AJCC Clinical stage is the extent of disease defined by diagnostic study before information is available from surgical resection or neoadjuvant treatment. The clinical stage incorporates information obtained from symptoms; physical examination; endoscopic examination; imaging studies; biopsies; and surgical exploration without resection. A blank clinical stage is used only when this criteria is not met; there is no information whatsoever in the EMR; or there was no indication there was a cancer present prior to surgical treatment. There should be very few instances where a clinical stage cannot be assigned.
The CoC does not require class of case 00 cases to be staged; however the AJCC does not take class of case into account for stage. Class of case 00 cases should be assigned a clinical stage per AJCC rules.
From The CAnswer Forum: http://cancerbulletin.facs.org/forums/forum/ajcc-tnm-staging/digestive-system-chapters-10-24/60283-class-00-colon-stageing
Question: If a pt is diagnosed by screening colonoscopy & then goes elsewhere for surgery (only a sx date, no further info) & all treatment & follow up(class 00). How do we enter the staging in the registry software? I am thinking…clinical Tx Nblank Mblank, stage group 99, pathologic all blank ??
Answer: If a patient qualifies for clinical staging, then all categories must be completed, not left blank. So the clinical stage would be TX NX M0 stage unknown (99). Remember, the patient had no signs or symptoms of mets, so it is M0. The pathologic stage would all be left blank unless you are able to get that information.
A cancer diagnosed at surgery is not the same thing as an incidental finding at surgery that was performed for other reasons.
Question: If a patient has scans prior to coming in for surgery showing a “2 cm kidney tumor” with no adenopathy or mets seen, and the patient is not actually diagnosed with cancer until he has the surgery:
Do I use the size criteria and the statement of no adenopathy or mets to code my TNM: cT1a cN0 cM0 or, do we code it cT blank cN0 cM0?
Answer: In this case, it sounds like they had a suspicion it was cancer, and it would be acceptable to assign the clinical stage. It would either be all or nothing – you either have to think it is cancer and assign the T, N, and M, or not assign any of them. It wouldn’t make sense to assign the nodes and mets, but not the primary tumor.
If the patient has suspected cancer, you can assign a clinical stage. This is what the physician is probably doing to then select the appropriate surgical treatment. The information from the imaging, and anything from the H&P would be used to assign the clinical stage.
This is different from the cancer being found incidentally during the surgery, and there wasn’t a suspicion of cancer. In that case, you would not assign any staging, those data fields in your registry software should all be blank. You don’t assign cN0 or cM0 if there is no suspicion of cancer.
If diagnostic workup is undertaken, there will be clinical staging, it should not be blank. Blank is only used for clinical staging when it was not known or suspected prior to surgery. If the cancer was not suspected, every clinical category will be blank. The registrar should not assign the clinical N and M but then don’t assign the T.
Question: For a colon case where the patient underwent colon resection for bowel obstruction with pathology showing adenocarcinoma through muscle into pericolic soft tissue, 2/16 regional lymph nodes positive & preop CT showing only bowel obstruction and no enlarged lymph nodes. Would the case be staged cT (blank) – cancer not suspected prior to resection; cN0 – no enlarged lymph nodes on CT and PE did not mention nodes; cM0 – CT did not mention distant metastases and pT3 – into pericolic fat; pN1b – 2/16 regional lymph nodes were positive; pMX – not assessed, no distant site examined pathologically?
Answer: There would be no clinical staging since no cancer was suspected prior to the surgery, and no clinical staging means ALL of the categories are blank. You cannot assign cN0 or cM0 for clinical staging since the patient was NOT eligible for clinical staging.
You do not use pMX, as there is no such category as MX. The pathologic stage M category is cM0. That is the correct assignment of the M, and in the registry data fields you must put that in the cM data field and not in the pM data field. Do not confuse the correct assignment of the stage with how it is recorded in the registry data fields.
*The article is part of the Registry Partners Oncology QC Newsletter- Summer 2016 Edition. Follow the blog to read more articles from the Newsletter or contact us to receive a copy of the full newsletter to share with your team!