How Should I Code This?: AJCC Cancer Staging Manual 7th Edition


Chapter 8 – Thyroid

Clinical Staging: The assessment of a thyroid tumor depends on inspection and palpation of the thyroid gland and regional lymph nodes.  Indirect laryngoscopy to evaluate vocal cord motion is essential. A variety of imaging procedures can provide additional useful information. These include radioisotope thyroid scans, ultrasonography, CT, MRI and PET scans. When cross-sectional imaging is utilized, MRI is recommended so as to avoid contamination of the body with the iodinated contrast medium generally used with CT. Iodinated contrast media make is necessary to delay the postoperative administration of radioactive iodine-131. The diagnosis of thyroid cancer must be confirmed by needle biopsy or open biopsy of the tumor. Further information for clinical staging may be obtained by biopsy of lymph nodes or other areas of suspected local or distant spread. All information available prior to first treatment should be used.

From the CAnswer Forum:

Question:   Patient with Grave’s disease underwent thyroidectomy along with removal of two regional nodes. Findings confirmed papillary adenocarcinoma, pT1b, N0, M0. The only information available for clinical staging is a thyroid US-no laryngoscopy. It seems that the physician suspected cancer since two lymph nodes were removed, but I am not sure if this meets clinical staging criteria because no laryngoscopy was done. Please advise.

Answer:    According to the AJCC 7th edition thyroid chapter, “diagnosis of thyroid cancer must be confirmed by needle biopsy or open biopsy of the tumor” for clinical classification. No clinical stage can be assigned.

Donna M Gress, RHIT, CTR


From the CAnswer Forum:

Question:    I have a patient who was clinically diagnosed by pet scan with a 3.2 cm focus of intense activity in left thyroid lobe compatible with FDG avid malignancy. The patient did not have a biopsy and had a left lobectomy with isthmus confirming hurthle cell ca and papillary microcarcinoma. My question is, since the patient did not have a biopsy confirming the cancer prior to surgery (in reference to Clinical Stage Thyroid-no bx forum dated 05/13/2015), but did have a diagnosis with ambiguous terminology-can clinical staging be assigned or should it be blank? Also can a clinical staging be assigned if the patient had a positive FNA confirming cancer without biopsy? Thank you.

Answer:     Ambiguous terminology may NOT be used for AJCC staging. AJCC does not have ambiguous terminology and does not endorse any ambiguous terminology.

The 7th edition thyroid chapter states that the diagnosis must be confirmed in order to assign clinical staging. Your clinical stage would be blank since it was not confirmed microscopically.

Donna M Gress, RHIT, CTR
Question: 20150023 

Question:    MP/H Rules/Histology–Thyroid: When is 8341/3, papillary microcarcinoma coded? The code description in ICD-O-3 is followed by (C739), yet there are two SINQ answers that tell us specifically to not use this code for thyroid primaries. Even the first revision of ICD-O-3 still carries the (C739) as part of this code, which goes against SINQ 20110027 and 20081127.

Answer:     Per the WHO Tumors of Endocrine Organs, for thyroid primaries/cancer only, the term micropapillary does not refer to a specific histologic type. It means that the papillary portion of the tumor is minimal or occult (1cm or less in diameter) and was found incidentally. WHO does not recognize the code 8341 and classifies papillary microcarcinoma of the thyroid as a variant of papillary thyroid and thereby should be coded to 8260. If the primary is thyroid and the pathology states papillary microcarcinoma or micropapillary carcinoma, code 8260 is correct. This information will be included in the upcoming revisions to the MP/H manual.