table of Contents**

**Preface to the Fourth Edition** vi

**Introduction SEER Program** 1

SEER Coding and Staging Manual Contents 1

Reportability 1

Dates of Diagnoses/Residency 1

Reportable Diagnoses 1

In Situ and Malignant/Invasive Histologies 1

Benign/Non-Malignant Histologies 2

Cases Diagnosed Clinically Are Reportable 3

Ambiguous Terminology 3

How to Use Ambiguous Terminology for Case Ascertainment 4

Changing Information on the Abstract 5

Determining Multiple Primaries: Solid Malignant Tumors 7

Terms 7

Definitions 7

Same vs. Different Primary Site 8

Same vs. Different Histology 10

Multiple Primary Rules for Solid Tumors 10

Definitions 10

Rules for Single Tumor 10

Rules for Multiple Tumors 10

COC Data Item - Type of First Recurrence 12

Determining Multiple Primaries: Hematopoietic Primaries 18

Determining Multiple Primaries: Benign and Borderline Brain Tumors 18

**Section I -- Basic Record Identification** 21

SEER Participant 23

Patient ID Number 25

Record Type 26

Record Number 27

**Section II -- Information Source** 29

Type of Reporting Source 31

**Section III -- Demographic Information** 33

Place of Residence at Diagnosis 35

Coding Priorities/Sources 35

Persons with More than One Residence 35

Persons with No Usual Residence 35

Temporary Residents of SEER Area 36

Persons in the Armed Forces and on Maritime Ships 36

County 37

Census Tract 2000 38

Census Tract Certainty 2000 39

Place of Birth 41

Date of Birth 42

Age at Diagnosis 44

Race 1 45

Race 2, 3, 4, 5 51

Spanish Surname or Origin 57

Computed Ethnicity 58

Computed Ethnicity Source 59

NHIA Derived Hispanic Origin 60

Sex 61

Marital Status at Diagnosis 62

**Section IV -- Description of This Neoplasm** 63

Date of Diagnosis 65

Sequence Number-Central 69

Primary Site 73

Laterality 78

Diagnostic Confirmation 81

Morphology 83

Histologic Type ICD-O-3 83

Behavior Code 89

Grade, Differentiation or Cell Indicator 91

ICD-O-2 Conversion Flag 98

ICD-O-3 Conversion Flag 99

**Section V -- Collaborative Staging and Coding Instructions** 101

Introduction 103

Changes in Abstracting Rules 104

How the Collaborative Staging System Works 106

Mapping and the Computer Algorithm 106

How Mapping Was Determined 109

General Instructions for Using the Collaborative Staging System Codes
and Coding Instructions 111

General Guidelines 111

Structure and Format of Site/Histology-Specific Code Schemas 114

Coding "None" Vs. "Unknown" in the Collaborative Staging System, TNM and
Summary Stage 114

Choosing the Correct Coding Schema for a Case 115

Schemas Where Tumor Size is Necessary for AJCC Staging 115

Schemas That Do Not Use Tumor Size for AJCC Staging 118

Death Certificate Only Cases 120

Definitions of Adjacent Tissues, Structures, and Organs 122

Ambiguous Terminology 122

Interpreting Ambiguous Terminology for Collaborative Staging 122

How to Code the Collaborative Staging System Data Elements 124

CS Tumor Size 126

CS Extension 130

CS Tumor Size\\Ext Eval 133

CS Lymph Nodes 136

CS Reg Nodes Eval 143

Regional Nodes Positive 146

Regional Nodes Examined 148

CS Mets at DX 150

CS Mets at Eval 152

CS Site-Specific Factor 1 154

CS Site-Specific Factor 2 156

CS Site-Specific Factor 3 158

CS Site-Specific Factor 4 160

CS Site-Specific Factor 5 162

CS Site-Specific Factor 6 164

SEER Summary Stage 1977 166

SEER Summary Stage 2000 167

**Section VI -- First Course of Therapy** 169

Date Therapy Initiated 174

Surgery of Primary Site 177

Scope of Regional Lymph Node Surgery 179

Surgical Procedure of Other Site 181

Reason for No Surgery of Primary Site 182

Radiation 184

Radiation Sequence with Surgery 188

Chemotherapy 189

Hormone Therapy 192

Immunotherapy 194

Hematologic Transplant Endocrine Procedures 197

Other Therapy 200

**Section VII -- Follow up Information** 203

Date of Last Follow up or of Death 205

Vital Status 206

ICD Code Revision Used for Cause of Death 207

Underlying Cause Death 208

Type of Follow up 210

**Section VIII -- Administrative Codes** 211

Site/Type Interfield Review 212

Histology/Behavior Type Interfield Review 213

Age/Site/Histology Interfield Review 214

Sequence Number/Diagnostic Interfield Review 215

Site/Histology/Laterality/Sequence Interrecord Review 216

Surgery/Diagnostic Confirmation Interfield Review 217

Type of Reporting Source/Sequence Number Interfield Review 218

Sequence Number Ill-Defined Site Interfield Review 219

Leukemia or Lymphoma Diagnostic Confirmation Interfield Review 220

Over-Ride Flag for Site/Behavior (IF39) 221

Over-Ride Flag for Site/EOD/Diagnosis Date (IF40) 222

Over-Ride Flag for Site/Laterality/EOD (IF41) 223

Over-Ride Flag for Site/Laterality/Morphology (IF42) 224

**Appendix A -- County Codes** A-1

**Appendix B -- SEER GEOCODES** B-1

**Appendix C -- Site-Specific Coding Modules** C-1

**Appendix D -- Race and Nationality Descriptions from the 2000 Census**

**and Bureau of Vital Statistics** D-1

**PREFACE TO THE SEER PROGRAM CODING AND STAGING MANUAL 2004**

The *Surveillance, Epidemiology and End Results (SEER) Program Coding
and Staging Manual 2004* is effective for cases diagnosed January 1,
2004 and forward. Previous editions of this manual are available on the
SEER website, CD, or may be ordered through the SEER website. *.* This
is a major rewrite of the manual.. The *SEER Program Coding and Staging
Manual 2004* includes all errata and revisions that apply to cases
diagnosed January 1, 2004 and forward. The 2004 changes and additions
include: Replacing EOD with Collaborative Stage, changes in instructions
and definitions for the race coding field, and the addition of
instructions for collecting and abstracting the benign and borderline
primary intracranial and central nervous system tumors (CNS). All of the
changes incorporated into the manual were approved by the Uniform Data
Standards Committee of the North American Association of Central Cancer
Registries.

This manual includes data item descriptions, codes, and coding
instructions for all data items required by SEER for cases diagnosed
January 1, 2004 and forward.

Data items that are not required for 2004 diagnoses but were collected
in years prior to 2004 still must be transmitted to SEER. These data
items should be blank for 2004 and forward diagnoses. Descriptions of
historic data items, allowable codes, and coding rules can be found in
historic manuals, but are not included in this manual.

SEER regions may submit technical questions to SEER using the web-based
SINQ system at <http://seer.cancer.gov/seerinquiry/>. The general
questions and answers from the SINQ system will be incorporated into the
next edition of the SEER manual.

This manual may be downloaded in electronic format from the SEER website
<http://seer.cancer.gov/>.

We gratefully acknowledge the representatives from each of the SEER
registries who participated in an electronic review of this manual. The
participants are listed on the acknowledgement page and we appreciate
the time they spent reviewing the manual.

Send suggestions or revisions to:

> Carol Hahn Johnson, BS, CTR
>
> Manager, Quality Improvement
>
> Surveillance, Epidemiology and End Results Program
>
> Cancer Statistics Branch, Surveillance Research Program,
>
> Division of Cancer Control and Population Sciences
>
> National Cancer Institute
>
> 6116 Executive Blvd
>
> Suite 504
>
> Bethesda, MD 20892-8316
>
> Fax: (301) 496-9949
>
> Email: <johnsoca@mail.nih.gov>
>
> SEER website: [http://seer.cancer.gov](http://seer.cancer.gov/)

**INTRODUCTION**

**SEER PROGRAM**

Two programs, the End Results Group and the Third National Cancer
Survey, were predecessors of the Surveillance, Epidemiology, and End
Results (SEER) Program. SEER publishes the *SEER Program Coding and
Staging Manual 2004* to provide instructions and descriptions that are
detailed enough to promote consistent abstracting and coding.

**SEER CODING AND STAGING MANUAL CONTENTS**

The *SEER Program Coding and Staging Manual 2004* explains the format
and the definitions of the data items required by SEER. For all cases
diagnosed on or after January 1, 2004, the instructions and codes in
this manual take precedence over all previous instructions and codes.

Documentation and codes for historical data items can be found in
earlier versions of the SEER Program Code Manual. Earlier versions are
available on CD and on the SEER website.

This coding manual does not prevent SEER contract registries or other
registries that follow SEER rules from collecting additional data items
useful for those regions.

##### REPORTABILITY

**DATES OF DIAGNOSIS/RESIDENCY**

SEER registries are required to collect data on persons who are
diagnosed with cancer who, at the time of diagnosis, are **residents**
of the geographic area covered by the SEER registry. Cases diagnosed on
or after January 1, **1973** are reportable to SEER. Registries that
joined the SEER Program after 1973 have different reporting start dates
specified in their contracts.

**REPORTABLE DIAGNOSES**

1.  **In Situ and Malignant/Invasive Histologies**

    a.  All histologies with a **behavior** **code** of **/2 or /3** in
        the *International Classification of Diseases for Oncology,*
        Third Edition (ICD-O-3).

    b.  ***Exceptions:*** Malignant and invasive histologies **not**
        **required** by SEER

        i.  **Skin** primary (C440-C449) with any of the following
            histologies:

> Malignant neoplasm (8000-8005)
>
> Epithelial carcinoma (8010-8046)
>
> Papillary and squamous cell carcinoma (8050-8084)
>
> Basal cell carcinoma (8090-8110)
>
> ***Note:*** If the registry collects basal or squamous cell carcinoma
> of **skin** sites C440-C449**,** sequence them in the 60 range and do
> not report them to SEER.

ii. Carcinoma **in situ** of **cervix** (/2) or cervical intraepithelial
    neoplasia (CIN III) of the cervix (C530-C539) (Collection
    **stopped** effective with cases diagnosed 1/1/1996 and later except
    as required in individual contracts.)

iii. Prostatic intraepithelial neoplasia (**PIN** III) of the prostate
     (C619) (Collection **stopped** effective with cases diagnosed
     1/1/2001 and later)

> 2\. **Benign/Non-Malignant Histologies**

a.  **Pilocytic/Juvenile astrocytomas** are reportable; code the
    histology and behavior code 9421/3.

b.  **Benign** and **borderline** primary **intracranial** and **CNS**
    tumors with a behavior code of /0 or /1 in ICD-O-3 are collected for
    the following sites (Effective with cases diagnosed 1/1/2004 and
    later). See the table below for required sites.

**Required Sites for Benign and Borderline Primary Intracranial and
Central Nervous System Tumors**

+---------------------------------+-------------------------+----------+
| **General Term**                | **Specific Sites**      | **I      |
|                                 |                         | CD-O-3** |
|                                 |                         |          |
|                                 |                         | **Topo   |
|                                 |                         | graphy** |
|                                 |                         |          |
|                                 |                         | **Code** |
+=================================+=========================+==========+
| **Meninges**                    | Cerebral meninges       | C700     |
+---------------------------------+-------------------------+----------+
|                                 | Spinal meninges         | C701     |
+---------------------------------+-------------------------+----------+
|                                 | Meninges, NOS           | C709     |
+---------------------------------+-------------------------+----------+
| **Brain**                       | Cerebrum                | C710     |
+---------------------------------+-------------------------+----------+
|                                 | Frontal lobe            | C711     |
+---------------------------------+-------------------------+----------+
|                                 | Temporal lobe           | C712     |
+---------------------------------+-------------------------+----------+
|                                 | Parietal lobe           | C713     |
+---------------------------------+-------------------------+----------+
|                                 | Occipital lobe          | C714     |
+---------------------------------+-------------------------+----------+
|                                 | Ventricle, NOS          | C715     |
+---------------------------------+-------------------------+----------+
|                                 | Cerebellum, NOS         | C716     |
+---------------------------------+-------------------------+----------+
|                                 | Brain stem              | C717     |
+---------------------------------+-------------------------+----------+
|                                 | Overlapping lesion of   | C718     |
|                                 | brain                   |          |
+---------------------------------+-------------------------+----------+
|                                 | Brain, NOS              | C719     |
+---------------------------------+-------------------------+----------+
| **Spinal cord, cranial nerves,  | Spinal cord             | C720     |
| and other parts of the central  |                         |          |
| nervous system**                |                         |          |
+---------------------------------+-------------------------+----------+
|                                 | Cauda equine            | C721     |
+---------------------------------+-------------------------+----------+
|                                 | Olfactory nerve         | C722     |
+---------------------------------+-------------------------+----------+
|                                 | Optic nerve             | C723     |
+---------------------------------+-------------------------+----------+
|                                 | Acoustic nerve          | C724     |
+---------------------------------+-------------------------+----------+
|                                 | Cranial nerve, NOS      | C725     |
+---------------------------------+-------------------------+----------+
|                                 | Overlapping lesion of   | C728     |
|                                 | brain and central       |          |
|                                 | nervous system          |          |
+---------------------------------+-------------------------+----------+
|                                 | Nervous system, NOS     | C729     |
+---------------------------------+-------------------------+----------+
| **Pituitary, craniopharyngeal   | Pituitary gland         | C751     |
| duct and pineal gland**         |                         |          |
+---------------------------------+-------------------------+----------+
|                                 | Craniopharyngeal duct   | C752     |
+---------------------------------+-------------------------+----------+
|                                 | Pineal gland            | C753     |
+---------------------------------+-------------------------+----------+

***Note:*** Benign and borderline tumors of the cranial bones (C410) are
**not** **reportable.**

**CASES DIAGNOSED CLINICALLY ARE REPORTABLE**

In the absence of a histologic or cytologic confirmation of a reportable
cancer, accession a case based on the **clinical diagnosis** (when a
recognized medical practitioner says the patient has a cancer or
carcinoma). A clinical diagnosis may be recorded in the final diagnosis
on the face sheet or other parts of the medical record.

***Note:*** A pathology report normally takes precedence over a clinical
diagnosis. If the patient has a negative biopsy, the case would not be
reported.

***Exception 1:*** If the physician treats a patient for cancer in spite
of the negative biopsy, accession the case.

***Exception 2:*** If enough time has passed that it is reasonable to
assume that the physician has seen the negative pathology, but the
clinician continues to call this a reportable disease, accession the
case. A reasonable amount of time would be equal to or greater than 6
months.

**AMBIGUOUS TERMINOLOGY**

Ambiguous terminology may originate from any source document, such as
pathology report, radiology report, or from a clinical report. The terms
listed below are grouped by reportable and not reportable.

> **Ambiguous terms that are reportable** (used to determine
> reportability)
>
> Apparent(ly)
>
> Appears (effective with cases diagnosed 1/1/1998 and later)
>
> Comparable with (effective with cases diagnosed 1/1/1998 and later)
>
> Compatible with (effective with cases diagnosed 1/1/1998 and later)
>
> Consistent with
>
> Favor(s)
>
> Malignant appearing (effective with cases diagnosed 1/1/1998 and
> later)
>
> Most likely
>
> Presumed
>
> Probable
>
> Suspect(ed)
>
> Suspicious (for)
>
> Typical (of)
>
> **Ambiguous terms that are NOT reportable** (Do **not** **accession**
> cases with a diagnosis based on **only these terms)**
>
> Cannot be ruled out
>
> Equivocal
>
> Possible
>
> Potentially malignant
>
> Questionable
>
> Rule(d) out
>
> Suggests
>
> Worrisome

**How To Use Ambiguous Terminology For Case Ascertainment**

1.  **In Situ and Invasive** (Behavior codes /2 and /3)

    a.  If any of the reportable **ambiguous terms** **precede** a word
        that is **synonymous** with an in situ or invasive tumor (e.g.:
        cancer, carcinoma, malignant neoplasm, etc.), the case is
        reportable. Accession the case.

> ***Example:*** The pathology report says: Prostate biopsy with
> markedly abnormal cells that are typical of adenocarcinoma." Accession
> the case.
>
> ***Negative Example:*** The final diagnosis on the outpatient report
> reads: Rule out leukemia. Do not accession the case.

b.  **Discrepancies**: If one section of the medical record(s) uses a
    reportable term such as "apparently" and another section of the
    medical record(s) uses a non-reportable term such as "cannot be
    ruled out", accept the reportable term and accession the case.

> ***Exception**:* Do not accession a case based only on suspicious
> cytology. The case is accessioned if proven by positive cytology or
> other diagnostic methods including a physician's clinical diagnosis.
> See the data item Diagnostic Confirmation for methods of diagnosis.
>
> ***Note:*** If the **word or an equivalent term does not appear** on
> either the reportable or not reportable list or is not a form of a
> word on the reportable list, the term is not diagnostic of cancer. Do
> not accession the case. Forms of the word are such as: "Favored"
> rather than Favor(s); "appeared to be" rather than appears. Do not
> substitute synonyms such as "supposed" for presumed or "equal" for
> comparable.

c.  Use these terms when **screening** diagnoses on pathology reports,
    operative reports, scans, mammograms, and other diagnostic testing
    other than tumor markers.

> ***Note**:* If the ambiguous diagnosis is **proven to be not
> reportable** by biopsy, cytology, or physician's statement, **do not
> accession** the case.
>
> ***Example**:* Mammogram shows calcifications suspicious for
> intraductal carcinoma. The biopsy of the area surrounding the
> calcifications is negative for malignancy. Do not accession the case.

2.  **Benign** and **borderline** primary **intracranial** and **CNS**
    tumors

    a.  Use the "Ambiguous Terms that are Reportable" list to identify
        benign and borderline primary intracranial and CNS tumors that
        are reportable.

    b.  If any of the reportable **ambiguous** **terms** **precede**
        either the word "**tumor"** or the word "**neoplasm**," the case
        is reportable. Accession the case.

> ***Example:*** The mass on the CT scan is consistent with pituitary
> tumor. Accession the case.

c.  **Discrepancies**: If one section of the medical record(s) uses a
    reportable term such as "apparently" and another section of the
    medical record(s) uses a non-reportable term such as "cannot be
    ruled out", accept the reportable term and accession the case.

> ***Exception**:* Do not accession a case based only on suspicious
> cytology. The case is accessioned if proven by positive cytology or
> other diagnostic methods including a physician's clinical diagnosis.
> See the data item Diagnostic Confirmation for methods of diagnosis.
>
> ***Note:*** If the **word or an equivalent term does not appear** on
> either the reportable or not reportable list or is not a form of a
> word on the reportable list, the term is not diagnostic of cancer. Do
> not accession the case. Forms of the word are such as: "Favored"
> rather than Favor(s); "appeared to be" rather than appears. Do not
> substitute synonyms such as "supposed" for presumed or "equal" for
> comparable.

d.  Use these terms when **screening** diagnoses on pathology reports,
    scans, ultrasounds, and other diagnostic testing other than tumor
    markers.

> ***Note**:* If the **ambiguous** diagnosis is proven to be **not
> reportable** by biopsy, cytology, or physician's statement, **do not
> accession** the case.

**CHANGING INFORMATION ON THE ABSTRACT**

There are circumstances under which the information originally collected
on the abstract should be changed or modified.

1.  To **correct** coding or abstracting **errors** whenever identified
    (for example, during quality control activities).

2.  **When clarifications** or **rule changes** retroactively affect
    data item codes

> ***Example:*** SEER adds codes to a data item and asks the registries
> to review a set of cases and update using the new codes.

3.  **When better** **information** is available later

> ***Example 1:*** Consults from specialty labs, pathology report
> addendums or comments or other information have been added to the
> chart. Reports done during the diagnostic workup and placed on the
> chart after the registrar abstracted the information may contain
> valuable information. Whenever these late reports give more specific
> information about the histology, grade of tumor, primary site, etc.,
> change the affected codes to reflect the better information.
>
> ***Example 2*:** The primary site was recorded as unknown at the time
> of diagnosis. At a later date, the physician determines that the
> cancer is primary to the testis. Change the primary site from unknown
> to testis.

4.  When in retrospect, the **date of diagnosis** is confirmed to be
    earlier than the original date abstracted.

> ***Example***: Patient has surgery for a benign argentaffin carcinoid
> (8240/1) of the sigmoid colon in May 2002. In January 2003 the patient
> is admitted with widespread metastasis consistent with malignant
> argentaffin carcinoid. The registrar accessions the malignant
> argentaffin carcinoid as a 2003 diagnosis. Two months later, the
> pathologist reviews the slides from the May 2002 surgery. The review
> concludes that the carcinoid diagnosed in 2002 was malignant. Change
> the date of diagnosis to May 2002 and histology to 8241 and the
> behavior code to malignant (/3).

**DETERMINING MULTIPLE PRIMARIES: SOLID MALIGNANT TUMORS**

(See separate sections for hematopoietic primaries and benign and
borderline primary intracranial and central nervous system tumors (CNS)

**Terms**

The words "**tumor**," "**neoplasm**," "**mass**," and "**lesion**" are
used interchangeably throughout this manual.

The terms "**original**" and "**initial**" are synonymous**.**

**Definitions**:

> **Focal:** Limited to one specific area
>
> **Foci/focus:** The starting point of a disease process, a single
> cell.
>
> **Laterality** describes the right or left side of the body or the
> right or left of a paired organ such as the right kidney or the left
> kidney. Unilateral describes a single organ/side. Bilateral describes
> both organs/sides.
>
> **Metachronous** tumors are multiple tumors or lesions that occur
> greater than two months from the original/initial diagnosis.
>
> **Multicentric:** A primary tumor with satellites in surrounding
> tissue.
>
> **Multifocal:** Multiple tumors arising from two or more locations.
>
> **Multiple primaries** describes two or more independent primary
> reportable neoplasms.
>
> **Non-synchronous** (**Metachronous**) tumors are multiple masses or
> lesions that occur greater than two months from the original/initial
> diagnosis.
>
> **Paired Organ:** Two separate organs, a right and a left. For example
> right breast and left breast.
>
> **Primary site** is the anatomical portion of the body where the
> cancer originated.
>
> **Simultaneous** tumors are multiple tumors identified at the time of
> diagnosis.
>
> **Synchronous** tumors are multiple tumors diagnosed within two months
> of the original/initial diagnosis.
>
> **Single primary** describes one distinctive reportable cancer.
>
> **Single Tumor** is a single lesion. A single tumor may **invade
> regional** organs by traveling along the mucosa or extending through
> the organ wall into **regional** tissue or organ A single tumor may
> have **multiple or mixed** histologies.
>
> ***Example 1:*** Colon primary: a large tumor originating in the
> ascending colon with intramucosal spread into the transverse colon.
> Abstract as a single primary and record the primary site as ascending
> colon.
>
> ***Example 2:*** The patient has multiple papillary urothelial bladder
> tumors with in situ spread into the ureters. Abstract as a single
> primary and record the primary site as bladder. (Mucosal spread of a
> urinary tract tumor may be called "field affect" or "regional
> diathesis").

**HOW TO DETERMINE SAME VS. DIFFERENT PRIMARY SITE**

**(BASED ON ICD-O-3 TOPOGRAPHY CODE)**

1.  The **third numeric digit** after the 'C' describes a subsite of the
    organ; it is **not used** to define individual (different) sites.

> ***Example:*** C50\_ is the code for breast and the third numeric
> digit, C50[5]{.underline} describes a subsite of the breast, the
> lower-outer quadrant.
>
> ***Exceptions*:** For the following sites, a difference in the third
> numeric digit designates a different primary site:

##### 

##### Colon (C18\_)

##### Anus and anal canal (C21\_)

##### Bones, joints, and articular cartilage (C40\_-C41\_) 

##### Melanoma of skin (C44\_)

##### Peripheral nerves and autonomic nervous system (C47\_)

##### Connective, subcutaneous and other soft tissues (C49\_)

> ***Example:*** If the patient has a melanoma on the skin of the scalp
> (C44[4]{.underline}) and another melanoma on the calf of the right leg
> (C44[7]{.underline}), these are two different primary sites because
> the third numeric digit of the site code is different.

2.  If the **first two numeric digits** after the C are **identical**,
    it is the **same site**.

> ***Example:*** If there is a tumor in the lower outer quadrant of the
> right breast (C[50]{.underline}5) and a separate tumor in the upper
> outer quadrant of the right breast, (C[50]{.underline}4), it is the
> same site.
>
> ***Possible exception:* Paired organ**: There are specific rules for
> paired organs. See the Multiple Primary Rules.

3.  If there is any difference in the first two numeric digits after the
    C, it is a **different** site.

> ***Example:*** Stomach, NOS (C[16]{.underline}9) and small intestine,
> NOS (C[17]{.underline}9) are different sites because the second
> numeric digit is not identical.
>
> ***Exception:* ICD-O-1** and **ICD-O-2/ICD-O-3 groupings**: The second
> edition of the *International Classification of Diseases for Oncology*
> (ICD-O-2) split several site codes into categories having differences
> in the second numeric digit after the C. The second and third edition
> ICD-O topography codes are identical. The SEER Program continues to
> use most of the ICD-O-1 subcategory site groupings to prevent
> artificial changes in site-specific incidence. When the patient has
> **multiple independent** tumors, any combination of site codes within
> the same row in the table are the same primary site. Use this table
> for in situ and/or invasive tumors. (Do not use this table for a
> single tumor with extension into another site).

**SEER Site Grouping Table**

The purpose of the table in this manual is to group sites that are
treated as a single site when abstracting a case.

+----------+----------------------------------+------------------------+
| > **I    | **Site Groupings**               | **Code To**            |
| CD-O-3** |                                  |                        |
| >        |                                  |                        |
| >        |                                  |                        |
| **Code** |                                  |                        |
+==========+==================================+========================+
| > C01    | Base of tongue                   | C029 Tongue, NOS       |
| >        |                                  |                        |
| > C02    | Other and unspecified parts of   |                        |
|          | tongue                           |                        |
+----------+----------------------------------+------------------------+
| > C05    | Palate                           | C069 Mouth, NOS        |
| >        |                                  |                        |
| > C06    | Other and unspecified parts of   |                        |
|          | mouth                            |                        |
+----------+----------------------------------+------------------------+
| > C07    | Parotid gland                    | C089 Major salivary    |
| >        |                                  | glands, NOS            |
| > C08    | Other and unspecified major      |                        |
|          | salivary glands                  |                        |
+----------+----------------------------------+------------------------+
| > C09    | Tonsil                           | C109 Oropharynx, NOS   |
| >        |                                  |                        |
| > C10    | Oropharynx                       |                        |
+----------+----------------------------------+------------------------+
| > C12    | Pyriform sinus                   | C139 Hypopharynx, NOS  |
| >        |                                  |                        |
| > C13    | Hypopharynx                      |                        |
+----------+----------------------------------+------------------------+
| > C23    | Gallbladder                      | C249 Biliary tract,    |
| >        |                                  | NOS                    |
| > C24    | Other and unspecified parts of   |                        |
|          | the biliary tract                |                        |
+----------+----------------------------------+------------------------+
| > C30    | Nasal cavity and middle ear      | C319 Accessory         |
| >        |                                  | sinuses, NOS           |
| > C31    | Accessory sinuses                |                        |
+----------+----------------------------------+------------------------+
| > C33    | Trachea                          | C349 Lung, NOS         |
| >        |                                  |                        |
| > C34    | Bronchus and lung                |                        |
+----------+----------------------------------+------------------------+
| > C37    | Thymus                           | C383 Mediastinum, NOS  |
| >        |                                  |                        |
| > C380   | Heart                            |                        |
| >        |                                  |                        |
| > C381-3 | Mediastinum                      |                        |
| >        |                                  |                        |
| > C388   | Overlapping lesion of heart,     |                        |
|          | mediastinum, and pleura          |                        |
+----------+----------------------------------+------------------------+
| > C51    | Vulva                            | C579 Female genital,   |
| >        |                                  | NOS                    |
| > C52    | Vagina                           |                        |
| >        |                                  |                        |
| > C577   | Other specified female genital   |                        |
| >        | organs                           |                        |
| > C578-9 |                                  |                        |
|          | Unspecified female genital       |                        |
|          | organs                           |                        |
+----------+----------------------------------+------------------------+
| > C569   | Ovary                            | Code C569 (ovary) when |
| >        |                                  | ovary is one of the    |
| > C570   | Fallopian tube                   | involved sites         |
| >        |                                  |                        |
| > C571   | Broad ligament                   | Code C579 (female      |
| >        |                                  | genital, NOS) when     |
| > C572   | Round ligament                   | only non-ovarian sites |
| >        |                                  | are involved.          |
| > C573   | Parametrium                      |                        |
| >        |                                  |                        |
| > C574   | Uterine adnexa                   |                        |
+----------+----------------------------------+------------------------+
| > C60    | Penis                            | C639 Male genital, NOS |
| >        |                                  |                        |
| > C63    | Other and unspecified male       |                        |
|          | genital organs                   |                        |
+----------+----------------------------------+------------------------+
| > C64    | Kidney                           | Code C649 when one of  |
| >        |                                  | the involved organs is |
| > C65    | Renal pelvis                     | kidney                 |
| >        |                                  |                        |
| > C66    | Ureter                           | Code C689 (Urinary     |
| >        |                                  | system, NOS) when only |
| > C68    | Other and unspecified urinary    | non-kidney sites are   |
|          | organs                           | involved               |
+----------+----------------------------------+------------------------+
| > C74    | Adrenal gland                    | C759 Endocrine gland,  |
| >        |                                  | NOS                    |
| > C75    | Other endocrine glands and       |                        |
|          | related structures               |                        |
+----------+----------------------------------+------------------------+

***Note:*** This table is **not** identical to the table in ICD-O-3. Two
combinations of sites are listed in the ICD-O-3 but not in the SEER
table: C19 (rectosigmoid) and C20 (rectum) and C40 (bones of limbs) and
C41 (bones of other sites). Multiple tumors in the rectosigmoid and
rectum are different sites. Multiple tumors in C40 and C41 are different
sites.

**HOW TO DETERMINE SAME VS. DIFFERENT HISTOLOGY**

**(BASED ON ICD-O-3 HISTOLOGY CODES)**

> 1\. If the **first three digits of the ICD-O-3 histology codes are the
> same,** it is the
>
> same histology.
>
> ***Exception:*** The ICD-O-3 histology code for non-small cell
> carcinoma (8046) is a separate morphology group from the small cell
> histologies (codes 8040 -- 8045). Even though the first three digits
> are the same, they are different histologies.

**MULTIPLE PRIMARY RULES FOR SOLID TUMORS**

**Definitions**

> **Simultaneous** tumors are identified at the time of diagnosis.
>
> **Synchronous** tumors are diagnosed within two months of the
> original/initial diagnosis.

**The multiple primary rules are presented in two formats, text and
table. Note that the rule numbers in both formats are identical.**

Use the following rules to determine whether to report a single primary
or multiple primaries. Coding rules for the data items mentioned such as
primary site, histology, laterality, etc. are not described in detail in
this section; refer to the instructions for coding each data item
elsewhere in this manual.

**Rules for Single Tumor**

> **Rule 1**: **A single lesion composed of one histologic type is a
> single primary, even if the lesion crosses site boundaries.**
>
> ***Example 1:*** A single lesion involving the tongue and floor of
> mouth is one primary.
>
> ***Example 2*:** A single, large mucinous adenocarcinoma involving the
> sigmoid and descending colon segments is one primary.
>
> **Rule 2: A single lesion composed of multiple (different) histologic
> types is a single primary even if it crosses site boundaries.**
>
> The most frequent combinations of histologic types are listed in
> ICD-O-3. For example, combination terms such as "adenosquamous
> carcinoma (8560/3)" or "small cell-large cell carcinoma (8045/3)" are
> included. A single lesion composed of mixed or multiple histologies is
> a single primary.
>
> ***Example 1:*** A single lesion containing both embryonal cell
> carcinoma and teratoma is a single primary and would be coded to
> 9081/3, mixed embryonal carcinoma and teratoma.
>
> ***Example 2*:** A single lesion of the liver composed of
> neuroendocrine carcinoma (8246/3) and hepatocellular carcinoma
> (8170/3) is a single primary and would be coded to the more specific
> histology, neuroendocrine carcinoma 8246/3.

**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.
>
> ***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
    8120-8130

> ***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.
>
> ***Exception 4:*** Kaposi sarcoma (9140) is reported only once and is
> coded to the site in which it arises. Code the primary site to skin
> (C44\_) when Kaposi sarcoma arises in skin and another site
> simultaneously.. If no primary site is stated, code the primary site
> to skin, NOS (C449).
>
> **Rule 6: Multiple synchronous lesions of different histologic types
> within a single paired or unpaired organ are separate primaries.**
>
> ***Example 1*:** A patient undergoes a partial gastrectomy for
> adenocarcinoma of the body of the stomach. In the resected specimen,
> the pathologist finds both adenocarcinoma and nodular non-Hodgkin
> lymphoma. Abstract two primaries.
>
> ***Exception 1:*** Multiple lesions in a single site occurring within
> two months: if one lesion is carcinoma, NOS, adenocarcinoma, NOS,
> sarcoma, NOS, or melanoma, NOS and the second lesion is more specific,
> such as large cell carcinoma, mucinous adenocarcinoma, spindle cell
> sarcoma, or superficial spreading melanoma, abstract as a single
> primary and code the histology to the more specific term.
>
> ***Exception 2:*** For colon and rectum tumors:

a.  When an adenocarcinoma (8140/\_; in situ or invasive) arises in the
    same segment of the colon or rectum as an adenocarcinoma in a polyp
    (8210/\_, 8261/\_, 8263/\_), abstract a single primary and code the
    histology as adenocarcinoma (8140/\_).

b.  Familial adenomatous polyposis (FAP) (8220) with malignancies
    arising in polyps in the same or multiple segments of the colon or
    rectum, abstract as a single primary.

> ***Exception 3:*** There are certain sites in which multiple foci of
> tumor and multiple histologic types are commonly found together. These
> multifocal, multi-histologic tumors occur most frequently in the
> thyroid (papillary and follicular), bladder (papillary and
> transitional cell) and breast (combinations of ductal and lobular, and
> combinations of Paget disease and ductal/intraductal). They are
> abstracted as a single primary with a mixed histology. In such cases,
> consult ICD-O-3 for a list of the most frequent histologic
> combinations.
>
> ***Example 1**:* A thyroid specimen contains two separate
> carcinomas--- one papillary and the other follicular. Abstract one
> primary when the histology is papillary and follicular (8340).
>
> ***Example 2:*** Abstract one primary when **multiple bladder** tumors
> are **papillary urothelial** (8130) and/or **transitional** cell
> (8120).
>
> ***Example 3:** A* left mastectomy specimen yields lobular carcinoma
> in the upper inner quadrant and intraductal carcinoma in the lower
> inner quadrant. Code one primary.
>
> ***Example 4:*** A right mastectomy specimen yields Paget in the
> nipple and a separate underlying ductal carcinoma. Code one primary.
> Assign the combination code 8543 (Ductal and Paget disease).
>
> **Rule 7: Multiple synchronous lesions of different histologic types
> in paired organs are multiple primaries.** If **one histologic type is
> reported in one side of a paired organ and a different histologic type
> is reported in the other paired organ**, these are two primaries
> unless there is a statement to the contrary.
>
> ***Example 1:*** If a ductal tumor occurs in one breast and a lobular
> tumor occurs in the opposite breast, these are two separate primaries.
>
> **Rule 8: Multiple metachronous lesions of different histologic types
> within a single site are separate primaries.**
>
> **Rule 9: Multiple lesions of different histologic types occurring in
> different sites are separate primaries whether occurring
> simultaneously or at different times.**
>
> ***Example 1:*** In 1999, the patient had a mucin-producing carcinoma
> of the transverse colon. In 2002, the patient was diagnosed with an
> astrocytoma of the frontal lobe of the brain. Abstract as separate
> primaries.
>
> ***Example 2:*** During the workup for a transitional cell carcinoma
> of the bladder, the patient has a TURP that shows adenocarcinoma of
> the prostate. Abstract as separate primaries.
>
> **Rule 10:** **Multiple lesions of the same histologic type occurring
> in different sites are separate primaries unless stated to be
> metastatic.**

**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 |         | Sync    | 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       |
+---+---+------+-------+------+---------+---------+---------------------+

**Multiple Primary Rules for Solid Tumors - Rule Number Conversion
Table**

This table displays the current Multiple Primary Rules for Solid Tumors
by rule number compared to the SEER Program Code Manual 3^rd^ edition
rule(s).

+-----------------+-----------------+----------------------------------+
| **Current**     | **SPCM 3^rd^    | # Comment                        |
|                 | edition Rule    |                                  |
| **Rule Number** | Number**        |                                  |
+-----------------+-----------------+----------------------------------+
| 1               | 1               |                                  |
+-----------------+-----------------+----------------------------------+
| 2               | 2               |                                  |
+-----------------+-----------------+----------------------------------+
| 3a              | 4a              |                                  |
+-----------------+-----------------+----------------------------------+
| 3b              | 3               | Former Rule 3 is now two rules:  |
|                 |                 | Rule 3b and Rule 5               |
+-----------------+-----------------+----------------------------------+
| 4a              | 6a, ii          |                                  |
+-----------------+-----------------+----------------------------------+
| 4b              | 6a, i           |                                  |
+-----------------+-----------------+----------------------------------+
| 4b, exception 1 | 6a, exception 1 |                                  |
+-----------------+-----------------+----------------------------------+
| 4b, exception 2 | 6a, exception 2 | Former Rule 6a, exception 2 is   |
|                 |                 | now two exceptions: Rule 4b,     |
|                 |                 | exception 2 and Rule 4b,         |
|                 |                 | exception 3                      |
+-----------------+-----------------+----------------------------------+
| 4b, exception 3 | 6a, exception 2 | Former Rule 6a, exception 2 is   |
|                 |                 | now two exceptions: Rule 4b,     |
|                 |                 | exception 2 and Rule 4b,         |
|                 |                 | exception 3                      |
+-----------------+-----------------+----------------------------------+
| 5               | 3               | Former Rule 3 is now two rules:  |
|                 |                 | Rule 3b and Rule 5               |
+-----------------+-----------------+----------------------------------+
| 5, exception 1  | 3               |                                  |
+-----------------+-----------------+----------------------------------+
| 5, exception 2  | 3, exception 2  |                                  |
+-----------------+-----------------+----------------------------------+
| 5, exception 3  | 3, exception 1  |                                  |
+-----------------+-----------------+----------------------------------+
| 5, exception 4  | 3, exception 3  |                                  |
+-----------------+-----------------+----------------------------------+
| 6               | 5a              |                                  |
+-----------------+-----------------+----------------------------------+
| 6, exception 1  | 5, exception 1  |                                  |
+-----------------+-----------------+----------------------------------+
| 6, exception 2, | 5, exception 1, |                                  |
| a               | i and ii        |                                  |
+-----------------+-----------------+----------------------------------+
| 6, exception 2, |                 |                                  |
| b               |                 |                                  |
+-----------------+-----------------+----------------------------------+
| 7               | 6b              |                                  |
+-----------------+-----------------+----------------------------------+
| 8               | 5a              |                                  |
+-----------------+-----------------+----------------------------------+
| 9               | 5b              |                                  |
+-----------------+-----------------+----------------------------------+
| 10              | 4b              |                                  |
+-----------------+-----------------+----------------------------------+

**DETERMINING MULTIPLE PRIMARIES: HEMATOPOIETIC PRIMARIES (Lymphoma and
Leukemia)**

If the physician clearly states that a hematopoietic diagnosis is a new
primary, use that information. If there is no clear information from the
physician, use the SEER table "Definitions of Single and Subsequent
Primaries for Hematologic Malignancies" to determine multiple primaries.
Go to <http://seer.cancer.gov/icd-o-3/> to download the SEER table in
PDF format.

**DETERMINING MULTIPLE PRIMARIES:**

**BENIGN AND BORDERLINE PRIMARY INTRACRANIAL AND CNS TUMORS**

**(C70.0-C72.9, C75.1-C75.3)**

**definitions**

> **Same site:** The first two numeric digits of the ICD-O-3 topography
> code are identical.
>
> **Different site:** The first two numeric digits of the ICD-O-3
> topography code are different.
>
> **Timing:** The amount of time between the original and subsequent
> tumors is not used to determine multiple primaries because the natural
> biology of non-malignant tumors is that of expansive, localized
> growth.

**HOW TO DETERMINE SAME VS DIFFERENT HISTOLOGIES**

**(BASED ON HISTOLOGIC GROUPINGS)**

When there are **multiple tumors**, use the following table to determine
if the tumors are the same histology or different histologies.

**Histologic groupings to determine same histology for non-malignant
brain tumors**

  -----------------------------------------------------------------------
  **Histologic Group**                    **ICD-O-3 Code**
  --------------------------------------- -------------------------------
  Choroid plexus neoplasms                9390/0, 9390/1

  Ependymomas                             9383, 9394, 9444

  Neuronal and neuronal-glial neoplasms   9384, 9412, 9413, 9442, 9505/1,
                                          9506

  Neurofibromas                           9540/0, 9540/1, 9541, 9550,
                                          9560/0

  Neurinomatosis                          9560/1

  Neurothekeoma                           9562

  Neuroma                                 9570

  Perineurioma, NOS                       9571/0
  -----------------------------------------------------------------------

**Instructions for Using Histologic Group Table**

1.  **Both** histologies are listed **in** the **table**

    a.  Histologies that are in the same **grouping** or row in the
        table are the **same histology**.

    b.  ***Note:*** Histologies that are in the same grouping are a
        progression, differentiation or subtype of a single histologic
        category.

    c.  Histologies listed in **different groupings** in the table are
        **different histologies**.

2.  One or both of the **histologies** is **not** listed **in** the
    **table**

```{=html}
<!-- -->
```
a.  If the **ICD-O-3 codes** for both histologies have the **identical**
    first three digits, the histologies are the **same**.

b.  If the first three digits of the **ICD-O-3** histology code are
    **different**, the histology types are different.

**MULTIPLE PRIMARY RULES FOR BENIGN AND BORDERLINE PRIMARY INTRACRANIAL
AND CNS TUMORS**

**The multiple primary rules are presented in two formats, text and
table. Note that the rule numbers in both formats are identical.**

Use the following rules to determine whether to report a single primary
or multiple primaries. Coding rules for the data items mentioned such as
primary site, histology, laterality, etc. are not described in detail
here; refer to the instructions for coding each data item.

**Note:** If there is a **single tumor**, it is always a **single**
primary

> **Rule 1:** Multiple non-malignant tumors of the **same histology**
> that recur in the **same site** and **same side** (laterality) as the
> original tumor are recurrences (single primary) even after 20 years.
>
> **Rule 2:** Multiple non-malignant tumors of the **same histology**
> that recur in the **same site** and it is unknown if it is the same
> side (laterality) as the original tumor are recurrences (single
> primary) even after 20 years.
>
> **Rule 3:** Multiple non-malignant tumors of the same histology in
> **different sites** of the CNS are separate (multiple) primaries.
>
> **Rule 4:** Multiple non-malignant tumors of the same histology in
> **different sides** (laterality) of the CNS are separate (multiple)
> primaries.
>
> **Rule 5:** Multiple non-malignant tumors of different histologies are
> separate (multiple) primaries)

**Table of Rules to Determine Multiple Primaries for Benign and
Borderline Primary Intracranial and CNS Tumors**

  --------- ----------- ----------------- ----------------- ------------------
  **Rule    **Site**    **Laterality**    **Histology**     **Primary(ies)**
  \#**                                                      

  **1**     Same        Same              Same              Single

  **2**     Same        Unknown           Same              Single

  **3**     Different   Any               Same              Multiple

  **4**     Same        Different sides   Same              Multiple
                        of the same site                    
                        in the CNS                          

  **5**     Any         Any               Different         Multiple
  --------- ----------- ----------------- ----------------- ------------------

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SECTION I

BASIC RECORD IDENTIFICATION

The Basic Record Identification fields provide a unique identifier for
individual records or a set of records for each person and tumor entered
into the SEER data system. The coded identifiers protect data
confidentiality.

***Note***: For San Francisco, Los Angeles, San Jose/Monterey and
Greater California the patient identifier identifies a unique patient
across the entire State.

The combination of the SEER Participant Number, Patient ID Number, and
Record Number identifies a unique patient record or tumor.

**This page left blank**

**SEER PARTICIPANT**

## Item Length: 10

## NAACCR Item #: 40

**NAACCR Name: Registry ID**

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                                          Detroit

  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    2000        Greater
               Institute,        Los 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                       
  -------------------------------------------------------------------------------

**PATIENT ID NUMBER**

## Item Length: 8

## NAACCR Item #: 20

**NAACCR Name: Patient ID Number**

The participating SEER registry generates a unique number and assigns
that number to one patient.

The SEER registry will assign this same number to all of the patient's
subsequent tumors (records).

Enter preceding zeros if the number is less than 8 digits.

***Example:*** Patient \# 7034 would be entered as 00007034.

***Note***: For the state of California, the patient ID number is
assigned for the entire state, not for the individual registries within
the state.

**RECORD TYPE**

**Item Length: 1**

## NAACCR Item #: 10

**NAACCR Name: RECORD TYPE**

This is a computer generated or manually entered field that identifies
the type of record that is being transmitted. A file should have records
of only one type.

**Codes**

I **I**ncidence-only record type (nonconfidential coded data)

Length = 1946

C **C**onfidential record type (incidence record plus confidential data)

Length = 2644

A Full case **A**bstract record type (incidence and confidential data
plus text summaries; used for reporting to central registries)

Length = 6694

U Correction/**U**pdate record type (short format record used to submit
corrections to data already submitted)

Length = 850

R Analysis/**R**esearch record type (incidence record plus appended
error flags and recoded values)

Length = 2215

M Record **M**odified since previous submission to central registry
(identical in format to the "A" record type)

Length = 6694

L Pathology **L**aboratory

**RECORD NUMBER**

**Item Length: 2**

## NAACCR Item #: 2190

**NAACCR Name: SEER Record Number**

The Record Number is a unique sequential number. The highest number for
each patient identifies the number of records that have been submitted
to SEER for that particular patient. This data item is helpful in record
linkage.

The record number is generated by the computer system for each SEER
submission. The record numbers are sequential starting with the number
01. The highest number assigned represents the total number of records
submitted to SEER for that particular patient.

# Codes

1.  One or first of more than one record for person

2.  Second record for the person

..

..

nn Last of nn records for person

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**SECTION II**

**INFORMATION SOURCE**

**This page left blank**

**Type of Reporting Source**

## Item Length: 1

## NAACCR Item #: 500

**NAACCR Name: Type of Reporting Source**

The Type of Reporting Source identifies the source documents used to
abstract the case. This is not necessarily the original document that
identified the case; rather, it is the source that provided the best
information.

**Codes**

1 Hospital Inpatient/Outpatient or Clinic

3 Laboratory Only (Hospital or Private)

4 Physician's Office/Private Medical Practitioner (LMD)

5 Nursing/Convalescent Home/Hospice

6 Autopsy Only

7 Death Certificate Only

**Code Definitions**

+----+--------------------+-------------------------------------------+
| ** | **Label**          | **Definition**                            |
| Co |                    |                                           |
| de |                    |                                           |
| ** |                    |                                           |
+----+--------------------+-------------------------------------------+
| 1  | Hospital           | One of the source documents used to       |
|    | In                 | abstract the case was from a hospital     |
|    | patient/Outpatient | admission as an inpatient or an           |
|    | or Clinic          | outpatient.                               |
|    |                    |                                           |
|    |                    | Includes outpatient services of HMOs and  |
|    |                    | large multi-specialty physician group     |
|    |                    | practices, such as Oncology or Radiation  |
|    |                    | Therapy, if the reports from multiple     |
|    |                    | physicians and laboratories are stored in |
|    |                    | a single unit record.                     |
+----+--------------------+-------------------------------------------+
| 3  | Laboratory Only    | Source documents from a laboratory were   |
|    | (Hospital or       | used to abstract the case. There were no  |
|    | Private)           | source documents from codes 1, 4, or 5.   |
+----+--------------------+-------------------------------------------+
| 4  | Physician's        | Source documents are from a physician's   |
|    | Office/Private     | office that is NOT an HMO or large        |
|    | Medical            | multi-specialty physician group practice. |
|    | Practitioner (LMD) | There were no source documents from code  |
|    |                    | 1.                                        |
+----+--------------------+-------------------------------------------+
| 5  | Nu                 | The source documents are from a nursing   |
|    | rsing/Convalescent | or convalescent home or a hospice. There  |
|    | Home/Hospice       | were no source documents from codes 1 or  |
|    |                    | 4.                                        |
+----+--------------------+-------------------------------------------+
| 6  | Autopsy Only       | The cancer was first diagnosed on         |
|    |                    | autopsy. There are no source documents    |
|    |                    | from codes 1-5.                           |
+----+--------------------+-------------------------------------------+
| 7  | Death Certificate  | Death certificate is the only source of   |
|    | Only               | information; follow-back activities did   |
|    |                    | not identify source documents from codes  |
|    |                    | 1-6. If another source document is        |
|    |                    | subsequently identified, the Type of      |
|    |                    | Reporting Source code must be changed to  |
|    |                    | the appropriate code in the range of 1-6. |
+----+--------------------+-------------------------------------------+

**Priority Order for Assigning Type of Reporting Source**

When multiple source documents are used to abstract a case, use the
following priority order to assign a code for Type of Reporting Source:

**Priority order of codes**

1 Hospital/Clinic

4 Physician office

5 Nursing home

3 Laboratory

6 Autopsy only

7 Death certificate only

**SECTION III**

**DEMOGRAPHIC INFORMATION**

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**Place of Residence at Diagnosis**

SEER registries collect information on place of residence at diagnosis.
This information is not transmitted to SEER. The SEER rules for
determining residency at diagnosis are either identical or comparable to
rules used by the US Census Bureau, to ensure comparability of
definitions of cases (numerator) and the population at risk
(denominator).

**Coding Priorities/Sources**

1.  Code the **street** **address** of usual residence as stated by the
    patient. Definition: *US* *Census Bureau Instructions:* "The place
    where he or she lives and sleeps most of the time or the place the
    person says is his or her usual home." The residency rules of
    departments of vital statistics may differ from those of the US
    Census Bureau/SEER.

2.  **Post Office Box** is not a reliable source to identify the
    residency at diagnosis. Post office box addresses do not provide
    accurate geographical information for analyzing cancer incidence.
    Use the post office box address only if no street address
    information is available after follow-back.

3.  Use residency information from a **death certificate** only when the
    residency from other sources is coded as unknown. Review each case
    carefully and apply the US Census Bureau/SEER rules for determining
    residence. The death certificate may give the person's previous home
    address rather than the nursing home address as the place of
    residence; use the nursing home address as the place of residence.

4.  Do not use **legal status** or **citizenship** to code residence..

**Persons with More than One Residence**

***Examples:*** Snowbirds who live in the south for the winter months,
sunbirds who live in the north during the summer months, people with
vacation residences that they occupy for a portion of the year.

1.  Code the residence where the patient spends the majority of time
    (usual residence).

2.  If the usual residence is not known or the information is not
    available, code the residence the patient specifies at the time of
    diagnosis.

**Persons with No Usual Residence**

Homeless people and transients are examples of persons with no usual
residence. Code the patient's residence at the time of diagnosis such as
the shelter or the hospital where diagnosis was confirmed.

#### Temporary Residents of SEER Area 

Code the place of usual residence rather than the temporary address for:

> **Migrant** workers
>
> **Educators** temporarily assigned to a university in the SEER area
>
> Persons **temporarily** **residing** with family during cancer
> treatment
>
> **Military** personnel on **temporary** duty assignments (TDY)
>
> **Boarding school** students below college level (code the parent's
> residence)

Code the residence where the student is living while attending
**college**

Code the address of the institution for **Persons in Institutions**

> *US Census Bureau definition:* "Persons under formally authorized,
> supervised care or custody" are residents of the institution."
>
> Persons who are incarcerated
>
> Persons who are physically handicapped, mentally retarded, or mentally
> ill who are residents of homes, schools, hospitals or wards
>
> Residents of nursing, convalescent, and rest homes
>
> Long-term residents of other hospitals such as Veteran's
> Administration (VA) hospitals

**Persons in the Armed Forces and on Maritime Ships (Merchant Marine)**

**Armed Forces**

/prod/www/titles.html. For military personnel and their family members,
code the address of the military installation or surrounding community
as stated by the patient.

**Personnel Assigned to Navy, Coast Guard, and Maritime Ships**

> The US Census Bureau has detailed rules for determining residency for
> personnel assigned to these ships. The rules refer to the ship's
> deployment, port of departure, destination, and its homeport. Refer to
> US Census Bureau Publications for detailed rules http://www.census.gov

**COUNTY**

**Item Length: 3**

## NAACCR Item #: 90

**NAACCR Name: County at DX**

Codes for county of residence for each SEER area are listed in Appendix
A.

Use code 999 when it is known that a person is a resident of a
particular SEER region, but the exact county is not known.

##### CENSUS TRACT 2000

**Item Length: 6**

## NAACCR Item #: 130

**NAACCR Name: Census Tract 2000**

Census Tract 2000 records the census tract of a patient's residence at
the time of diagnosis. The codes are the same codes used by the US
Census Bureau for the Year 2000 census. This item is coded for cases
diagnosed January 1, 1996 and forward. This field allows a central
registry to add year 2000 Census tracts to cases diagnosed in previous
years without losing the codes in the field Census Tract 1970/80/90
which is only collected historically.

A Census tract is a small statistical subdivision of a county that, in
general, has between 2,500 and 8,000 residents. Local committees and the
US Census Bureau establish census tract boundaries and try to keep the
same boundaries from census to census to maintain historical
comparability, though this is not always possible. When populations
increase or decrease, old tracts may be subdivided, disappear, or have
their boundaries changed. Because the census tracts do change, it is
important to know which census tract definition is used to code them.

**Codes**

Census tract codes 000100-999998

**Special Codes**

000000 Area not census tracted

999999 Area census-tracted, but census tract is not available

Blank Census Tract 2000 not coded

**Coding Instructions**

1.  Code the Census tract of the patient's residence at the time of
    diagnosis.

2.  Assign code 999999 when an area does have an assigned Census tract
    but the Census tract is not available.

3.  Census tracts are identified by four-digit numbers ranging from 0001
    to 9989 and a two-digit suffix.

4.  Right justify the first four digits and zero fill to the left. Add
    the suffix as the fifth and sixth digits if it exists, otherwise use
    00 so all six positions are coded.

> ***Example 1**:* Code Census tract 516 and suffix 21 to 051621
>
> ***Example 2**:* Census tract 409 and suffix does not exist should be
> coded 040900

5.  Census tract codes should be assigned based on a computer match
    (geocoding software).

**CENSUS TRACT CERTAINTY 2000**

**Item Length: 1**

## NAACCR Item #: 365

**NAACCR Name: Census Tr Certainty 2000**

Cencus tract certainty records the basis on which the 2000 census tract
was assigned for an individual record. Most of the time, this
information is provided by a geocoding vendor service. Central registry
staff should codes this field manually when geocoding is not available
through a vendor service. This item is coded for cases diagnosed January
1, 1996 and forward.

**Codes**

1 Census tract based on complete and valid street address of residence

2 Census tract based on residence ZIP + 4

3 Census tract based on residence ZIP + 2

4 Census tract based on residence ZIP code only

5 Census tract based on ZIP code of post office box

9 Unable to assign census tract based on available information

Blank Not applicable (e.g., census tracting not attempted); Census tract
Certainty information for 2000 not coded

**Coding Priority**

The codes are hierarchical with the numerically lower codes having
priority.

1.  Code 1 has priority over codes 2-5 and 9

2.  Code 2 has priority over codes 3-5 and 9

3.  Code 3 has priority over codes 4, 5, and 9

4.  Code 4 has priority over codes 5 and 9

5.  Code 5 has priority over code 9

**Coding Instructions**

1.  Code 1

    a.  Used when the census tract is assigned with certainty based on
        street address

    b.  May be assigned based on a computer match (geocoding software)

    c.  May be assigned based on a central registry's manual coding
        system

> ***Example 1**:* The registry used a complete and valid street address
> to assign the census tract.
>
> ***Example 2:*** The registry used a rural route number to assign the
> census tract, and has confirmed that the rural route lies completely
> within a single census tract.
>
> ***Example 3:*** The registry used an incomplete street address to
> assign the census tract, and has confirmed that the entire street lies
> within a single census tract.

2.  Codes 2-5

    a.  Assign when there is some uncertainty about the census tract
        assignment

    b.  May be assigned based on a computer match (geocoding software)

    c.  May be assigned based on a central registry manually appointed
        code

    d.  Assign code 4 when

        1.  Street address is incomplete or invalid, but ZIP code is
            known

        2.  Only rural route number is available, but ZIP code is known

    e.  Assign code 5 when the registry used a post office box and ZIP
        code to code the census tract

3.  Code 9

    a.  ZIP code is missing OR

    b.  The complete address of the patient is unknown or cannot be
        determined OR

    c.  There is insufficient information to assign a census code .

> ***Note:*** Avoid using the post office box mailing address to code
> the census tract whenever possible.

**PLACE OF BIRTH**

## 

## Item Length: 3

## NAACCR Item #: 250

## NAACCR Name: Birthplace

The numeric and alphabetic lists of birthplaces and corresponding
geocodes are provided in Appendix B of this manual.

SEER Geocodes were originally assigned during the 1970's. Since that
time, many countries and islands have been given their independence or
control has been turned over to another country. To maintain consistency
over time, SEER has maintained the original code for these countries and
islands. The names have been annotated to display the current political
designation.

## 

## Special Codes

000 United States, NOS

998 Non-United States, NOS

999 Unknown

## 

## Coding Instructions

> Assign the most specific code possible from Appendix B.

**DATE OF BIRTH**

**Item Length: 8**

## NAACCR Item #: 240

**NAACCR Name: Birth Date**

Date of Birth identifies the month, day and year of the patient's birth.
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 birth. 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 birth

Record 9999 for unknown year

**Special Codes**

99999999 Unknown date

## Coding Instructions

1.  Code the Date of Birth

2.  If the Date of **Birth** is **unknown**, but the **Age** at
    Diagnosis and Date of **Diagnosis** are **known:**

```{=html}
<!-- -->
```
1.  Record the month as 99 (unknown) and day as 99 (unknown).

2.  Calculate the year of birth by subtracting the patient's age at
    diagnosis from the year of diagnosis.

***Note:*** A zero must precede a single-digit month and a single-digit
day

**Age at Diagnosis**

## 

## Item Length: 3

## NAACCR Item #: 230

**NAACCR Name: Age at Diagnosis**

This data item represents the age of the patient at diagnosis **for this
cancer.**

**Codes**

000 Less than one year old

001 One year old, but less than two years old

002 Two years old

...

... (Actual age in years)

...

101 One hundred one years old

...

120 One hundred twenty years old

999 Unknown age

**Coding Instructions**

1.  **Measure** the patient's age in **completed** **years** of life,
    i.e., age at the patient's **last** birthday.

2.  Generally, the registry software program calculates the Age at
    Diagnosis using the Date of Birth and Date of Diagnosis.

3.  Age at Diagnosis can be manually calculated using the date of birth
    and the date of diagnosis.

**RACE 1**

**Item Length: 2**

## NAACCR Item #: 160

**NAACCR Name: Race 1**

Race (and ethnicity) is defined by specific physical, hereditary and
cultural traditions or origins, not necessarily by birthplace, place of
residence, or citizenship. 'Origin' is defined by the US Census Bureau
as the heritage, nationality group, lineage, or in some cases, the
country of birth of the person or the person's parents or ancestors
before their arrival in the United States.

All resources in the facility, including the medical record, face sheet,
physician and nursing notes, photographs, and any other sources, must be
used to determine race. If a facility does not print race in the medical
record but does maintain it in electronic form, the electronic data must
also be reviewed. Recommendation: document how the race code was
determined in a text field.

The data item Race 1 identifies the primary race of the patient.

**Codes**

01 White

02 Black

03 American Indian, Aleutian, Alaskan Native or Eskimo (includes all
indigenous populations of the Western hemisphere)

04 Chinese

05 Japanese

06 Filipino

07 Hawaiian

08 Korean (Effective with 1/1/1988 dx)

09 Asian Indian, Pakistani (Effective with 1/1/1988 dx)

10 Vietnamese (Effective with 1/1/1988 dx)

11 Laotian (Effective with 1/1/1988 dx)

12 Hmong (Effective with 1/1/1988 dx)

13 Kampuchean (including Khmer and Cambodian) (Effective with 1/1/1988
dx)

14 Thai (Effective with 1/1/1994 dx)

20 Micronesian, NOS (Effective with 1/1/1991)

21 Chamorran (Effective with 1/1/1991 dx)

22 Guamanian, NOS (Effective with 1/1/1991 dx)

25 Polynesian, NOS (Effective with 1/1/1991 dx)

26 Tahitian (Effective with 1/1/1991 dx)

27 Samoan (Effective with 1/1/1991 dx)

28 Tongan (Effective with 1/1/1991 dx)

30 Melanesian, NOS (Effective with 1/1/1991 dx)

31 Fiji Islander (Effective with 1/1/1991 dx)

32 New Guinean (Effective with 1/1/1991 dx)

96 Other Asian, including Asian, NOS and Oriental, NOS (Effective with
1/1/1991 dx)

97 Pacific Islander, NOS (Effective with 1/1/1991 dx)

98 Other

99 Unknown

SEER Participants San Francisco, San Jose-Monterey, and Los Angeles are
permitted to use codes 14 and 20-97 for cases diagnosed after January 1,
1987. Greater California is permitted to use codes 14 and 20-97 for
cases diagnosed after January 1, 1988. Other SEER participants may
choose to recode cases diagnosed prior to 1991 using 14 and 20-97 if all
cases in the following race codes are reviewed: 96 Other Asian; 97
Pacific Islander, NOS; 98 Other; and 99 unknown.

**Coding Instructions**

1.  Code the primary race(s) of the patient in fields Race 1, Race 2,
    Race 3, Race 4, and Race 5. The five race fields allow for the
    coding of multiple races consistent with the Census 2000. Rules 2 -
    8 further specify how to code Race 1, Race 2, Race 3, Race 4 and
    Race 5. See Editing Guidelines below for further instructions.

2.  If a person's race is a combination of white and any other race(s),
    code the appropriate other race(s) first and code white in the next
    race field.

3.  If a person's race is a combination of Hawaiian and any other
    race(s), code Race 1 as 07 Hawaiian and code the other races in Race
    2, Race 3, Race 4, and Race 5 as appropriate.

> ***Example**:* Patient is described as Japanese and Hawaiian. Code
> Race 1 as 07 Hawaiian, Race 2 as 05 Japanese, and Race 3 through Race
> 5 as 88.

4.  If the person is not Hawaiian, code Race 1 to the first stated
    non‑white race (02‑98).

> ***Example:*** Patient is stated to be Vietnamese and Black. Code Race
> 1 as 10 Vietnamese, Race 2 as 02 Black, and Race 3 through Race 5 as
> 88.
>
> ***Note*:** in the following scenarios, only the race code referred to
> in the example is coded. For cases diagnosed after January 1, 2000,
> all race fields must be coded.

5.  The fields Place of Birth, Race, Marital Status, Name, Maiden Name,
    and Hispanic Origin are inter-related. Use the following guidelines
    in priority order:

    a.  Code the patient's stated race, if possible. Refer to Appendix
        "Race and Nationality Descriptions from the 2000 Census and
        Bureau of Vital Statistics" for guidance.

> ***Example 1**:* Patient is stated to be Japanese. Code as 05
> Japanese.
>
> ***Example 2:*** Patient is stated to be German-Irish. Code as 01
> White.
>
> ***Example 3:*** Patient is described as Arabian. Code as 01 White.
>
> ***Exception**:* When the race is recorded as Oriental, Mongolian, or
> Asian (coded to 96 Other Asian) and the place of birth is recorded as
> China, Japan, the Philippines, or another Asian nation, code the race
> based on birthplace information.
>
> ***Example 4:*** The person's race is recorded as Asian and the place
> of birth is recorded as Japan. Code race as 05 Japanese because it is
> more specific than 96 Asian, NOS.
>
> ***Example 5:*** The person describes himself as an Asian-American
> born in Laos. Code race as 11 Laotian because it is more specific than
> 96 Asian, NOS.

6.  If the patient's race is determined on the basis of the races of
    relatives, there is no priority to coding race, other than to list
    the non-white race(s) first.

> ***Example*:** The patient is described as Asian-American with Korean
> parents. Code race as 08 Korean because it is more specific than 96
> Asian \[-American\].

7.  If no race is stated in the medical record, or if the stated race
    cannot be coded, review the documentation for a statement of a race
    category.

> ***Example 1**:* Patient described as a black female. Code as 02
> Black.
>
> ***Example 2:*** Patient describes herself as multi-racial (nothing
> more specific) and nursing notes say "African-American." Code as 02
> Black.
>
> ***Example 3:*** Patient states she has a Polynesian mother and
> Tahitian father. Code Race 1 as 25 Polynesian, Race 2 as 26 Tahitian
> and Race 3 through Race 5 as 88.

8.  If race is unknown or not stated in the medical record and birth
    place is recorded, in some cases race may be inferred from the
    nationality. Refer to the Appendix entitled "Race and Nationality
    Descriptions from the 2000 Census and Bureau of Vital Statistics" to
    identify nationalities from which race codes may be inferred.

> ***Example 1:*** Record states: "this native of Portugal\..." Code
> race as 01 White per the Appendix.
>
> ***Example 2**:* Record states: "this patient was Nigerian\..." *Code
> race as 02 Black* per the Appendix.
>
> ***Exception:*** If the patient's name is incongruous with the race
> inferred on the basis of nationality, code Race 1 through Race 5 as
> 99, Unknown.
>
> ***Example 1:*** Patient's name is Siddhartha Rao and birthplace is
> listed as England. Code Race 1 through Race 5 as 99 Unknown.
>
> ***Example 2:*** Patient's name is Ping Chen and birthplace is
> Ethiopia. *Code* Race 1 through Race 5 as 99 Unknown.

9.  Use of patient name in determining race:

    a.  Do not code race from name alone, especially for females with no
        maiden name given.

    b.  In general, a name may be an indicator of a racial group, but
        should not be taken as the only indicator of race.

    c.  A patient name may be used to identify a more specific race
        code.

> ***Example 1*:** Race reported as Asian, name is Hatsu Mashimoto. Code
> race as 05 Japanese.
>
> ***Example 2**:* Birthplace is reported as Guatemala and name is Jose
> Chuicol \[name is identified as Mayan\]. Code race as 03 Native
> American

d.  A patient name may be used to infer Spanish ethnicity or place of
    birth, but a Spanish name alone (without a statement about race or
    place of birth) cannot be used to determine the race code. Refer to
    ethnicity guidelines for further information.

> ***Example:*** Alice Gomez is a native of Indiana (implied birthplace:
> United States). Code Race 1 through Race 5 as 99 Unknown, because
> nothing is known about her race..

10. Persons of Spanish or Hispanic origin may be of any race, although
    persons of Mexican, Central American, South American, Puerto Rican,
    or Cuban origin are usually white. Do NOT code a patient stated to
    be Hispanic or Latino as 98 Other Race in Race 1 and 88 in Race 2
    through Race 5.

> ***Example:*** Sabrina Fitzsimmons is a native of Brazil. Code race as
> 01 White per Appendix*.*

11. When the race is recorded as Negro or African‑American, code race as
    02 Black.

12. Code 03 should be used for any person stated to be Native American
    or \[western hemisphere\] Indian, whether from North, Central,
    South, or Latin America. For Central, South, or Latin American
    Indians, see additional ethnicity coding guidelines under Spanish
    Surname or Origin.

13. Death certificate information may be used to supplement antemortem
    race information only when race is coded unknown in the patient
    record or when the death certificate information is more specific.

> ***Example 1:*** In the cancer record Race 1 through Race 5 are coded
> as 99 Unknown. The death certificate states race as black. Change
> cancer record for Race 1 to 02 Black and Race 2 through Race 5 to 88.
>
> ***Example 2:*** Race 1 is coded in the cancer record as 96 Asian.
> Death certificate gives birthplace as China. Change Race 1 in the
> cancer record to 04 Chinese and code Race 2 through Race 5 as 88.

**EDITING GUIDELINES**

All tumors for the same patient should have the same race code(s).

***Cases diagnosed prior to January 1, 2000:***

For cases diagnosed prior to January 1, 2000, Race 2 through Race 5 must
be blank **unless** the patient has multiple records and at least one
primary is diagnosed on or after January 1, 2000. In this case, the race
codes must be identical on each record.

***Cases diagnosed on or after January 1, 2000:***

1.  If only one race is reported for the person, use code 88 for the
    remaining race fields (Race 2 - Race 5).

2.  If the patient is multiracial, code all races using items Race 1
    through Race 5.

3.  If any race code is 99 Unknown, then all race codes must be 99
    Unknown.

4.  If Race 1 is 01-98, Race 2 through Race 5 cannot be 99.

5.  If more than Race 1 is coded, and if any Race 2 through Race 5 is
    88, then all subsequent race codes must be 88.

6.  A unique race code (other than 88, 99 or blank {for diagnoses prior
    to 01/01/2000}) can be coded only once in Race 1 through Race 5. For
    example, do not code 01 White in Race 1 for one parent and 01 White
    in Race 2 for the other parent.

7.  Document the specified race in a remarks field when any of the race
    fields are coded as 96 Other Asian, 97 Pacific Islander, NOS or 98
    Other Race and a more specific race is given that is not included in
    the list of race codes. If there is no information on race in the
    medical record, document that there is no race information in a
    remarks field. If the information in the medical record is not
    consistent (for example, if the patient is identified as black in
    nursing notes and white in a dictated physical exam), document why
    the coded race was chosen.

> ***Note:*** Do not code 96 Other Asian in a subsequent race field if a
> specific Asian race(s) has already been coded.
>
> ***Example 1**:* Patient is described as Asian in a consult note and
> as second generation Korean American in the history. Code Race 1 as 08
> Korean and Race 2 through Race 5 as 88.

**HISTORY**

1.  Race 1 is the field used to compare with race data on cases
    diagnosed prior to January 1, 2000.

2.  For cases diagnosed prior to January 1, 2000, Race 2 through Race 5
    must be blank **unless** the patient has multiple records with at
    least one primary diagnosed on or after January 1, 2000. In this
    case, the race codes must be identical on each record..

3.  Codes 08 - 13 became effective with diagnoses on or after January 1,
    1988.

4.  Code 14 became effective with diagnoses on or after January 1, 1994.

5.  Codes 20 - 97 became effective with diagnoses on or after January
    1, 1991. SEER participants in San Francisco, San Jose-Monterey, and
    Los Angeles are permitted to use codes 14 and 20 - 97 for cases
    diagnosed after January 1, 1987; Greater California is permitted to
    use codes 14 and 20-97 for cases diagnosed after January 1, 1988.
    Other SEER participants may choose to recode cases diagnosed prior
    to 1991 using 14 and 20-97 if all cases in the following race codes
    are reviewed: 96 Other Asian; 97 Pacific Islander, NOS; 98 Other;
    and 99 unknown.

**RACE 2, 3, 4, 5**

**Item Length: 2**

## NAACCR Item #: 161, 162, 163, 164

####### NAACCR Name: Race 2, Race 3, Race 4, Race 5

Race (and ethnicity) is defined by specific physical, heredity and
cultural traditions or origins, not necessarily by birthplace, place of
residence, or citizenship. 'Origin' is defined by the US Census Bureau
as the heritage, nationality group, lineage, or in some cases, the
country of birth of the person or the person's parents or ancestors
before their arrival in the United States.

All resources in the facility, including the medical record, face sheet,
physician and nursing notes, photographs, and any other sources, must be
used to determine race. If a facility does not print race in the medical
record but does maintain it in electronic form, the electronic data must
also be reviewed. Recommendation: document how the race code was
determined in a text field.

The data item Race identifies the primary race of the patient.

**Codes**

01 White

02 Black

03 American Indian, Aleutian, Alaskan Native or Eskimo (includes all
indigenous populations of the Western hemisphere)

04 Chinese

05 Japanese

06 Filipino

07 Hawaiian

08 Korean (Effective with 1/1/1988 dx)

09 Asian Indian, Pakistani (Effective with 1/1/1988 dx)

10 Vietnamese (Effective with 1/1/1988 dx)

11 Laotian (Effective with 1/1/1988 dx)

12 Hmong (Effective with 1/1/1988 dx)

13 Kampuchean (including Khmer and Cambodian) (Effective with 1/1/1988
dx)

14 Thai (Effective with 1/1/1994 dx)

20 Micronesian, NOS (Effective with 1/1/1991)

21 Chamorran (Effective with 1/1/1991 dx)

22 Guamanian, NOS (Effective with 1/1/1991 dx)

25 Polynesian, NOS (Effective with 1/1/1991 dx)

26 Tahitian (Effective with 1/1/1991 dx)

27 Samoan (Effective with 1/1/1991 dx)

28 Tongan (Effective with 1/1/1991 dx)

30 Melanesian, NOS (Effective with 1/1/1991 dx)

31 Fiji Islander (Effective with 1/1/1991 dx)

32 New Guinean (Effective with 1/1/1991 dx)

88 No further race documented

96 Other Asian, including Asian, NOS and Oriental, NOS (Effective with
1/1/1991 dx)

97 Pacific Islander, NOS (Effective with 1/1/1991 dx)

98 Other

99 Unknown

SEER Participants San Francisco, San Jose-Monterey, and Los Angeles are
permitted to use codes 14 and 20-97 for cases diagnosed after January 1,
1987. Greater California is permitted to use codes 14 and 20-97 for
cases diagnosed after January 1, 1988. Other SEER participants may
choose to recode cases diagnosed prior to 1991 using 14 and 20-97 if all
cases in the following race codes are reviewed: 96 Other Asian; 97
Pacific Islander, NOS; 98 Other; and 99 unknown.

**Coding Instructions**

1.  Code the primary race(s) of the patient in fields Race 1, Race 2,
    Race 3, Race 4, and Race 5. The five race fields allow for the
    coding of multiple races consistent with the Census 2000. Rules 2 -
    8 further specify how to code Race 1, Race 2, Race 3, Race 4 and
    Race 5. See Editing Guidelines below for further instructions.

2.  If a person's race is a combination of white and any other race(s),
    code the appropriate other race(s) first and code white in the next
    race field.

3.  If a person's race is a combination of Hawaiian and any other
    race(s), code Race 1 as 07 Hawaiian and code the other races in Race
    2, Race 3, Race 4, and Race 5 as appropriate.

> ***Example**:* Patient is described as Japanese and Hawaiian. Code
> Race 1 as 07 Hawaiian, Race 2 as 05 Japanese, and Race 3 through Race
> 5 as 88.

4.  If the person is not Hawaiian, code Race 1 to the first stated
    non‑white race (02 ‑ 98).

> ***Example**:* Patient is stated to be Vietnamese and Black. Code Race
> 1 as 10 Vietnamese, Race 2 as 02 Black, and Race 3 through Race 5 as
> 88.
>
> ***Note*:** in the following scenarios, only the race code referred to
> in the example is coded. For cases diagnosed after January 1, 2000,
> all race fields must be coded.

5.  The fields Place of Birth, Race, Marital Status, Name, Maiden Name,
    and Hispanic Origin are inter-related. Use the following guidelines
    in priority order:

    a.  Code the patient's stated race, if possible. Refer to Appendix
        "Race and Nationality Descriptions from the 2000 Census and
        Bureau of Vital Statistics" for guidance.

> ***Example 1**:* Patient is stated to be Japanese. Code as 05
> Japanese.
>
> ***Example 2:*** Patient is stated to be German-Irish. Code as 01
> White.
>
> ***Example 3:*** Patient is described as Arabian. Code as 01 White.
>
> ***Exception**:* When the race is recorded as Oriental, Mongolian, or
> Asian (coded to 96 Other Asian) and the place of birth is recorded as
> China, Japan, the Philippines, or another Asian nation, code the race
> based on birthplace information.
>
> ***Example 4**:* The person's race is recorded as Asian and the place
> of birth is recorded as Japan. Code race as 05 Japanese because it is
> more specific than 96 Asian, NOS.
>
> ***Example 5**:* The person describes himself as an Asian-American
> born in Laos. Code race as 11 Laotian because it is more specific than
> 96 Asian, NOS.

6.  If the patient's race is determined on the basis of the races of
    relatives, there is no priority to coding race, other than to list
    the non-white race(s) first.

> ***Example:*** The patient is described as Asian-American with Korean
> parents. Code race as 08 Korean because it is more specific than 96
> Asian \[-American\].

7.  If no race is stated in the medical record, or if the stated race
    cannot be coded, review the documentation for a statement of a race
    category.

> ***Example 1:*** Patient described as a black female. Code as 02
> Black.
>
> ***Example 2**:* Patient describes herself as multi-racial (nothing
> more specific) and nursing notes say "African-American." Code as 02
> Black.
>
> ***Example 3:*** Patient states she has a Polynesian mother and
> Tahitian father. Code Race 1 as 25 Polynesian, Race 2 as 26 Tahitian
> and Race 3 through Race 5 as 88.

8.  If race is unknown or not stated in the medical record and birth
    place is recorded, in some cases race may be inferred from the
    nationality. Refer to the Appendix entitled "Race and Nationality
    Descriptions from the 2000 Census and Bureau of Vital Statistics" to
    identify nationalities from which race codes may be inferred.

> ***Example 1:*** Record states: "this native of Portugal\..." Code
> race as 01 White per the Appendix.
>
> ***Example 2:*** Record states: "this patient was Nigerian\..." Code
> race as 02 Black per the Appendix.
>
> ***Exception*** If the patient's name is incongruous with the inferred
> race, code Race 1 through Race 5 as 99, Unknown.
>
> ***Example 1:*** Patient's name is Siddhartha Rao and birthplace is
> listed as England. Code Race 1 through Race 5 as 99 Unknown.
>
> ***Example 2:*** Patient's name is Ping Chen and birthplace is
> Ethiopia. Code Race 1 through Race 5 as 99 Unknown.

9.  Use of patient name in determining race

    a.  Do not code race from name alone, especially for females with no
        maiden name given.

    b.  In general, a name may be an indicator of a racial group, but
        should not be taken as the only indicator of race.

    c.  A patient name may be used to identify a more specific race
        code.

> ***Example 1:*** Race reported as Asian, name is Hatsu Mashimoto. Code
> race as 05 Japanese.
>
> ***Example 2:*** Birthplace is reported as Guatemala and name is Jose
> Chuicol \[name is identified as Mayan\]. Code race as 03 Native
> American

d.  A patient name may be used to infer Spanish ethnicity or place of
    birth, but a Spanish name alone (without a statement about race or
    place of birth) cannot be used to determine the race code. Refer to
    ethnicity guidelines for further information.

> ***Example:*** Alice Gomez is a native of Indiana (implied birthplace:
> United States). Code Race 1 through Race 5 as 99 Unknown, because we
> know nothing about her race.

10. Persons of Spanish or Hispanic origin may be of any race, although
    persons of Mexican, Central American, South American, Puerto Rican,
    or Cuban origin are usually white. Do NOT code a patient stated to
    be Hispanic or Latino as 98 Other Race in Race 1 and 88 in Race 2
    through Race 5.

> ***Example:*** Miss Sabrina Fitzsimmons is a native of Brazil. Code
> race as 01 White per Appendix*.*

11. When the race is recorded as Negro or African‑American, code race as
    02.

12. Code 03 should be used for any person stated to be Native American
    or \[western hemisphere\] Indian, whether from North, Central,
    South, or Latin America. See additional ethnicity coding guidelines
    under Spanish Surname or Origin for instructions on coding Central,
    South, or Latin American Indians.

13. Death certificate information may be used to supplement antemortem
    race information only when race is coded unknown in the patient
    record or when the death certificate information is more specific.

> ***Example 1:*** In the cancer record Race 1 through Race 5 are coded
> as 99 Unknown. The death certificate states race as black. Change
> cancer record for Race 1 to 02 Black and Race 2 through Race 5 to 88.
>
> ***Example 2:*** Race 1 is coded in the cancer record as 96 Asian.
> Death certificate gives birthplace as China. Change Race 1 in the
> cancer record to 04 Chinese and code Race 2 through Race 5 as 88.

**EDITING GUIDELINES**

All tumors for the same patient should have the same race code(s).

***Cases diagnosed prior to January 1, 2000:***

For cases diagnosed prior to January 1, 2000, Race 2 through Race 5 must
be blank **unless** the patient has multiple records and at least one
primary is diagnosed on or after January 1, 2000. In this case, the race
codes must be identical on each record.

***Cases diagnosed on or after January 1, 2000:***

1.  If only one race is reported for the person, use code 88 for the
    remaining race fields (Race 2 - Race 5).

2.  If the patient is multiracial, code all races using items Race 1
    through Race 5.

3.  If any race code is 99 Unknown, then all race codes must be 99
    Unknown. If Race 1 is 01-98, Race 2 through Race 5 cannot be 99.

4.  If more than Race 1 is coded, and if any Race 2 through Race 5 is
    88, then all subsequent race codes must be 88.

5.  A unique race code (other than 88, 99 or blank {for diagnoses prior
    to 01/01/2000}) can be coded only once in Race 1 through Race 5. For
    example, do not code 01 White in Race 1 for one parent and 01 White
    in Race 2 for the other parent.

6.  Document the specified race in a remarks field when any of the race
    fields are coded as 96 Other Asian, 97 Pacific Islander, NOS or 98
    Other Race and a more specific race is given that is not included in
    the list of race codes. If there is no information on race in the
    medical record, document that there is no race information in a
    remarks field. If the information in the medical record is not
    consistent (for example, if the patient is identified as black in
    nursing notes and white in a dictated physical exam), document why
    the coded race was chosen.

> ***Note:*** Do not code 96 Asian in a subsequent race field if a
> specific Asian race(s) has already been coded.
>
> ***Example 1:*** Patient is described as Asian in a consult note and
> as second generation Korean American in the history. Code Race 1 as 08
> Korean and Race 2 through Race 5 as 88.
>
> ***Example 2**:* Patient is described as having one Thai parent and
> one Malaysian parent. Code Race 1 as 14 Thai, Race 2 as 96 Other Asian
> (where Malaysian is coded), and Race 3 through Race 5 as 88.

**HISTORY**

1.  Race 1 is the field used to compare with race data on cases
    diagnosed prior to January 1, 2000.

2.  For cases diagnosed prior to January 1, 2000, Race 2 through Race 5
    must be blank **unless** the patient has multiple records and at
    least one primary is diagnosed on or after January 1, 2000. In this
    case, the race codes must be identical on each record.

3.  Codes 08 - 13 became effective with diagnoses on or after January 1,
    1988.

4.  Code 14 became effective with diagnoses on or after January 1, 1994.

5.  Codes 20 - 97 became effective with diagnoses on or after January
    1, 1991. SEER participants in San Francisco, San Jose-Monterey, and
    Los Angeles are permitted to use codes 14 and 20 - 97 for cases
    diagnosed after January 1, 1987. Other SEER participants may choose
    to recode cases diagnosed prior to 1991 using 14 and 20-97 if all
    cases in the following race codes are reviewed: 96 Other Asian; 97
    Pacific Islander, NOS; 98 Other; and 99 unknown.

> **Spanish Surname or Origin**
>
> **Item Length: 1**
>
> **NAACCR item #: 190**
>
> **NAACCR Name: Spanish/Hispanic Origin**

This data item is used to identify patients with Spanish/Hispanic
surname or of Spanish origin. Persons of Spanish or Hispanic
surname/origin may be of any race.

**Codes**

0 Non-Spanish/Non-Hispanic

1 Mexican (includes Chicano)

2 Puerto Rican

3 Cuban

4 South or Central American (except Brazil)

5 Other specified Spanish/Hispanic origin (includes European; excludes
Dominican Republic)

6 Spanish, NOS; Hispanic, NOS; Latino, NOS

> **There is evidence, other than surname or maiden name, that the
> person is Hispanic but he/she cannot be assigned to any of the
> categories 1-5.**

7 Spanish surname only (effective with diagnosis on or after 1/1/1994)

> **The only evidence of the person's Hispanic origin is the surname or
> maiden name and there is no contrary evidence that the patient is not
> Hispanic.**

8 Dominican Republic (effective with diagnosis on or after 1/1/2005)

9 Unknown whether Spanish/Hispanic or not

**Coding Instructions**

1.  Coding Spanish Surname or Origin is not dependent on race. A person
    of Spanish descent may be white, black, or any other race.

2.  Portuguese, Brazilians and Filipinos are not Spanish; code
    non-Spanish (code 0).

3.  All information should be used to determine the Spanish/Hispanic
    Origin including the stated ethnicity in the medical record, stated
    Hispanic origin on the death certificate, birthplace, information
    about life history and/or language spoken found in the abstracting
    process and a last name and maiden name found on a list of
    Hispanic/Spanish names. Assign code 7 when the only evidence of the
    patient's Hispanic origin is a surname or maiden name and there is
    no evidence that the patient is not Hispanic. Code 7 is ordinarily
    for central registry use only. If the origin is not stated in the
    medical record and the hospital registry does not have a list of
    Hispanic surnames, assign code 9 "Unknown whether Spanish/Hispanic
    or not". Code 7 was adapted for use effective with 1/1/1994
    diagnoses.

# COMPUTED ETHNICITY

> **Item Length: 1**

## NAACCR Item #: 200

## NAACCR Name: Computed Ethnicity

Computed Ethnicity records the ethnicity based on last name and/or
maiden name using a computer algorithm. The computer algorithm is a list
of names which is compared to the patient's surname and/or maiden name
to test for Hispanic ethnicity. A computer algorithm must be used to
compute ethnicity for all cases diagnosed January 1, 1994 and later.
This data item is used in conjunction with the data item Computed
Ethnicity Source.

Ethnicity derived from the same algorithm facilitates comparisons
between regions with large populations. When data collectors use
identical methods and rules to code the Hispanic population, it may be
possible to identify population denominators.

The computer-derived ethnicity may differ from the manually assigned
ethnicity (Spanish/Hispanic Origin).

[Do not record results from NHIA in this field.]{.underline}

**Codes**

0 No match was run (for 1994 and later cases)

1 Non-Hispanic last name and non-Hispanic maiden name

2 Non-Hispanic last name, did not check maiden name, or patient was male

3 Non-Hispanic last name, missing maiden name

4 Hispanic last name, non-Hispanic maiden name

5 Hispanic last name, did not check maiden name or patient was male

6 Hispanic last name, missing maiden name

7 Hispanic maiden name (females only) (regardless of last name)

Blank 1993 and earlier cases, no match was run

***Note:*** For SEER, blank is allowed only for tumors diagnosed in 1993
and earlier.

> **COMPUTED ETHNICITY SOURCE**
>
> **Item Length: 1**

## NAACCR Item #: 210

## NAACCR Name: Computed Ethnicity Source

Computed Ethnicity Source identifies the database, method, or computer
algorithm that was used to determine ethnicity as recorded in the
Computed Ethnicity. The two fields are used together to describe
computed ethnicity data.

[Do not record results of NHIA in this field.]{.underline}

**Codes**

0 No match was run for 1994 and later cases

1 Census Bureau list of Spanish surnames, NOS

2 1980 Census Bureau list of Spanish surnames

3 1990 Census Bureau list of Spanish surnames

4 GUESS program

5 Combination list including South Florida names

6 Combination of Census and other locally generated list

7 Combination of Census and GUESS, with or without other lists

8 Other type of match (Do not record results of NHIA in this field)

9 Unknown type of match

Blank 1993 and earlier tumors, no match was given

***Note:*** For SEER, blank is allowed only for tumors diagnosed in 1993
and earlier.

> **NHIA Derived Hispanic Origin**
>
> **Item Length: 1**
>
> **NAACCR Item #: 191**
>
> **NAACCR Name: NHIA Derived Hisp Origin**

The NAACCR Hispanic Identification Algorithm (NHIA) is a computerized
algorithm that uses a combination of variables to directly or indirectly
classify cases as Hispanic for analytic purposes. The computer program
that is run to derive Hispanic origin will automatically assign the code
for this data item. The algorithm must be run for all cases.

**Codes**

0 Non-Hispanic

1 Mexican, by birthplace or other specific identifier

2 Puerto Rican, by birthplace or other specific identifier

3 Cuban, by birthplace or other specific identifier

4 South or Central American (except Brazil), by birthplace or other
specific identifier

5 Other specified Spanish/Hispanic origin (includes European; excludes
Dominican

Republic), by birthplace or other specific identifier

6 Spanish, NOS; Hispanic, NOS; Latino, NOS

7 NHIA surname match only

8 Dominican Republic

Blank Algorithm has not been run

> **SEX**
>
> **Item Length: 1**

## NAACCR Item #: 220

## NAACCR Name: Sex

Code the sex of the patient at the time of diagnosis.

**Codes**

1 Male

2 Female

3 Other (hermaphrodite)

4 Transsexual

9 Not stated/Unknown

**Definition:**

Transsexual: Surgically altered gender

**MARITAL STATUS AT DIAGNOSIS**

> **Item Length: 1**

## NAACCR Item #: 150

## NAACCR Name: Marital Status at DX

Code the patient's marital status at the time of diagnosis for the
reportable tumor.

**Codes**

1 Single (never married)

2 Married (including common law)

3 Separated

4 Divorced

5 Widowed

9 Unknown

***Note:*** If the patient has multiple tumors, marital status may be
different for each tumor.

Persons of the opposite sex living together as part of a long-term
personal relationship would be coded to '2,' Married (including common
law).

Persons of the same sex living together as part of a long-term personal
relationship would be coded according to their legal status (usually
single, separated, divorced, or widowed).

> **SECTION IV**
>
> **DESCRIPTION OF THIS NEOPLASM**
>
> **This page left blank**
>
> **DATE OF DIAGNOSIS**

## Item Length: 8

## NAACCR Item #: 390

## NAACCR Name: Date of Diagnosis

The date of diagnosis is the month, day and year the tumor was first
diagnosed by a recognized medical practitioner, whether clinically or
microscopically confirmed.

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 diagnosis. 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 diagnosis

Record 9999 for unknown year

**Special Codes**

99999999 Unknown date

**Coding Instructions**

> The diagnosis date refers to the first diagnosis by any recognized
> medical practitioner.

1.  Code the date of diagnosis for this cancer.

2.  The first diagnosis of cancer may be **clinical** (i.e. based on
    physical exam, scans or laboratory results for hematopoietic
    malignancies)

    a.  Do not change the date of diagnosis when a clinical diagnosis is
        confirmed later by positive histology or cytology.

> ***Example:*** On May 15, 2004, the physician states that the patient
> has lung cancer based on clinical findings. The patient has a positive
> biopsy of the lung in June 3, 2004. The date of diagnosis remains May
> 15, 2004 (05152004).

b.  If the patient receives first course treatment and there is no
    information about the date of diagnosis, use the date of admission
    as the date of diagnosis.

c.  If the patient receives first course of treatment and there is no
    information about the date of diagnosis nor is there an admission
    date, code the date of first treatment as the date of diagnosis.

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3.  Positive **tumor** **markers** alone are not diagnostic of cancer.
    Use the date of clinical, histologic, or positive cytologic
    confirmation as the date of diagnosis.

> ***Example 1**:* The patient has an elevated PSA and the physical
> examination is negative. The physician documents only that the patient
> is referred for a needle biopsy of the prostate. The biopsy is
> positive for adenocarcinoma. The date of diagnosis is the date of the
> positive biopsy.
>
> ***Example 2:*** The patient has an elevated PSA and the physical
> examination is negative. The physician documents that he/she suspects
> that the patient has prostatic cancer and is referring the patient for
> a needle biopsy. The needle biopsy is positive. The date of diagnosis
> is the date the physician documented that he/she suspects that the
> patient has prostatic cancer.
>
> ***Note:*** Positive tumor markers alone are never used for case
> ascertainment.

4.  **Suspicious cytology** **only** is not diagnostic of cancer. Use
    the date of clinical, histologic, or **positive** cytologic
    confirmation as the date of diagnosis.

> ***Note*:** Suspicious cytology alone is never used for case
> ascertainment.

5.  If a recognized medical practitioner says that, in **retrospect**,
    the patient had cancer at an earlier date, code the date of
    diagnosis as the earlier date. If the original slides are reviewed
    and the pathologist documents cancer, code the diagnosis date as the
    date the original slides were made.

> ***Example:*** The patient had an excision of a benign fibrous
> histiocytoma in January 2004. Six months later, a wide reexcision was
> positive for malignant fibrous histiocytoma. The physician documents
> in the chart that the previous tumor (benign fibrous histiocytoma)
> must have been malignant. Code the diagnosis date as January 2004.

6.  If there is **no review** of previous slides with a revised
    diagnosis of cancer, and **no physician's statement** that, in
    retrospect, the previous tumor was malignant, or if information on
    the previous tumor is unclear, do not back-date the date of
    diagnosis.

> ***Example:*** The patient had a total hysterectomy and a bilateral
> salpingo oophorectomy (BSO) in June 2004 with pathology diagnosis of
> papillary cystadenoma of the ovaries. In December 2004 the patient is
> diagnosed with widespread metastatic papillary cystadenocarcinoma. The
> slides from June 2004 are not reviewed and there is no physician
> statement saying the previous tumor was malignant. The date of
> diagnosis is December 2004.

7.  Code the **date of death** as the date of diagnosis for:

    a.  Autopsy only cases

    b.  Death Certificate Only cases

8.  If the case is found by **death certificate** and

    a.  There is no mention of cancer in the nursing home records or in
        the work-up records, code the date of death as the date of
        diagnosis. The case remains a Death Certificate Only case.

    b.  The death certificate is signed by a physician and there is no
        additional follow-back information, code the date of death as
        the date of diagnosis. The case remains a Death Certificate Only
        case.

    c.  No additional information is gathered from another source code
        the date of death as the date of diagnosis. The case remains a
        Death Certificate Only case.

9.  **Estimate the date of diagnosis** if an exact date is not
    available.

    a.  Estimating the **month**

        i.  Code "spring of" to April

        ii. Code "summer" or "middle of the year" to July

        iii. Code "fall" or "autumn" as October

        iv. For "winter of," try to determine whether the physician
            means the first of the year or the end of the year and code
            January or December as appropriate.

        v.  Code "early in year" to January

        vi. Code "late in year" to December

        vii. Use whatever information is available to calculate the
             month of diagnosis

> ***Example 1*:** Admitted October 2004. History states diagnosed 7
> months ago. Subtract 7 from the month of admit and code date of
> diagnosis to March 2004 (03992004).
>
> ***Example 2*:** Outpatient bone scan done January 2004 that states
> history of prostate cancer. The physician says the patient was
> diagnosed in 2004. Assume bone scan was part of initial work-up and
> code date of diagnosis to January 2004 (012004).

viii. Code the month of admission when there is no basis for estimation

ix. Code month as 99 if there is no basis for approximation

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b.  Estimating the year

    i.  Code "a couple of years" to two years earlier

    ii. Code "a few years" to three years earlier

    iii. Use whatever information is available to calculate the year of
         diagnosis

    iv. Code the year of admission when there is no basis for estimation

    v.  Code year as 9999 when there is no basis for approximation of
        the year.

c.  Estimating **both the month and year**: use whatever information is
    available to calculate the month and year of diagnosis.

### Nursing Home Residents (Not hospitalized for their cancer; no information other than nursing home records and/or death certificate)

1.  If the only information available is that the patient **had cancer
    when admitted** to the nursing home, use the date of admission as
    the date of diagnosis.

2.  If the only information available is that the patient **had cancer
    while in the nursing home**, but it is unknown whether the patient
    had cancer when admitted, use the best approximation possible for
    date of diagnosis. If there is no basis for an approximation, the
    default code is the date of admission to the nursing home.

# SEQUENCE NUMBER-CENTRAL

## Item Length: 2

## NAACCR Item #: 380

## NAACCR Name: Sequence Number\--Central

Sequence Number-Central describes the number and sequence of all
reportable malignant, in situ, benign, and borderline primary tumors,
which occur over the lifetime of a patient.

This sequence number counts all tumors that were reportable in the year
they were diagnosed even if the tumors occurred before the registry
existed, or before the registry participated in the SEER Program. See
coding instructions below.

While the Sequence Number-Hospital (NAACCR Item #560) may be useful in
determining Sequence Number-Central, the two sequence numbers do not
have to be identical.

Rules for Determining Multiple Primaries and the reportability
requirements for each diagnosis year should be used to decide which
primaries need to be sequenced.

**Codes**

**In Situ/Malignant as Federally Required based on Diagnosis Year**

00 One primary only in the patient's lifetime

01 First of two or more primaries

02 Second of two or more primaries

.. ..

.. (Actual number of this primary)

.. ..

35 Thirty-fifth of thirty-five or more primaries

99 Unspecified or unknown sequence number of Federally required in situ
or malignant tumors. Sequence number 99 can be used if there is a
malignant tumor and its sequence number is unknown. (If there is known
to be more than one malignant tumor, then the tumors must be sequenced.)

**Non-malignant Tumor as Federally Required based on Diagnosis Year**

60 Only one non-malignant tumor or central registry-defined neoplasm

61 First of two or more non-malignant tumors or central registry-defined
neoplasms

62 Second of two or more non-malignant tumors or central
registry-defined neoplasms

.. ..

87 Twenty-seventh of twenty-seven

88 Unspecified or unknown sequence number of non-malignant tumor or
central-registry defined neoplasms. (Sequence number 88 can be used if
there is a non-malignant tumor and its sequence number is unknown. If
there is known to be more than one non-malignant tumor, then the tumors
must be sequenced.)

98 Cervix carcinoma in situ (CIS/CIN III, Diagnosis Years 1996-2002)

> **Type of Neoplasm/Sequence Number Series**

+-------------------------------------------------+--------------------+
| > **Neoplasm**                                  | > **Sequence       |
|                                                 | >                  |
|                                                 | Number\--Central** |
+=================================================+====================+
|                                                 | > **Numeric        |
|                                                 | > Series**         |
+-------------------------------------------------+--------------------+
| > **[Series 1: In situ*/*Malignant as Federally | > 00-35,99         |
| > Required based on Diagnosis                   |                    |
| > Year]{.underline}**                           |                    |
+-------------------------------------------------+--------------------+
| > All in situ (behavior code 2):                | > 00-35            |
| >                                               |                    |
| > Cervix CIS, CIN III (diagnosis year before    |                    |
| > 1996)                                         |                    |
| >                                               |                    |
| > All other in situ including VIN III, VAIN     |                    |
| > III, AIN III                                  |                    |
+-------------------------------------------------+--------------------+
| > Malignant (behavior code 3)                   |                    |
+-------------------------------------------------+--------------------+
| > Juvenile astrocytoma (diagnosis year 2001 and |                    |
| > later)\*                                      |                    |
+-------------------------------------------------+--------------------+
| > Invasive following in situ -- new primary     |                    |
| > defined by SEER                               |                    |
+-------------------------------------------------+--------------------+
| > Unspecified Federally required sequence       | > 99               |
| > number or unknown                             |                    |
+-------------------------------------------------+--------------------+
| > **Series 2: Non-malignant Tumor as Federally  | > 60-87,88         |
| > Required based on Diagnosis Year or State or  |                    |
| > Regional Registry Defined \*\***              |                    |
+-------------------------------------------------+--------------------+
| > [Examples:]{.underline}                       |                    |
+-------------------------------------------------+--------------------+
| > Non-malignant tumor/benign brain              | > 60-87            |
+-------------------------------------------------+--------------------+
| > Borderline ovarian (diagnosis year 2001+)     | > 60-87            |
+-------------------------------------------------+--------------------+
| > Other borderline/benign                       | > 60-87            |
+-------------------------------------------------+--------------------+
| > Skin SCC/BCC                                  | > 60-87            |
+-------------------------------------------------+--------------------+
| > PIN III (diagnosis year 2001+)                | > 60-87            |
+-------------------------------------------------+--------------------+
| > Cervix CIS/CIN III (diagnosis year 2003+)     | > 60-87            |
+-------------------------------------------------+--------------------+
| > Unspecified non-malignant tumor or central    | > 88               |
| > registry-defined sequence number              |                    |
+-------------------------------------------------+--------------------+
| > Cervix CIS/CINIII (diagnosis year 1996-2002)  | > 98               |
+-------------------------------------------------+--------------------+

> \*Juvenile astrocytomas should be reported as 9421/3.
>
> \*\*Series 2 - the only tumors in Series 2 that SEER requires are
> benign/borderline intracranial and central nervous system (CNS)
> tumors.

***Note***: Conversion Guidance: The sequence numbers for neoplasms
whose histologies were associated with behavior codes that changed from
in situ/malignant to benign/borderline or vice versa during the
coversion from ICD-O-2 to ICD-O-3 should not be re-sequenced.

######## 

######## Coding Instructions

1.  For any reportable in situ or malignant cancer diagnosed in 2004 and
    forward, count all previous in situ/malignant reportable primaries
    which occurred over the lifetime of the patient to determine the
    correct sequence number. A 'reportable' primary refers to the
    site/histology of the tumor and the years for which its reporting
    was required. For 2004+ diagnoses, see Reportability Requirements. A
    person did not have to be a resident of the SEER area for a primary
    to be counted.

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a.  If there are multiple primaries, sequence the cases chronologically
    as 01 (first of one or more), 02 (second primary), 03 (third
    primary), and assign the appropriate sequence number to all cases in
    the database. All primaries in the database for the patient should
    be evaluated/changed to reflect the correct sequence number.

> ***Example 1:*** The patient has a history of breast cancer in 1960.
> She has colon cancer in 2004. Assign sequence number 02 to the colon
> cancer.
>
> ***Example 2:*** In 1987, patient was diagnosed and treated for
> childhood leukemia in another state. After becoming a resident of a
> SEER region, the patient develops bladder cancer. The SEER registry
> assigns a sequence number of 02 to the bladder cancer.

b.  If there were no prior primaries, the sequence number is 00 unless
    the patient develops subsequent primaries. If a person has a primary
    with sequence 00 and then develops another reportable /2 or /3
    primary, the sequence number of the first primary is changed from 00
    to 01.

> **Exception:** There are certain cancers that were only reportable for
> some years. The following are some examples (not a complete list):
>
> Borderline tumors of the ovary were reported for 1992-2000
>
> Refractory anemia was reported only for 2001+
>
> Myelodysplastic syndromes were only reported for 2001+
>
> Cervix in situ were only required prior to 1996 diagnosis year
>
> ***Example 1:*** The patient was diagnosed with carcinoma in situ of
> the cervix in 1994. In 2004 the patient was diagnosed with lung
> cancer. The SEER registry assigns a sequence number of 01 to the
> carcinoma in situ of the cervix and a sequence number of 02 to the
> lung cancer.
>
> ***Example 2:*** The patient was diagnosed with carcinoma in situ of
> the cervix in 2003. In 2004 the patient was diagnosed with lung
> cancer. The SEER registry is not required to collect the 2003
> carcinoma in situ of the cervix and assigns a sequence number of 00 to
> the lung cancer.

2.  For any reportable non-malignant tumor of the brain/CNS diagnosed in
    2004 and forward, count all previous non-malignant tumors of the
    brain/CNS primaries in chronological order which occurred over the
    lifetime of the patient to determine the correct sequence number.
    The previous and newly diagnosed cancers are restricted to primary
    site codes C700-C729, C751-C753 with behavior codes of /0 or /1. A
    person did not have to be a resident of the SEER area for a primary
    to be counted.

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a.  If there were prior non-malignant brain/CNS, sequence the case
    chronologically as 61 (if it is the first), 62 (if it is the
    second),..,... If the first tumor is in the registry's database,
    change the sequence number from 60 to 61.

b.  If there were no prior or subsequent non-malignant brain/CNS tumors,
    the sequence number is 60.

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3.  If a patient has both a non-malignant brain/CNS tumor and a
    reportable /2 or /3 tumor, they are sequenced independent of each
    other and their chronology, i.e., the non-malignant tumor has a
    sequence number of 60 and the reportable /2 or /3 tumor has a
    sequence number of 00.

4.  If a registry chooses to collect tumors other than those required by
    SEER (see Reportability Requirements), those tumors should be
    sequenced in the 60-87 series with the non-malignant brain tumors.

> ***Example:*** Cervix in situ was diagnosed in 2003 and lung cancer
> was diagnosed in 2004. The the cervix in situ, if collected, would be
> a sequence number 60 and the lung would be assigned a sequence number
> of 00.

5.  Assign the lower sequence number to the primary with the worse
    prognosis when **two primaries are diagnosed simultaneously**.

    a.  Base the prognosis decision on the primary site, histology, and
        extent of disease for each of the primaries.

    b.  If there is no difference in prognosis, the sequence numbers may
        be assigned in any order.

> **Primary Site**
>
> **Item Length: 4**

## NAACCR Item #: 400

## NAACCR Name: Primary Site

For cases diagnosed 1/1/2001 and later, code the primary site using the
topography section of the *International Classification of Diseases for
Oncology*, Third Edition (ICD-O-3).

The ICD-O-3 has topography codes listed in two sections; the first is a
numeric listing by code number, the second is an alphabetic listing by
anatomic site. The topography code consists of a lead character (the
letter 'C') followed by two numeric digits, a decimal point, then one
additional numeric digit. The decimal point is not entered as part of
the code.

***Example:*** The pathology report says the primary site is the cardia
of the stomach. The code (C16.0) is found in the Alphabetic Index under
either "stomach" or "cardia." Enter the code as C160; do not record the
decimal point.

**Coding Instructions**

> **Site-Specific Topography Terms** (See the Coding Guidelines for
> Topography and Morphology in the introduction of the ICD-O-3 for
> additional details)
>
> Refer to "Determining Multiple Primaries" in the first section of this
> manual to determine the number of primaries. Use all of the
> information for a single primary to code the site.

1.  Code the **site** in which the **primary tumor originated, even if
    it extends into an adjacent "subsite**."

> ***Example 1:*** Final diagnosis is adenocarcinoma of the upper lobe
> of the right lung. Code the topography to lung, upper lobe (C341).
>
> ***Example 2:*** Pathology report shows adenocarcinoma arising in an
> ectopic patch of endometriosis on the sigmoid colon. Code the primary
> site to sigmoid colon (C187), the site in which the cancer originated.
>
> ***Example 3:*** Patient has a right branchial cleft cyst; the
> pathology report identifies an adenocarcinoma arising in an ectopic
> focus of thyroid tissue within the branchial cleft cyst. Thyroidectomy
> pathology is negative. Code primary site to branchial cleft (C104).

#### 

> ***Example 4:*** The patient had a total hysterectomy with a bilateral
> salpingo-oophorectomy ten years ago for non cancer reasons. She now
> has widespread cystadenocarcinoma in the peritoneum. Code the primary
> site to peritoneum, NOS (C482). (The chart may or may not state that
> the patient has extra-ovarian carcinoma).
>
> ***Example 5:*** The patient has a 4 cm tumor in the right breast. The
> tumor originated in the upper inner quadrant and extends into the
> lower inner quadrant. Code primary site to upper inner quadrant of
> breast (C502).

2.  Use the SEER Site Grouping Table in the Rules for Determining
    Multiple Primaries section to code the primary site specified in the
    table in those rare cases when:

    a.  A single tumor overlaps adjacent **sites** in the same group

    b.  Multiple tumors reported as a single primary involve adjacent
        **sites** in the same group

> ***Example***: The patient has a 5cm tumor overlapping the base of
> tongue and anterior 2/3 of tongue. Use the SEER Site Grouping Table to
> determine the correct code for the primary site, C029 (Tongue, NOS).

3.  Code the last digit of the primary site code to '8' when a **single
    tumor overlaps** an adjacent **subsite**(s) of an organ and the
    point of origin cannot be determined.,

> ***Example***: The patient has a 5cm tumor that involves the dorsal
> surface and anterior 2/3 of tongue. Code the primary site to C028
> (overlapping lesion of tongue).

4.  Code the last digit of the primary site code to '9' for single
    primaries, when **multiple tumors arise** in **different subsites**
    of the same anatomic site, unless the subsite is defined in one of
    the site groups listed in the SEER Site Grouping Table. Refer to the
    SEER Site Grouping Table in the section entitled "How to Determine
    Same vs Different Primary Site" to determine the primary site code
    for specified site groups.

> ***Example 1:*** During a TURB, the physician describes multiple
> papillary tumors in the bladder neck (C675) and the lateral wall of
> the bladder (C672). Code the primary site as bladder, NOS (C679).
>
> ***Example 2:*** Patient has an infiltrating duct tumor in the upper
> outer quadrant (C504) of the right breast and another infiltrating
> duct carcinoma in the lower inner (C503) quadrant of the right breast.
> Code the primary site as breast, NOS (C509).

5.  Some histology/behavior terms in ICD-O-3 have a **related** **site
    code** in parenthesis; for example: hepatoma (C220).

    a.  Code the site as documented in the medical record and ignore the
        suggested ICD-O-3 code when a primary site is specified in the
        medical record.

> ***Example:*** The pathology report says "ductal carcinoma of the head
> of the pancreas." The listing in ICD-O-3 is ductal carcinoma 8500/3
> (C50). Code the primary site to head of pancreas, NOT to breast as
> suggested by the ICD-O-3.

b.  Use the site code suggested by ICD-O-3 when the primary site is the
    same as the site code suggested or the primary site is unknown

> ***Example 1:*** The biopsy is positive for hepatoma, but there is no
> information available about the primary site. Code the primary site to
> liver (C220) as suggested by ICD-O-3.
>
> ***Example 2:*** The patient has an excision of the right axillary
> nodes which reveals metastatic infiltrating duct carcinoma. The right
> breast is negative. The ICD-O-3 shows duct carcinoma (8500) with a
> suggested site of breast (C50\_). Code the primary site as breast, NOS
> (C509).

6.  Code the primary site, not the metastatic site. If a tumor is
    metastatic and the primary site is unknown, code the primary site as
    unknown (C809).

7.  When the medical record does **not** contain **enough information**
    to assign a primary site:

    a.  Consult a physician advisor to assign the site code

    b.  Use the NOS category for the organ system or the Ill Defined
        Sites (C760-C768.) if the physician advisor cannot identify a
        primary site,

    c.  Code Unknown Primary Site (C809) if there is not enough
        information to assign an NOS or Ill Defined Site category.

## Leukemia

1.  Code leukemia primaries to bone marrow (C421); blood cells originate
    in the bone marrow.

> **Lymphoma**
>
> **Definitions**
>
> **Extralymphatic:** Originating in tissue or an organ that is not a
> part of the lymphatic system.
>
> **Extranodal lymphoma:** Lymphoma originating in tissue or organ other
> than lymph nodes. Lymphatic system organs may be extranodal. (e.g.:
> Spleen is a lymphatic system organ and is also extranodal.)
>
> **Lymphatic system:** An umbrella term that includes: lymph nodes,
> spleen, thymus, tonsils, Waldeyer's ring, and Peyer's patches.
>
> **Nodal lymphoma:** A lymphoma originating in lymph nodes.

## 

######### Lymphoma Coding Instructions

1.  When a single lymph node chain is involved, code that chain as the
    primary site.

2.  When **multiple lymph node chains** are involved at the time of
    **diagnosis**, do not simply code the lymph node chain that was
    biopsied.

    a.  If it is possible to determine where the disease originated,
        code the primary site to that lymph node chain.

    b.  If multiple lymph node chains are involved and all involved
        chains are located in the same lymph node region (i.e. the same
        primary site code) and it is not possible to determine the lymph
        node chain where the disease originated, code the primary site
        to lymph nodes of the specified nodal region (C77\_),.

    c.  If multiple lymph node chains are involved and the involved
        chains are in different lymph node regions, code C778 (lymph
        nodes of multiple regions).

3.  When the lymphoma is **extranodal and is**

    a.  **Confined to the organ of origin,** code the organ of origin.

> ***Example:*** Pathology from a stomach resection shows lymphoma. No
> other pathologic or clinical disease identified. Code the primary site
> as stomach, NOS (C169).

b.  Present in an **extranodal organ/site and** in that organ/site's
    **regional lymph nodes** code the extranodal organ/site as the
    primary site.

> Lymphomas that are primary in an extranodal organ/site may metastasize
> to that organ/site's regional lymph nodes. In rare cases a lymphoma
> may spread from the lymph node to an extranodal site or extralymphatic
> organ by direct extension.
>
> ***Example 1:*** Lymphoma is present in the spleen and splenic lymph
> nodes. Code the primary site to spleen (C422).
>
> ***Example 2:*** Lymphoma is present in the stomach and the gastric
> lymph nodes. Code the primary site to stomach, NOS (C169).

c.  Present in **extranodal organ(s)/site and non-regional lymph**
    **nodes**, consult the physician to determine the primary site. If a
    site cannot be determined, code primary site to Lymph Node, NOS
    (C779).

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4.  If the **primary site is unknown** or not given:

    a.  Code retroperitoneal lymph nodes if described as retroperitoneal
        mass

    b.  Code inguinal lymph nodes if described as inguinal mass

    c.  Code mediastinal lymph nodes if described as mediastinal mass

    d.  Code mesenteric lymph nodes if described as mesenteric mass

    e.  If the primary site is unknown code Lymph Nodes, NOS (C779)

> ***Exception**:* Code unknown primary site (C809) only when there is
> no evidence of lymphoma in lymph nodes and/or the medical record
> documents that the physician suspects that it is an extranodal
> lymphoma
>
> **Esophagus**
>
> There are two systems that divide the esophagus into three subsites.
> The first system divides the esophagus into the upper third, middle
> third, and lower third. The second system describes the subsites as
> the cervical esophagus, the thoracic esophagus and the abdominal
> esophagus. The subsites for these two different systems are not
> identical. Assign the ICD-O-3 topography code that describes the
> primary site documented in the medical record. See the SEER *Self
> Instructional Manual for Tumor Registrars, Book 4* for illustrated
> descriptions of each system.
>
> **Kaposi Sarcoma**
>
> Kaposi sarcoma is a rare condition. When not AIDS-related, it usually
> presents as localized disease with an easily recognized primary site.
>
> AIDS-related Kaposi sarcoma usually presents as a disseminated disease
> with involvement of mucosal surfaces, visceral surfaces of organs, and
> skin. It is important to review consecutive records carefully to
> determine the extent of involvement at diagnosis. Review of a single
> record may reveal only the site being treated during that admission.

1.  Code Kaposi to the **site in which it arises**.

2.  If the Kaposi is present in the **skin and another site**
    simultaneously, code to the specified skin site, (C44\_).

3.  If the **primary site is unknown** or cannot be determined, code
    skin, NOS (C449).

> **Sarcoma**
>
> The majority of sarcomas arise in mesenchymal or connective tissues
> that are located in the musculoskeletal system. The musculoskeletal
> system includes the fat, muscles, blood vessels, deep skin tissues,
> nerves, bones and cartilage. The default code for sarcomas of unknown
> primary site is C499 rather than C809.
>
> Sarcomas may also arise in the walls of hollow organs and in the
> viscera covering an organ. Code the primary site to the organ of
> origin.
>
> ***Example:*** The pathology identifies a mixed Mullerian tumor of the
> uterus. Code the site to uterus, NOS (C559).

## 

> **Laterality**
>
> **Item Length: 1**

##### NAACCR Item #: 410

## NAACCR Name: Laterality

Laterality describes the side of a paired organ or side of the body on
which the reportable tumor originated. For each primary you need to
determine whether laterality should be coded.

Starting with cases diagnosed January 1, 2004 and later, laterality is
coded for select invasive, benign, and borderline primary intracranial
and CNS tumors.

**Codes**

0 Not a paired site

1 Right: origin of primary

2 Left: origin of primary

3 Only one side involved, right or left origin unspecified

4 Bilateral involvement, lateral origin unknown; stated to be single
primary

9 Paired site, but no information concerning laterality; midline tumor

###### Coding Instructions

1.  Code laterality using codes 1-9 for all of the sites listed in the
    following table.

2.  Code the side where the primary tumor originated

```{=html}
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```
a.  Assign **code 3** if the laterality is not known but the tumor is
    confined to a single side of the paired organ.

> ***Example:*** Pathology report: Patient has a 2 cm carcinoma in the
> upper pole of the kidney. Code laterality as 3 because there is
> documentation that the disease exists in only one kidney, but it is
> unknown if the disease originated in the right or left kidney.

b.  **Code 4** is seldom used EXCEPT for the following diseases:

    i.  Both ovaries involved simultaneously, single histology

    ii. Bilateral retinoblastomas

    iii. Bilateral Wilms tumors

> ***Note:*** Laterality may be coded for sites other than those
> required above.

3.  Assign **code 9** when there is a midline tumor or when the disease
    originated in a paired site, but the laterality is unknown.

> ***Example 1:*** Admitting history says patient was diagnosed with
> lung cancer based on a positive sputum cytology. Patient is treated
> for painful bony metastases. There is no information about laterality
> in the diagnosis of this
>
> lung cancer.
>
> ***Example 2:*** Patient has an excision of a melanoma located just
> above the umbilicus. Assign code 9 for a midline tumor.
>
> Sites for Which Laterality Codes Must Be Recorded

+------------+---------------------------------------------------------+
| >          | > **Site or Subsite**                                   |
|  **ICD-O-3 |                                                         |
| > Code**   |                                                         |
+============+=========================================================+
| > C079     | > Parotid gland                                         |
+------------+---------------------------------------------------------+
| > C080     | > Submandibular gland                                   |
+------------+---------------------------------------------------------+
| > C081     | > Sublingual gland                                      |
+------------+---------------------------------------------------------+
| > C090     | > Tonsillar fossa                                       |
+------------+---------------------------------------------------------+
| > C091     | > Tonsillar pillar                                      |
+------------+---------------------------------------------------------+
| > C098     | > Overlapping lesion of tonsil                          |
+------------+---------------------------------------------------------+
| > C099     | > Tonsil, NOS                                           |
+------------+---------------------------------------------------------+
| > C300     | > Nasal cavity (excluding nasal cartilage, nasal        |
|            | > septum)                                               |
+------------+---------------------------------------------------------+
| > C301     | > Middle ear                                            |
+------------+---------------------------------------------------------+
| > C310     | > Maxillary sinus                                       |
+------------+---------------------------------------------------------+
| > C312     | > Frontal sinus                                         |
+------------+---------------------------------------------------------+
| > C340     | > Main bronchus (excluding carina)                      |
+------------+---------------------------------------------------------+
| >          | > Lung                                                  |
|  C341-C349 |                                                         |
+------------+---------------------------------------------------------+
| > C384     | > Pleura                                                |
+------------+---------------------------------------------------------+
| > C400     | > Long bones of upper limb, scapula, and associated     |
|            | > joints                                                |
+------------+---------------------------------------------------------+
| > C401     | > Short bones of upper limb and associated joints       |
+------------+---------------------------------------------------------+
| > C402     | > Long bones of lower limb and associated joints        |
+------------+---------------------------------------------------------+
| > C403     | > Short bones of lower limb and associated joints       |
+------------+---------------------------------------------------------+
| > C413     | > Rib, clavicle (excluding sternum)                     |
+------------+---------------------------------------------------------+
| > C414     | > Pelvic bones (excluding sacrum, coccyx, symphysis     |
|            | > pubis)                                                |
+------------+---------------------------------------------------------+
| > C441     | > Skin of the eyelid                                    |
+------------+---------------------------------------------------------+
| > C442     | > Skin of the external ear                              |
+------------+---------------------------------------------------------+
| > C443     | > Skin of other and unspecific parts of the face (if    |
|            | > midline, assign code 9)                               |
+------------+---------------------------------------------------------+
| > C445     | > Skin of the trunk (if midline, assign code 9)         |
+------------+---------------------------------------------------------+
| > C446     | > Skin of upper limb and shoulder                       |
+------------+---------------------------------------------------------+
| > C447     | > Skin of the lower limb and hip                        |
+------------+---------------------------------------------------------+
| > C471     | > Peripheral nerves and autonomic nervous system of     |
|            | > upper limb and shoulder                               |
+------------+---------------------------------------------------------+
| > C472     | > Peripheral nerves and autonomic nervous system of the |
|            | > lower limb and hip                                    |
+------------+---------------------------------------------------------+
| > C491     | > Connective, subcutaneous, and other soft tissues of   |
|            | > upper limb and shoulder                               |
+------------+---------------------------------------------------------+
| > C492     | > Connective, subcutaneous, and other soft tissues of   |
|            | > the lower limb and hip                                |
+------------+---------------------------------------------------------+
| >          | > Breast                                                |
|  C500-C509 |                                                         |
+------------+---------------------------------------------------------+
| > C569     | > Ovary                                                 |
+------------+---------------------------------------------------------+
| > C570     | > Fallopian tube                                        |
+------------+---------------------------------------------------------+
| >          | > Testis                                                |
|  C620-C629 |                                                         |
+------------+---------------------------------------------------------+
| > C630     | > Epididymis                                            |
+------------+---------------------------------------------------------+
| > C631     | > Spermatic cord                                        |
+------------+---------------------------------------------------------+
| > C649     | > Kidney, NOS                                           |
+------------+---------------------------------------------------------+
| > C659     | > Renal pelvis                                          |
+------------+---------------------------------------------------------+
| > C669     | > Ureter                                                |
+------------+---------------------------------------------------------+
| >          | > Eye and adnexa                                        |
|  C690-C699 |                                                         |
+------------+---------------------------------------------------------+
| > C700     | > Cerebral meninges, NOS (Effective with cases          |
|            | > diagnosed 1/1/2004)                                   |
+------------+---------------------------------------------------------+
| > C710     | > Cerebrum (Effective with cases diagnosed 1/1/2004)    |
+------------+---------------------------------------------------------+
| > C711     | > Frontal lobe (Effective with cases diagnosed          |
|            | > 1/1/2004)                                             |
+------------+---------------------------------------------------------+
| > C712     | > Temporal lobe (Effective with cases diagnosed         |
|            | > 1/1/2004)                                             |
+------------+---------------------------------------------------------+
| > C713     | > Parietal lobe (Effective with cases diagnosed         |
|            | > 1/1/2004)                                             |
+------------+---------------------------------------------------------+
| > C714     | > Occipital lobe (Effective with cases diagnosed        |
|            | > 1/1/2004)                                             |
+------------+---------------------------------------------------------+
| > C722     | > Olfactory nerve (Effective with cases diagnosed       |
|            | > 1/1/2004)                                             |
+------------+---------------------------------------------------------+
| > C723     | > Optic nerve (Effective with cases diagnosed 1/1/2004) |
+------------+---------------------------------------------------------+
| > C724     | > Acoustic nerve (Effective with cases diagnosed        |
|            | > 1/1/2004)                                             |
+------------+---------------------------------------------------------+
| > C725     | > Cranial nerve, NOS (Effective with cases diagnosed    |
|            | > 1/1/2004)                                             |
+------------+---------------------------------------------------------+
| >          | > Adrenal gland                                         |
|  C740-C749 |                                                         |
+------------+---------------------------------------------------------+
| > C754     | > Carotid body                                          |
+------------+---------------------------------------------------------+

> ***Note:*** A laterality code of 1-4 or 9 **must** be assigned for the
> above sites except as noted. If the site is not listed on the table,
> assign code 0 for laterality. Laterality **may** be coded for sites
> other than those required above.
>
> **Diagnostic Confirmation**
>
> []{.mark}
>
> **Item Length: 1**
>
> **NAACCR Item #: 490**
>
> **NAACCR Name: Diagnostic Confirmation**

Records the best method used to confirm the presence of the cancer being
reported. The data item is not limited to the confirmation at the time
of diagnosis; it is the best method of confirmation during the entire
course of the disease.

**Codes**

**Microscopically Confirmed**

1 Positive histology

2 Positive cytology

4 Positive microscopic confirmation, method not specified

**Not Microscopically Confirmed**

5 Positive laboratory test/marker study

6 Direct visualization without microscopic confirmation

7 Radiology and other imaging techniques without microscopic
confirmation

8 Clinical diagnosis only (other than 5, 6, or 7)

**Confirmation Unknown**

9 Unknown whether or not microscopically confirmed; death certificate
only

**Coding Instructions**

1.  The codes are in **priority order**; code 1 has the highest
    priority. Always code the procedure with the lower numeric value
    when presence of cancer is confirmed with multiple diagnostic
    methods.

2.  Change to a lower code, if at ANY TIME during the course of disease
    the patient has a diagnostic confirmation which has a higher
    priority.

3.  Assign **code 1** when the microscopic diagnosis is based on

    a.  Tissue specimens from biopsy, frozen section, surgery, autopsy
        or D&C

    b.  Bone marrow specimens (aspiration and biopsy)

    c.  For leukemia only, positive hematologic findings including
        peripheral blood smears, CBCs and WBCs

4.  Assign **code 2** when the microscopic diagnosis is based on

    a.  Examination of cells (rather than tissue) including but not
        limited to: sputum smears, bronchial brushings, bronchial
        washings, prostatic secretions, breast secretions, gastric
        fluid, spinal fluid, peritoneal fluid, pleural fluid, urinary
        sediment, cervical smears and vaginal smears.

    b.  Paraffin block specimens from concentrated spinal, pleural, or
        peritoneal fluid

5.  Assign **code 4** when there is information that the diagnosis of
    cancer was microscopically confirmed, but the type of confirmation
    is unknown.

6.  Assign **code 5** when the diagnosis of cancer is based on
    laboratory tests or marker studies which are clinically diagnostic
    for that specific cancer.

> ***Example 1*:** The presence of alpha-fetoprotein for liver cancer
>
> ***Example 2:*** An abnormal electrophoretic spike for multiple
> myeloma or Waldenstrom macroglobulinemia.
>
> ***Example 3:*** If the workup for a prostate cancer patient is
> limited to a
>
> highly elevated PSA and the physician diagnoses and/or treats the
> patient based only on that PSA, code the diagnostic confirmation to 5.

7.  Assign **code 6** when the diagnosis is based only on

    a.  The surgeon's operative report from a surgical exploration or
        endoscopy such as colonoscopy, mediastinoscopy, or
        peritoneoscopy and no tissue was examined.

    b.  Gross autopsy findings (no tissue or cytologic confirmation)

8.  Assign **code 7** when the only confirmation of malignancy was
    diagnostic imaging such as computerized axial tomography (CT scans),
    magnetic resonance imaging (MRI scans), or ultrasounds/sonography.

9.  Assign **code 8** when the case was diagnosed by any clinical method
    not mentioned in preceding codes. The diagnostic confirmation is
    coded 8 when the only confirmation of disease is a physician's
    clinical diagnosis.

10. Assign **code 9**:

    a.  It is unknown if the diagnosis was confirmed microscopically.

Death certificate only cases.

**Morphology**

> **Item Length: 6**
>
> **NAACCR Item #: 521**
>
> **NAACCR Name: Morph---Type&Behav ICD-O-3**

The International Classification of Diseases for Oncology, Third Edition
(ICD-O-3), is used for coding the morphology of all cancers. In the
Alphabetic Index all morphology codes are indicated by an 'M-' preceding
the code number. The 'M-' should not be coded. The '/' appearing between
the histology and behavior codes is also not recorded.

Morphology is a 6-digit code consisting of three parts:

A.  Histologic type (4-digits)

B.  Behavior code (1-digit)

C.  Grading or differentiation; or for lymphoma and leukemia,
    designation of T-cell, B-cell, null cell, or NK cell (1-digit)

The morphology of a tumor can be coded only after the determination of
multiple primaries has been completed. (Refer to the Rules for
Determining Multiple Primaries to determine the number of primaries.)

To code morphology (histology, behavior and grade), use the best
information from the entire pathology report (microscopic description,
final diagnosis, comments.)

**General Rule**

If the final diagnosis gives a specific histology, code it. Similarly,
if grade is specified in the final diagnosis, code it. Exceptions are
found on the following pages under "Histologic Type," "Behavior Code,"
and "Grade, Differentiation, or Cell Indicator."

**Histologic Type ICD-O-3**

> **Item Length: 4**
>
> **NAACCR Item #: 522**
>
> **NAACCR Name: Histologic Type ICD-O-3**

The data item Histologic Type describes the microscopic composition of
cells and/or tissue for a specific primary. In the rare instance where
there is no tissue pathology, code the histology the medical
practitioner uses to describe the tumor. The tumor type or histology is
a basis for staging and determination of treatment options. It affects
the prognosis and course of the disease.

The *International Classification of Diseases for Oncology*, Third
Edition (ICD-O-3) is the standard reference for coding the histology for
tumors diagnosed in 2001 and later. Do not record the 'M' that precedes
the histology code. Refer to *ICD-O-3* for guidance in coding the
histology. See sections *Coding Guidelines for Topography and
Morphology.* and *Summary of Principal Rules for Using the ICD-O*, Third
Edition.

The histology can be coded only after the determination of multiple
primaries has been made.

**Synonyms and Equivalent Terms**

> **Mixed**, **combined**, and **complex** are **usually** used as
> synonyms when describing histology.

**Definitions**

> **Cancer,** NOS (8000) and **carcinoma**, NOS (8010) are not
> interchangeable.
>
> **Carcinoma,** NOS (8010) and **adenocarcinoma** (8140) are
> interchangeable (See ICD-O-3).
>
> **Complex (mixed, combined) histology:** The pathologist uses
> **multiple histologic terms** to describe a tumor. The histologic
> terms are frequently connected by the word "and" (for example ductal
> and lobular carcinoma).
>
> **Different histology**: The first three digits of the ICD-O-3
> histology code are different.
>
> **Different subtypes:** The NOS cell types often have multiple
> subtypes; for example, scirrhous adenocarcinoma (8143),
> adenocarcinoma, intestinal type (8144), and linitis plastica (8141)
> are subtypes of Adenocarcinoma, NOS (8140).

Majority of Tumor:

  --------------------------------------- -------------------------------
  **Terms that mean the majority of       **Terms that DO NOT mean the
  tumor**                                 majority of tumor**

  Predominantly                           With foci of

  With features of                        Focus of/focal

  Major                                   Areas of

  Type^1^                                 Elements of

  With .... Differentiation^1^            Component[^1]

  Pattern (Only if written in College of  
  American Pathologists \[CAP\]           
  Protocol)[^2]                           

  Architecture (Only if written in        
  College of American Pathologists        
  \[CAP\] Protocol) ^2^                   
  --------------------------------------- -------------------------------

> ***Note:*** Examples of CAP protocols for specific primary sites may
> be found on the website -
> <http://www.cap.org/cancerprotocols/protocols_intro.html>
>
> **Mixed/combined histology:** Different cell types in one tumor; terms
> used interchangeably. In most cases, the terms mixed and combined are
> used as synonyms; however the term mixed may designate a specific
> tumor.
>
> **Not Otherwise Specified (NOS):** "Not Otherwise Specified."
>
> **Same histology:** The first three digits of the ICD-O-3 histology
> code are identical.

**Coding Instructions**

> Refer to "Determining Multiple Primaries" in the first section of this
> manual to determine the number of primaries. Use all of the
> information for a single primary to code the histology.

1.  If there is no tumor specimen, code the histology described by the
    medical practitioner.

> ***Example 1:*** The patient has a CT scan of the brain with a final
> diagnosis of glioblastoma multiforme (9440). The patient refuses all
> further workup or treatment. Code the histology to glioblastoma
> multiforme (9440).
>
> ***Example 2*:** If the physician says that the patient has carcinoma,
> code carcinoma, NOS (8010).

2.  Use the histology stated in the **final diagnosis** from the
    pathology report. Use the pathology from the procedure that resected
    the majority of the primary tumor.

> If a more specific histologic type is definitively described in the
> microscopic portion of the pathology report or the comment, code the
> more specific diagnosis.

3.  Lymphomas may be classified by the **WHO** Classification, **REAL**
    system, **Rappaport,** or **Working Formulation**. The WHO
    Classification is preferred. See page 13 in the ICD-O-3 for a
    discussion of hematologic malignancies.

4.  Cases reported to SEER cannot have a metastatic (/6) behavior code.
    If the only pathology specimen is from a metastatic site, code the
    appropriate histology code and the malignant behavior code /3. The
    primary site and its metastatic site(s) have the same basic
    histology.

Histology Coding Rules for Single Tumor

-   The rules are in hierarchical order. Rule 1 has the highest
    priority.

-   Use the rules in priority order.

-   Use the first rule that applies to the case. (Do not apply any
    additional rules.)

1.  Code the histology if only one type is mentioned in the pathology
    report.

2.  Code the **invasive** **histology** when both invasive and in situ
    tumor are present

> ***Example:*** Pathology report reads infiltrating ductal carcinoma
> and cribriform ductal carcinoma in situ. Code the invasive histology
> 8500/3.
>
> ***Exception:*** If the histology of the invasive component is an
> 'NOS' term (e.g., carcinoma, adenocarcinoma, melanoma, sarcoma), then
> code the histology of the specific term associated with the in situ
> component and an invasive behavior code.

3.  Use a **mixed** histology code if one exists

> ***Examples*** of mixed codes: (This is not a complete list, these are
> examples only)
>
> 8490 Mixed tumor, NOS
>
> 9085 Mixed germ cell tumor
>
> 8855 Mixed liposarcoma
>
> 8990 Mixed mesenchymal sarcoma
>
> 8951 Mixed mesodermal tumor
>
> 8950 Mixed Mullerian tumor
>
> 9362 Mixed pineal tumor
>
> 8940 Mixed salivary gland tumor, NOS
>
> 9081 Teratocarcinoma, mixed embryonal carcinoma and teratoma

4.  Use a **combination** histology code if one exists

> ***Examples*** of combination codes: (This is not a complete list;
> these are examples only)
>
> 8255 Renal cell carcinoma, mixed clear cell and chromophobe types
>
> 8523 Infiltrating duct carcinoma mixed with other types of carcinoma
>
> 8524 Infiltrating lobular carcinoma mixed with other types of
> carcinoma
>
> 8560 Adenosquamous carcinoma
>
> 8045 Combined small cell carcinoma, combined small cell-large cell

5.  Code the **more specific term** when one of the terms is 'NOS' and
    the other is a more specific description of the same histology.

> ***Example 1:*** Pathology report reads poorly differentiated
> carcinoma, probably squamous in origin. Code the histology as squamous
> cell carcinoma rather than the non-specific term "carcinoma."
>
> ***Example 2:*** The pathology report from a nephrectomy reads renal
> cell carcinoma (8312) (renal cell identifies the affected organ system
> rather than the histologic cell type) in one portion of the report and
> clear cell carcinoma (8310) (a histologic cell type) in another
> section of the report. Code clear cell carcinoma (8310); renal cell
> carcinoma (8312) refers to the renal system rather than the cell type,
> so renal cell is the less specific code.

6.  Code the **majority** of tumor.

> a\. Based on the pathology report description of the tumor.
>
> b\. Based on the use of majority terms. See definition for majority
> terms.

7.  Code the **numerically** **higher** ICD-O-3 code. This is the rule
    with the lowest priority and should be used infrequently.

######## Histology Coding Rules for Multiple Tumors with Different Behaviors in the Same Organ Reported as a Single Primary

1.  Code the histology of the invasive tumor when one lesion is in situ
    (/2) and the other is invasive (/3).

> ***Example:*** At mastectomy for removal of a 2 cm invasive ductal
> carcinoma, an additional 5 cm area of intraductal carcinoma was noted.
> Code histology and behavior as invasive ductal carcinoma (8500/3).

######## Histology Coding Rules for Multiple Tumors in Same Organ Reported as a Single Primary

1.  Code the histology when multiple tumors have the same histology.

2.  Code the histology to adenocarcinoma (8140/\_; in situ or invasive)
    when there is an adenocarcinoma and an adenocarcinoma in a polyp
    (8210/\_, 8261/\_, 8263/) in the same segment of the colon or
    rectum.

3.  Code the histology to carcinoma (8010/\_; in situ or invasive) when
    there is a carcinoma and a carcinoma in a polyp (8210/\_) in the
    same segment of the colon or rectum.

4.  Use a **combination** code for the following:

    a.  Bladder: Papillary and urothelial (transitional cell) carcinoma
        (8130)

    b.  Breast: Paget Disease and duct carcinoma (8541)

    c.  Breast: Duct carcinoma and lobular carcinoma (8522)

    d.  Thyroid: Follicular and papillary carcinoma (8340)

5.  Code the more specific term when one of the terms is 'NOS' and the
    other is a more specific description of the same histology.

6.  Code all other multiple tumors with different histologies as
    multiple primaries.

**How to determine same vs different histologies for benign and
borderline primary intracranial and CNS tumors (C70.0-C72.9,
C75.1-C75.3)** **(Based on histologic groupings)**

When there are **multiple tumors**, use the following table to determine
if the tumors are the same histology or different histologies.

**Histologic groupings to determine same histology for non-malignant
brain tumors**

  -----------------------------------------------------------------------
  **Histologic Group**                  **ICD-O-3 Code**
  ------------------------------------- ---------------------------------
  Choroid plexus neoplasm               9390/0, 9390/1

  Ependymoma                            9383, 9394, 9444

  Neuronal and neuronal-glial neoplasm  9384, 9412, 9413, 9442, 9505,
                                        9506

  Neurofibroma                          9540/0, 9540/1, 9541, 9550, 9560

  Neurinomatosis                        9560

  Neurothekeoma                         9562

  Neuroma                               9570

  Perineurioma, NOS                     9571
  -----------------------------------------------------------------------

**Instructions for Using Histologic Group Table**

1.  **Both** histologies are listed **in** the **table**

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a.  Histologies that are in the same **grouping** or row in the table
    are the **same histology**.

> ***Note:*** Histologies that are in the same grouping are a
> progression, differentiation or subtype of a single histologic
> category.

b.  Histologies listed in **different groupings** in the table

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```
2.  One or both of the **histologies** is **not** listed **in** the
    **table** are **different histologies**.

```{=html}
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```
a.  If the **ICD-O-3 codes** for both histologies have the **identical**
    first three digits, the histologies are the **same**.

b.  If the first three digits of the **ICD-O-3** histology code are
    **different**, the histology types are different.

## Leukemia/Lymphoma (Chronic Lymphocytic Leukemia \[CLL} and Small Lymphocytic Lymphoma \[SLL\])

1.  Code the diagnosis of chronic lymphocytic leukemia (9823/3) and/or
    small lymphocytic lymphoma (9670/3) to SLL if there are positive
    lymph nodes or deposits of lymphoma/leukemia in organs or in other
    tissue. Code the histology to CLL if there are no physical
    manifestations of the disease other than a positive blood study or
    positive bone marrow.

**Behavior Code**

> **Item Length: 1**
>
> **NAACCR Item #: 523**
>
> **NAACCR Name: Behavior Code ICD-O-3**

SEER requires registries to collect malignancies with in situ /2 and
malignant /3 behavior codes as described in ICD-O-3. SEER requires
registries to collect benign /0 and borderline /1 intracranial and CNS
tumors for cases diagnosed on or after 1/1/2004. Behavior is the fifth
digit of the morphology code after the slash (/). See ICD-O-3 (page 66)
for a discussion of the behavior code.

**Codes**

0 Benign (Reportable for intracranial and CNS sites only)

1 Uncertain whether benign or malignant, borderline malignancy, low
malignant potential, and uncertain malignant potential (Reportable for
intracranial and CNS sites only)

2 Carcinoma in situ; intraepithelial; noninfiltrating; noninvasive

3 Malignant, primary site (invasive)

**Coding Instructions**

> Behavior codes 0 (benign) and 1 (borderline) are reportable for
> intracranial and CNS sites only, beginning with January 1, 2004
> diagnoses.
>
> **Metastatic or Nonprimary Sites**
>
> Cases reported to SEER cannot have a metastatic (/6) behavior code. If
> the only pathologic specimen is from a **metastatic** site, code the
> appropriate histology code and the malignant behavior code /3. The
> primary site and its metastatic site(s) have the same basic histology.
>
> **In situ**
>
> Clinical evidence alone cannot identify the behavior as in situ; the
> code must be based on pathologic examination and documentation.
>
> **In situ and Invasive**
>
> Code the behavior as malignant /3 if any portion of the primary tumor
> is invasive no matter how limited; i.e. microinvasion.
>
> ***Example:*** Pathology from mastectomy: Large mass composed of
> intraductal carcinoma with a single focus of invasion. Code the
> behavior as malignant /3.

###### ICD-O-3 Histology/Behavior Code Listing

> ICD-O-3 may have only one behavior code, either in situ /2 or
> malignant /3, listed for a specific histology. If the pathology report
> describes the histology as in situ /2 and the ICD-O-3 histology code
> is only listed with a malignant /3 behavior code, assign the histology
> code listed and change the behavior code to in situ /2. If the
> pathology report describes histology as malignant /3 and the ICD-O-3
> histology code is only listed with an in situ /2 behavior code, assign
> the histology code listed and change the behavior code to malignant
> /3. See the Morphology and Behavior Code Matrix discussion on page 29
> in ICD-O-3.
>
> ***Example***: The pathology report says large cell carcinoma in situ.
> The ICD-O-3 lists large cell carcinoma as 8013/3; there is only a
> malignant listing. Change the /3 to /2 and code the histology and
> behavior code to 8013/2 as specified by the physician.

###### Synonyms for In situ

> AIN III (C211)
>
> Behavior code '2'
>
> Bowen disease (not reportable for C440-C449)
>
> Clark level I for melanoma (limited to epithelium)
>
> Confined to epithelium
>
> Hutchinson melanotic freckle, NOS (C44\_)
>
> Intracystic, non-infiltrating
>
> Intraductal
>
> Intraepidermal, NOS
>
> Intraepithelial, NOS
>
> Involvement up to, but not including the basement membrane
>
> Lentigo maligna (C44\_)
>
> Lobular, noninfiltrating (C50\_)
>
> Noninfiltrating
>
> Noninvasive
>
> No stromal invasion/involvement
>
> Papillary, noninfiltrating or intraductal
>
> Precancerous melanosis (C44\_)
>
> Queyrat erythroplasia (C60\_)
>
> Stage 0 (except Paget's disease (8540/3) of breast and colon or rectal
> tumors confined to the lamina propria)
>
> VAIN III (C529)
>
> VIN III (C51\_)

**Grade, Differentiation or Cell Indicator**

> **Item Length: 1**
>
> **NAACCR Item #: 440**
>
> **NAACCR Name: Grade**

**Grade, Differentiation (Codes 1, 2, 3, 4, 9)**

Pathologic testing determines the grade, or degree of differentiation,
of the tumor. For cancers, the grade is a measurement of how closely the
tumor cells resemble the parent tissue (organ of origin). Well
differentiated tumor cells closely resemble the tissue from the organ of
origin. Poorly differentiated and undifferentiated tumor cells are
disorganized and abnormal looking; they bear little or no resemblance to
the tissue from the organ of origin.

Pathologists describe the tumor grade by levels of similarity.
Pathologists may define the tumor by describing two levels of similarity
(two-grade system which may be used for colon); by describing three
levels of similarity (three-grade system); or by describing four levels
of similarity (four-grade system). The four-grade system describes the
tumor as grade I, grade II, grade III, and grade IV (also called well
differentiated, moderately differentiated, poorly differentiated, and
undifferentiated/anaplastic). These similarities/differences may be
based on pattern (architecture), cytology, or nuclear features or a
combination of these elements depending upon the grading system that is
used. The information from this data item is useful for determining
prognosis.

**Cell Indicator (Codes 5, 6, 7, 8, 9)**

Describes the lineage or phenotype of the cell that became malignant.
Cell indicator codes apply to lymphomas and leukemias and for these
diagnoses, cell indicator takes precedence over grade/differentiation.

See the ICD-O-3 chapter *Morphology* for further instructions on coding
grade.

**Codes**

1 Grade I; grade i; grade 1; well differentiated; differentiated, NOS

2 Grade II; grade ii; grade 2; moderately differentiated; moderately
well differentiated; intermediate differentiation

3 Grade III; grade iii, grade 3; poorly differentiated; dedifferentiated

4 Grade IV; grade iv; grade 4; undifferentiated; anaplastic

5 T-cell; T-precursor

6 B-Cell; Pre-B; B-precursor

7 Null cell; Non T-non B

8 NK cell (natural killer cell) (effective with diagnosis 1/1/1995 and
after)

9 Grade/differentiations unknown, not stated, or not applicable

######## General Coding Rules

1.  The site-specific coding guidelines in Appendix C also include rules
    for coding grade for the following primary sites: prostate, kidney,
    lymphoma, leukemia, astrocytoma, and sarcoma.

2.  Code the grade from the final diagnosis in the pathology report. If
    there is more than one path report, and the grades in the final
    diagnoses differ, code the highest grade for the primary site from
    any pathology report.

3.  If grade is not stated in the final pathology diagnosis, use the
    information in the microscopic section, addendum, or comment to code
    grade.

4.  If more than one grade is recorded for a single tumor, code the
    highest grade, even if it is a focus.

> ***Example:*** Pathology report reads: Grade II adenocarcinoma with a
> focus of undifferentiated adenocarcinoma. Code the tumor grade as
> grade 4.

5.  Code the grade from the **primary tumor** only, never from a
    metastatic site or a recurrence.

6.  Code the grade for all **unknown** **primaries** to 9 (unknown
    grade) unless grade is explicit by histology (i.e. anaplastic
    carcinoma (grade = 4).

7.  Code the grade of the invasive component when the tumor has **both
    in situ** and **invasive** portions. If the **invasive** component
    **grade** is **unknown**, code the grade as unknown (9).

8.  Code the information from the **consult** if the specimen is sent to
    a specialty pathology department for a consult.

9.  If there are **multiple** **pathology** **consults**, ask the
    pathologist or physician advisor to determine which information
    should be used.

10. Do **not** **code** the grade assigned to **dysplasia**, i.e.: High
    grade dysplasia (adenocarcinoma in situ) would be coded to 9
    (unknown grade).

######## Coding Grade for Cases without Pathology or Cytology Confirmation

> Code the grade of tumor given on a Magnetic Resonance Imaging (MRI) or
> Positron Emission Tomography (PET) report if there is no tissue
> diagnosis (pathology or cytology report). Use the MRI or PET grade
> only when there is no tissue diagnosis.

######## In situ Tumors

In situ tumors are not always graded. Code the grade if it is specified
for an in situ lesion unless there is an invasive component. Do not code
the in situ grade if the tumor has both in situ and invasive components.

Terminology Conversion Table

> 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 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                 |
+------------------+----------------------------+---------------------+

> **Do not use for breast primaries**

**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.

###### Kidney Cancer

###### Priority Order for Coding Kidney Cancer Grade

Code grade in the following priority order:

1.  Fuhrman's grade

2.  Nuclear grade

3.  Terminology (well diff, mod diff)

4.  Histologic grade (grade 1, grade 2)

These prioritization rules do not apply to Wilms tumor (8960). Use the
general rules for coding grade for Wilms tumor.

###### Prostate

###### Priority Rules for Coding Prostate Cancer Grade

> Code grade in the following priority order:

1.  Gleason's grade (Use the table to convert Gleason's grade
    information into the appropriate code)

2.  Terminology

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

3.  Histologic grade

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

4.  Nuclear grade only

> **Gleason's Pattern**
>
> Prostate cancers are commonly graded using Gleason's score or pattern.
> Gleason's grading is based on a 5-component system, meaning it is
> based on 5 histologic patterns. The pathologist will evaluate the
> primary (majority) and secondary patterns for the tumor. The pattern
> is written as a range, with the majority pattern appearing first and
> the secondary pattern as the last number
>
> ***Example:*** A Gleason pattern of 2 + 4 means that the primary
> pattern is 2 and the secondary pattern is 4.
>
> **Gleason's Score**
>
> The patterns are added together to create a score.
>
> ***Example**:* If the pattern is 2 + 4, the pattern score is 6 (the
> sum of 2 and 4).

1.  If the pathology report contains only **one number**, and that
    number is **less than or equal to** **5,** it is a pattern.

2.  If the pathology report contains only **one number**, and that
    number is **greater than 5**, it is a score.

3.  If the pathology report specifies a specific **number out of a total
    of 10**, the first number given is the score.

> ***Example:*** The pathology report says "Gleason's 3/10". The
> Gleason's score would be 3.

4.  If there are **two numbers other than 10**, assume they refer to two
    patterns. The first number is the primary pattern and the second is
    the secondary pattern.

> ***Example:*** If the pathology report says "Gleason's 3 + 5," the
> Gleason's score would be 8, the sum of 3 and 5.
>
> Use the following table to convert Gleason's pattern or score into
> SEER codes:

Gleason Conversion Table

  ------------------------------------------------------------------------------
  **Gleason's      **Gleason's   **Histologic   **Terminology**      **SEER
  Score**          Pattern**     Grade**                             Code**
  ---------------- ------------- -------------- -------------------- -----------
  2, 3, 4          1, 2          I              Well differentiated  1

  5, 6             3             II             Moderately           2
                                                differentiated       

  7, 8, 9, 10      4, 5          III            Poorly               3
                                                differentiated       
  ------------------------------------------------------------------------------

> ***Note:*** Gleason's score 7 was previously coded to moderately
> differentiated (2). Effective with cases diagnosed 1/1/2003, Gleason's
> score 7 is coded to poorly differentiated (3).

###### Astrocytoma

> Grade astrocytomas according to ICD-O-3 rules

1.  Do not use the **WHO** **grade** to code this field.

2.  Do not automatically code **glioblastoma** **multiforme** as
    grade IV. If no grade is given, code unknown, 9.

3.  If **no grade** is given, code unknown, 9.

###### 

###### Lymphoma and Leukemia

1.  Do not use the terms "high grade," "low grade," and "intermediate
    grade" to code differentiation. These terms refer to histology, not
    grade.

2.  The designation of T-cell, B-cell, null cell, or NK cell has
    **precedence** over any statement of differentiation.

    a.  Code ANY statement of **T-cell**, **B-cell**, **null cell**, or
        **NK cell:**

> T-cell (**code 5**)
>
> Cortical T
>
> Mature T
>
> Pre-T
>
> Pro-T
>
> T-cell phenotype
>
> T-precursor
>
> B-Cell (**code 6**)
>
> B-cell phenotype
>
> B-precursor
>
> Pre-B
>
> Pre-pre-B
>
> Pro-B
>
> Null-Cell; Non-T-non-B (**code 7**)
>
> Null-cell
>
> Non T-non-B
>
> Common cell
>
> NK (Natural Killer) cell (code 8)
>
> NK/T cell
>
> Cell type not determined, not stated or not applicable (code 9)
>
> Combined B cell and T cell
>
> b\. Use any source to code information on cell type whether or not
> marker studies are documented in the patient record.
>
> ***Example:*** The history portion of the medical record documents
> that the patient has a T-cell lymphoma. There are no marker studies on
> the chart. Code the grade as T-cell.

# Sarcoma

> If sarcomas are graded low, intermediate or high grade by the
> pathologist use the three-grade system table.
>
> **ICD-O-2 Conversion Flag**
>
> **Item Length: 1**
>
> **NAACCR Item #: 1980**
>
> **NAACCR Name: ICD-O-2 Conversion Flag**

For cases diagnosed 2001 and forward, this computer generated code
reflects how the conversion of site and morphology codes from ICD-O-3 to
ICD-O-2 was accomplished. This flag refers to conversion of ICD-O-3 to
ICD-O-2 and placement of the converted morphology data into the ICD-O-2
morphology field. The original ICD-O-3 code is retained.

**Codes**

5 Morphology converted from ICD-O-3 to ICD-O-2 without review

6 Morphology converted from ICD-O-3 to ICD-O-2 with review

Blank Not converted

> **ICD-O-3 Conversion Flag**
>
> **Item Length: 1**
>
> **NAACCR Item #: 2116**
>
> **NAACCR Name: ICD-O-3 Conversion Flag**

This is a computer generated code specifying how the conversion of site
and morphology codes from ICD-O-2 to ICD-O-3 was accomplished.

**Codes**

0 Morphology (Morph\--Type&Behav ICD-O-3 originally coded in ICD-O-3

1 Morphology (Morph\--Type&Behav ICD-O-3 converted from
(Morph\--Type&Behav ICD-O-2 without review

3 Morphology (Morph\--Type&Behav ICD-O-3 converted from
(Morph\--Type&Behav ICD-O-2 with review

Blank Not converted

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> **SECTION V**

**COLLABORATIVE STAGING AND CODING INSTRUCTIONS**

From version 1.0

**This page left blank**

**INTRODUCTION**

The Collaborative Staging System is a carefully selected set of data
items that describe how far a cancer has spread at the time of
diagnosis. Most of the data items have traditionally been collected by
cancer registries, including tumor size, extension, lymph node status,
and metastatic status. New items were created to collect information
necessary for the conversion algorithms, including the evaluation fields
that describe how the collected data were determined, and
site/histology-specific factors that are necessary to derive the final
stage grouping for certain primary cancers. In addition to the items
coded by the registrar, this unified data set also includes several data
items derived from the computer algorithms that classify each case in
multiple staging systems: the sixth edition of the AJCC TNM system
(TNM), Summary Stage 1977 (SS77), and SEER Summary Stage 2000 (SS2000).

AJCC TNM staging provides forward flexibility and clinical utility for
individual cancer cases. TNM is dynamic and is changed periodically to
meet the decision-making needs of clinicians regarding appropriate
treatment methods and the evaluation of their results. The AJCC TNM
staging system uses three basic descriptors that are then grouped into
stage categories. The first component is AT,@ which describes the extent
of the primary tumor. The next component is AN,@ which describes the
absence or presence and extent of regional lymph node metastasis. The
third component is AM,@ which describes the absence or presence of
distant metastasis. The final stage groupings (determined by the
different permutations of AT,@ AN,@ and AM@) range from Stage 0 through
Stage IV. The stage group is generated when specific criteria are met in
the TNM system, for example, prostate cancer stage grouping will only be
generated for adenocarcinomas. When a case does not meet the criteria
for stage grouping, the result will be reported as Not Applicable. An
example of this type of case is leiomyosarcoma of the uterus, which is
specifically excluded from TNM staging in both the uterus and the soft
tissue sarcoma chapter. The Collaborative Staging System is based on,
and compatible with, the terminology and staging in the sixth edition of
the *AJCC Cancer Staging Manual*,^1^ published in 2002. The general
rules of the TNM system have been incorporated into the general rules
for Collaborative Staging.

Summary Staging provides a measure for cancer surveillance with
longitudinal stability for population-based cancer registries. Summary
staging is a single digit system and has only eight categories: in situ,
local, regional to lymph nodes, regional by direct extension, both
regional lymph nodes and regional extension, regional not otherwise
specified, distant, and unknown. It is less complex than other staging
systems and was developed for registrars and epidemiologists who want
some information on stage but did not wish to collect the more detailed
EOD or TNM system. Summary Staging can be useful when a series of cases
is so small that only general categories produce enough data for
meaningful analysis. The version of Summary Staging commonly used dates
from 1977^2^; the site-specific sections were revised and updated in a
new edition published in 2001^3^.

The Collaborative Staging System uses a modified EOD format to collect
information about each case. The SEER Extent of Disease (EOD)^4^ coding
system provided longitudinal stability for epidemiological and cancer
control studies. More detailed than the Summary Staging System, EOD was
developed to assure consistency over time as other staging systems
changed. EOD also allows collected data to be collapsed into different
and previous staging systems. SEER EOD is a five-field, 10 digit system:
tumor size (3 digits), extension of the primary tumor (2 digits),
regional lymph node involvement (highest specific lymph node chain
involved by tumor) (1 digit), the number of pathologically reviewed
regional lymph nodes that are positive (2 digits), and the number of
pathologically examined regional lymph nodes (2 digits).

**CHANGES IN ABSTRACTING RULES**

> **Note:** This introductory discussion refers to schemas based on
> primary site when in fact some schemas, such as melanoma and lymphoma,
> are based on histologic type. The schemas are referred to as
> site-specific for the sake of brevity.

Agreement among the participating organizations has resulted in
resolution of the rule for timing of data collection and the development
of standardized coding rules so that a single format can be used to
collect stage information. The timing rule effective 1/1/2004 for
Collaborative Staging is: Ause all information gathered through
completion of surgery(ies) in first course of treatment, or all
information available within four months of the date of diagnosis in the
absence of disease progression, whichever is *longer*.@ This timing rule
change allows the CS Data Set to derive a Abest stage@ using pathologic
data supplemented by clinical data.

Disease progression is defined as further direct extension or distant
metastasis known to have developed after the diagnosis was established.
Information about tumor extension, lymph node involvement, or distant
metastasis obtained after disease progression is documented should be
excluded from the Collaborative Staging fields. Collaborative Staging
represents the aggregate information obtained during the period of
diagnosis and work-up, not just the initial contact with the patient.
For example, within the limits of the timing rule, if further diagnostic
tests show more precise extension or a more precise tumor size, this
revised information is not considered disease progression. In other
words, Collaborative Staging does not consider as disease progression a
change from lack of evidence of disease (status unknown) to known status
of disease (negative or positive). However, a change from negative
status to positive, is disease progression. Take, for example, an
asymptomatic patient who is treated surgically. She then develops bone
pain and is found to have osseous metastases within a few weeks of
surgery. This would be considered disease progression because she was
asymptomatic at the time her treatment decisions were made. Furthermore,
if the treatment plan is discontinued or changed due to a revised
disease status, this is progression of disease and collection of
Collaborative Staging information stops at this point.

Other rule modifications have been made and are printed in the
site/histology-specific chapters.

In the process of bringing together the principles of Summary Stage, the
TNM categories and stage groupings, and the SEER Extent of Disease
coding structure, the Collaborative Staging System has also attempted to
update abstracting rules to deal with the contemporary health care
environment, in which completeness of staging documentation in the
medical record has become an issue. In many circumstances, a patient=s
insurance will not pay for an imaging study or lab test that is expected
to be negative but may otherwise be considered part of an \>ideal=
cancer staging workup. Similarly, the content of clinician notes has
changed over time to simply report any symptomatic, suspicious, or
involved areas rather than chronicle every body part that is normal.
This change in documentation is a source of frustration to data
collectors who rely on statements of normalcy or negativity to establish
the boundaries of how far the cancer has spread.

When clinical practice changes and data collection guidelines do not,
the completeness of the data is affected. The implementation of the
Collaborative Staging System introduces a paradigm shift in the
collection of information documenting the extent of disease,
particularly in the collection of information about regional lymph nodes
or distant metastases for primary sites not easily examined by
palpation, observation, physical examination, or other clinical methods.
These \>inaccessible= primary sites include (but are not limited to)
bladder, kidney, prostate, esophagus, stomach, lung, liver, corpus
uteri, and ovary.

The Collaborative Staging System allows data collectors to record
regional lymph nodes as negative (based on clinical evaluation) rather
than unknown when there is no mention of regional lymph node involvement
in the physical examination, pre-treatment diagnostic testing or
surgical exploration, and the patient receives what would be usual
treatment to the primary site (treatment appropriate to the stage of
disease as determined by the physician). The basis for this shift in the
approach to information missing from the medical record is that
typically the clinician reports positive findings and tends to remain
silent on some or all negative findings. This new coding guideline also
allows data collectors to record distant metastasis clinically as none
rather than unknown (again, based on clinical evaluation) when the
clinician proceeds with usual treatment of the primary site, since this
action presumes the absence of distant metastasis that would otherwise
change the treatment approach.

These guidelines apply primarily to localized or early (T1, T2) stage in
the TNM system for inaccessible primary sites such as those mentioned
previously. The code(s) for unknown information can and should be used
in situations where there is reasonable doubt that the tumor is no
longer localized. An example would be when there is clinical evidence
that a prostate cancer has penetrated through the capsule into the
surrounding tissues (regional direct extension/T3a) and regional lymph
node involvement is not mentioned.

By coding regional lymph nodes as negative and/or coding distant
metastasis as none rather than coding these fields as unknown, the
Collaborative Staging System computer algorithms will be able to derive
a stage group that includes the best information.

For accessible primary sites that can be observed, palpated or examined
without instruments, such as breast, oral cavity, skin, salivary gland,
thyroid, and other organs, there should be some description of the
regional lymph nodes. A statement such as Aremainder of examination
negative@ is sufficient to code regional lymph nodes as clinically
negative.

In summary, the developers of the CS model believe that it will improve
the quality of data being collected by the cancer registry community.
Uniform rules and standardized training will make it easier for cancer
registry personnel to complete staging tasks.

**HOW THE COLLABORATIVE STAGING SYSTEM WORKS**

For each cancer case, the data collector determines the site of origin
or general histology for the cancer. The data items specific to that
cancer site/histology are extracted from the medical record and coded in
the Collaborative Staging System fields. When data collection is
complete, the data collector activates the computer algorithms to derive
the values for the items in the TNM system and Summary Stage (both 1977
and 2000). These algorithms are provided in portable
platform-independent form by the Task Force. The classification or stage
of each tumor is actually determined by the computer in a consistent and
accurate manner (see Mapping and the Computer Algorithm, below).

Table 1 lists the individual Collaborative Staging data items, both
input and derived, together with their NAACCR item number, length and
other information, as published in the NAACCR Standards Volume II
Version 10.1, Chapter X, Data Descriptor Table (revised November 2003).

**Mapping and the Computer Algorithm**

Once the data collector has coded all of the Collaborative Staging
System elements for a case (the input values), the coded values are
passed to a computer program that generates the correct stage for the
case in three systems: AJCC TNM, 6th edition; SEER Summary Stage 1977;
and SEER Summary Stage 2000. The program returns a set of values for the
set of output items included in Table 1.

The output values are returned as a set of numeric codes designed for
storage in the computerized abstract. Each of the numeric codes is also
provided with a display value, or English language character string
showing the meaning of the code. For example, a returned value of 12 for
T means T1a, and a 15 means T1b.

The computer algorithm that generates the stages is based on the values
in the mapping columns for each of the Collaborative Staging System data
elements. Mapping is provided from each code to the appropriate category
in TNM and each summary stage. Some schemas require reference to two or
more tables to determine the appropriate category. The mapping column
either contains the category or a pointer to a further table where the
category can be determined. Once each of the categories is determined, a
further step is performed to generate the final stage groups. Although
the data collector does not code the stage groups directly, the rules by
which the stages are derived are explicit in all of the tables, and the
logic that the computer program follows should be fully evident from the
tables available to the data collector.

As part of the output of the CS algorithm, two additional fields should
be stored by the computer in the CS data base: CS Version 1^st^ and CS
Version Latest. CS Version 1^st^ is the number of the version initially
used to code CS fields and may be updated if cases are recoded, for
example for a special study, using a later version of the Collaborative
Staging manual. Depending on the structure of the registry software, CS
Version 1^st^ could be stored automatically by the computer or entered
manually by the abstractor. The meaning and interpretation of CS Version
1st will be dependent on vendor implementation and local practices. This
field should be interpreted with caution in a dataset where the actual
coding procedures are unknown. CS Version Latest is the number of the
version of the CS algorithm used most recently to derive the CS output
fields and should be updated by the computer (rather than manually)
every time the CS Derived items are re-computed.

**Table 1. Allowable Values and Format for Collaborative Staging Data
Items**

+-------------+---------+-----+------------+--------+------+----------+
| **INPUT     |         |     |            |        |      |          |
| ITEMS**     |         |     |            |        |      |          |
+=============+=========+=====+============+========+======+==========+
| **Data Item | *       | **  | *          | *      | *    | **NAACCR |
| Name**      | *NAACCR | Cha | *Allowable | *Right | *Bla | Ver      |
|             | Data    | r-a | Values**   | Justif | nks: | 10.1**   |
|             | Item    | cte |            | ied,** | Yes  |          |
|             | N       | r** | **(sit     |        | or   | **Column |
|             | umber** |     | e-specific | **Zero | No** | \#**     |
|             |         | *   | unless     | fi     |      |          |
|             |         | *Le | otherwise  | lled** |      |          |
|             |         | ngt | stated)**  |        |      |          |
|             |         | h** |            |        |      |          |
+-------------+---------+-----+------------+--------+------+----------+
| CS Tumor    | 2800    | 3   | 000-999    | Yes    | No   | 629-631  |
| Size        |         |     |            |        |      |          |
+-------------+---------+-----+------------+--------+------+----------+
| CS          | 2810    | 2   | 00-99      | Yes    | No   | 632-633  |
| Extension   |         |     |            |        |      |          |
+-------------+---------+-----+------------+--------+------+----------+
| CS Tumor    | 2820    | 1   | 0-9        | N/A    | No   | 634-634  |
| Size/Ext    |         |     |            |        |      |          |
| Eval        |         |     |            |        |      |          |
+-------------+---------+-----+------------+--------+------+----------+
| CS Lymph    | 2830    | 2   | 00-99      | Yes    | No   | 635-636  |
| Nodes       |         |     |            |        |      |          |
+-------------+---------+-----+------------+--------+------+----------+
| CS Reg      | 2840    | 1   | 0-9        | N/A    | No   | 637-637  |
| Nodes Eval  |         |     |            |        |      |          |
+-------------+---------+-----+------------+--------+------+----------+
| Regional    | 830     | 2   | 00-90, 95, | Yes    | No   | 541-542  |
| Nodes       |         |     | 96, 97,    |        |      |          |
| Examined    |         |     | 98, 99     |        |      |          |
|             |         |     | (all       |        |      |          |
|             |         |     | sites)     |        |      |          |
+-------------+---------+-----+------------+--------+------+----------+
| Regional    | 820     | 2   | 00-90, 95, | Yes    | No   | 539-540  |
| Nodes       |         |     | 97, 98, 99 |        |      |          |
| Positive    |         |     | (all       |        |      |          |
|             |         |     | sites)     |        |      |          |
+-------------+---------+-----+------------+--------+------+----------+
| CS Mets At  | 2850    | 2   | 00-99      | Yes    | No   | 638-639  |
| Dx          |         |     |            |        |      |          |
+-------------+---------+-----+------------+--------+------+----------+
| CS Mets     | 2860    | 1   | 0-9        | N/A    | No   | 640-640  |
| Eval        |         |     |            |        |      |          |
+-------------+---------+-----+------------+--------+------+----------+
| CS          | 2880    | 3   | 000-999    | Yes    | No   | 641-643  |
| Si          |         |     |            |        |      |          |
| te-Specific |         |     |            |        |      |          |
| Factor 1    |         |     |            |        |      |          |
+-------------+---------+-----+------------+--------+------+----------+
| CS          | 2890    | 3   | 000-999    | Yes    | No   | 644-646  |
| Si          |         |     |            |        |      |          |
| te-Specific |         |     |            |        |      |          |
| Factor 2    |         |     |            |        |      |          |
+-------------+---------+-----+------------+--------+------+----------+
| CS          | 2900    | 3   | 000-999    | Yes    | No   | 647-649  |
| Si          |         |     |            |        |      |          |
| te-Specific |         |     |            |        |      |          |
| Factor 3    |         |     |            |        |      |          |
+-------------+---------+-----+------------+--------+------+----------+
| CS          | 2910    | 3   | 000-999    | Yes    | No   | 650-652  |
| Si          |         |     |            |        |      |          |
| te-Specific |         |     |            |        |      |          |
| Factor 4    |         |     |            |        |      |          |
+-------------+---------+-----+------------+--------+------+----------+
| CS          | 2920    | 3   | 000-999    | Yes    | No   | 635-655  |
| Si          |         |     |            |        |      |          |
| te-Specific |         |     |            |        |      |          |
| Factor 5    |         |     |            |        |      |          |
+-------------+---------+-----+------------+--------+------+----------+
| CS          | 2930    | 3   | 000-999    | Yes    | No   | 656-658  |
| Si          |         |     |            |        |      |          |
| te-Specific |         |     |            |        |      |          |
| Factor 6    |         |     |            |        |      |          |
+-------------+---------+-----+------------+--------+------+----------+

**Table 1 continued. Allowable Values and Format for Collaborative
Staging Data Items**

+------------+--------+-------+-----------+-------+-------+---------+
| **OUTPUT   |        |       |           |       |       |         |
| ITEMS**    |        |       |           |       |       |         |
+------------+--------+-------+-----------+-------+-------+---------+
| **Data     | **     | **Ch  | **        | **    | **Bl  | *       |
| Item       | NAACCR | ar-ac | Allowable | Right | anks: | *NAACCR |
| Name**     | Data   | ter** | Values**  | Justi | Yes   | Ver     |
|            | Item   |       |           | fied, | or    | 10.1**  |
|            | Nu     | **Len |           | Zero  | No**  |         |
|            | mber** | gth** |           | fil   |       | *       |
|            |        |       |           | led** |       | *Column |
|            |        |       |           |       |       | \#**    |
+------------+--------+-------+-----------+-------+-------+---------+
| Derived    | 2940   | 2     | 00, 01,   | N/A   | N/A   | 659-660 |
| AJCC T     |        |       | 05, 06,   |       |       |         |
|            |        |       | 07, 10,   |       |       |         |
|            |        |       | 11, 12,   |       |       |         |
|            |        |       | 13, 14,   |       |       |         |
|            |        |       | 15, 16,   |       |       |         |
|            |        |       | 17, 18,   |       |       |         |
|            |        |       | 19, 20,   |       |       |         |
|            |        |       | 21, 22,   |       |       |         |
|            |        |       | 23, 29,   |       |       |         |
|            |        |       | 30, 31,   |       |       |         |
|            |        |       | 32, 33,   |       |       |         |
|            |        |       | 39, 40,   |       |       |         |
|            |        |       | 41, 42,   |       |       |         |
|            |        |       | 43, 44,   |       |       |         |
|            |        |       | 49, 88,   |       |       |         |
|            |        |       | 99        |       |       |         |
+------------+--------+-------+-----------+-------+-------+---------+
| Derived    | 2960   | 2     | 00, 01,   | N/A   | N/A   | 662-663 |
| AJCC N     |        |       | 02, 03,   |       |       |         |
|            |        |       | 04, 09,   |       |       |         |
|            |        |       | 10, 11,   |       |       |         |
|            |        |       | 12, 13,   |       |       |         |
|            |        |       | 18, 19,   |       |       |         |
|            |        |       | 20, 21,   |       |       |         |
|            |        |       | 22, 23,   |       |       |         |
|            |        |       | 29, 30,   |       |       |         |
|            |        |       | 31, 32,   |       |       |         |
|            |        |       | 33, 39,   |       |       |         |
|            |        |       | 88, 99    |       |       |         |
+------------+--------+-------+-----------+-------+-------+---------+
| Derived    | 2980   | 2     | 00, 10,   | N/A   | N/A   | 665-666 |
| AJCC M     |        |       | 11, 12,   |       |       |         |
|            |        |       | 13, 19,   |       |       |         |
|            |        |       | 88, 99    |       |       |         |
+------------+--------+-------+-----------+-------+-------+---------+
| Derived    | 2950   | 1     | c, p, a,  | N/A   | N/A   | 661-661 |
| AJCC T     |        |       | y         |       |       |         |
| Descriptor |        |       |           |       |       |         |
+------------+--------+-------+-----------+-------+-------+---------+
| Derived    | 2970   | 1     | c, p, a,  | N/A   | N/A   | 664-664 |
| AJCC N     |        |       | y         |       |       |         |
| Descriptor |        |       |           |       |       |         |
+------------+--------+-------+-----------+-------+-------+---------+
| Derived    | 2990   | 1     | c, p, a,  | N/A   | N/A   | 667-667 |
| AJCC M     |        |       | y         |       |       |         |
| Descriptor |        |       |           |       |       |         |
+------------+--------+-------+-----------+-------+-------+---------+
| Derived    | 3000   | 2     | 00, 01,   | N/A   | N/A   | 668-669 |
| AJCC Stage |        |       | 02, 10,   |       |       |         |
| Group      |        |       | 11, 12,   |       |       |         |
|            |        |       | 13, 14,   |       |       |         |
|            |        |       | 15, 16,   |       |       |         |
|            |        |       | 17, 18,   |       |       |         |
|            |        |       | 19, 20,   |       |       |         |
|            |        |       | 21, 22,   |       |       |         |
|            |        |       | 23, 24,   |       |       |         |
|            |        |       | 30, 31,   |       |       |         |
|            |        |       | 32, 33,   |       |       |         |
|            |        |       | 34, 35,   |       |       |         |
|            |        |       | 36, 37,   |       |       |         |
|            |        |       | 38, 39,   |       |       |         |
|            |        |       | 40, 41,   |       |       |         |
|            |        |       | 42, 43,   |       |       |         |
|            |        |       | 50, 51,   |       |       |         |
|            |        |       | 52, 53,   |       |       |         |
|            |        |       | 54, 55,   |       |       |         |
|            |        |       | 56, 57,   |       |       |         |
|            |        |       | 58, 59,   |       |       |         |
|            |        |       | 60, 61,   |       |       |         |
|            |        |       | 62, 63,   |       |       |         |
|            |        |       | 70, 71,   |       |       |         |
|            |        |       | 72, 73,   |       |       |         |
|            |        |       | 74, 88,   |       |       |         |
|            |        |       | 90, 99    |       |       |         |
+------------+--------+-------+-----------+-------+-------+---------+
| Derived    | 3030   | 1     | Blank, 1, | N/A   | Yes   | 672-672 |
| AJCC Flag  |        |       | 2         |       |       |         |
+------------+--------+-------+-----------+-------+-------+---------+
| Derived    | 3010   | 1     | Blank, 0, | N/A   | Yes   | 670-670 |
| SS1977     |        |       | 1, 2, 3,  |       |       |         |
|            |        |       | 4, 5, 7,  |       |       |         |
|            |        |       | 8, 9      |       |       |         |
+------------+--------+-------+-----------+-------+-------+---------+

  ------------- --------- -------- --------------- -------- -------- ----------
  Derived       3040      1        Blank, 1, 2     N/A      Yes      673-673
  SS1977 Flag                                                        

  Derived       3020      1        Blank, 0, 1, 2, N/A      Yes      671-671
  SS2000                           3, 4, 5, 7, 8,                    
                                   9                                 

  Derived       3050      1        Blank, 1, 2     N/A      Yes      674-674
  SS2000 Flag                                                        

  CS Version    2935      6        000000-999999   N/A      No       705-710
  1^st^                                                              

  CS Version    2936      6        000000-999999   N/A      No       711-716
  Latest                                                             
  ------------- --------- -------- --------------- -------- -------- ----------

**How Mapping Was Determined**

The Collaborative Staging Task Force based its codes for the extension,
lymph nodes, and metastases fields on SEER=s Extent of Disease, which
had been designed to accommodate collapsing into TNM 3rd edition and the
SEER Summary Stages. Some fundamental restructuring of the EOD codes was
necessary to accommodate the sixth edition of TNM with its greater
detail and supplementary prognostic information. For example, in EOD,
all lymph node involvement (regional and distant) was coded in the lymph
nodes field. In Collaborative Staging, regional lymph node involvement
is coded in the CS lymph node field, and distant lymph node involvement
is coded with other distant metastases. In each table, codes were added
or combined where necessary to accommodate the 6th edition of TNM. The
following rules and procedures were used to determine the correct
mapping to TNM 6th edition:

-   **Downstaging rule**. The Collaborative Staging Task Force applied
    the stated rule from the AJCC manual, AIf there is doubt concerning
    the T, N, or M classification to which a particular case should be
    assigned, then the lower (less advanced) category should be
    assigned.@ When a mapping could be made to more than one
    classification, for example, T1 or T2, the mapping was always made
    to the lower or less extensive category. Occasionally this rule did
    not seem to apply, for example, when a lower category seemed to
    provide an exclusive list, while the higher category was more
    general. The downstaging rule was not applied to the assignment of
    stage group, only to the assignment of T, N, and M classification.

-   **Use of NOS.** The Collaborative Staging Task Force added NOS (not
    otherwise specified) to some of its T, N, M, and stage group
    categories for clarity and ease of processing. The NOS is added when
    a further breakdown of the T, N, and M permutations into subsets is
    available, but the correct subset cannot be determined. NOS can
    appear in both the descriptions of codes and the mapping. This NOS
    terminology is not official AJCC usage. The NOS can safely be
    ignored in reports and analyses when it is not a useful distinction.
    In addition, the data collector should only code to a category such
    as AStated as T1 NOS@ when the appropriate subset (e.g., T1a or T1b)
    cannot be determined.

> **Example**. For glottic larynx, T1 means ATumor limited to the vocal
> cord(s) . . . .@ T1a means tumor limited to one vocal cord, and T1b
> means tumor involves both vocal cords. In Collaborative Staging, the
> subgroup of T1 NOS is designated for use when the tumor is known to be
> limited to the vocal cords, but it cannot be determined whether one or
> both cords are involved. In Collaborative Staging, the category T1
> would be used to mean all of the T1=s, including the T1a=s, T1b=s, and
> T1 NOS=s.

**REFERENCES**

1.  Greene FL, Page DL, Fleming ID et al. *AJCC Cancer Staging Manual,
    sixth edition.* American Joint Committee on Cancer. New York:
    Springer-Verlag, 2002.

2.  Shambaugh EM and Weiss MA. SEER Summary Staging Guide 1977.
    Bethesda, MD: National Cancer Institute, NIH Publication Number
    98-2313, reprinted December 1997.

3.  Young JL, Roffers SD, Ries LAG, Fritz AG, Hurlbut AA (eds). *Summary
    Staging Manual 2000: Codes and Coding Instructions.* Bethesda, MD:
    National Cancer Institute, NIH Publication Number 01-4969, 2001

4.  Fritz AG and Ries LAG (eds). *SEER Extent of Disease Coding, 1998:
    Codes and Coding Instructions, Third Edition*. Bethesda, MD:
    National Cancer Institute, NIH Publication Number 98-1999, April
    1999

**General Instructions for Using the Collaborative Staging System**

**Codes and Coding Instructions**

The Collaborative Staging System schemas consist of the 15 data fields
necessary to derive T, N, M, and Stage Group according to the sixth
edition of the *AJCC Cancer Staging Manual*; Summary Stage 1977; and
SEER Summary Stage 2000.

This manual provides codes and coding instructions for the process of
data entry. In order to derive the desired T, N, M, and Stage Group in
the TNM system or the Summary Stage(s), the computer algorithms
described in the introduction must be used. This manual provides the
logic of the computer algorithms in table format for each schema, but is
not intended to be used for generating the stages manually, because for
some sites, additional tables are necessary to determine T, N, M, or
Stage Group. These additional tables are available for review on the
Collaborative Staging web site, http://www.cancerstaging.org

These schemas apply to cases diagnosed January 1, 2004 and later. **Do
NOT use these schemas for cases diagnosed prior to January 1, 2004**;
cases diagnosed prior to 01/01/2004 should be coded to whatever coding
system was in effect at the time of diagnosis.

**GENERAL GUIDELINES**

> **Note:** These general instructions refer to schemas based on primary
> site when, in fact, some schemas, such as melanoma and lymphoma, are
> based on histologic type. The schemas are referred to as site-specific
> for the sake of brevity.

1\. Collaborative Staging is collected on all cases regardless of
whether they are microscopically confirmed. A description of the type of
diagnostic confirmation is collected in a separate data item. The
diagnostic confirmation field can be used to exclude non-microscopically
confirmed cases during analysis as necessary, since the *AJCC* *Cancer
Staging Manual* states that Aall cases should be microscopically
confirmed. Cases not microscopically confirmed should be coded from the
schema for the site/histology the clinician considers most likely to be
the primary.@

2\. Collaborative Staging is collected on all sites/histologies. Summary
Stage 1977 and Summary Stage 2000 are generated for all sites and
histologies. The TNM elements and stage group are only generated for
cases that meet the TNM criteria. For example, there is no TNM schema
for brain.

> a\. The Collaborative Staging System consists of 94 schemas, most of
> which are site-specific. Some malignancies that can develop in many
> parts of the body are coded according to the histology of the case.
> For example, all lymphomas are coded according to the lymphoma schema,
> regardless of the organ in which the lymphoma develops.

3\. All schemas apply to all histologies unless otherwise noted. Summary
Stage 1977 and Summary Stage 2000 are generated for all histologies. The
computer algorithms for determining the final TNM stage group take into
account any histologies that are excluded from TNM staging. For example,
the TNM schema for prostate applies only to adenocarcinomas. For
excluded histologies, the computer algorithm returns values representing
ANot Applicable,@ meaning that AJCC T, N, M, and Stage Group are not
generated for that site-histology combination.

4\. ***Timing of Data Collection:*** The data collected in the
Collaborative Staging System are limited to

> \$ information gathered through completion of surgery(ies) in first
> course of treatment, OR
>
> \$ all information available within four months of the date of
> diagnosis in the absence of disease progression (metastasis known to
> have developed after the diagnosis was established should be excluded)

\$ whichever is ***longer***.

5\. Site-specific and histology-specific guidelines take precedence over
general guidelines. Always read the notes pertaining to a specific site
or histology schema.

6\. For each field, code the highest applicable number. (Exception:
codes for Unknown, Not Applicable, and NOS categories such as Localized,
NOS do not take priority over more specific codes with lower numbers.)
The codes are ordered in a hierarchy so that increasing numbers
generally indicate increasing degrees of tumor involvement. The
hierarchies are not the same for the different staging systems, and
Collaborative Staging generally follows the hierarchies of the TNM
system.

> a\. Combination codes (for example, code 35 for A25 plus 30@) have
> been assigned when using the higher number does not result in the
> appropriate mapping for all three stage groups. Combination codes have
> been omitted when use of a higher number results in correct mapping
> for all three staging systems.

7\. For the fields CS Tumor Size, CS Extension, CS Lymph Nodes, and CS
Mets at DX, Collaborative Staging records the greatest extent of disease
based on combined clinical and operative/pathological assessment.

> a\. Gross observations at surgery are particularly important when all
> malignant tissue is not removed. In the event of a discrepancy between
> pathology and operative reports concerning excised tissue, priority is
> given to the pathology report.
>
> b Clinical information, such as a description of skin involvement for
> breast cancer and size of the primary lesion and distant lymph nodes
> for any site, can change the stage. Clinical information should be
> reviewed carefully to assure accurate recording of the Collaborative
> Staging data set.

8\. When the patient does not receive preoperative treatment and the
operative/pathology information disproves the clinical information, code
the operative/pathology information.

9\. When the patient does receive preoperative treatment, the greatest
extent of disease prior to the beginning of treatment should be
recorded. Preoperative, or neoadjuvant, treatment is defined as systemic
(chemotherapy, hormone therapy, or immunotherapy) treatment or radiation
therapy that is administered as an attempt to shrink the tumor, improve
resectability, or control symptoms before the patient undergoes surgery.
In the infrequent situation where post-operative disease is more
extensive despite neoadjuvant treatment, this can be coded in the method
of evaluation field for extension, regional lymph nodes or metastases at
diagnosis.

10\. The fields Reg LN Pos and Reg LN Exam are based on pathologic
(microscopic) information only.

11\. The fields CS Tumor Size/Ext Eval, CS Reg Nodes Eval, and CS Mets
Eval document how the most extensive tumor was established as well as
whether the patient received preoperative treatment.

12\. Site-Specific Factors (SSFs) are included in every schema. They are
incorporated into the staging algorithms when additional information is
necessary to derive tumor (T), lymph node (N), metastasis (M), or TNM
stage group, or where the factor is considered to be of clinical or
prognostic importance. Information formerly coded as tumor markers, such
as estrogen receptor assay or progesterone receptor assay for breast, is
coded in site-specific factors. For sites/histologies where some or all
site specific factors are not used, they are coded 888, not applicable.
Table 2 lists the schemas that require one or more Site Specific
Factors.

**Table 2. Site Specific Factors Used For Primary Site/Histology
Schemas**

+-----+--------------------+--------------------+--------------------+
| *   | *                  |                    |                    |
| *SS | *Sites/histologies |                    |                    |
| F** | where used**       |                    |                    |
+-----+--------------------+--------------------+--------------------+
| **  | **head and         | **mycosis          | **melanoma/iris    |
| 1** | neck\***           | fungoides breast** | and**              |
|     |                    |                    |                    |
|     | **colon**          | **ovary**          | **ciliary body**   |
|     |                    |                    |                    |
|     | **rectum**         | **placenta**       | **retinoblastoma** |
|     |                    |                    |                    |
|     | **liver**          | **prostate**       | **brain**          |
|     |                    |                    |                    |
|     | **pleura**         | **testis**         | **other cns**      |
|     |                    |                    |                    |
|     | **melanoma**       | **mela             | **thyroid**        |
|     |                    | noma/conjunctiva** |                    |
|     |                    |                    | **other            |
|     |                    | **                 | endocrine**        |
|     |                    | melanoma/choroid** |                    |
|     |                    |                    | **Kaposi sarcoma** |
|     |                    |                    |                    |
|     |                    |                    | **lymphoma**       |
+-----+--------------------+--------------------+--------------------+
| **  | **head and neck\*, |                    |                    |
| 2** | liver, melanoma,   |                    |                    |
|     | breast, prostate,  |                    |                    |
|     | testis, lymphoma** |                    |                    |
+-----+--------------------+--------------------+--------------------+
| **  | **head and neck\*, |                    |                    |
| 3** | melanoma, breast,  |                    |                    |
|     | prostate, testis,  |                    |                    |
|     | lymphoma**         |                    |                    |
+-----+--------------------+--------------------+--------------------+
| **  | **head and neck\*, |                    |                    |
| 4** | melanoma, breast,  |                    |                    |
|     | prostate, testis** |                    |                    |
+-----+--------------------+--------------------+--------------------+
| **  | **head and neck\*, |                    |                    |
| 5** | breast, prostate,  |                    |                    |
|     | testis**           |                    |                    |
+-----+--------------------+--------------------+--------------------+
| **  | **head and neck\*, |                    |                    |
| 6** | breast, prostate** |                    |                    |
+-----+--------------------+--------------------+--------------------+

\* head and neck includes the following schemas: upper lip; lower lip;
other lip; base of tongue; anterior tongue; upper gum; lower gum and
retromolar trigone; other gum; floor of mouth; hard palate; soft
palate/uvula; other mouth; buccal mucosa; parotid gland; submandibular
gland; other salivary glands; oropharynx; anterior surface of
epiglottis; nasopharynx; pyriform sinus/hypopharynx; other pharynx;
nasal cavity; middle ear; maxillary sinus; ethmoid sinus; other sinus;
glottic larynx; supraglottic larynx; subglottic larynx; other larynx

13\. Metastasis known to have developed after the initial extent of
disease was established (in other words, disease progression) should be
excluded when determining the farthest extent of disease at the time of
diagnosis.

14\. Autopsy reports are used in coding the Collaborative Staging System
in the same way as are pathology reports, applying the same rules for
inclusion and exclusion.

15\. The extent of disease may be described only in terms of T (tumor),
N (node), and M (metastasis) characteristics. In such cases, assign the
code in the appropriate field that corresponds to the TNM information.
If there is a discrepancy between documentation in the medical record
and the physician=s assignment of TNM, the documentation takes
precedence. Cases of this type should be discussed with the physician
who assigned the TNM.

**STRUCTURE AND FORMAT OF SITE/HISTOLOGY-SPECIFIC CODE SCHEMAS**

The schemas in this manual are listed according to the order of the
first ICD-O-3 primary site code to which a schema applies. Schemas for
which there is no TNM classification are included in ICD-O-3 sequence in
the manual. Some of the histology-based schemas appear in site code
order (for example, melanoma of the skin is with other skin schemas),
and others are at the end of the list. Two indices to the schemas are
provided at the end of this manual, one by ICD-O-3 code and the other by
common primary site and histology terms.

Within the schemas themselves, the code structures for the various
organs, lymph nodes, and other tissues are organized according to the T,
N, and M categories (T1, then T2, then T3, for example). As such, they
may not be sequential for Summary Stage definitions. Regardless of the
relative order of the codes in the schemas, the staging algorithms will
properly account for the information.

The categories of TNM are the basis for the CS Extension, CS Lymph Nodes
and CS Mets at DX fields. Tissues categorized under T in the TNM system
are listed in CS Extension and tissues categorized under M are listed in
the CS Mets at DX field. However, for the Summary Staging (1977 and/or
2000) algorithms, there may be codes in the CS Extension field that map
to regional direct extension or distant stage, and there may be codes in
CS Mets at DX that map to regional or even localized disease. The
details of the case should be coded in the fields where they are listed;
the computer algorithm is designed to generate the correct stage. It
should also be noted that information in fields other than CS Extension
may be used to derive the T, N, M and Stage Group, for example tumor
size and various site-specific factors.

**CODING ANONE@ VS. AUNKNOWN@ IN THE COLLABORATIVE STAGING SYSTEM, TNM
AND SUMMARY STAGE**

As noted in the introduction, cancers of certain primary sites are not
easily examined by palpation, observation, physical examination, or
other clinical methods. These \>inaccessible= primary sites include, but
are not limited to, bladder, kidney, prostate, esophagus, stomach, lung,
liver, corpus uteri and ovary.

A new coding rule in the Collaborative Staging System applies to these
inaccessible sites, primarily for localized or early (T1, T2) stage
cancers. The Collaborative Staging System allows data collectors to
record regional lymph nodes as negative (based on clinical evaluation)
rather than unknown when there is no mention of regional lymph node
involvement in the physical examination, pre-treatment diagnostic
testing or surgical exploration, and the patient receives what would be
usual treatment to the primary site (treatment appropriate to the stage
of disease as determined by the physician).

This new coding guideline also permits data collectors to record distant
metastasis clinically as none rather than unknown (again, based on
clinical evaluation) when the clinician proceeds with usual treatment of
the primary site, since this action presumes that there are no distant
metastasis that would otherwise change the treatment approach.

The code(s) for unknown information can and should be used in situations
where there is reasonable doubt that the tumor is no longer localized.
For example, when there is clinical evidence that a prostate cancer has
penetrated through the capsule into the surrounding tissues (regional
direct extension/T3a) and regional lymph node involvement is not
mentioned, it would be correct to code lymph node involvement and
metastases at diagnosis as unknown in the absence of any specific
information regarding nodes or distant metastases.

For accessible primary sites that can be observed, palpated or examined
without instruments, such as breast, oral cavity, skin, salivary gland,
thyroid, and other organs, there should be some description of the
regional lymph node status. A statement such as Aremainder of
examination negative@ is sufficient to code regional lymph nodes as
clinically negative.

**CHOOSING THE CORRECT CODING SCHEMA FOR A CASE**

Most of the Collaborative Staging System schemas apply to cases defined
by their primary site codes in ICD-O-3. A few of the schemas apply to
cases defined by their histologic type codes in ICD-O-3, and these
schemas take precedence over the schema for the site. The histologically
defined schemas are shown in Table 3.

**TABLE 3. HISTOLOGY-SPECIFIC CODING SCHEMAS**

> Melanoma (ICD-O-3 morphology codes 8720-8790)
>
> Kaposi sarcoma (9140)
>
> Retinoblastoma (9510-9514)
>
> Lymphoma (9590-9699 and 9702-9729)
>
> Mycosis Fungoides (9700-9701)
>
> Hematopoietic and reticuloendothelial system (9731-9989)

A case with one of these ICD-O-3 histologic types must be coded using
the schema for the histologic type group.

Melanomas are further broken down by primary site code, as follows:

> Malignant melanoma of the skin, vulva, penis and scrotum (C44.0-C44.9,
> C51.0-C51.2, C51.8-C51.9, C60.0-C60.1, C60.8-C60.9, C63.2)
>
> Malignant melanoma of conjunctiva (C69.0)
>
> Malignant melanoma of iris and ciliary body (C69.4)
>
> Malignant melanoma of choroid (C69.3)
>
> Malignant melanoma of other eye (C69.1, C69.2, C69.5, C69.8-C69.9)

For cases with all other histologic types, the correct schema to use is
determined by the primary site code.

Each schema clearly states the applicable primary site codes and
histologic type codes at the beginning of the schema.

> **Note:** The appropriate site or histology schema to use for coding
> surgical treatment(s) may be different from the site or histology
> schema used for coding the Collaborative Staging data set. For
> example, an extralymphatic lymphoma of the stomach treated surgically
> would use the lymphoma schema in this manual to code Collaborative
> Staging, but surgery would be coded using the stomach codes for
> surgery of primary site. Refer to the treatment coding rules in the
> SEER Program coding manual or the FORDS manual for more details.

**SCHEMAS WHERE TUMOR SIZE IS NECESSARY FOR AJCC STAGING**

In order to classify the T category for certain sites/histologies, it is
necessary to know the size of the primary tumor, usually for T1 - T3.
For the following sites/histologies, the size of the primary tumor must
be recorded in order to assign the T category and derive a stage group.
Tumor size is not necessary to assign Summary Stage. The name of the
Collaborative Staging schema and its website file name (shown in
parentheses) are double indented under the **TNM chapter** and *subsite*
names. (See Table 4.)

**Table 4. Schemas Where Tumor Size Is Necessary For AJCC Staging**

**Lip and oral cavity**

Lip

Upper Lip (LipUpper)

Lower Lip (LipLower)

Other Lip (OthLip)

Oral Cavity

Anterior Tongue (AntTongue)

Upper Gum (GumUpper)

Lower Gum (GumLower)

Other Gum (OthGum)

Floor of Mouth (FOM)

Hard Palate (HardPalate)

Buccal Mucosa (BuccalMucosa)

Other Mouth (OthMouth)

**Pharynx**

Oropharynx

Oropharynx (Oropharynx)

Base of Tongue (BaseTongue)

Soft Palate (SoftPalate)

Hypopharynx

Hypopharynx (Hypopharynx)

**Major Salivary Glands**

Parotid Gland (ParotidGland)

Submandibular Gland

(SubmandibularGland)

Other Salivary Gland (OthSalivary)

**Thyroid**

Thyroid (Thyroid)

**Anal Canal**

> Anus (Anus)

**Liver including Intrahepatic Bile Ducts**

> Liver and intrahepatic bile ducts (Liver)

**Exocrine Pancreas**

Pancreas Head (PancreasHead)

Pancreas Body and Tail

(PancreasBodyTail)

Other Pancreas (OthPancreas)

**Lung**

> Lung (Lung)

**Bone**

> Bone (Bone)

**Soft tissue sarcoma**

Heart and Mediastinum

(HeartMediastinum)

Soft Tissue (SoftTissue)

Peritoneum (Peritoneum)

**Carcinoma of the Skin**

Skin, Vulva, Penis, ScrotumBCarcinoma

(Skin)

**Carcinoma of the Eyelid**

Skin of EyelidBCarcinoma (SkinEyelid)

**Breast**

Breast (Breast)

**Vulva**

Vulva (Vulva)

**Cervix Uteri**

Cervix (Cervix)

**Kidney**

Kidney (Kidney)

**Carcinoma of the Conjunctiva**

ConjunctivaBCarcinoma (Conjunctiva)

**Malignant Melanoma of the Uvea**

Iris and Ciliary BodyBMelanoma ciliary

body only) (MelanomaIrisCiliary)

ChoroidBMelanoma Melanoma Choroid)

**Carcinoma of the Lacrimal Gland**

> Lacrimal glandBCarcinoma (LacrimalGland)

**Sarcoma of the Orbit**

Orbit (Orbit)

**SCHEMAS THAT DO NOT USE TUMOR SIZE FOR AJCC STAGING**

In order to classify both summary stage and the AJCC T category for
certain sites/histologies, it is necessary to know how far the tumor has
extended in a contiguous, continuous or direct manner from its point of
origin. For the following sites/histologies, the extension of the
primary tumor must be recorded in order to assign the T category and
derive a stage group. The name of the Collaborative Staging schema and
its website file name (in parentheses) are double indented under the
**TNM chapter** and *subsite* names. (See Table 5.)

**Table 5. Schemas That Do Not Use Tumor Size For AJCC Staging**

**Pharynx**

Nasopharynx

Nasopharynx (Nasopharynx)

**Larynx** Other Larynx (OthLarynx)

Glottic Larynx

Glottic Larynx (GlotticLarynx)

Supraglottic Larynx

Supraglottic Larynx (SupraLarynx)

Anterior Surface of Epiglottis

(AntEpiglottis)

Subglottic Larynx

Subglottic Larynx (SubLarynx)

**Nasal Cavity and Paranasal Sinuses**

Nasal Cavity (NasalCavity)

> Maxillary Sinus (MaxillarySinus)
>
> Ethmoid Sinus (EthmoidSinus)

**Esophagus**

Esophagus (Esophagus)

**Stomach**

Stomach (Stomach)

**Small Intestine**

Small intestine (SmallIntestine)

**Colon and rectum**

Colon (Colon)

Rectum (Rectum)

**Gallbladder**

> Gallbladder (Gallbladder)

**Extrahepatic bile ducts**

> Extrahepatic bile ducts

(ExtraHepaticDucts)

Other Biliary and Biliary, NOS

(OthBiliary)

**Ampulla of Vater**

Ampulla (Ampulla)

**Pleural mesothelioma**

Pleura (Pleura)

**Melanoma of the Skin**

Skin, Vulva, Penis ScrotumBMelanoma

(Melanoma)

**Vagina**

> Vagina (Vagina)

**Corpus uteri**

> Corpus uteri (Corpus)

**Ovary**

> Ovary (Ovary)

**Fallopian Tube**

Fallopian tube (FallopianTube)

**Gestational trophoblastic tumor**

Placenta (Placenta)

**Penis**

> Penis (Penis)

**Prostate**

> Prostate (Prostate)

**Testis**

> Testis (Testis)

**Renal Pelvis and Ureter**

Renal Pelvis and Ureter (RenalPelvis)

**Urinary Bladder**

Bladder (Bladder)

**Urethra**

Urethra (Urethra)

**Malignant Melanoma of the Conjunctiva**

ConjunctivaBMelanoma

(MelanomaConjunctiva)

**Malignant Melanoma of the Uvea**

Iris and Ciliary BodyBMelanoma (iris

only) (MelanomaIrisCiliary)

**Retinoblastoma**

Retinoblastoma (Retinoblastoma)

**Lymphoid neoplasms**

Mycosis Fungoides (MF)

Malignant Lymphoma (Lymphoma)

**Table 6. Schemas For Which AJCC Staging Is Not Applicable**

For the following schemas, TNM is not applicable. The name of the
Collaborative Staging schema and its website file name (in parentheses)
are shown below.

> Other pharynx (OthPharynx)
>
> Other digestive (OthDigestive)
>
> Middle ear (MiddleEar)
>
> Other sinus (OthSinus)
>
> Trachea (Trachea)
>
> Other respiratory (OthRespiratory)
>
> Other adnexa (OthAdnexa)
>
> Other female genital (OthFemaleGen)
>
> Other male genital (OthMaleGen)

Other urinary (OthUrinary)

> Brain (Brain)
>
> Other CNS (OthCNS)
>
> Other endocrine (OthEndocrine)
>
> Other eye (OthEye)

Melanoma of Other Eye (MelanomaOthEye)

> Kaposi sarcoma (KS)

Hematopoietic, Reticuloendothelial,

Immunoproliferative and

Myeloproliferative Neoplasms

(HemeRetic)

> Other Ill-defined and Unknown Primary

Sites (OthIllDef)

**DEATH CERTIFICATE ONLY CASES**

Death Certificate **only** cases are coded as unknown (usually 9, 99,
999, etc.) or not applicable (usually 8, 88, 888, etc.) in all
Collaborative Staging fields. Although there may be some
site/histology-specific exceptions, the usual pattern for coding Death
Certificate Only cases is as follows:

CS Tumor Size 999

CS Extension 99

CS Tumor Size/Ext Eval 9

CS Lymph Nodes 99

CS Reg Nodes Eval 9

Reg LN Pos 99

Reg LN Exam 99

CS Mets at DX 99

CS Mets Eval 9

CS Site‑Specific Factor 1 888

CS Site‑Specific Factor 2 888

CS Site‑Specific Factor 3 888

CS Site‑Specific Factor 4 888

CS Site‑Specific Factor 5 888

CS Site‑Specific Factor 6 888

**USE OF AUTOPSY INFORMATION IN COLLABORATIVE STAGING**

Information obtained from autopsy may be used in either of two ways in
the Collaborative Staging System. The evaluation fields must then be
coded correctly to indicate how the autopsy information is to be
interpreted. If a patient with a suspected diagnosis of cancer dies and
an autopsy is performed, extent of disease information obtained from the
autopsy may be included along with other clinical and pathologic
information, if it meets the timing rules for inclusion. In this case,
the computer algorithm will assign the T, N, or M to Ap@ (pathologic)
classification. If cancer is not suspected at the time of autopsy, the
extent of disease information from the autopsy is included, but the
algorithm will assign the T, N, and M to the autopsy (a) classification
of the TNM system rather than to clinical or pathologic evaluation. Each
of the evaluation field schemas has appropriate codes to allow this
distinction.

**DEFINITIONS OF ADJACENT TISSUES, STRUCTURES, AND ORGANS**

**Adjacent connective tissue**

Some of the Collaborative Staging System schemas for ill-defined or
non-specific sites in this manual contain a code for adjacent connective
tissue, which is defined here as the unnamed tissues that immediately
surround an organ or structure containing a primary cancer. Use this
code when a tumor has invaded past the outer border (capsule, serosa, or
other edge) of the primary organ into the organ=s surrounding supportive
structures but has not invaded into larger structures or adjacent
organs.

The structures identified in ICD-O-3 as connective tissue include the
following: adipose tissue; aponeuroses; arteries; blood vessels; bursa;
connective tissue, NOS; fascia; fatty tissue; fibrous tissue; ganglia;
ligaments; lymphatic channels (not nodes); muscle; nerves (spinal,
sympathetic and peripheral); skeletal muscle; subcutaneous tissue;
synovia; tendons; tendon sheaths; veins; and vessels, NOS. In general,
these tissues do not have specific names. These tissues form the
framework of many organs, provide support to hold organs in place, bind
tissues and organs together, and serve as storage sites for nutrients.
Blood, cartilage and bone are sometimes considered connective tissues,
but in this manual they would be listed separately.

**Adjacent organs**

Organs are anatomic structures with specific physiologic functions other
than (or in addition to) support and storage. Continuous tumor growth
from one organ into an organ anatomically next to the primary would be
coded to the appropriate code for \>adjacent organs/structures= in the
Collaborative Staging schemas for ill-defined and non-specific sites.

**Adjacent structures**

Connective tissues large enough to be given a specific name would be
considered adjacent structures. For example, the brachial artery has a
name, as does the broad ligament. Continuous tumor growth from one organ
into an adjacent named structure would be coded to the appropriate code
for \>adjacent organs/structures= in the Collaborative Staging for
ill-defined or non-specific sites.

**AMBIGUOUS TERMINOLOGY**

**INTERPRETING AMBIGUOUS TERMINOLOGY FOR COLLABORATIVE STAGING**

Determination of the cancer stage is both a subjective and objective
assessment of how far the cancer has spread. Sometimes the clinician is
hesitant to commit to a definite statement that a particular organ or
tissue is involved by the cancer and uses what data collectors refer to
as Aambiguous terminology.@ The following lists can generally be used to
interpret the intent of the clinician; however, if individual clinicians
use these terms differently, the clinician=s definitions and choice of
therapy should be recognized. If a term used in a diagnostic statement
is not listed below, consult the clinician to determine the intent of
the statement.

**Involvement**

adherent

apparent(ly)

appears to

comparable with

compatible with

consistent with

contiguous/continuous with

encroaching upon\*

extension to, into, onto, out onto

features of

fixation to another structure\*\*

fixed\*\*

impending perforation of

impinging upon

impose/imposing on

incipient invasion

induration

infringe/infringing

into\*

intrude

invasion to into, onto, out onto

most likely

onto\*

overstep

presumed

probable

protruding into (unless encapsulated)

suspected

suspicious

to\*

up to

> \* interpreted as involvement whether the description is clinical or
> operative/ pathological
>
> \*\* interpreted as involvement of other organ or tissue

**DO NOT Consider as Involvement**

abuts

approaching

approximates

attached

cannot be excluded/ruled out

efface/effacing/effacement

encased/encasing

encompass(ed)

entrapped

equivocal

> extension to without invasion/

involvement of

kiss/kissing

matted (except for lymph nodes)

possible

questionable

reaching

rule out

suggests

very close to

worrisome

**HOW TO CODE THE COLLABORATIVE STAGING SYSTEM DATA ELEMENTS**

> ***Note:*** This procedure focuses on only the Collaborative Staging
> data fields and assumes other registry operations such as case
> finding, completion of text fields and other data fields, edit
> checking and case submission are also being performed appropriately.

1\. Before you begin to code using the Collaborative Staging System,
read completely the general rules in this manual.

2\. Read the medical record carefully to determine the primary site and
histology and identify the correct ICD‑O‑3 codes. While you are
reviewing the record, make mental notes about the tissues and lymph
nodes that are involved by tumor.

3\. If the histology is melanoma (8720-8790), Kaposi sarcoma (9140),
retinoblastoma (9510-9514), lymphoma (9590-9699 and 9702-9729), mycosis
fungoides (9700-9701), or hematopoietic and reticuloendothelial system
(9731-9989), use the histology-specific schema for the appropriate
histology-site combination.

4\. Otherwise, turn to the correct site-specific schema in the Part II
of this manual. Schemas are in

> ICD-O-3 order by the first code that uses the schema. Verify that you
> are in the correct chapter by confirming that the code is in the list
> at the beginning of the schema.

5\. Begin assigning codes for the 15 fields in the Collaborative Staging
System. Be sure to read the notes and follow the site/histology-specific
instructions at the beginning of each data field. Some schemas may have
site-specific factors associated with extension, lymph nodes or
metastasis; keep these in mind as you assign the codes.

> a\. Code the tumor size in the CS Tumor Size field.
>
> b\. Code how far the tumor has directly spread in the CS Extension
> field.
>
> c\. Code how the farthest tumor spread was determined in the CS Tumor
> Size/Ext Eval field.
>
> d\. Code whether regional lymph nodes are involved in the CS Lymph
> Nodes field.
>
> e\. Code how the farthest regional node spread was determined in the
> CS Reg Node Eval field.
>
> f\. Code the number of positive regional lymph nodes from the
> pathology report in the Reg Nodes Pos field.
>
> g\. Code the number of regional lymph nodes examined by the
> pathologist in the Reg Nodes Exam field.
>
> h\. Code the farthest distant metastasis (including distant lymph
> nodes) in the CS Mets at Dx field.
>
> i\. Code how the distant metastasis was determined in the CS Mets Eval
> field.
>
> j\. Code the six site-specific factors. If the first site-specific
> factor is listed as ANot Applicable,@ code 888 in all site specific
> factors. Otherwise, code the specific information requested for each
> site specific factor. When the next site-specific factor is 888 Not
> Applicable, all the remaining site-specific factors will also be 888.

Congratulations! You have collected all the facts about the case and the
codes are ready for the computer to convert into the T, N, M, Stage
Group, Summary Stage 1977 and Summary Stage 2000. Depending on your
software system, the final stage information may be derived now, when
the case is saved, or prior to exiting the case. Finish the rest of the
abstract, edit check it and save it.

When the computer derives the final stage information, the program will
check the histology code and other coded information to determine
whether T, N, M and Stage Group will be generated for the case. If the
histology code is on the computer=s exceptions list for that site, the
T, N, M, and Stage Group will be reported as ANot Applicable.@ Summary
Stage is generated for every case. The computer algorithm will also
record which version of the Collaborative Staging System was used to
derive the final stages.

**CS TUMOR SIZE**

**Item Length: 3**

## NAACCR Item #: 2800

**NAACCR Name: CS Tumor Size**

Records the largest dimension or diameter of the **primary tumor**, and
is always recorded in millimeters. To convert centimeters to
millimeters, multiply the dimension by 10. If tumor size is given in
tenths of millimeters, round down if between .1 and .4 mm, and round up
if between .5 and .9 mm.

  -------------------------------------------------------------------------
  **Code**   **Description**
  ---------- --------------------------------------------------------------
  000        Indicates no mass or no tumor found; for example, when a tumor
             of a stated primary site is not found, but the tumor has
             metastasized.

  001B988    Exact size in millimeters.

  989        989 millimeters or larger.

  990        Microscopic focus or foci only; no size of focus is given.

  991        Described as less than 1 cm

  992        Described as less than 2 cm

  993        Described as less than 3 cm

  994        Described as less than 4 cm

  995        Described as less than 5 cm

             **SITE-SPECIFIC CODES WHERE NEEDED**

  999        Unknown; size not stated; not stated in patient record.
  -------------------------------------------------------------------------

***Examples:***

Mammogram shows 2.5 cm breast malignancy Code as 025 (2.5 cm = 25
millimeters)

CT of chest shows 4 cm mass in RUL Code as 040 (4 cm = 40 mm)

Thyroidectomy specimen yields 8 mm carcinoma Code as 008

Prostate needle biopsy shows 0.6 mm carcinoma Code as 001 (round up
six-tenths of mm)

**For schemas that do not use tumor size:**

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

  888         Not applicable
  ----------- -----------------------------------------------------------

**Instructions for Coding**

1\. Refer to general guidelines for Collaborative Staging for timing
rules for data collection.

2\. Refer to site/histology-specific instructions for additional
information. Site/histology-specific instructions replace or over-ride
general instructions. Where there are no site/histology-specific
instructions, these general instructions apply.

3\. Record tumor size information in the following order:

> a\. Record tumor size from the pathology report, if it is available,
> when the patient receives no radiation or systemic treatment prior to
> surgery.
>
> ***Example**:* Chest x-ray shows 3.5 cm mass; the pathology report
> from the surgery states that the same mass is malignant and measures
> 2.8 cm. Record tumor size as 028.

b.  If the patient receives preoperative (neoadjuvant) systemic therapy
    (chemotherapy, hormone therapy, immunotherapy) or radiation therapy,
    code the largest size of tumor prior to treatment.

> ***Example:*** Patient has a 2.2 cm mass in the oropharynx; fine
> needle aspiration of mass confirms squamous cell carcinoma. Patient
> receives course of neoadjuvant combination chemotherapy. Pathologic
> size of tumor after total resection is 0.8 cm. Record tumor size as
> 022.
>
> c\. Information on size from imaging/radiographic techniques can be
> used to code size when there is no more specific size information from
> a pathology or operative report, but it should be taken as low
> priority, just above a physical exam.
>
> d\. If there is a difference in reported tumor size among imaging and
> radiographic techniques, record the largest size of tumor reported in
> the record.
>
> e\. In the infrequent event that the tumor does not respond to
> neoadjuvant treatment and is, in fact, more extensive after
> preoperative treatment as determined by the operative or pathology
> report, code the farthest extension and code CS Tumor Size/Ext Eval as
> 6, based on pathology/operative report after treatment.

4\. Record the exact size of the primary tumor for all sites/histologies
except those for which it is stated to be not applicable. If no size is
given, code as 999.

> a\. Always code the size of the primary tumor, not the size of the
> polyp, ulcer, cyst, or distant metastasis. However, if the tumor is
> described as a Acystic mass,@ and only the size of the entire mass is
> given, code the size of the entire mass, since the cysts are part of
> the tumor itself.
>
> b\. Record the largest dimension or diameter of tumor, whether it is
> from an excisional biopsy specimen or the complete resection of the
> primary tumor.
>
> ***Example 1:*** A 3.3 cm tumor would be 33 millimeters and would be
> coded as 033.
>
> ***Example 2**:* Tumor is described as 2.4 x 5.1 x 1.8 cm in size.
> Record tumor size as 051.
>
> c\. Record the size of the invasive component, if given.
>
> d\. If both an *in situ* and an invasive component are present and the
> invasive component is measured, record the size of the invasive
> component even if it is smaller.
>
> ***Example**:* Tumor is mixed in situ and invasive adenocarcinoma,
> total 3.7 cm in size, of which 1.4 cm is invasive. Record tumor size
> as 014.

e.  Additional rule for breast primaries*:* If the size of the invasive
    component is ***not*** given, record the size of the entire tumor
    from the surgical report, pathology report, radiology report or
    clinical examination.

***Example 1:*** Infiltrating duct carcinoma with extensive in situ
component; total size 2.3 cm.

Record tumor size as 023.

***Example 2:*** Duct carcinoma in situ covering a 1.9 cm area with
focal areas of invasive

ductal carcinoma. Record tumor size as 019.

> ***Note*:** For breast cancer, document how the size of the tumor was
> determined in Site Specific Factor field 6. Information from the
> pathology report can be used to identify in situ versus invasive tumor
> even if exact size is not given. If tumor size is a clinical
> measurement only in the range 001-989, Site Specific Factor 6 must be
> coded as 888.
>
> f\. For purely *in situ* lesions, code the size as stated.
>
> g\. Microscopic residual tumor does not affect overall tumor size.
>
> h\. Do **not** add pieces or chips together to create a whole; they
> may not be from the same location, or they may represent only a very
> small portion of a large tumor. However, if the pathologist states an
> aggregate or composite size (determined by fitting the tumor pieces
> together and measuring the total size), record that size.
>
> i\. If an excisional biopsy is performed and residual tumor at time of
> resection of the primary is found to be larger than the excisional
> biopsy, code the size of the residual tumor.
>
> j\. For an incisional needle biopsy, code tumor size as 999. Do not
> code the tumor size from a needle biopsy unless no residual tumor is
> found on further resection.
>
> k\. Record tumor size (lateral dimension) for malignant melanoma.
> Depth of invasion is coded in a site-specific factor.

5\. Special codes

> a\. Tumor dimension is to be recorded for all schemas, except as noted
> below. Other information collected in this field in previous staging
> systems, such as depth of invasion for melanoma, has been moved to
> Site-Specific Factors for those sites/histologies.
>
> b\. If size is not reported, code as 999, which means unknown size,
> not applicable, or not documented in the patient record.
>
> c\. The descriptions in code 998 take precedence over any mention of
> size. Code 998 is used only for the following sites:

Esophagus (C15.0‑C15.5, C15.8‑C15.9): Entire circumference

Stomach (C16.0‑C16.6, C16.8‑C16.9): Diffuse, widespreadC: or more,
linitis plastica

Colorectal (M‑8220/8221 with /2 or /3): Familial/multiple polyposis

Lung and main stem bronchus (C34.0‑C34.3, C34.8‑C34.9): Diffuse, entire
lobe or lung

Breast (C50.0‑C50.6, C50.8‑C50.9): Inflammatory carcinoma; Diffuse,
widespreadC: or

more of breast.

> d\. Code 990, Microscopic focus or foci only; no size is given, should
> be used when no gross tumor is seen and tumor is only identified
> microscopically.
>
> **Note:** the terms microscopic focus, microfocus, and microinvasion
> are NOT the same as \[macroscopic\] focal or focus. A macroscopic
> focus or foci indicates a very small or isolated area, pinpoint, or
> spot of tumor that may be visible grossly. Only tumor identified
> microscopically should be coded to 990.
>
> ***Example 1:*** Ovary specimen: extensive cystic disease with focal
> areas of tumor seeding.

Disregard Afocal@ and code tumor size to 999 unknown.

> ***Example 2:*** Cervix conization: severe dysplasia with focal areas
> of microinvasion.

Code tumor size as 990 microscopic focus, no size given.

> e\. Codes 991 through 995 are non-specific size descriptions that, for
> some sites, could still be used to determine a T category. However, if
> a specific size is given, the more precise size should be coded in the
> range 001-989.
>
> f\. Other special codes in the range 996 to 997 are used on a
> site-specific basis. See the individual site/histology schemas for
> further information and definitions.
>
> g\. For the following diagnoses and/or primary sites, size is not
> applicable. Record as code 888.

Disseminated Langerhans cell histiocytosis (Letterer-Siwe disease)

> Hematopoietic neoplasms

Immunoproliferative diseases

Leukemia

Malignant lymphoma (Hodgkin lymphoma and non-Hodgkin lymphoma)

Mast cell tumors

Multiple myeloma and other plasma cell tumors

Myelodysplastic syndromes

Myeloproliferative diseases

> Unknown and ill-defined primary sites (C76.0BC76.5, C76.7BC76.8,
> C80.9)
>
> h\. The source of the tumor size (radiographs, endoscopy, pathology
> specimen, etc.) is documented in the CS Tumor Size/Ext Eval field.

6\. It is strongly recommended that the choice of tumor size codes be
documented in a related text field on the abstract.

**CS EXTENSION**

**Item Length: 2**

## NAACCR Item #: 2810

**NAACCR Name: CS Extension**

Identifies contiguous growth (extension) of the primary tumor within the
organ of origin or its direct extension into neighboring organs. For
certain sites such as ovary, discontinuous metastasis is coded in the CS
Extension field. See site-specific schemas for detailed codes and coding
instructions.

+-----+-------------------------------------+--------+--------+-------+
| **  | **Description**                     | **TNM  | **     | **S   |
| Cod |                                     | Map    | SS77** | S2000 |
| e** |                                     | ping** |        | Mapp  |
|     |                                     |        | **Map  | ing** |
|     |                                     |        | ping** |       |
+-----+-------------------------------------+--------+--------+-------+
| 00  | In situ; non-invasive               | Tis    | IS     | IS    |
+-----+-------------------------------------+--------+--------+-------+
|     | **SITE/HISTOLOGY-SPECIFIC CODES**   |        |        |       |
+-----+-------------------------------------+--------+--------+-------+
| 80  | Further contiguous extension        |        |        |       |
+-----+-------------------------------------+--------+--------+-------+
| 95  | No evidence of primary tumor        | T0     | U      | U     |
+-----+-------------------------------------+--------+--------+-------+
| 99  | Unknown extension; primary tumor    | TX     | U      | U     |
|     | cannot be assessed; not stated in   |        |        |       |
|     | patient record                      |        |        |       |
+-----+-------------------------------------+--------+--------+-------+

**INSTRUCTIONS FOR CODING**

1\. Code the farthest documented extension of the primary tumor. Do not
include discontinuous metastases to distant sites (these are coded in CS
Mets at Dx) except for ovary and corpus uteri (see 2e below).

2\. Record extension information in the following order:

> a\. Record extension from the pathology report, if it is available,
> when the patient receives no radiation or systemic treatment prior to
> surgery.
>
> b\. If the patient receives preoperative (neoadjuvant) systemic
> therapy (chemotherapy, hormone therapy, immunotherapy) or radiation
> therapy, code the farthest extension identified prior to treatment
> (clinically).
>
> ***Example:*** Patient has rectal mass firmly attached to pelvic wall
> (clinically T4, extension code 60). Patient undergoes preoperative
> radiation therapy. The pathology report from the low anterior
> resection shows residual tumor outside the rectum in perimuscular
> tissue (pathologically T3, extension code 40). Code extension as 60,
> because the preoperative treatment apparently Ashrank@ the tumor away
> from the pelvic wall.

c.  In the infrequent event that the tumor does not respond to
    neoadjuvant treatment and is, in fact, more extensive after
    preoperative treatment as determined by the operative or pathology
    report, code the farthest extension and code CS Tumor Size/Ext Eval
    as 6, based on pathology/operative report after treatment.

> ***Example 1:*** Patient found to have an obstructing central lung
> tumor very close to the main stem bronchus (clinically T2, extension
> code 20). Patient undergoes six weeks of intensive chemotherapy. At
> thoracotomy, tumor was observed directly extending into trachea
> (pathologically T4, extension code 70). Code extension as 70, because
> the tumor was noted to be more extensive after the preoperative
> treatment.
>
> ***Example 2**:* Patient has a 5.5 cm hard, moveable mass in the right
> breast (clinically T3, extension code 10) and receives preoperative
> chemotherapy. The pathology report from the modified radical
> mastectomy shows residual 2.8 cm mass with infiltration of the deep
> subcutaneous tissues over the mass (pathologically T2, extension code
> 20). Code extension as 20, because although the chemotherapy Ashrank@
> the tumor, the residual tumor was found to be more extensive than the
> clinical presentation.
>
> d\. Information on extent of disease from imaging/radiographic
> techniques can be used to code extension when there is no more
> specific extension information from a pathology or operative report,
> but it should be taken as low priority, just above a physical exam.
>
> e\. If an involved organ or tissue is not mentioned in the schema,
> approximate the location and code it with listed organs or tissues in
> the same anatomic area.
>
> f\. With the exception of corpus uteri and ovary, all codes represent
> contiguous (direct) extension of tumor from the site of origin to the
> organ/structure/tissue represented in the code.
>
> ***Example***: Carcinoma of the prostate with extension to pubic bone
> would be coded 60.
>
> Carcinoma of the prostate with metastases to thoracic spine would be
> coded in CS Extension to the appropriate code for tumor extension and
> the metastases to the thoracic spine would be coded in the CS Mets at
> Dx field.

3\. Refer to general guidelines for Collaborative Staging for timing
rules for data collection.

4\. Refer to the ambiguous terminology section for terms that constitute
tumor involvement or extension.

5\. If the information in the medical record is ambiguous or incomplete
regarding the extent to which the tumor has spread, the extent of
disease may be inferred from the T category stated by the physician.

6\. If the only indication of extension in the record is the physician=s
statement of a T category from the TNM staging system or a stage from a
site-specific staging system, such as Dukes= C, record the numerically
lowest equivalent extension code for that T category.

7\. Some site or histology schemas include designations such as T1, NOS;
T2, NOS; Localized, NOS; and other non-specific categories. The NOS is
added when there is further breakdown of the category into subsets (such
as T1a, T1b, T1c), but the correct subset cannot be determined. The NOS
designation, which can appear in both the descriptions of codes and the
mapping, is not official AJCC descriptive terminology. The NOS should be
disregarded in reports and analyses when it is not a useful distinction.
The data collector should only code to a category such as AStated as T1
NOS@ when the appropriate subset (e.g., T1a or T1b) cannot be
determined.

8\. Distant metastases must be coded in the CS Mets at Dx field.

9\. Do not code CS Extension as in situ if there is any evidence of
nodal or metastatic involvement; use the code for Localized, NOS, if
there is no better information.

> ***Example:*** Excisional biopsy of breast tumor shows extensive DCIS.
> Sentinel node biopsy reveals one positive axillary node. Code CS
> Extension as 10, localized, NOS, because an in situ tumor
> theoretically cannot metastasize and apparently an area of invasion
> was missed by the pathologist.

10\. The presence of microscopic residual disease or positive tumor
margins does not increase the extension code.

11\. It is strongly recommended that the choice of extension codes be
documented in a related text field on the abstract.

**CS TUMOR SIZE\\EXT EVAL**

**Item Length: 1**

## NAACCR Item #: 2820

**NAACCR Name: CS Tumor Size\\Ext Eval**

Records how the codes for the two items ACS Tumor Size@ and ACS
Extension@ were determined, based on the diagnostic methods employed.

> **Note:** This field is used primarily to describe whether the staging
> basis for the T category in the TNM system is clinical or
> pathological.

+------+-------------------------------------------------------+------+
| **Co | **Description**                                       | *    |
| de** |                                                       | *Sta |
|      |                                                       | ging |
|      |                                                       | Bas  |
|      |                                                       | is** |
+------+-------------------------------------------------------+------+
| 0    | No surgical resection done. Evaluation based on       | c    |
|      | physical examination, imaging examination, or other   |      |
|      | non-invasive clinical evidence. No autopsy evidence   |      |
|      | used.                                                 |      |
+------+-------------------------------------------------------+------+
| 1    | No surgical resection done. Evaluation based on       | c\*  |
|      | endoscopic examination, diagnostic biopsy, including  |      |
|      | fine needle aspiration biopsy, or other invasive      |      |
|      | techniques. No autopsy evidence used.                 |      |
|      |                                                       |      |
|      | Does not meet criteria for AJCC pathologic staging.   |      |
+------+-------------------------------------------------------+------+
| 2    | No surgical resection done, but evidence derived from | p    |
|      | autopsy (tumor was suspected or diagnosed prior to    |      |
|      | autopsy)                                              |      |
+------+-------------------------------------------------------+------+
| 3    | Surgical resection performed WITHOUT pre-surgical     | p    |
|      | systemic treatment or radiation                       |      |
|      |                                                       |      |
|      | **OR** surgical resection performed, unknown if       |      |
|      | pre-surgical systemic treatment or radiation          |      |
|      | performed                                             |      |
|      |                                                       |      |
|      | Meets criteria for AJCC pathologic staging.           |      |
|      |                                                       |      |
|      | Evaluation based on evidence acquired before          |      |
|      | treatment, supplemented or modified by the additional |      |
|      | evidence acquired during and from surgery,            |      |
|      | particularly from pathologic examination of the       |      |
|      | resected specimen                                     |      |
+------+-------------------------------------------------------+------+
| 5    | Surgical resection performed WITH pre-surgical        | c    |
|      | systemic treatment or radiation; tumor size/extension |      |
|      | based on clinical evidence                            |      |
+------+-------------------------------------------------------+------+
| 6    | Surgical resection performed WITH pre-surgical        | y    |
|      | systemic treatment or radiation, BUT tumor            |      |
|      | size/extension based on pathologic evidence           |      |
+------+-------------------------------------------------------+------+
| 8    | Evidence from autopsy only (tumor was unsuspected or  | a    |
|      | undiagnosed prior to autopsy)                         |      |
+------+-------------------------------------------------------+------+
| 9    | Unknown if surgical resection done                    | c    |
|      |                                                       |      |
|      | Not assessed; cannot be assessed                      |      |
|      |                                                       |      |
|      | Unknown if assessed                                   |      |
|      |                                                       |      |
|      | Not documented in patient record                      |      |
|      |                                                       |      |
|      | ***For sites with no TNM schema:*** not applicable    |      |
+------+-------------------------------------------------------+------+

\* For some primary sites, code 1 may be a pathologic staging basis, as
determined by the site-specific chapter in the *AJCC Cancer Staging
Manual, sixth edition*.

**INSTRUCTIONS FOR CODING**

1\. Select the CS Tumor Size/Ext Eval code that documents the report or
procedure from which the information about the farthest extension or
size of the primary tumor was obtained; this may not be the numerically
highest Eval code.

> ***Example:*** Fine needle aspiration biopsy (Eval code 2) confirms
> adenocarcinoma of prostate. CT scan of pelvis (Eval code 1) shows
> tumor extension through the prostatic capsule into adjacent connective
> tissues. Code CS Tumor Size/Ext Eval as 1 because the CT scan showed
> more extensive tumor than the biopsy.

2\. For primary sites/histologies where tumor size is not a factor in
determining the T category in TNM (see Table 5 in the General
Instructions), code CS Tumor Size/Ext Eval on the basis of the CS
extension field only.

3\. For primary sites where both tumor size and extension determine the
T category in TNM (see Table 4 in the General Instructions), select the
code that best explains how the information in the CS Tumor Size and CS
Extension fields were determined.

> a\. If there is a difference between the derived category for the
> tumor size and the CS extension, select the evaluation code that
> reflects how the worse or higher category was determined.
>
> ***Example:*** Tumor size for a breast cancer biopsy is 020 (maps to
> T1). There is ulceration of the skin (extension code 50, maps to T4).
> Code CS Tumor Size/Ext Eval field as 0, physical examination, because
> the ulceration information from the physical examination results in a
> higher T category.

b.  If the patient had no surgery, use code 0, 1, or 9.

> ***Example 1:*** Patient has a chest x-ray showing an isolated 4 cm
> tumor in the right upper lobe. Patient opts for radiation therapy.
> Code this field as 0. Staging algorithm would identify information as
> clinical (c).
>
> ***Example 2:*** Colon cancer with colonoscopy and biopsy confirming
> cancer. Code this field as 1. Staging algorithm would identify
> information as clinical (c).The biopsy does not meet the criteria for
> pathologic staging.
>
> ***Example 3:*** Endoscopies for cervix or bladder would be coded as 1
> in this field and the staging algorithm would identify the information
> as clinical (c).
>
> ***Exception:*** Lung cancer with mediastinoscopy showing direct
> extension into mediastinum. Code this field as 1. Staging algorithm
> would identify information as pathologic (p), because mediastinoscopy
> is defined as a pathologic procedure in TNM.
>
> c\. If the patient had surgery followed by other treatment(s), use
> code 3 or 9.
>
> d\. If the size or extension of the tumor determined prior to
> treatment was the basis for neoadjuvant therapy, use code 5.
>
> e\. If the size or extension of the tumor was greater after
> presurgical treatment than before treatment, use code 6. This code is
> likely to be used infrequently and maps to the Ay@ intercurrent
> treatment staging basis.
>
> f\. If the patient had an autopsy, use code 2 if the diagnosis was
> known or suspected prior to death. Use code 8 if the malignancy was
> not known or suspected prior to death.

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**

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\. If there is a discrepancy between clinical information and
> pathologic information about the same lymph nodes, the pathologic
> information takes precedence if no preoperative treatment was
> administered.
>
> ***Example:*** Axillary lymphadenopathy stated as Asuspicious *for*
> involvement@ noted on physical exam. After axillary dissection, all
> lymph nodes are negative. Code CS Lymph Nodes as 0, no regional lymph
> node involvement.
>
> d\. For inaccessible sites, primarily for localized or early stage
> (T1, T2) cancers*:* record regional lymph nodes as negative rather
> than unknown (based on clinical evaluation) when there is no mention
> of regional lymph node involvement in the physical examination,
> pre-treatment diagnostic testing or surgical exploration, and the
> patient receives what would be usual treatment to the primary site
> (see general rules for further discussion).
>
> e\. If there is direct extension of the primary tumor into a regional
> lymph node, record the involved node in this field.
>
> f\. If the patient receives preoperative (neoadjuvant) systemic
> therapy (chemotherapy, hormone therapy, immunotherapy) or radiation
> therapy, code the farthest involved regional lymph nodes, based on
> information prior to surgery.
>
> ***Example:*** Patient has a hard matted mass in the axilla (code 50)
> and a needle biopsy of the breast that confirms ductal carcinoma.
> Patient receives three months of chemotherapy. The pathology report
> from the modified radical mastectomy shows only scar tissue in the
> axilla with no involvement of axillary lymph nodes (Negative, code
> 00). Code CS Lymph Nodes as 50 because the chemotherapy apparently
> Asterilized@ the lymph nodes.

g.  In the infrequent event that clinically involved regional lymph
    nodes do not respond to neoadjuvant treatment and are, in fact, more
    extensively involved after preoperative treatment as determined by
    the operative or pathology report, code the farthest extension and
    code CS Reg Nodes Eval as 6, based on pathology/operative report
    after treatment.

> ***Example:*** Patient has needle biopsy-proven prostate cancer with
> no mention of involved lymph nodes on physical examination (Negative,
> code 00). He receives Lupron while deciding whether to undergo a
> radical prostatectomy. At the time of surgery, a laparoscopic pelvic
> node biopsy is reported to show metastases (Regional nodes involved,
> code 10) to lymph nodes and the prostatectomy is canceled. Code CS
> Lymph Nodes as 10 because the preoperative treatment (Lupron) had no
> effect on the lymph nodes.

2\. Use code 00 for lymph node involvement when the CS Extension is
coded in situ, even if no lymph nodes are removed, since Ain situ@ by
definition means noninvasive. If there is evidence of nodal involvement
associated with a tumor described as in situ, it would indicate that an
area of invasion was missed and the primary tumor is not an in situ
lesion, so lymph nodes can be coded as appropriate for the case.

3\. For solid tumors, the terms Afixed@ or Amatted@ and Amass in the
hilum, mediastinum, retroperitoneum, and/or mesentery@ (with no specific
information as to tissue involved) are considered involvement of lymph
nodes.

> a\. Any other terms, such as Apalpable,@ Aenlarged,@ Avisible
> swelling,@ Ashotty,@ or Alymph-adenopathy@ should be ignored, unless
> there is a statement of involvement by the clinician.
>
> ***Exception:*** The terms adenopathy, enlargement, and mass in the
> hilum or mediastinum should be coded as involvement for lung primaries
> only.
>
> b\. For lymphomas, *any* positive mention of lymph nodes indicates
> involvement of those lymph nodes.
>
> c\. Regional lymph nodes are not palpable for inaccessible sites such
> as bladder, kidney, prostate, esophagus, stomach, lung, liver, corpus
> uteri and ovary. The best description concerning regional lymph nodes
> will be on imaging studies or in the surgeon\'s evaluation at the time
> of exploratory surgery or definitive surgery. If regional lymph nodes
> for these inaccessible sites are not mentioned on imaging or
> exploratory surgery, they are presumed to be clinically negative.
>
> d\. The terms Ahomolateral,@ Aipsilateral,@ and Asame side@ are used
> interchangeably.
>
> e\. Any unidentified nodes included with the resected primary site
> specimen are to be coded as regional lymph nodes, NOS.
>
> f\. Where more specific categories are provided, the codes for
> Aregional lymph node(s), NOS@; Alymph nodes, NOS@; and AStated as N\_,
> no additional information@ should be used *only* after an exhaustive
> search for more specific information.

4\. When size of involved regional lymph nodes is required, code from
pathology report, if available.

> a\. Code the size of the metastasis, not the entire node, unless
> otherwise stated in site-specific schemas. The size of the metastasis
> within the lymph node can be inferred if the size for the entire node
> falls within one of the codes; for example, a single involved node 1.5
> cm in size can be coded to Asingle lymph node  2 cm@ because the
> metastasis cannot be larger than 1.5 cm.

5\. If the only indication of lymph node involvement in the record is
the physician=s statement of an N category from the TNM staging system
or a stage from a site-specific staging system, such as Dukes= C, record
the numerically lowest equivalent CS Lymph Nodes code for that N
category.

> a\. If there is a discrepancy between documentation in the medical
> record and the physician=s assignment of TNM, the documentation takes
> precedence. Cases of this type should be discussed with the physician
> who assigned the TNM.
>
> b\. If the information in the medical record is ambiguous or
> incomplete regarding the extent to which the tumor has spread, lymph
> node involvement may be inferred from the N category stated by the
> physician.

6\. Some site or histology schemas include designations such as N1, NOS;
N2, NOS, and other non-specific categories. The NOS is added when there
is further breakdown of the category into subsets (such as N1a, N1b,
N1c), but the correct subset cannot be determined. The NOS designation,
which can appear in both the descriptions of codes and the mapping, is
not official AJCC descriptive terminology. The NOS should be disregarded
in reports and analyses when it is not a useful distinction. The data
collector should only code to a category such as AStated as N1 NOS@ when
the appropriate subset (e.g., N1a or N1b) cannot be determined.

7\. For colon, rectosigmoid and rectum primaries, if there is a
statement about tumor nodule(s) in the pericolic or perirectal fat, use
the following guidelines for coding regional lymph node involvement:

> Code as regional lymph node involvement if the nodule has a smooth
> contour.

Code as tumor extension if the nodule has an irregular contour.

8\. It is strongly recommended that the choice of regional lymph node
codes be documented in a related text field on the abstract.

**CODING REGIONAL LYMPH NODES FOR HEAD AND NECK SITES**

For head and neck sites, regional lymph node information is coded in
several fields. The CS Lymph Nodes field contains information about the
nodes involved, their number and laterality. Site-Specific Factors 1 and
2 are used to code the size of involved lymph nodes and the presence of
extracapsular extension. Site-Specific Factors 3 through 6 are used to
code the presence or absence of lymph node involvement in each of 7
different levels and other groups defined by AJCC. The definitions of
the levels are the same for all applicable head and neck sites. One
digit is used to represent lymph nodes of a single level, with the three
digits of Site-Specific Factor 3 representing lymph nodes of,
respectively, Levels I-III; the digits of Site-Specific Factor 4
representing lymph nodes of Levels IV and V and the retropharyngeal
nodes; the digits of Site-Specific Factor 5 representing lymph nodes of
Levels VI and VII and the facial nodes; and the digits of Site-Specific
Factor 6 representing the remaining Other groups as defined by AJCC. In
each digit, a code 1 means Yes, the nodes are involved. See Figure 2a
for the layout of Site-Specific Factors 3 through 6 and Figure 2b for
the interpretation of a coded example.

**Figure 2a. Layout of Site-Specific Factors for Head and Neck Sites**

> **SSF 3 Levels I-III \_\_\_ \_\_\_ \_\_\_**

**I II III**

> **SSF 4 Levels IV-V, \_\_\_ \_\_\_ \_\_\_**
>
> **retropharyngeal (RP) IV V RP**
>
> **SSF 5 Levels VI-VII, \_\_\_ \_\_\_ \_\_\_**
>
> **Facial (F) VI VII F**
>
> **SSF 6 Other groups \_\_\_ \_\_\_ \_\_\_**
>
> **Parapharyngeal (PP), PP PA S**

**Parotid (PA), Suboccipital (S)**

**Figure 2b. Example and Interpretation of Site-Specific Factors for
Head and Neck Sites**

***Example:* Left Radical Neck Dissection: 2 positive parotid node (\< 3
cm with extra-capsular extension), 1 positive buccal (facial) node (2
cm), and 1 positive 2 cm submandibular node.**

> **SSF 3 Levels I-III \_[1]{.underline}\_ \_[0]{.underline}\_
> \_[0]{.underline}\_**

**I II III**

> **SSF 4 Levels IV-V, \_[0]{.underline}\_ \_[0]{.underline}\_
> \_[0]{.underline}\_**
>
> **retropharyngeal (RP) IV V RP**
>
> **SSF 5 Levels VI-VII, \_[0]{.underline}\_ \_[0]{.underline}\_
> \_[1]{.underline}\_**
>
> **Facial (F) VI VII F**
>
> **SSF 6 Other groups \_[0]{.underline}\_ \_[1]{.underline}\_
> \_[0]{.underline}\_**
>
> **Parapharyngeal (PP), PP PA S**

**Parotid (PA), Suboccipital (S)**

> **[Stored in database as]{.underline} [Interpretation]{.underline}**
>
> **SSF 3 100 Level 1 only**
>
> **SSF 4 000 All nodes neg**
>
> **SSF 5 001 Facial nodes only**
>
> **SSF 6 010 Parotid nodes only**

**UNKNOWN**

In Site-Specific Factors 3-6 for lymph node levels, use code 9 only when
it is unknown if lymph nodes are involved. Within each of the
Site-Specific Factors 3-6, do not code 9 in some positions and 0 or 1 in
other positions. If specific information is available about the positive
or negative status of some but not all nodes in any one level or group,
assume that the rest of the nodes in the same Site-Specific Factor are
negative and code accordingly.

**NOS**

When the only information available is ARegional nodes, NOS@ or
ACervical nodes, NOS@ or AInternal jugular lymph nodes, NOS@ or ALymph
nodes, NOS,@ code 0 in all digits of Site-Specific Factors 3-6.

> ***Example 1:*** A carcinoma of the base of tongue involves bilateral
> submandibular nodes and left upper, mid-, and lower jugular nodes, the
> largest measuring 4 cm. There is no extracapsular extension. These are
> level I, II, III, and IV lymph nodes according to AJCC definitions. CS
> Lymph Nodes is coded 40 (bilateral or contralateral nodes).
> Site-Specific Factor 1 is coded 040 indicating the largest size.
> Site-Specific Factor 2 is coded 000 for no extracapsular extension.
> Site-Specific Factor 3 is coded 111, to show that levels I, II, and
> III are involved. Site-Specific Factor 4 is coded 100 to show that
> level IV is involved. Site-Specific Factors 5 and 6 are each coded
> 000, since no other nodes are involved.
>
> ***Example 2:*** Laryngeal biopsy with squamous cell carcinoma, no
> other information available. CS Lymph Nodes is coded 99. Site-Specific
> factors 1-6 are each coded 999, since no information is available
> regarding lymph node involvement.
>
> ***Example 3:*** Patient diagnosed elsewhere with carcinoma of
> oropharynx with cervical lymph node involvement. No other information
> available. CS Lymph Nodes is coded 50 (regional nodes, NOS, not stated
> if ipsilateral, bilateral, or contralateral, or if single or
> multiple). Site-specific Factors 1 and 2 are each coded 999.
> Site-Specific Factors 3-6 are each coded 000.

**DEFINITIONS OF LEVELS FOR HEAD AND NECK SITES**

The definitions of the levels and the lymph node chains included in each
level are as follows:

**Level I** contains the submental and submandibular triangles bounded
by the anterior and posterior bellies of the digastric muscle, and the
hyoid bone inferiorly, and the body of the mandible superiorly.

> Submandibular
>
> Submaxillary
>
> Submental

**Level II** contains the upper jugular lymph nodes and extends from the
level of the skull base superiorly to the hyoid bone inferiorly.

> Jugulodigastric (subdigastric)
>
> Upper deep cervical
>
> Upper jugular

**Level III** contains the middle jugular lymph nodes from the hyoid
bone superiorly to the level of the lower border of the cricoid
cartilage inferiorly.

> Middle deep cervical
>
> Mid-jugular

**Level IV** contains the lower jugular lymph nodes from the level of
the cricoid cartilage superiorly to the clavicle inferiorly.

> Jugulo-omohyoid (supraomohyoid)
>
> Lower deep cervical
>
> Lower jugular

**Level V** contains the lymph nodes in the posterior triangle bounded
by the anterior border of the trapezius muscle posteriorly, the
posterior border of the sternocleidomastoid muscle anteriorly, and the
clavicle inferiorly. For descriptive purposes, Level V may be further
subdivided into upper, middle, and lower levels corresponding to the
superior and inferior planes that define Levels II, III, and IV.

> Posterior cervical
>
> Posterior triangle (spinal accessory and transverse cervical) (upper,
> middle, and lower, corresponding to the levels that define upper,
> middle, and lower jugular nodes)

**Level VI** contains the lymph nodes of the anterior central
compartment from the hyoid bone superiorly to the suprasternal notch
inferiorly. On each side, the lateral boundary is formed by the medial
border of the carotid sheath.

> Anterior deep cervical
>
> Laterotracheal
>
> Paralaryngeal
>
> Paratracheal
>
> Prelaryngeal (Delphian)
>
> Pretracheal
>
> Recurrent laryngeal

**Level VII** contains the lymph nodes inferior to the suprasternal
notch in the superior mediastinum.

> Upper mediastinal

**Other groups**

> Buccinator (facial)
>
> Nasolabial
>
> Parapharyngeal
>
> Periparotid and

intraparotid

Preauricular

Retropharyngeal

Sub-occipital

**CS REG NODES EVAL**

**Item Length: 1**

## NAACCR Item #: 2840

**NAACCR Name: CS Reg Nodes Eval**

Records how the code for the item ACS Lymph Nodes@ was determined, based
on the diagnostic methods employed.

+-----+---------------------------------------------------------+------+
| **  | **Description**                                         | *    |
| Cod |                                                         | *Sta |
| e** |                                                         | ging |
|     |                                                         | Bas  |
|     |                                                         | is** |
+-----+---------------------------------------------------------+------+
| 0   | No regional lymph nodes removed for examination.        | c    |
|     | Evaluation based on physical examination, imaging, or   |      |
|     | other non-invasive clinical evidence. No autopsy        |      |
|     | evidence used.                                          |      |
+-----+---------------------------------------------------------+------+
| 1   | No regional lymph nodes removed for examination.        | c    |
|     | Evaluation based on endoscopic examination, diagnostic  |      |
|     | biopsy including fine needle aspiration of lymph        |      |
|     | node(s) or other invasive techniques. No autopsy        |      |
|     | evidence used.                                          |      |
|     |                                                         |      |
|     | Does not meet criteria for AJCC pathologic staging.     |      |
+-----+---------------------------------------------------------+------+
| 2   | No regional lymph nodes removed for examination, but    | p    |
|     | evidence derived from autopsy (tumor was suspected or   |      |
|     | diagnosed prior to autopsy).                            |      |
+-----+---------------------------------------------------------+------+
| 3   | Regional lymph nodes removed for examination (removal   | p    |
|     | of at least 1 lymph node) WITHOUT pre-surgical systemic |      |
|     | treatment or radiation                                  |      |
|     |                                                         |      |
|     | **OR** lymph nodes removed for examination, unknown if  |      |
|     | pre-surgical systemic treatment or radiation performed  |      |
|     |                                                         |      |
|     | Meets criteria for AJCC pathologic staging.             |      |
+-----+---------------------------------------------------------+------+
| 5   | Regional lymph nodes removed for examination WITH       | c    |
|     | pre-surgical systemic treatment or radiation, and lymph |      |
|     | node evaluation based on clinical evidence.             |      |
+-----+---------------------------------------------------------+------+
| 6   | Regional lymph nodes removed for examination WITH       | y    |
|     | pre-surgical systemic treatment or radiation, BUT lymph |      |
|     | node evaluation based on pathologic evidence.           |      |
+-----+---------------------------------------------------------+------+
| 8   | Evidence from autopsy; tumor was unsuspected or         | a    |
|     | undiagnosed prior to autopsy.                           |      |
+-----+---------------------------------------------------------+------+
| 9   | Unknown if lymph nodes removed for examination          | c    |
|     |                                                         |      |
|     | Not assessed; cannot be assessed                        |      |
|     |                                                         |      |
|     | Unknown if assessed                                     |      |
|     |                                                         |      |
|     | Not documented in patient record                        |      |
|     |                                                         |      |
|     | **For sites that have no TNM staging:** Not applicable  |      |
+-----+---------------------------------------------------------+------+

**INSTRUCTIONS FOR CODING**

1.  Select the CS Reg Nodes Eval code that documents the report or
    procedure from which the information about the farthest involved
    regional lymph nodes was obtained; this may not be the numerically
    highest eval code.

> ***Example**:* Modified radical neck dissection for hypopharyngeal
> cancer shows one lower jugular node involved (CS Reg LN code 10, Eval
> code 3). Physical exam shows hard, matted scalene (transverse
> cervical) node presumed to contain metastasis (CS Reg LN code 32, Eval
> code 0). Code CS Reg Nodes Eval as 0 since the scalene node
> involvement was determined clinically rather than by examination of
> tissue.
>
> 2\. For sites/histologies where there is no TNM schema (see Table 5 in
> the General Instructions), CS Reg Node Eval may be coded 9 (not
> applicable).
>
> 3\. Select the code that best explains how the information in the CS
> Lymph Nodes field was determined.
>
> a\. If the patient had no removal of lymph node(s), use code 0, 1, or
> 9.
>
> ***Example 1**:* Prostate cancer with laparoscopic lymph node biopsy
> showing involved nodes; radical prostatectomy canceled. Code CS Reg
> Node Eval as 3. Staging algorithm would identify information as
> pathologic (p). According to AJCC, a positive biopsy of one or more
> regional lymph nodes is sufficient to meet the pathologic staging
> basis for prostate cancer.
>
> ***Example 2:*** Lung cancer with CT scan or MRI showing involved
> contralateral mediastinal nodes. Code CS Reg Node Eval as 1. Staging
> algorithm would identify information as

clinical (c).

> b\. If the patient had removal of lymph node(s) surgery followed by
> other treatment(s), use code 3 or 9.
>
> c\. If the patient receives preoperative (neoadjuvant) systemic
> therapy (chemotherapy, hormone therapy, immunotherapy) or radiation
> therapy, the clinical status of lymph nodes takes precedence (code 5).
>
> d\. If the size, number or extension of regional lymph node
> involvement determined prior to treatment was the basis for
> neoadjuvant therapy, use code 5. However, if more extensive tumor is
> during lymph node examination after neoadjuvant therapy, use code 6.
>
> e\. If the patient had an autopsy, use code 2 if the diagnosis was
> known or suspected prior to death. Use code 8 if the malignancy was
> not known or suspected prior to death.

4\. 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.

5\. Codes 0-3 are oriented to the AJCC staging basis. Code 1 includes
microscopic analysis of tissue insufficient to meet the requirements for
pathologic staging in the TNM system. For example, a needle biopsy of an
axillary lymph node will document that a lymph node is involved by
breast cancer, but does not meet the requirement for removal of a
sufficient number of lymph nodes so that the highest N stage can be
assessed. 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*. Code 1 also includes observations at surgery, such as
abdominal exploration at the time of a colon resection, where regional
lymph nodes are not biopsied.

6\. Code 3 maps to pathologic staging across all sites. Use code 3 if
the lymph node procedure meets the requirements for pathologic staging
basis of regional lymph nodes. The requirements vary among sites as to
the location and number of lymph nodes involved, the size of the
involved nodes, and other characteristics. For prostate cancer, a
positive biopsy of a single regional lymph node is sufficient to assign
CS Reg Nodes Eval code 3 to the case.

**REGIONAL NODES POSITIVE**

**Item Length: 2**

## NAACCR Item #: 820

**NAACCR Name: Regional Nodes Positive**

**Description**

Records the exact number of regional lymph nodes examined by the
pathologist and found to contain metastases.

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

  00         All nodes examined are negative.

  01B89      1B89 nodes are positive. (Code exact number of nodes positive)

  90         90 or more nodes are positive.

  95         Positive aspiration of lymph node(s) was performed.

  97         Positive nodes are documented, but the number is unspecified.

  98         No nodes were examined.

  99         It is unknown whether nodes are positive; not applicable; not
             stated in patient record.
  ---------- --------------------------------------------------------------

**INSTRUCTIONS FOR CODING**

1\. Record information about only regional lymph nodes in this field.
Involved distant lymph nodes should be coded in the ACS Mets at Dx@
field.

2\. Rules for coding Regional Nodes Positive are the same for both in
situ and invasive cases.

3\. This field is based on pathologic information only. If no lymph
nodes were removed for examination, or if a lymph node drainage area was
removed but no lymph nodes were found, code as 98.

4\. Record the total number of regional lymph nodes removed and found to
be positive by pathologic examination.

> a\. The number of regional lymph nodes positive is cumulative from all
> procedures that removed lymph nodes through the completion of
> surgeries in the first course of treatment.
>
> b\. This field is to be recorded regardless of whether the patient
> received preoperative treatment.

5\. Any combination of positive aspirated, biopsied, sampled or
dissected lymph nodes should be coded to 97 if the number of involved
nodes cannot be determined on the basis of cytology or histology.

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

Placenta

Brain and Cerebral Meninges

Other Parts of Central Nervous System

Hodgkin and non-Hodgkin Lymphoma

> Hematopoietic, Reticuloendothelial, Immunoproliferative and
> Myeloproliferative Neoplasms

Other and Ill-Defined Primary Sites

> Unknown Primary Site

**REGIONAL NODES EXAMINED**

**Item Length: 2**

## NAACCR Item #: 830

**NAACCR Name: Regional Nodes Examined**

Records the total number of regional lymph nodes that were removed and
examined by the pathologist.

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

  00         No nodes were examined.

  01B89      1B89 nodes were examined. (Code the exact number of regional
             lymph nodes examined.)

  90         90 or more nodes were examined.

  95         No regional nodes were removed, but aspiration of regional
             nodes was performed.

  96         Regional lymph node removal was documented as a sampling, and
             the number of nodes is unknown/not stated.

  97         Regional lymph node removal was documented as a dissection, and
             the number of nodes is unknown/not stated.

  98         Regional lymph nodes were surgically removed, but the number of
             lymph nodes is unknown/not stated and not documented as a
             sampling or dissection; nodes were examined, but the number is
             unknown.

  99         It is unknown whether nodes were examined; not applicable or
             negative; not stated in patient record.
  ---------- ---------------------------------------------------------------

**INSTRUCTIONS FOR CODING**

1\. Record information about only regional lymph nodes in this field.
Distant lymph node information should be coded in the ACS Mets at Dx@
field.

2\. Rules for coding Regional Nodes Examined are the same for in situ
and invasive cases.

3\. This field is based on pathologic information only. If no lymph
nodes were removed for examination, or if a lymph node drainage area was
removed but no lymph nodes were found, code as 00. If it is unknown
whether nodes were removed or examined, code as 99.

4\. Record the total number of regional lymph nodes removed and examined
by the pathologist.

> a\. The number of regional lymph nodes examined is cumulative from all
> procedures that removed lymph nodes through the completion of
> surgeries in the first course of treatment.
>
> b\. If lymph nodes are aspirated and other lymph nodes are removed,
> use code 98.
>
> 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**

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

+-----+-----------------------------------+--------+--------+--------+
| **  | **Description**                   | **TNM  | **SS77 | **     |
| Cod |                                   | Map    | Map    | SS2000 |
| e** |                                   | ping** | ping** | Map    |
|     |                                   |        |        | ping** |
+-----+-----------------------------------+--------+--------+--------+
| 00  | No; none                          | M0     | None   | None   |
+-----+-----------------------------------+--------+--------+--------+
| 10  | Distant lymph node(s)             | M1     | D      | D      |
+-----+-----------------------------------+--------+--------+--------+
| 40  | Distant metastases except code 10 | M1     | D      | D      |
|     |                                   |        |        |        |
|     | 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.

3\. Metastasis known to have developed after the extent of disease was
established (also referred to as progression of disease) should not be
recorded in the CS Mets at Dx field.

4\. Record CS Mets at Dx as Code 00 (None) rather than Code 99 (Unknown)
when the clinician proceeds with standard treatment of the primary site
for localized or early (T1, T2) stage disease, since this action
presumes that there are no distant metastasis that would otherwise alter
the treatment approach. Code 99 can and should be used in situations
where there is reasonable doubt that the tumor is no longer localized
and there is no documentation of distant metastases.

5\. If the only indication of extension in the record is the physician=s
statement of an M category from the TNM staging system or a stage from a
site-specific staging system, such as Dukes= D, record the numerically
lowest equivalent extension code for that M category. In most cases,
this will be 40, Distant metastasis, NOS.

6\. If the information in the medical record is ambiguous or incomplete
regarding the extent to which the tumor has spread, the extent of
disease may be inferred from the M category stated by the physician.

7\. Some site or histology schemas include a designation of M1, NOS. The
NOS is added when there is further breakdown of the category into
subsets (such as M1a, M1b, M1c), but the correct subset cannot be
determined. The NOS designation, which can appear in both the
descriptions of codes and the mapping, is not official AJCC descriptive
terminology. The NOS should be disregarded in reports and analyses when
it is not a useful distinction. The data collector should only code to a
category such as AStated as M1 NOS@ when the appropriate subset (such as
M1a or M1b) cannot be determined.

8\. It is strongly recommended that the choice of distant lymph nodes
and/or distant metastasis codes be documented in a related text field on
the abstract.

**CS METS EVAL**

**Item Length: 1**

## NAACCR Item #: 2860

**NAACCR Name: CS Mets Eval**

Records how the code for the item ACS Mets at Dx@ was determined based
on the diagnostic methods employed.

+------+-------------------------------------------------------+------+
| **Co | **Description**                                       | *    |
| de** |                                                       | *Sta |
|      |                                                       | ging |
|      |                                                       | Bas  |
|      |                                                       | is** |
+------+-------------------------------------------------------+------+
| *    | No pathologic examination of metastatic tissue        | c    |
| *0** | performed. Evaluation of distant metastasis based on  |      |
|      | physical examination, imaging examination, and/or     |      |
|      | other non-invasive clinical evidence. No autopsy      |      |
|      | evidence used.                                        |      |
+------+-------------------------------------------------------+------+
| *    | No pathologic examination of metastatic tissue        | c    |
| *1** | performed. Evaluation of distant metastasis based on  |      |
|      | endoscopic examination or other invasive technique.   |      |
|      | No autopsy evidence used.                             |      |
|      |                                                       |      |
|      | Does not meet criteria for AJCC pathologic staging of |      |
|      | distant metastasis.                                   |      |
+------+-------------------------------------------------------+------+
| *    | No pathologic examination of metastatic tissue done   | p    |
| *2** | prior to death, but evidence derived from autopsy     |      |
|      | (tumor was suspected or diagnosed prior to autopsy).  |      |
+------+-------------------------------------------------------+------+
| *    | Pathologic examination of metastatic tissue performed | p    |
| *3** | WITHOUT pre-surgical systemic treatment or radiation  |      |
|      |                                                       |      |
|      | **OR** pathologic examination of metastatic tissue    |      |
|      | performed, unknown if pre-surgical systemic treatment |      |
|      | or radiation performed                                |      |
|      |                                                       |      |
|      | Meets criteria for AJCC pathologic staging of distant |      |
|      | metastasis.                                           |      |
+------+-------------------------------------------------------+------+
| *    | Pathologic examination of metastatic tissue performed | c    |
| *5** | WITH pre-surgical systemic treatment or radiation,    |      |
|      | and metastasis based on clinical evidence.            |      |
+------+-------------------------------------------------------+------+
| *    | Pathologic examination of metastatic tissue performed | y    |
| *6** | WITH pre-surgical systemic treatment or radiation,    |      |
|      | BUT metastasis based on pathologic evidence.          |      |
+------+-------------------------------------------------------+------+
| *    | Evidence from autopsy; tumor was unsuspected or       | a    |
| *8** | undiagnosed prior to autopsy.                         |      |
+------+-------------------------------------------------------+------+
| *    | Not assessed; cannot be assessed                      | c    |
| *9** |                                                       |      |
|      | Unknown if assessed                                   |      |
|      |                                                       |      |
|      | Not documented in patient record                      |      |
|      |                                                       |      |
|      | ***For sites with no TNM staging***: Not applicable   |      |
+------+-------------------------------------------------------+------+

**Instructions for Coding**

1.  Select the CS Mets Eval code that documents the report or procedure
    from which the information was obtained about metastatic involvement
    farthest from the primary site; this may not be the numerically
    highest eval code.

> ***Example:*** Liver palpated and reported as normal during laparotomy
> for stomach cancer (Eval code 1). CT scan of brain shows multiple
> metastatic nodules (Eval code 0).
>
> Code CS Mets Eval as 0; the brain would be reported as involved but
> the liver would not be reported as involved..

2\. For primary sites/histologies where there is no TNM schema (Table
6), this field may be coded as 9 (not applicable).

3\. Select the code that best explains how the information in the CS
Metastases field was determined.

> a\. If the patient had no examination of metastatic tissue, use code
> 0, 1, or 9.
>
> ***Example 1:*** Patient has diagnosis of colon cancer by biopsy. CT
> scan shows liver metastasis.
>
> Code this field as 0. Staging algorithm will indicate information is
> clinical (c).
>
> ***Example 2**:* Lung cancer with endoscopy of contralateral lung
> showing involvement of contralateral mainstem bronchus. Code this
> field as 1. Staging algorithm will indicate information is clinical
> (c).
>
> ***Example 3:*** Prostate cancer with enlarged scalene node confirmed
> as cancer on needle biopsy.
>
> Code this field as 3. Staging algorithm will indicate information is
> pathologic (p), since the biopsy of the metastatic site confirms M1
> disease.
>
> b\. If the patient had removal of presumed metastatic tissue (even
> though the pathology report was negative), use code 3.
>
> c\. Code the method of evaluation for the site(s) farthest from the
> primary.
>
> ***Example:*** Colon cancer patient has CT scan showing normal lungs.
> During the resection, the surgeon palpates the liver and finds it to
> be normal. Code this field as 0, since the CT scan shows that
> potential metastatic sites outside the surgical field are negative.
>
> d\. If the patient had an autopsy, use code 2 if the diagnosis was
> known or suspected prior to death. Use code 8 if the malignancy was
> not known or suspected prior to death.

4\. If the patient receives preoperative (neoadjuvant) systemic therapy
(chemotherapy, hormone therapy, immunotherapy) or radiation therapy, the
clinical status of metastases at diagnosis takes precedence (code 5).

5\. If the patient has biopsies of some metastases while others are
visible only on imaging, use code 6 to indicate if, after preoperative
treatment, the biopsy is negative for metastasis but there is still
evidence of clinical metastasis.

6\. 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.

7\. Any positive biopsy or resection of distant metastasis meets the
requirement for pathologic staging basis and should be coded to CS Mets
Eval code 3.

8\. Code 1 includes endoscopy and observations at surgery, such as
abdominal exploration at the time of a colon resection, where distant
metastasis is not biopsied.

**CS SITE-SPECIFIC FACTOR 1**

**Item Length: 3**

## NAACCR Item #: 2880

**NAACCR Name: CS Site-Specific Factor1**

Identifies additional information needed to generate stage, or
prognostic factors that have an effect on stage or survival.

+-----+----------------------------------------------------------------+
| **  | **Description**                                                |
| Cod |                                                                |
| e** |                                                                |
+-----+----------------------------------------------------------------+
| 000 | None                                                           |
+-----+----------------------------------------------------------------+
|     | **SITE/HISTOLOGY-SPECIFIC CODES**                              |
+-----+----------------------------------------------------------------+
| 999 | Unknown; \[site-specific title\] cannot be assessed;           |
|     |                                                                |
|     | Not documented in patient record                               |
+-----+----------------------------------------------------------------+

**For schemas that do not use this site-specific factor:**

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

  888        Not applicable for this site
  ---------- ----------------------------------------------------------------

**INSTRUCTIONS FOR CODING**

1\. If there is no site/histology-specific factor for a schema, code
888.

2\. The following primary sites/histologies use Site Specific Factor 1
to code information. See the site-specific schemas for acceptable codes
and their definitions.

**[Site/Histology]{.underline} [Factor]{.underline}**

> Head and neck\* Size of Lymph Nodes
>
> Colon Carcinoembryonic Antigen (CEA)
>
> Rectosigmoid, rectum Carcinoembyronic Antigen (CEA)
>
> Liver Alpha Fetoprotein (AFP)
>
> Pleura Pleural Effusion

Malignant Melanoma of Skin,

> Vulva, Penis, Scrotum Measured Thickness (Depth), Breslow=s
> Measurement
>
> Mycosis Fungoides Peripheral Blood Involvement
>
> Breast Estrogen Receptor Assay (ERA)
>
> Ovary Carbohydrate Antigen 125 (CA-125)
>
> Placenta Prognostic Scoring Index
>
> Prostate Prostate Specific Antigen Laboratory Value (PSA PSA Lab
> Value)
>
> Testis Alpha Fetoprotein (AFP)
>
> Thyroid Single vs. Multiple Nodules

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> \* Head and neck includes the following schemas: upper lip; lower lip;
> other lip; base of tongue; anterior tongue; upper gum; lower gum and
> retromolar trigone; other gum; floor of mouth; hard palate; soft
> palate/uvula; other mouth; buccal mucosa; parotid gland; submandibular
> gland; other salivary glands; oropharynx; anterior surface of
> epiglottis; nasopharynx; pyriform sinus/ hypopharynx; other pharynx;
> nasal cavity; middle ear; maxillary sinus; ethmoid sinus; other sinus;
> glottic larynx; supraglottic larynx; subglottic larynx; other larynx
>
> **[Site/Histology]{.underline} [Factor]{.underline}**
>
> Melanoma of Conjunctiva Measured Thickness (Depth), Breslow=s
> Measurement
>
> Melanoma of Choroid Measured Thickness (Depth), Breslow=s Measurement
>
> Melanoma of Iris and Ciliary Body Measured Thickness (Depth),
> Breslow=s Measurement
>
> Retinoblastoma Extension Evaluated at Enucleation
>
> Brain WHO Grade
>
> Other CNS WHO Grade
>
> Thyroid Solitary vs. Multifocal
>
> Other Endocrine WHO Grade
>
> Kaposi Sarcoma Associated with HIV/AIDS
>
> Lymphoma Associated with HIV/AIDS

3\. Code 000 Not done is used when there is a statement in the record
that a test was not performed.

> a\. If there is no report of a lab test in the patient record, code as
> 999 Unknown; Not documented in patient record.
>
> b\. For Kaposi sarcoma, if AIDS status is not documented, code as 999
> Unknown rather than 002, Not Present.

**CS SITE-SPECIFIC FACTOR 2**

**Item Length: 3**

## NAACCR Item #: 2890

**NAACCR Name: CS Site-Specific Factor2**

Identifies additional information needed to generate stage, or
prognostic factors that have an effect on stage or survival.

+-----+----------------------------------------------------------------+
| **  | **Description**                                                |
| Cod |                                                                |
| e** |                                                                |
+-----+----------------------------------------------------------------+
| 000 | None                                                           |
+-----+----------------------------------------------------------------+
|     | **SITE/HISTOLOGY-SPECIFIC CODES**                              |
+-----+----------------------------------------------------------------+
| 999 | Unknown; \[site-specific title\] cannot be assessed;           |
|     |                                                                |
|     | Not documented in patient record                               |
+-----+----------------------------------------------------------------+

**For schemas that do not use this site-specific factor:**

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

  888        Not applicable for this site
  ---------- ----------------------------------------------------------------

**INSTRUCTIONS FOR CODING**

1\. If there is no site/histology-specific factor for a schema, code
888.

2\. The following primary sites use Site Specific Factor 2 to code
information. See the site-specific schemas for acceptable codes and
their definitions.

**[Site/Histology]{.underline} [Factor]{.underline}**

> Head and neck\* Extracapsular Extension, Lymph Nodes for

Head and Neck

> Liver Fibrosis Score

Malignant Melanoma of Skin,

> Vulva, Penis, Scrotum Ulceration
>
> Breast Progesterone Receptor Assay (PRA)
>
> Prostate Prostate Specific Antigen (PSA)
>
> Testis Human Chorionic Gonadotropin (HCG)
>
> Hodgkin and non-Hodgkin Lymphoma Symptoms at Diagnosis

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> \* Head and neck includes the following schemas: upper lip; lower lip;
> other lip; base of tongue; anterior tongue; upper gum; lower gum and
> retromolar trigone; other gum; floor of mouth; hard palate; soft
> palate/uvula; other mouth; buccal mucosa; parotid gland; submandibular
> gland; other salivary glands; oropharynx; anterior surface of
> epiglottis; nasopharynx; pyriform sinus/ hypopharynx; other pharynx;
> nasal cavity; middle ear; maxillary sinus; ethmoid sinus; other sinus;
> glottic larynx; supraglottic larynx; subglottic larynx; other larynx

3\. Code 000 Not done is used when there is a statement in the record
that a test was not performed.

> a\. If there is no report of a lab test in the health record, code as
> 999 Unknown; Not documented in patient record.
>
> b\. For malignant melanoma of skin, if ulceration is not mentioned in
> the pathology report, code as 000 No ulceration present.

**CS SITE-SPECIFIC FACTOR 3**

**Item Length: 3**

## NAACCR Item #: 2900

**NAACCR Name: CS Site-Specific Factor3**

Identifies additional information needed to generate stage, or
prognostic factors that have an effect on stage or survival.

+-----+----------------------------------------------------------------+
| **  | **Description**                                                |
| Cod |                                                                |
| e** |                                                                |
+-----+----------------------------------------------------------------+
| 000 | None                                                           |
+-----+----------------------------------------------------------------+
|     | **SITE/HISTOLOGY-SPECIFIC CODES**                              |
+-----+----------------------------------------------------------------+
| 999 | Unknown; \[site-specific title\] cannot be assessed;           |
|     |                                                                |
|     | Not documented in patient record                               |
+-----+----------------------------------------------------------------+

**For schemas that do not use this site-specific factor:**

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

  888        Not applicable for this site
  ---------- ----------------------------------------------------------------

**INSTRUCTIONS FOR CODING**

1\. If there is no site/histology-specific factor for a schema, code
888.

2\. The following primary sites use Site Specific Factor 3 to code
information. See the site-specific schemas for acceptable codes and
their definitions.

**[Site/Histology]{.underline} [Factor]{.underline}**

> Head and Neck\* Levels I-III, Lymph Nodes of Head and Neck

Malignant Melanoma of Skin,

> Vulva, Penis, Scrotum Clinical Status of Lymph Node Mets
>
> Breast Number of Positive Ipsilateral Axillary Lymph Nodes
>
> Prostate CS Extension - Pathologic Extension
>
> Testis LDH (Lactate Dehydrogenase)
>
> Lymphoma International Prognostic Index (IPI) Score

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> \* Head and neck includes the following schemas: upper lip; lower lip;
> other lip; base of tongue; anterior tongue; upper gum; lower gum and
> retromolar trigone; other gum; floor of mouth; hard palate; soft
> palate/uvula; other mouth; buccal mucosa; parotid gland; submandibular
> gland; other salivary glands; oropharynx; anterior surface of
> epiglottis; nasopharynx; pyriform sinus/ hypopharynx; other pharynx;
> nasal cavity; middle ear; maxillary sinus; ethmoid sinus; other sinus;
> glottic larynx; supraglottic larynx; subglottic larynx; other larynx

3\. Code 000 Not done is used when there is a statement in the record
that a test was not performed.

> a\. If there is no report of a lab test in the health record, code as
> 999 Unknown; Not documented in patient record.
>
> b\. For the lymphomas, if the IPI score is not stated in the record,
> code as 999 Unknown; Not documented in patient record. It is not
> necessary to calculated the IPI score from other information in the
> record.

**FOR HEAD AND NECK SITES ONLY:**

4\. Use code 9 only when it is unknown if lymph nodes are involved.
Within the Site-Specific Factors, do not code 9 in some positions and 0
or 1 in other positions. If specific information is available about the
positive or negative status of some but not all nodes in any one level
or group, assume that the rest of the nodes in the same Site-Specific
Factor are negative and code accordingly.

5\. When the only information available is ARegional nodes, NOS@ or
ACervical nodes, NOS@ or AInternal jugular lymph nodes, NOS@ or ALymph
nodes, NOS,@ code 0 in all digits of Site-Specific Factors 3-6.

6\. See ACoding Regional Lymph Nodes for Head and Neck Sites@ under CS
Lymph Nodes for further information about the regional nodes of the head
and neck, including definitions of the levels.

**CS SITE-SPECIFIC FACTOR 4**

**Item Length: 3**

## NAACCR Item #: 2910

**NAACCR Name: CS Site-Specific Factor4**

Identifies additional information needed to generate stage, or
prognostic factors that have an effect on stage or survival.

+-----+----------------------------------------------------------------+
| **  | **Description**                                                |
| Cod |                                                                |
| e** |                                                                |
+-----+----------------------------------------------------------------+
| 000 | None                                                           |
+-----+----------------------------------------------------------------+
|     | **SITE/HISTOLOGY-SPECIFIC CODES**                              |
+-----+----------------------------------------------------------------+
| 999 | Unknown; \[site-specific title\] cannot be assessed;           |
|     |                                                                |
|     | Not documented in patient record                               |
+-----+----------------------------------------------------------------+

**For schemas that do not use this site-specific factor:**

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

  888        Not applicable for this site
  ---------- ----------------------------------------------------------------

**INSTRUCTIONS FOR CODING**

1\. If there is no site/histology-specific factor for a schema, code
888.

2\. The following primary sites use Site Specific Factor 4 to code
information. See the site-specific schemas for acceptable codes and
their definitions.

> **[Site/Histology]{.underline} [Factor]{.underline}**
>
> Head and Neck\* Levels IV-V, Lymph Nodes of Head and Neck

Malignant Melanoma of Skin,

> Vulva, Penis, Scrotum Lactate Dehydrogenase (LDH)
>
> Breast Immunohistochemistry (IHC) of Regional Lymph Nodes
>
> Prostate Prostatic Acid Phosphatase (PAP)
>
> Testis Radical Orchiectomy Performed

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> \* Head and neck includes the following schemas: upper lip; lower lip;
> other lip; base of tongue; anterior tongue; upper gum; lower gum and
> retromolar trigone; other gum; floor of mouth; hard palate; soft
> palate/uvula; other mouth; buccal mucosa; parotid gland; submandibular
> gland; other salivary glands; oropharynx; anterior surface of
> epiglottis; nasopharynx; pyriform sinus/ hypopharynx; other pharynx;
> nasal cavity; middle ear; maxillary sinus; ethmoid sinus; other sinus;
> glottic larynx; supraglottic larynx; subglottic larynx; other larynx

3\. Code 000 Not done is used when there is a statement in the record
that a test was not performed.

> a\. If there is no report of a lab test in the health record, code as
> 999 Unknown; Not documented in patient record.

**FOR HEAD AND NECK SITES ONLY:**

4\. Use code 9 only when it is unknown if lymph nodes are involved.
Within the Site-Specific Factors, do not code 9 in some positions and 0
or 1 in other positions. If specific information is available about the
positive or negative status of some but not all nodes in any one level
or group, assume that the rest of the nodes in the same Site-Specific
Factor are negative and code accordingly.

5\. When the only information available is ARegional nodes, NOS@ or
ACervical nodes, NOS@ or AInternal jugular lymph nodes, NOS@ or ALymph
nodes, NOS,@ code 0 in all digits of Site-Specific Factors 3-6.

6\. See ACoding Regional Lymph Nodes for Head and Neck Sites@ under CS
Lymph Nodes for further information about the regional nodes of the head
and neck, including definitions of the levels.

**CS SITE-SPECIFIC FACTOR 5**

**Item Length: 3**

## NAACCR Item #: 2920

**NAACCR Name: CS Site-Specific Factor5**

Identifies additional information needed to generate stage, or
prognostic factors that have an effect on stage or survival.

+-----+----------------------------------------------------------------+
| **  | **Description**                                                |
| Cod |                                                                |
| e** |                                                                |
+-----+----------------------------------------------------------------+
| 000 | None                                                           |
+-----+----------------------------------------------------------------+
|     | **SITE/HISTOLOGY-SPECIFIC CODES**                              |
+-----+----------------------------------------------------------------+
| 999 | Unknown; \[site-specific title\] cannot be assessed;           |
|     |                                                                |
|     | Not documented in patient record                               |
+-----+----------------------------------------------------------------+

**For schemas that do not use this site-specific factor:**

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

  888        Not applicable for this site
  ---------- ----------------------------------------------------------------

**INSTRUCTIONS FOR CODING**

1\. If there is no site/histology-specific factor for a schema, code
888.

2\. The following primary sites use Site Specific Factor 5 to code
information. See the site-specific schemas for acceptable codes and
their definitions.

**[Site/Histology]{.underline} [Factor]{.underline}**

> Head and Neck\* Levels VI-VIII, Lymph Nodes of Head and Neck
>
> Breast Molecular Studies of Regional Lymph Nodes
>
> Prostate Gleason=s Primary and Secondary Patterns
>
> Testis Size of Metastasis in Lymph Nodes

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> \* Head and neck includes the following schemas: upper lip; lower lip;
> other lip; base of tongue; anterior tongue; upper gum; lower gum and
> retromolar trigone; other gum; floor of mouth; hard palate; soft
> palate/uvula; other mouth; buccal mucosa; parotid gland; submandibular
> gland; other salivary glands; oropharynx; anterior surface of
> epiglottis; nasopharynx; pyriform sinus/ hypopharynx; other pharynx;
> nasal cavity; middle ear; maxillary sinus; ethmoid sinus; other sinus;
> glottic larynx; supraglottic larynx; subglottic larynx; other larynx

3\. Code 000 Not done is used when there is a statement in the record
that a test was not performed.

> a\. If there is no report of a lab test in the health record, code as
> 999 Unknown; Not documented in patient record.

**FOR HEAD AND NECK SITES ONLY:**

4\. Use code 9 only when it is unknown if lymph nodes are involved.
Within the Site-Specific Factors, do not code 9 in some positions and 0
or 1 in other positions. If specific information is available about the
positive or negative status of some but not all nodes in any one level
or group, assume that the rest of the nodes in the same Site-Specific
Factor are negative and code accordingly.

5\. When the only information available is ARegional nodes, NOS@ or
ACervical nodes, NOS@ or AInternal jugular lymph nodes, NOS@ or ALymph
nodes, NOS,@ code 0 in all digits of Site-Specific Factors 3-6.

6\. See ACoding Regional Lymph Nodes for Head and Neck Sites@ under CS
Lymph Nodes for further information about the regional nodes of the head
and neck, including definitions of the levels.

**CS SITE-SPECIFIC FACTOR 6**

**Item Length: 3**

## NAACCR Item #: 2930

**NAACCR Name: CS Site-Specific Factor6**

Identifies additional information needed to generate stage, or
prognostic factors that have an effect on stage or survival.

+-----+----------------------------------------------------------------+
| **  | **Description**                                                |
| Cod |                                                                |
| e** |                                                                |
+-----+----------------------------------------------------------------+
| 000 | None                                                           |
+-----+----------------------------------------------------------------+
|     | **SITE/HISTOLOGY-SPECIFIC CODES**                              |
+-----+----------------------------------------------------------------+
| 999 | Unknown; \[site-specific title\] cannot be assessed;           |
|     |                                                                |
|     | Not documented in patient record                               |
+-----+----------------------------------------------------------------+

**For schemas that do not use this site-specific factor:**

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

  888        Not applicable for this site
  ---------- ----------------------------------------------------------------

**INSTRUCTIONS FOR CODING**

1\. If there is no site/histology-specific factor for a schema, code
888.

2\. The following primary sites use Site Specific Factor 6 to code
information. See the site-specific schemas for acceptable codes and
their definitions.

**[Site/Histology]{.underline} [Factor]{.underline}**

> Head and Neck\* Parapharyngeal, Parotid, Preauricular, and
> Sub-Occipital Lymph Nodes, Lymph Nodes for Head and Neck
>
> Breast Size of Tumor\--Invasive Component
>
> Prostate Gleason=s Score

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> \* Head and neck includes the following schemas: upper lip; lower lip;
> other lip; base of tongue; anterior tongue; upper gum; lower gum and
> retromolar trigone; other gum; floor of mouth; hard palate; soft
> palate/uvula; other mouth; buccal mucosa; parotid gland; submandibular
> gland; other salivary glands; oropharynx; anterior surface of
> epiglottis; nasopharynx; pyriform sinus/ hypopharynx; other pharynx;
> nasal cavity; middle ear; maxillary sinus; ethmoid sinus; other sinus;
> glottic larynx; supraglottic larynx; subglottic larynx; other larynx

3\. Code 000 Not done is used when there is a statement in the record
that a test was not performed.

> a\. If there is no report of a lab test in the health record, code as
> 999 Unknown; Not documented in patient record.

**For Head And Neck Sites Only:**

4\. Use code 9 only when it is unknown if lymph nodes are involved.
Within the Site-Specific Factors, do not code 9 in some positions and 0
or 1 in other positions. If specific information is available about the
positive or negative status of some but not all nodes in any one level
or group, assume that the rest of the nodes in the same Site-Specific
Factor are negative and code accordingly.

5\. When the only information available is ARegional nodes, NOS@ or
ACervical nodes, NOS@ or AInternal jugular lymph nodes, NOS@ or ALymph
nodes, NOS,@ code 0 in all digits of Site-Specific Factors 3-6.

6\. See ACoding Regional Lymph Nodes for Head and Neck Sites@ under CS
Lymph Nodes for further information about the regional nodes of the head
and neck, including definitions of the levels.

> **SEER SUMMARY STAGE 1977**
>
> **Item Length: 1**
>
> **NAACCR Item #: 760**
>
> **NAACCR Name: SEER SUMMARY STAGE 1977**

For SEER registries who elect to have SEER submit their date to NAACCR,
only. Tumors diagnosed before January 1, 2001, should be assigned a
summary stage according to *SEER* *Summary Staging Guide*.

SEER Summary Stage 1977 is limited to information available within 2
months of the date of diagnosis.

***Note**:* See also the data item Derived SS21977 \[NAACCR Item #3010\]
for the value of SEER Summary Stage 1977 as generated by the
Collaborative Staging algorithm.

Data may be submitted using either manually entered SEER Summary Stage
1977 code or Collaborative Stage generated code.

**Codes**

0 In situ

1 Localized

2 Regional, direct extension only

3 Regional, regional lymph nodes only

4 Regional, direct extension and regional lymph nodes

5 Regional, NOS

7 Distant

9 Unstaged

> **SEER SUMMARY STAGE 2000**
>
> **Item Length: 1**
>
> **NAACCR Item #: 759**
>
> **NAACCR Name: SEER SUMMARY STAGE 2000**

For SEER registries who elect to have SEER submit their date to NAACCR,
only. Tumors diagnosed January 1, 2001 or after, should be assigned a
summary stage according to *SEER* *Summary Staging Manual 2000*.

Summary stage should include all information available through
completion of surgery(ies) in the first course of treatment or within 4
months of diagnosis in the absence of disease progression, whichever is
longer.

***Note**:* See also the data item Derived SS2000 \[NAACCR Item #3020\]
for the value of SEER Summary Stage 2000 as generated by the
Collaborative Staging algorithm.

Data may be submitted using either manually entered SEER Summary Stage
2000 code or Collaborative Stage generated code.

**Codes**

0 In situ

1 Localized

2 Regional, direct extension only

3 Regional, regional lymph nodes only

4 Regional, direct extension and regional lymph nodes

5 Regional, NOS

7 Distant

9 Unstaged

**This page left blank**

**SECTION VI**

**FIRST COURSE OF THERAPY**

**All Diseases (including Benign and borderline intracranial & CNS
tumors) Except Leukemia and Hematopoietic Diseases**

**Definitions**

> **Cancer tissue**: Proliferating malignant cells; an area of active
> production of malignant cells. Cancer tissue includes primary tumor
> and metastatic sites where cancer tissue grows. Cells in fluid such as
> pleural fluid or ascitic fluid are not "cancer tissue" because the
> cells do not grow and proliferate in the fluid.
>
> **Disease recurrence:** The patient must have had a disease-free
> interval or remission (the cancer was not clinically evident).
> Following a disease-free interval, there is documentation that the
> initial/original tumor gave rise to the later tumor.
>
> **First course of therapy**: All of the treatments administered to the
> patient after the original diagnosis of cancer in an attempt to
> destroy or modify the cancer tissue. See below for detailed
> information on timing and treatment plan documentation requirements.
>
> **Palliative treatment:** The World Health Organization describes
> palliative care as treatment that improves the quality of life by
> preventing or relieving suffering. Palliative therapy is also part of
> the first course of therapy when the treatment destroys or modifies
> cancer tissue. Palliative therapy may also be part of the first course
> of therapy if it destroys proliferating cancer tissue.
>
> ***Example:*** The patient was diagnosed with stage IV cancer of the
> prostate with painful boney metastases. The patient starts radiation
> treatment intended to shrink the tumor in the bone and relieve the
> intense pain. The radiation treatments are palliative because they
> relieve the bone pain; the radiation is also first course of therapy
> because it destroys proliferating cancer tissue.
>
> **Surgical Procedure:** Any surgical procedure coded in the fields
> Surgery of Primary Site, Scope of Regional Lymph Node Surgery, or
> Surgery of Other Regional or Distant Sites.
>
> **Treatment:** Procedures that destroy or modify primary (primary
> site) or secondary (metastatic).cancer tissue.
>
> **Treatment failure:** The treatment modalities did not destroy or
> modify the cancer cells. The tumor either became larger (disease
> progression) or stayed the same size after treatment.
>
> **Watchful waiting:** A treatment option for patients with slow,
> indolent diseases, such as prostate cancer and chronic lymphocytic
> leukemia (CLL). The physician closely monitors the patient and delays
> treatment until the patient becomes symptomatic or there are other
> signs of disease progression, such as rising PSA.

**Treatment Timing**

> Use the following instructions in hierarchical order.

1.  Use the **documented** first course of therapy from the medical
    record. First course ends when the treatment plan is **completed**.
    (No matter how long it takes to complete the plan).

> ***Example 1:*** First course of treatment for childhood leukemia
> typically spans two years from induction, consolidation, to
> maintenance.
>
> ***Example 2:*** The first course of therapy for a breast cancer
> patient is surgery, chemotherapy, and radiation. The patient completes
> surgery and chemotherapy. Bone metastases are diagnosed before the
> radiation was started. The physician says that the patient will start
> the radiation treatment as planned. Code the radiation as first course
> of therapy since it was given in agreement with the treatment plan and
> the treatment plan was not changed as a result of disease progression.

2.  First course of therapy ends when there is documentation of disease
    progression, recurrence or treatment failure.

> ***Example 1:*** The documented treatment plan for sarcoma is
> chemotherapy, surgery, then radiation or chemotherapy depending upon
> the pathology from surgery. Scans show the tumor is not regressing
> after chemotherapy. Plans for surgery are cancelled and a different
> type of chemotherapy is started. Code only the first chemotherapy as
> first course. Do not code the second chemotherapy as first course
> because it is administered after documented treatment failure.
>
> ***Example 2:*** The documented treatment plan for a patient with
> locally advanced breast cancer includes mastectomy, chemotherapy,
> radiation to the chest wall and axilla, and hormone therapy. The
> patient has the mastectomy and completes chemotherapy. During the
> course of radiation therapy, the liver enzymes are rising. Workup
> proves liver metastases. The physician stops the radiation and does
> not continue with hormone therapy (the treatment plan is altered). The
> patient is placed on a clinical trial to receive Hercepton for
> metastatic breast cancer. Code the mastectomy, chemotherapy, and
> radiation as first course of treatment. Do not code the Hercepton as
> first course of therapy because it is administered after documented
> disease progression.

3.  When there is **no documentation** of a treatment plan, a
    progression, recurrence or a treatment failure, first course ends
    one year after the date of diagnosis. Any treatment given after one
    year is second course of therapy in the absence of a documented
    treatment plan or a standard of treatment.

**Coding Instructions**

1.  When physician decides to do watchful waiting for a patient who has
    prostate cancer, the first course of therapy is no treatment. Code
    all of the treatment fields to 00, not done. When the disease
    progresses and the patient is symptomatic; any prescribed treatment
    is second course.

2.  When the patient refuses treatment the first course of therapy is no
    treatment. Code the treatment fields to refused. If the patient
    later changes his/her mind and decides to have the prescribed
    treatment code:

    a.  Code the treatment as first course of therapy if it has been
        less than one year since the cancer was diagnosed and there has
        been no documented disease progression.

    b.  Code the treatment as second course of therapy if it has been
        more than one year since the original cancer was diagnosed or if
        there has been documented disease progression.

3.  Code all treatment that was started and administered.

> ***Example:*** The patient completed only the first dose of a planned
> 30 day chemotherapy regimen. Code chemotherapy as administered.

4.  If a patient has multiple primaries and the treatment given for one
    primary also affects/treats the other primary, code the treatment
    for both primary sites.

> ***Example 1**:* The patient had prostate and bladder cancer. The
> bladder cancer was treated with a TURB. The prostate cancer was
> treated with radiation to the prostate and pelvis. The pelvic
> radiation includes the regional lymph nodes for the bladder. Code the
> radiation as treatment for both the bladder and prostate cases.
>
> ***Example 2:*** The patient had a hysterectomy for ovarian cancer.
> The pathology report reveals a previously unsuspected microinvasive
> cancer of the cervix. Code the hysterectomy as surgical treatment for
> both the ovarian and cervix primaries.

4.  If a patient has multiple primaries and the treatment given affects
    only one of the primaries, code the treatments only on the site that
    is affected.

> ***Example:*** The patient has colon and tonsil primaries. The colon
> cancer is treated with a hemicolectomy and the tonsil primary is
> treated with radiation to the tonsil and regional nodes. Do not code
> the radiation for the colon. Do not code the hemicolectomy for the
> tonsil.

5.  If a patient is diagnosed with an unknown primary, code the
    treatment given as first course even if the correct primary is
    identified later.

> ***Example:*** The patient is diagnosed with metastatic carcinoma,
> unknown primary site. After a full course of chemotherapy, the primary
> site is identified as prostate. Hormonal treatment is started. Code
> the chemotherapy as first course of treatment. The hormone therapy is
> second course.

**First Course for Leukemia and Hematopoietic Diseases (diagnosed 1/2001
and after)**

**Leukemia**:

> Leukemia is grouped or typed by how quickly the disease develops and
> gets worse. **Chronic** leukemia gets worse **slowly**. **Acute**
> leukemia gets worse **quickly**.
>
> Leukemias are also grouped by the **type** of **white blood cell**
> that is affected. The groupings are: **lymphoid** leukemia and
> **myeloid** leukemia.

**Definitions**

> **Consolidation:** Repetitive cycles of chemotherapy given immediately
> after the remission.
>
> **Induction:** Initial intensive course of chemotherapy.
>
> **Maintenance:** Chemotherapy given for a period of months or years to
> maintain remission.
>
> **Remission**: The bone marrow is normocellular with less than 5%
> blasts, there are no signs or symptoms of the disease, no signs or
> symptoms of central nervous system leukemia or other extramedullary
> infiltration, and all of the following laboratory values are within
> normal limits: white blood cell count and differential,
> hematocrit/hemoglobin level, and platelet count.

**Treatment** for leukemia is divided into **three phases**:

1.  Remission induction (chemotherapy and/or biologic response
    modifiers)

2.  CNS prophylaxis or consolidation (irradiation to brain,
    chemotherapy)

3.  Remission continuation or maintenance (chemotherapy or bone marrow
    transplants).

**Coding First Course of Therapy for Leukemia and Hematopoietic
Diseases:**

1.  If a patient **has** a partial or complete **remission** during the
    first course of therapy:

    a.  Code all therapy that is "remission-inducing" as first course.

    b.  Code all therapy that is "consolidation" as first course.

    c.  Code all therapy that is "remission-maintaining" as first
        course.

> ***Note**:* Do not record treatment given after the patient relapses
> (is no longer in remission).

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**

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 cancer-directed
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

**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 cancer-directed 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 cancer-directed therapy. The
    first cancer-directed therapy may be coded in the following data
    items:

-   Surgery of Primary Site

-   Scope of Regional Lymph Node Surgery when cancer directed

-   Surgical Procedure of Other Site when cancer-directed

-   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.

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.  Primary sites

        i.  Brain (C700-C709) OR

        ii. Spinal cord (C710-C719) OR

        iii. Cranial nerves and other parts of the central nervous
             system (C720-C729)

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

        i.  9590-9596 OR

        ii. 9650-9719 OR

        iii. 9727-9729

    c.  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

**Scope of Regional Lymph Node Surgery**

**Item Length: 1**

**NAACCR Item #: 1292**

**NAACCR Name: RX Summ\--Scope Reg LN Sur**

Scope of Regional Lymph Node Surgery describes the procedure of removal,
biopsy, or aspiration of **regional** lymph nodes performed during the
initial work-up or first course of therapy.

**Codes**

0 No regional lymph nodes removed or aspirated; diagnosed at autopsy.

1 Biopsy or aspiration of regional lymph node, NOS

2 Sentinel lymph node biopsy \[only\]

3 Number of regional lymph nodes removed unknown, not stated; regional
lymph nodes removed, NOS

4 1 to 3 regional lymph nodes removed

5 4 or more regional lymph nodes removed

6 Sentinel node biopsy and code 3, 4, or 5 at same time or timing not
noted

7 Sentinel node biopsy and code 3, 4, or 5 at different times

9 Unknown or not applicable; death certificate only

**Coding Instructions**

1.  Code 0 when regional lymph node removal procedure was not performed.

2.  Code regional lymph node procedures in this data item. Record
    distant lymph node removal in Surgical Procedure of Other Site.

3.  Codes 1-7 are **hierarchical**. Code the procedure that is
    numerically higher.

4.  The regional lymph node surgical procedure(s) may be done to
    **diagnose** cancer, **stage** the disease, or as a part of the
    initial **treatment**. Record all surgical procedures that remove,
    biopsy, or aspirate regional lymph node(s) whether or not there were
    any surgical procedures of the primary site.

> Example: Patient has a sentinel node biopsy of a single lymph node.
> Assign code 2 (Sentinel lymph node biopsy \[only\]).

5.  The Scope of Regional Lymph Node field is **cumulative**; add the
    number of all of the lymph nodes removed during each surgical
    procedure performed as part of the first course of treatment.

> ***Example:*** Patient has a positive cervical node biopsy. The
> pathology report from a subsequent node dissection identifies three
> cervical nodes. Assign code 5 (4 or more regional lymph nodes
> removed).

6.  If the operative report lists a lymph node dissection, but **no
    nodes were found by the pathologist,** code the Scope of Regional
    Lymph Node Surgery to 0 (No lymph nodes removed)

7.  If the patient has **two primaries with common regional lymph
    nodes**, code the removal of regional nodes for both primaries.

> ***Example:*** Patient has a cystoprostatectomy and pelvic lymph node
> dissection for bladder cancer. Pathology identifies prostate cancer as
> well as the bladder cancer and 4/21 nodes positive for metastatic
> adenocarcinoma. Code Scope of Regional Lymph Node Surgery to 5 (4 or
> more regional lymph nodes removed) for both primaries.

11. Assign **code 9** for

    a.  Primary sites

        i.  Brain (C700-C709) OR

        ii. Spinal cord (C710-C719) OR

        iii. Cranial nerves and other parts of the central nervous
             system (C720-C729)

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

        i.  9590-9596 OR

        ii. 9650-9719 OR

        iii. 9727-9729

    c.  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)

> **Surgical Procedure of Other Site**
>
> **Item Length: 1**
>
> **NAACCR Item #: 1294**
>
> **NAACCR Name: Rx Summ\--Surg Oth Reg/Dis**

Surgical Procedure of Other Site describes the surgical removal of
distant lymph node(s) or other tissue(s) or organ(s) beyond the primary
site.

**Codes**

0 None; diagnosed at autopsy

1 Nonprimary surgical procedure performed

2 Nonprimary surgical procedure to other regional sites

3 Non-primary surgical procedure to distant lymph node(s)

4 Nonprimary surgical procedure to distant site

5 Combination of codes 2, 3, or 4

9 Unknown; death certificate only

**Coding Instructions**

1.  Code 0 when no surgical procedures were performed that removed
    distant lymph node(s) or other tissue(s) or organ(s) beyond the
    primary site.

2.  The codes are **hierarchical**. Code the procedure that is
    numerically higher.

3.  Codes 1-5 have priority over codes 0 and 9

4.  Do not code tissue or organs such as an appendix that were removed
    **incidentally,** and the organ was not involved with cancer.

> ***Note:*** Incidental removal of organs means that tissue was removed
> for reasons other than removing cancer or preventing the spread of
> cancer. Examples of incidental removal of organ(s) would be removal of
> appendix, gallbladder, etc. during abdominal surgery.

**Reason for No Surgery of Primary Site**

**Item Length: 1**

**NAACCR Item #: 1340**

**NAACCR Name: Reason for No Surgery**

Records the reason that surgery was not performed on the primary site.

**Codes**

0 Surgery of the primary site was performed

1 Surgery of the primary site was not performed because it was not part
of the planned first-course treatment

2 Surgery of the primary site was not recommended/performed because it
was contraindicated due to patient risk factors (comorbid conditions,
advanced age, etc.)

5 Surgery of the primary site was not performed because the patient died
prior to planned or recommended surgery

6 Surgery of the primary site was not performed; it was recommended by
the patient's physician, but was not performed as part of the first
course of therapy. No reason was noted in the patient's record.

7 Surgery of the primary site was not performed; it was recommended by
the patient's physician, but was refused by the patient, the patient's
family member, or the patient's guardian. The refusal was noted in the
patient record.

8 Surgery of the primary site was recommended, but it is unknown if it
was performed. Further follow up is recommended.

9 It is unknown if surgery of the primary site was recommended or
performed; death certificate only cases and autopsy only cases.

**Coding Instructions**

1.  Assign **code 0** when Surgery of Primary Site is coded in the range
    of 10-90 (the patient did have surgery of primary site)

2.  Assign a code in the **range of 1-8** if Surgery of Primary Site is
    coded 00 or 98.

3.  Assign **code 1**

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

        i.  It is known that surgery 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 surgery of primary site.

    b.  If the treatment plan offered multiple treatment options and the
        patient selected treatment that did not include surgery of the
        primary site Patient elects to pursue no treatment following the
        discussion of radiation treatment. Discussion does not equal a
        recommendation.

    c.  Only information available is that the patient was referred to a
        surgeon. Referral does not equal a recommendation.

    d.  Watchful waiting (prostate)

    e.  Patient diagnosed at autopsy

4.  Assign **code 6**

    a.  When it is known that surgery was recommended AND

    b.  It is known that surgery was not performed AND

    c.  There is no documentation explaining why surgery was not done.

5.  Assign **code 7** (refused) if the patient refused recommended
    surgery, or made a blanket statement that he/she refused all
    treatment.

6.  Assign **code 8** (unknown) if the treatment plan offered surgery,
    but it is unknown if the patient actually had the surgery.

7.  Assign **code 9**

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

    b.  Death certificate only.

    c.  Autopsy only (Diagnosis 1/1/2003)

**Radiation**

**Item Length: 1**

**NAACCR Item #: 1360**

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

Record the method of administration of radiation administered as a part
of the first course of treatment. Record all radiation that is given,
even if it is palliative.

The Commission on Cancer (COC) does not require the collection of the
radiation summary data field effective 1/1/2002. If this data item is
not reported by a COC hospital, SEER central registries can generate the
code for this field by combining information from fields required by
COC. Tables for deriving the radiation summary are included in this
section.

**Codes**

0 None; diagnosed at autopsy

1 Beam radiation

2 Radioactive implants

3 Radioisotopes

4 Combination of 1 with 2 or 3

5 Radiation, NOS -- method or source not specified

7 Patient or patient's guardian refused radiation therapy

8 Radiation recommended, unknown if administered

9 Unknown if radiation administered

**Coding Instructions**

1.  Assign **code 0**

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

        i.  It is known that radiation 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 radiation.

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

    c.  Patient elects to pursue no treatment following the discussion
        of radiation treatment. Discussion does not equal a
        recommendation.

    d.  Only information available is that the patient was referred to a
        radiation oncologist. Referral does not equal a recommendation.

    e.  Watchful waiting (prostate)

    f.  Patient diagnosed at autopsy

2.  Assign **code 1** for beam radiation directed to cancer tissue. The
    source of the beam radiation is not used for coding purposes.
    Sources may include, but are not limited to: X-ray, Cobalt, linear
    accelerator, neutron beam, betatron, spray radiation, stereotactic
    radiosurgery such as gamma knife and proton beam.

3.  Assign **code 2** when the radiation is delivered by interstitial
    implant, molds, seeds, needles or intracavitary applicators. The
    radioactive material used in implants includes, but is not limited
    to: cesium, radium, radon, radioactive gold, and iodine.

4.  Assign **code 3** when radioactive isotopes are given orally,
    intracavitary or by intravenous injection. Radioactive isotopes
    include but are not limited to: I-131 or P-32.

5.  If the patient has multiple radiation types, code the dominant type
    (the greatest dose of radiation).

6.  For cases diagnosed prior to 1/1/1998, radiation to the brain and/or
    central nervous system for lung and leukemia cases was coded in the
    field Radiation to the Brain and/or Central Nervous System.

7.  Assign **code 9**

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

    b.  Death certificate only.

**Translation of Regional Treatment Modality and/or Boost Treatment
Modality Field to RX Summ\--Radiation**

  ----------------------------------------------------------------------------
  **RX Summ---Radiation**         **Code**   **Regional Treatment Modality
                                             and/or Boost Treatment**
  ------------------------------- ---------- ---------------------------------
  0 None                          00         No radiation treatment

  1 Beam radiation                20         External beam, NOS

                                  21         Orthovoltage

                                  22         Cobalt-60, Cesium-137

                                  23         Photons (2-5 MV)

                                  24         Photons (6-10 MV)

                                  25         Photons (11-19 MV)

                                  26         Photons (\>19 MV)

                                  27         Photons (mixed energies)

                                  28         Electrons

                                  29         Photons and electrons mixed

                                  30         Neutrons, with or without
                                             photons/electrons

                                  31         IMRT

                                  32         Conformal or 3-D therapy

                                  40         Protons

                                  41         Stereotactic radiosurgery, NOS

                                  42         Linac radiosurgery

                                  43         Gamma Knife

  2 Radioactive implants          50         Brachytherapy, NOS

                                  51         Brachytherapy, intracavitary, LDR

                                  52         Brachytherapy, intracavitary, HDR

                                  53         Brachytherapy, interstitial, LDR

                                  54         Brachytherapy, interstitial, HDR

                                  55         Radium

  3 Radioisotopes                 60         Radioisotopes, NOS

                                  61         Strontium-89

                                  62         Strontium-90

  4 Combination of 1 with 2 or 3  80         Combination modality, specified

                                  85         Combination modality, NOS

  5 Radiation therapy, NOS,       98         Other, NOS
  method or source unspecified               

  9 Unknown                       99         Unknown
  ----------------------------------------------------------------------------

If a code for TX Summ-Radiation is not received from hospital
registrars, the code can be derived from the following sources if
radiation is not received from hospital registries. The code for RX
Summ---Radiation is derived from Rad-Boost RX Modality, Rad-Regional TX
Modality, and/or Reason For No Radiation.

  -----------------------------------------------------------------------
  **Rad---Boost RX        **Rad---Regional TX        **RX
  Modality**              Modality**                 Summ\--Radiation**
  ----------------------- -------------------------- --------------------
  00                      00, 99                     0\*

  00                      20-43                      1

  00                      50-55                      2

  00                      60-62                      3

  00                      80-85                      4

  00                      98                         5

  20-43                   00, 20-43, 98, 99          1

  20-43                   50-55, 60-62, 80-85        4

  50-55                   00, 50-55, 98, 99          2

  50-55                   20-43, 80-85               4

  50-55                   60-62                      3

  60-62                   00, 50-55, 60-62, 98, 99   3

  60-62                   20-43, 80-85               4

  80-85                   00-99                      4

  98                      00, 98, 99                 5

  98, 99                  20-43                      1

  98, 99                  50-55                      2

  98, 99                  60-62                      3

  98, 99                  80-85                      4

  99                      00                         0\*

  99                      99                         9
  -----------------------------------------------------------------------

\* Reason No Radiation is reviewed for asterisked items only. If Reason
for No Radiation is 7, RX Summ\--Radiation is 7; If Reason for No
Radiation is 8, RX Summ\--Radiation code is 8.

**Radiation Sequence with Surgery**

**Item Length: 1**

**NAACCR Item #: 1380**

**NAACCR Name: RX Summ\--Surg/Rad Seq**

This field records the order in which surgery and radiation therapies
were administered for those patients who had **both surgery and
radiation**. For the purpose of coding Radiation Sequence with Surgery,
'Surgery' is defined as a Surgical Procedure to the Primary Site (codes
10-90) or Scope of Regional Lymph Node Surgery (codes 1-7) or Surgical
Procedure of Other Site (codes 1-5).

**Codes**

0 No radiation and/or surgery as defined above

2 Radiation before surgery

3 Radiation after surgery

4 Radiation both before and after surgery

5 Intraoperative radiation therapy

6 Intraoperative radiation with other radiation given before or after
surgery

9 Sequence unknown, but both surgery and radiation were given

**Definition**

> **Surgery**: Surgical Procedure to the Primary Site (codes 10-90) or
> Scope of Regional Lymph Node Surgery (codes 1-7) or Surgical Procedure
> of Other Site (codes 1-5).

**Coding Instructions**

> Assign code 0 when

-   The patient did not have either surgery or radiation.

-   The patient had surgery but not radiation.

-   The patient had radiation but not surgery

> ***Note:*** For cases diagnosed prior to 1/1/1998, Radiation to the
> Brain and/or Central Nervous System was counted as radiation when
> coding this field.
>
> Assign codes 2-9 when first course of therapy consists of both
> cancer-directed surgery and radiation therapy.

**Chemotherapy**

####### Item Length: 2

**NAACCR Item #: 1390**

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

The data item Chemotherapy records the chemotherapy given as a part of
the first course of treatment or the reason that chemotherapy was not
given. See *SEER Self Instructional Manuals for Tumor Registrars Book 8*
for chemotherapy drug codes.

Chemotherapeutic agents are chemicals that affect cancer tissue by means
other than hormonal manipulation. The agents inhibit the production of
cancer cells by interfering with DNA synthesis and mitosis. They may be
divided into three classes with respect to their dependence on the cell
cycle.

1.  Alkylating agents are **not cell-cycle-specific**. Although they are
    toxic to all cells, they are especially toxic to proliferating
    cells.

2.  Other drugs are **cell-cycle-specific**. Cells must be proliferating
    for these drugs to be effective.

3.  Cell-cycle-specific drugs may also be **cell-cycle phase-specific**;
    such drugs are active only in one stage of the cell cycle.

Chemotherapy agents are also grouped by their ingredients and the way
they attack the cells. Those groups are:

1.  Alkylating

2.  Antimetabolites

3.  Natural products

4.  Other miscellaneous

**Codes**

00 None, chemotherapy was not part of the planned first course of
therapy; diagnosed at autopsy

01 Chemotherapy administered as first course therapy, but the type and
number of agents is not documented in the patient record.

02 Single agent chemotherapy administered as first course therapy.

03 Multiagent chemotherapy administered as first course therapy.

82 Chemotherapy was not recommended/administered because it was
contraindicated due to patient risk factors (comorbid conditions,
advanced age, etc.).

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

86 Chemotherapy 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 patient record.

87 Chemotherapy was not administered. It was recommended by the
patient's physician, but the 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 Chemotherapy was recommended, but it is unknown if it was
administered.

99 It is unknown whether a chemotherapeutic agent(s) was recommended or
administered because it is not stated in the patient record. Death
certificate only.

**Definitions**

> **Chemotherapy recommended:** There was a consult recommending
> chemotherapy or the attending physician documented that chemotherapy
> was recommended. A referral to a clinical oncologist does not equal a
> recommendation.
>
> **Multiple agent chemotherapy:** Two or more chemotherapeutic agents
> were administered to destroy cancer tissue during the first course of
> therapy. The chemotherapeutic agents may or may not have been
> administered with other drugs classified as immunotherapy, hormone
> therapy, ancillary or other treatment.
>
> **Single agent chemotherapy:** Only one chemotherapeutic agent was
> administered to destroy cancer tissue during the first course of
> therapy. The chemotherapeutic agent may or may not have been
> administered with other drugs classified as immunotherapy, hormone
> therapy, ancillary, or other treatment.

**Coding Instructions**

1.  Code the chemotherapeutic agents whose actions are chemotherapeutic
    only; **do not code** the method of **administration**.

2.  When chemotherapeutic agents are used as radiosensitizers or
    radioprotectants, they are given at a much lower dosage and do not
    affect the cancer. Radiosensitizers and radioprotectants are
    classified as ancillary drugs. Do not code as chemotherapy.

3.  The physician may change a drug during the first course of therapy
    because the patient cannot tolerate the original agent. If the
    chemotherapeutic agent that is substituted belongs to the same group
    (alkylating, antimetabolites, natural products, or other
    miscellaneous), this is a continuation of the first course of
    therapy. If treated with a single agent and this agent is changed to
    another single agent in the same group code remains 02 single agent.

4.  Assign **code 00** when

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

        i.  It is known that chemotherapy 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 chemotherapy.

    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

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 radiation.

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

    c.  Patient elects to pursue no treatment following the discussion
        of hormone therapy treatment. Discussion does not equal a
        recommendation.

    d.  Only information available is that the patient was referred to
        an oncologist. Referral does not equal a recommendation.

    e.  Watchful waiting (prostate)

    f.  Patient diagnosed at autopsy

2.  Assign **code 99**

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

    b.  Death certificate only.

3.  Some types of cancer **thrive and proliferate** **because** of
    **hormones** (estrogen, progesterone and testosterone) that
    naturally occur in the body. These types of cancer may be treated by
    an **antihormone** or by the surgical removal/radiation of the
    organ(s) that produce the hormone, such as the testes and ovaries.
    **Surgical removal** of **organs** for hormone manipulation is not
    coded in this data item. Code these procedures in the data field
    Hematologic Transplant and Endocrine Procedures.

4.  Other types of cancers are **slowed** or **suppressed** by
    **hormones**. These cancers are treated by administering hormones.

> ***Example 1:*** Endometrial cancer may be treated with progesterone.
> Code all administration of progesterone to patients with endometrial
> cancer in this field. Even if the progesterone is given for menopausal
> symptoms, it has an effect on the growth or recurrence of endometrial
> cancer.
>
> ***Example 2:*** **Follicular** and papillary cancers of the
> **thyroid** are often treated with thyroid hormone to suppress serum
> thyroid-stimulating hormone (TSH). If a patient with papillary and/or
> follicular cancer of the thyroid is given a thyroid hormone, code the
> treatment in this field.

5.  Code the hormonal agent given as part of combination chemotherapy,
    e.g. MOPP, COPP whether it affects the cancer cells or not.

**Immunotherapy**

> **Item Length: 2**

**NAACCR Item #: 1410**

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

The data item Immunotherapy records immunotherapeutic (biological
therapy, biotherapy or biological response modifier) agents administered
as first course of therapy.

Immunotherapy **uses** the body's **immune** **system**, either directly
or indirectly, to fight cancer or to lessen the side effects that may be
caused by some cancer treatments. Record only those treatments that are
administered to affect the cancer cells.

Immunotherapy is **designed** to:

1.  Make **cancer cells** more **recognizable** and therefore more
    **susceptible** to destruction by the immune system.

2.  **Boost** the killing power of **immune** system cells, such as
    T-cells, NK-cells, and macrophages.

3.  **Alter** cancer cells\' **growth** **patterns** of cancer cells to
    promote behavior like that of healthy cells

4.  **Block** or **reverse** the process that **changes** a normal cell
    or a pre-cancerous cell into a cancerous cell.

5.  **Enhance** the body's ability to **repair** or **replace** normal
    cells damaged or destroyed by other forms of cancer treatment, such
    as chemotherapy or radiation.

6.  **Prevent** cancer cells from **spreading** to other parts of the
    body.

**Codes**

00 None, immunotherapy was not part of the planned first course of
therapy; not customary therapy for this cancer; diagnosed at autopsy
only.

01 Immunotherapy was administered as first course therapy.

82 Immunotherapy was not recommended/administered because it was
contraindicated due to patient risk factors (comorbid conditions,
advanced age etc.).

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

86 Immunotherapy 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 noted in the patient's record.

87 Immunotherapy 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 Immunotherapy was recommended, but it is unknown if it was
administered.

99 It is unknown if immunotherapy was recommended or administered
because it is not stated in patient record; death certificate only
cases.

**Definitions**

> **Types of immunotherapy**
>
> **Cancer Vaccines:** Cancer vaccines are still in the experimental
> phase and are not coded in this data item. They may be coded in the
> field Other Therapy. Currently clinical trials use cancer vaccines for
> brain, breast, colon, kidney, lung, melanoma and ovary.
>
> **Interferons:** Interferons belong to a group of proteins called
> cytokines. They are produced naturally by the white blood cells in the
> body. Interferon-alpha is able to slow tumor growth directly as well
> as activate the immune system. It is used for a number of cancers
> including multiple myeloma, chronic myelogenous leukemia (CML), hairy
> cell leukemia, and malignant melanoma.
>
> **Interleukins** (IL-2) are often used to treat kidney cancer and
> melanoma.
>
> **Monoclonal Antibodies:** Monoclonal antibodies are produced in a
> laboratory. The artificial antibodies are injected into the patient to
> seek out and disrupt cancer cell activities and to enhance the immune
> response against the cancer. For example, Rituximab (Rituxan) may be
> used for non-Hodgkin lymphoma, and trastuzumab (Herceptin) may be used
> for certain breast cancers.

**Coding Instructions**

1.  Assign **code 00**

    a.  When there is no information in the patient's medical record
        about immunotherapy AND

        i.  It is known that radiation 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 immunotherapy.

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

    c.  Patient elects to pursue no treatment following the discussion
        of immunotherapy. Discussion does not equal a recommendation.

    d.  Only information available is that the patient was referred to
        an oncologist. Referral does not equal a recommendation.

    e.  Watchful waiting (prostate)

    f.  Patient diagnosed at autopsy

2.  Assign **code 87**

    a.  If the patient refused recommended immunotherapy.

    b.  If the patient made a blanket refusal of all recommended
        treatment.

    c.  If the patient refused all treatment before any was recommended.

3.  Assign **code 99**

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

    b.  Death certificate only.

**Hematologic Transplant and Endocrine Procedures**

**Item Length: 2**

**NAACCR Item #: 3250**

**NAACCR Name: RX Summ\--Transplnt/Endocr**

This data item records systemic therapeutic procedure administered as
part of the first course of treatment. These procedures include bone
marrow transplants (BMT) and stem cell harvests with rescue (stem cell
transplant), endocrine surgery and/or radiation performed for hormonal
effect (when cancer originates at another site), as well as combination
of transplants and endocrine therapy.

**Codes**

00 None, transplant procedure or endocrine therapy was not a part of the
first course of therapy; not customary therapy for this cancer;
diagnosed at autopsy only.

10 Bone marrow transplant, NOS. A bone marrow transplant procedure was
administered as first course therapy, but the type was not specified.

> 11 Bone marrow transplant autologous
>
> 12 Bone marrow transplant allogeneic

20 Stem cell harvest (stem cell transplant) as first course therapy.

30 Endocrine surgery and/or endocrine radiation therapy as first course
therapy.

40 Combination of transplant procedure with endocrine surgery and/or
endocrine radiation (Code 30 in combination with 10, 11, 12, or 20) as
first course therapy.

82 Transplant procedure and/or endocrine therapy was not
recommended/administered because it was contraindicated due to patient
risk factors (comorbid conditions, advanced age, etc.).

85 Transplant procedures and/or endocrine therapy were not administered
because the patient died prior to planned or recommended therapy.

86 Transplant procedures and/or endocrine therapy were not administered;
it was recommended by the patient's physician, but was not administered
as part of first course therapy. No reason was noted in the patient
record.

87 Transplant procedures and/or endocrine therapy were not administered;
this treatment was recommended by the patient's physician but was
refused by the patient, a patient's family member, or the patient's
guardian. The refusal was noted in the patient record.

88 Transplant procedures and/or endocrine therapy was recommended, but
it is unknown if it was administered.

99 It is unknown if a transplant procedure or endocrine therapy was
recommended or administered because it is not stated in patient record;
death certificate only cases.

**Definitions:**

> **Bone marrow transplant (BMT):** Procedure used to restore stem cells
> that were destroyed by chemotherapy and/or radiation. Replacing the
> stem cells allows the patient to undergo higher doses of chemotherapy.
>
> **BMT Allogeneic:** Receives bone marrow or stem cells from a donor.
>
> **BMT Autologous:** Uses the patient's own bone marrow and/or stem
> cells. The tumor cells are filtered out and the purified blood and
> stem cells are returned to the patient.
>
> ***Note:*** Used for breast cancer, lymphoma, leukemia, aplastic
> anemia, myeloma, germ cell tumors, ovarian cancer, and small cell lung
> cancer.
>
> **Conditioning:** High-dose chemotherapy with or without radiation
> administered prior to transplants such as BMT and stem cell to kill
> cancer cells. This conditioning also destroys normal bone marrow cells
> so the normal cells need to be replaced (rescue). The high dose
> chemotherapy is coded in the Chemotherapy field.
>
> **Hematopoietic Growth Factors:** A group of substances that support
> hematopoietic (blood cell) colony formation. The group includes
> erythropoietin, interleukin-3, and colony-stimulating factors (CSFs).
> The growth-stimulating substances are ancillary drugs and not coded.
>
> **Non-Myeloablative Therapy:** Uses immunosuppressive drugs pre- and
> post-transplant to ablate the bone marrow. These are not recorded as
> therapeutic agents.
>
> **Peripheral Blood Stem Cell Transplantation (PBSCT):** Rescue that
> replaces stem cells after conditioning.
>
> **Rescue:** Rescue is the actual BMT or stem cell transplant done
> after conditioning.
>
> **Stem Cells:** Immature cells found in bone marrow, blood stream and
> umbilical cords. The stem cells mature into blood cells.

**Coding Instructions**

1.  Assign **code 00**

    a.  When there is no information in the patient's medical record
        about transplant procedure or endocrine therapy AND

        i.  It is known that transplant procedure or endocrine 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 transplant procedure or endocrine therapy.

    b.  If the treatment plan offered multiple treatment options and the
        patient selected treatment that did not include transplant
        procedure or endocrine therapy

    c.  Patient elects to pursue no treatment following the discussion
        of transplant procedure or endocrine therapy. Discussion does
        not equal a recommendation.

    d.  Only information available is that the patient was referred to
        an oncologist. Referral does not equal a recommendation.

    e.  Watchful waiting (CLL)

    f.  Patient diagnosed at autopsy

2.  Assign **code 10** if the patient has "mixed chimera transplant
    (mini-transplant or non-myeloablative transplant). These transplants
    are a mixture of the patient's cells and donor cells.

3.  **Codes 11 and 12** have priority over code 10 (BMT, NOS).

4.  Assign **code 12** (allogeneic) for a syngeneic bone marrow
    transplant (from an identical twin) or for a transplant from any
    person other than the patient.

5.  Assign **code 20** when the patient has a stem cell harvest followed
    by a rescue or reinfusion (stem cell transplant). If the patient
    does not have a rescue, code the stem cell harvest as 88,
    recommended, unknown if administered.

6.  Assign **code 30** for endocrine radiation and/or surgery. Endocrine
    organs are testes and ovaries. Endocrine radiation and/or surgical
    procedures must be bilateral, or must remove the remaining paired
    organ for hormonal effect.

7.  Assign **code 87**

    a.  If the patient **refused** recommended **transplant or endocrine
        procedure**.

    b.  If the patient made a **blanket refusal** of all recommended
        treatment.

    c.  If the patient **refused all treatment** before any was
        recommended.

8.  Assign **code 99**

    a.  When there is no documentation that transplant procedure or
        endocrine therapy was recommended or performed

    b.  Death certificate only.

**Other Therapy**

**Item Length: 1**

**NAACCR Item #: 1420**

**NAACCR Name: RX Summ---Other**

Other Therapy identifies other treatment given that cannot be classified
as surgery, radiation, systemic therapy, or ancillary treatment.

**Codes**

0 None

1 Other

2 Other-Experimental

3 Other-Double Blind

6 Other-Unproven

7 Refusal

8 Recommended, unknown if administered

9 Unknown

**Coding Instructions**

1.  Assign **Code 0** when

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

        i.  It is known that other 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 other therapy.

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

    c.  Patient elects to pursue no treatment following the discussion
        of other therapy. Discussion does not equal a recommendation.

    d.  Only information available is that the patient was referred for
        consideration of other therapy. Referral does not equal a
        recommendation.

    e.  Patient diagnosed at autopsy

2.  Assign **code 1**

    a.  Hematopoietic treatments such as: phlebotomy, transfusions, or
        aspirin

    b.  Patient had cancer treatment that could not be assigned to the
        previous treatment fields (surgery, radiation, chemotherapy,
        immunotherapy, or systemic therapy)

3.  Assign **Code 2** for any experimental or newly developed treatment
    that differs greatly from proven types of cancer therapy such as a
    clinical trial.

> ***Note:*** Hyperbaric oxygen has been used to treat cancer in
> clinical trials, but it is also used to promote tissue healing
> following head and neck surgeries. Do not code the administration of
> hyperbaric oxygen to promote healing as an experimental treatment.

4.  Assign **code 3** when the patient is enrolled in a double blind
    clinical **trial**. When the trial is complete and the code is
    broken, review and recode the therapy.

5.  Assign **code 6** for **unconventional** methods whether they are
    the single therapy or given in combination with conventional
    therapy.

6.  Assign **code 8** When other therapy was recommended by the
    physician but there is no information that the treatment was given.

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8.  Assign **code 9**

    a.  When there is no documentation that other therapy was
        recommended or performed

    b.  Death certificate only.

The following explanations and definitions are quoted from the website
for the National Center for Complimentary and Alternative Medicine
(NCCAM). Complementary and alternative medicine, as defined by NCCAM, is
a group of diverse medical and health care systems, practices, and
products that are not presently considered to be part of conventional
medicine. While some scientific evidence exists regarding some CAM
therapies, for most there are key questions that are yet to be answered
through well-designed scientific studies\--questions such as whether
they are safe and whether they work for the diseases or medical
conditions for which they are used.

-   **Complementary** medicine is used **together with** conventional
    medicine. An example of a complementary therapy is using
    aromatherapy to help lessen a patient\'s discomfort following
    surgery.

-   **Alternative** medicine is used **in place of** conventional
    medicine. An example of an alternative therapy is using a special
    diet to treat cancer instead of undergoing surgery, radiation, or
    chemotherapy that has been recommended by a conventional doctor.

> See complete information on types of complementary and alternative
> medicine at <http://nccam.nih.gov/health/whatiscam/>

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**SECTION VII**

**FOLLOW UP INFORMATION**

**Date of Last Follow up or of Death**

**Item Length: 8**

**NAACCR Item #: 1750**

**NAACCR Name: Date of Last Contact**

SEER requires the registries to update the follow up information on all
cases on an annual basis. The exception is carcinoma in situ of the
cervix diagnosed on or after 1/1/1996. This data item records the date
of last follow up or the date of death.

Date fields are recorded in the month, day, century, year format
(MMDDCCYY) with 99 for unknown day or month and 9999 for unknown year.

SEER registries collect the month, day, and year of last follow up or of
death. 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 follow up or death

Record 9999 for unknown year

**Special Codes**

99999999 Unknown date

**Coding instructions**

1.  Code the date the patient was actually seen by the physician or
    contacted by the hospital registry as the follow up date. Do not
    code the date the follow up report was received.

2.  Do not change the follow up date unless new information is
    available.

3.  The field is associated with the patient, not the cancer, so all
    records (primary sites) for the same patient will have the same
    follow up date.

**Vital Status**

**Item Length: 1**

**NAACCR Item #: 1760**

**NAACCR Name: Vital Status**

SEER requires the registries to update the follow up information on all
cases on an annual basis. The exception is carcinoma in situ of the
cervix diagnosed on or after 1/1/1996. This field records the vital
status of the patient on the date of last follow up.

If the patient has multiple records, the vital status must be identical
on each record.

**Codes**

1 Alive

4 Dead

The field is associated with the patient, not the cancer, so if the
patient has multiple tumors, vital status should be the same for all
tumors.

**ICD Code Revision Used for Cause of Death**

**Item Length: 1**

**NAACCR Item #: 1920**

**NAACCR Name: ICD Revision Number**

SEER requires the registries to update the follow up information on all
cases on an annual basis. The exception is carcinoma in situ of the
cervix diagnosed on or after 1/1/1996. Shows the revision of the
International Classification of Diseases (ICD) used to code the
underlying cause of death.

If the patient has multiple records, the ICD Code Revision Used for
Cause of Death must be identical on each record.

**Codes**

0 Patient alive at last follow up

1 ICD-10 (1999+ deaths)

7 ICD-7

8 ICDA-8

9 ICD-9

**Underlying Cause of Death**

**Item Length: 4**

**NAACCR Item #: 1910**

**NAACCR Name: Cause of Death**

This is the official underlying cause of death coded from the death
certificate using ICD-7, ICDA-8, ICD-9, or ICD-10 codes.

**Special Codes**

0000 Patient alive at last contact

7777 State death certificate or listing not available

7797 State death certificate or listing available, but underlying cause
of death not coded

**Coding Instructions for ICD-10**

1.  Use the underlying cause of death as coded by a State Health
    Department even if the code seems to be in error.

2.  Report the coded underlying cause of death code from another source
    such as NDI plus or state data exchange if the coded death
    certificate is not available.

3.  If the coded underlying cause of death code is not on the death
    certificate and is not available from other sources, code 7797.

4.  If neither the death certificate nor the coded underlying cause of
    death is available, code 7777.

> ***Example*:** Medical doctor states patient died, but death
> certificate not available (not on state death file, not available
> through federal or state agencies), code 7777.

5.  Ignore (do not record) decimal points when copying codes.

6.  The cause of death code is commonly four characters. Ignore (do not
    code) a fifth character if present.

7.  Left justify the codes; if less than four characters, left justify
    and add a 9 to the right.

8.  If the underlying cause of death code is not available, do not
    attempt to code the underlying cause of death unless you have a
    trained ICD-10 nosologist on staff or on consult.

Beginning for deaths in 1999, the United States agreed to code all
deaths using the *International Statistical Classification of Diseases
and Related Health Problems*, Tenth Revision (ICD-10). The ICD-10 codes
have up to four characters: a letter followed by 2 or 3 digits.

***Examples:***

> **Underlying Cause of Death ICD-10 SEER Code**
>
> Malignant neoplasm of the thyroid C73 C739
>
> Acute appendicitis with peritonitis K35.0 K350
>
> Malignant neoplasm of stomach C16.9 C169

If the patient has multiple records, the underlying cause of death must
be identical on each record.

> **Type of Follow up**

**Item Length: 1**

**NAACCR Item #: 2180**

**NAACCR Name: SEER Type of Follow up**

Codes for the type of follow up expected for a SEER case

**Codes**

1 "Autopsy Only" or "Death Certificate Only" case

2 Active follow up case

3 In situ cancer of the cervix uteri only

4 Case not originally in active follow up, but in active follow up now
(San Francisco-Oakland only)

**Coding Instructions**

1.  All cases other than in situ cancers of the cervix uteri must be
    followed annually, including benign and borderline intractranial and
    CNS tumors diagnosed 1/1/2004 and forward.

2.  If information is received on a person with an in situ cancer of the
    cervix diagnosed before 1/1/1996, the follow up information should
    be updated.

3.  Cases of in situ cancer of the cervix diagnosed on or after 1/1/1996
    are not reportable; follow up is not required.

**SECTION VIII**

**ADMINISTRATIVE CODES**

Each calendar year the SEER participants submit records to NCI for all
persons/cancers diagnosed since the participant started reporting. Many
of these records have been updated with information received by the
participant since the prior data submission. NCI edits the information
to ensure correctness and comparability of reporting. Some of these
edits identify conditions that require additional review. To eliminate
the need to review the same cases each submission, the Administrative
Codes section contains a set of indicators used to show that the
information on a record has already been reviewed.

**SITE/TYPE INTERFIELD REVIEW**

####### Item Length: 1

## NAACCR Item #: 2030

## NAACCR Name: Over-Ride Site/Type

**Site/Type Interfield Review (Interfield Edit 25) (SEER #1)**

**Codes**

blank Not reviewed

1 Reviewed: The coding of an unusual combination of primary site and
histologic type has been reviewed.

**HISTOLOGY/BEHAVIOR INTERFIELD REVIEW**

####### Item Length: 1

## NAACCR Item #: 2040

## NAACCR Name: Over-Ride Histology

**Histology/Behavior Interfield Review (Field Item Edit Morph) (SEER
#2)**

**Codes**

blank Not reviewed

1 Reviewed: The behavior code of the histology is designated as "benign"
or "uncertain" in ICD-O-2 or ICD-O-3, and the pathologist states the
primary to be "*in situ*" or "malignant" (flag for a "Morphology Type &
Behavior" edit).

2 Reviewed: The behavior is in situ, but the tumor is not
microscopically confirmed (flag for a "Diagnostic Confirmation, Behavior
Code" edit).

3 Reviewed: Both conditions 1 and 2 above apply.

**AGE/SITE/HISTOLOGY INTERFIELD REVIEW**

####### Item Length: 1

## NAACCR Item #: 1990

## NAACCR Name: Over-Ride Age/Site/Morph

**Age/Site/Histology Interfield Review** **(Interfield Edit 15) (SEER
#3)**

**Codes**

blank Not reviewed

1 Reviewed: An unusual occurrence of a particular site/histology
combination for a given age group has been reviewed.

**SEQUENCE NUMBER/DIAGNOSTIC CONFIRMATION INTERFIELD REVIEW**

####### Item Length: 1

## NAACCR Item #: 2000

## NAACCR Name: Over-ride SeqNo/DxConf

**Sequence Number/Diagnostic Confirmation Interfield Review**
(**Interfield Edit 23) (SEER #4)**

**Codes**

blank Not reviewed

1 Reviewed: Multiple primaries of special sites in which at least one
diagnosis has not been microscopically confirmed have been reviewed.

**SITE/HISTOLOGY/LATERALITY/SEQUENCE INTERRECORD REVIEW**

####### Item Length: 1

## NAACCR Item #: 2010

## NAACCR Name: Over-Ride Site/Lat/SeqNo

**Site/Histology/Laterality/Sequence Number Interrecord Review**
(**Interrecord Edit 09) (SEER #5)**

**Codes**

blank Not reviewed

1 Reviewed: Multiple primaries of the same histology (3 digit) in the
same primary site group have been reviewed.

**SURGERY/DIAGNOSTIC CONFIRMATION INTERFIELD REVIEW**

####### Item Length: 1

## NAACCR Item #: 2020

## NAACCR Name: Over-Ride Surg/DxConf

**Surgery/Diagnostic Confirmation Interfield Review (Interfield Edit 46)
(SEER #6)**

**Codes**

blank Not reviewed

1 Reviewed: A patient who had (cancer‑directed) surgery, but the tissue
removed was not sufficient for microscopic confirmation.

**Type of Reporting Source/Sequence Number Interfield Review**

####### Item Length: 1

## NAACCR Item #: 2050

## NAACCR Name: Over-Ride Report Source

**Type of Reporting Source/Sequence Number Interfield Review**
(**Interfield Edit 04) (SEER #7)**

**Codes**

blank Not reviewed

1 Reviewed: A second or subsequent primary with a reporting source of
death certificate only has been reviewed and is indeed an independent
primary.

**SEQUENCE NUMBER/ILL‑DEFINED SITE INTERFIELD REVIEW**

####### Item Length: 1

## NAACCR Item #: 2060

## NAACCR Name: Over-Ride Ill-define Site

**Sequence Number/Ill‑defined Site Interfield Review** **(Interfield
Edit 22) (SEER #8)**

**Codes**

blank Not reviewed

1 Reviewed: A second or subsequent primary reported with an ill‑defined
primary site (C76.0‑C76.8, C80.9) has been reviewed and is an
independent primary.

**LEUKEMIA OR LYMPHOMA/DIAGNOSTIC CONFIRMATION INTERFIELD REVIEW**

####### Item Length: 1

## NAACCR Item #: 2070

## NAACCR Name: Over-Ride Leuk, Lymphoma

**Lymphoma/Diagnostic Confirmation Interfield Review** **(Interfield
Edit 48) (SEER #9)**

**Codes**

blank Not reviewed

1 Reviewed: A patient was diagnosed with leukemia or lymphoma and the
diagnosis was not microscopically confirmed.

**OVER-RIDE FLAG FOR SITE/BEHAVIOR (IF39)**

####### Item Length: 1

## NAACCR Item #: 2071

## NAACCR Name: Over-Ride Site/Behavior

**Over-ride Flag for Site/Behavior (IF39) (SEER #11)**

**Codes**

blank Not reviewed

1 Reviewed: A patient has an in situ cancer of a nonspecific site and no
further information about the primary site is available.

The IF39 edit does not allow in situ cases of nonspecific sites, such as
gastrointestinal tract, NOS; uterus, NOS; female genital tract, NOS;
male genital organs, NOS; and others. This over-ride indicates that the
conflict has been reviewed.

This was a new over-ride flag in the third edition of the code manual,
but the flag may be applied to cases from any year.

**OVER-RIDE FLAG FOR SITE/EOD/DIAGNOSIS DATE (IF40)**

####### Item Length: 1

## NAACCR Item #: 2072

## NAACCR Name: Over-Ride Site/EOD/DX Dt

**Over-ride Flag for Site/EOD/Diagnosis Date (IF40) (SEER #13)**

**Codes**

blank Not reviewed

1 Reviewed: A patient had "localized" disease with a non-specific site
and no further information about the primary site is available.

The IF40 edit does not allow "localized" disease with non-specific
sites, such as mouth, NOS; colon, NOS (except histology 8220); bone,
NOS; female genital system, NOS; male genital organs, NOS; and others.
This over-ride indicates that the conflict has been reviewed.

This was a new over-ride flag in the third edition of the code manual,
but the flag may be applied to cases from any year.

**OVER-RIDE FLAG FOR SITE/LATERALITY/EOD (IF41)**

####### Item Length: 1

## NAACCR Item #: 2073

## NAACCR Name: Over-Ride Site/Lat/EOD

**Over-ride Flag for Site/Laterality/EOD (IF41) (SEER #12)**

**Codes**

blank Not reviewed

1 Reviewed: A patient had laterality coded non-specifically and EOD
coded specifically.

The IF41 edit for paired organs does not allow EOD to be specified as in
situ, localized, or regional by direct extension if laterality is coded
as "bilateral, side unknown" or "laterality unknown." This over-ride
indicates that the conflict has been reviewed.

This was a new over-ride flag in the third edition of the code manual,
but the flag may be applied to cases from any year.

**OVER-RIDE FLAG FOR SITE/LATERALITY/MORPHOLOGY (IF42)**

####### Item Length: 1

## NAACCR Item #: 2074

## NAACCR Name: Over-Ride Site/Lat/Morph

**Over-ride Flag for Site/Laterality/Morphology (IF42) (SEER #13)**

**Codes**

blank Not reviewed

1 Reviewed: A patient had behavior code of "in situ" and laterality is
not stated as right: origin of primary; left: origin of primary; or only
one side involved, right or left origin not specified.

The IF42 edit does not allow behavior code of "in situ" with
non-specific laterality codes. This over-ride indicates that the
conflict has been reviewed.

This was a new over-ride flag in the third edition of the code manual,
but the flag may be applied to cases from any year.

[^1]: Effective 1/1/1999 diagnosis

[^2]: Effective 1/1/2003 diagnosis