1. The Anatomy of Collaborative Staging: Head and Neck Presentation developed by Collaborative Staging Steering Committee ajcc@facs.org 2005 update

2. CS Head and Neck Coding 2005 Head and Neck Cancer  Collaborative Stage fields (in general) Tumor Size--standard Extension TS/Ext Eval--standard Lymph Nodes LN Eval--standard LN Pos--standard LN Exam--standard Mets at Dx Mets Eval--standard Site-Specific Factors SSF1 Size of LN SSF2 Extracapsular exten. SSF3 Levels I-III SSF4 Levels IV-V, Retrophar SSF5 Levels VI-VII, Facial SSF6 Other H&N nodes

3. CS Head and Neck Coding 2005 Head and Neck Schemes TNM Chapters: 6 Summary Stage Sites:22 Collaborative Staging:30  Determining the correct primary site is important!  Site-specific factors are the same for all head and neck sites.

4. CS Head and Neck Coding 2005  Lip Upper Lower Other  Tongue Base Anterior  Gum Upper Lower Other  Floor of Mouth  Palate Hard Soft  Other Mouth  Buccal Mucosa  Salivary Glands Parotid Submandibular Other Salivary  Pharynx Oropharynx Anterior Epiglottis Nasopharynx Hypopharynx Other Pharynx *  Nasal Cavity  Middle Ear  Sinus Maxillary Ethmoid Other *  Larynx Glottic Supraglottic Subglottic Other Head and Neck -- CS Tumor Size Thyroid is NOT included * no TNM staging ABC requires Tumor Size for TNM XYZ Tumor Size not a factor in TNM

5. CS Head and Neck Coding 2005 Head and Neck -- CS Extension  General format 00In situ 10Lamina propria/submucosa 30Localized, NOS 40-59Adjacent structures (T3) 60-69Mixed T3-T4 (site specific) 70-80Adjacent structures (T4) 95No evidence of primary tumor

6. CS Head and Neck Coding 2005 Head and Neck -- CS Extension  Muscles of the tongue Used in shaping the mouth for speech, chewing and swallowing  Intrinsic musculature Muscles within the tongue (no bony attachment) Also called lingual Used to curl sides of tongue upward When mentioned as involved, code in CS Extension 20 range NOT part of T4 category in TNM  Extrinsic musculature Muscles anchoring the tongue in the mouth Attached to mandible, hyoid bone, styloid process of temporal bone, or palate When mentioned as involved, code in CS Extension 70-75 range (except sites: floor of mouth and submandibular gland) When involved, map to T4 in TNM

7. CS Head and Neck Coding 2005 Head and Neck Lymph Nodes Overview Level I (* = not shown) A Submental B Submandibular (submaxillary) Level II C Upper deep cervical (upper jugular) * Jugulodigastric (subdigastric) Level III D Middle deep cervical (mid-jugular) Level IV E Lower deep cervical (lower jugular) * Jugulo-omohyoid (supraomohyoid) Level V F Posterior cervical G Posterior triangle * Supraclavicular, NOS Level VI H Pre/paralaryngeal and pre/paratracheal (anterior deep cervical) Level VII J Upper mediastinal Adapted from: TNM Interactive (CD-ROM), Wiley-Liss J A B B C C D E E F G G H H H

8. CS Head and Neck Coding 2005 Head and Neck Lymph Nodes Overview  Regional lymph node information is coded in several fields. CS Lymph Nodes field  nodes involved, their number and laterality Site-Specific Factors 1 and 2  size of involved lymph nodes  presence of extracapsular extension Site-Specific Factors 3-6  presence or absence of lymph node involvement in each of 7 different levels and other groups defined by AJCC.

9. CS Head and Neck Coding 2005  CS LN: which nodes, number and laterality  SSF1: size of involved node  SSF2: extracapsular extension  SSF3: levels I-III  SSF4: levels IV-V  SSF5: levels VI-VII and face  SSF6: other LN groups Lymph Nodes--Specific Fields Image source: AJCC Cancer Staging Manual, 5th edition

10. CS Head and Neck Coding 2005 Head and Neck Lymph Nodes CS Lymph Nodes  Contains information about the nodes involved, their general number and laterality.  Code ranges vary by primary site.  Major categories: Single positive ipsilateral node involved Multiple positive ipsilateral nodes Bilateral or contralateral positive nodes Positive regional nodes, NOS

11. CS Head and Neck Coding 2005 Head and Neck Lymph Nodes CS Lymph Nodes  New note March 2005 Supraclavicular lymph nodes can be either Level IV or Level V.  Level IV: deep to sternocleidomastoid muscle or in lower jugular chain  Level V: posterior triangle, inferior to transverse cervical artery Try to determine whether Level IV or Level V. If cannot be determined, code as Level V. Excludes Nasopharynx and Thyroid  March 2005 revision: Add “Supraclavicular, NOS” to code 12 Excludes Nasopharynx and Thyroid

12. CS Head and Neck Coding 2005 Head and Neck Lymph Nodes CS Lymph Nodes  Example--Parotid Gland 00None 10-19Single positive ipsilateral node involved 20-29Multiple positive ipsilateral nodes 30-32Positive ipsilateral nodes, unk. if 1 or > 1 40-49Bilateral or contralateral positive nodes 50-52Regional nodes, NOS, unk. number and laterality 80Lymph nodes, NOS

13. CS Head and Neck Coding 2005 Head and Neck Lymph Nodes CS Lymph Nodes--N Categories  Example--Parotid Gland 00N0 18N1, no other information 19N2a, no other information 29N2b, no other information 49N2c, no other information 60N2, NOS 70N3, no other information

14. CS Head and Neck Coding 2005 Site-Specific Factor 1 Size of Involved Node  Code size of NODE, not size of metastasis  Code largest diameter measured clinically or pathologically  Code regional nodes only  Size format same as tumor size with extra choices 996 Described as less than 6 cm 997 Described as more than 6 cm

15. CS Head and Neck Coding 2005 Site-Specific Factor 2 Extracapsular Extension  Code extracapsular extension identified clinically or pathologically Pathologic confirmation takes precedence Imaging studies may show  amorphous spiculated margins on nodes  involvement of internodal fat  loss of normal oval to round shape  Code regional nodes only  Code 888 if nodes are negative

16. CS Head and Neck Coding 2005 Site-Specific Factor 2 Extracapsular Extension  Codes 000No extracapsular extension 001Extracapsular extension clinically, no path; Nodes described as “fixed,” no path 005Extracapsular extension on path exam 888Not applicable: no node involvement 999Unknown; not documented; not assessed Image source: TNM Interactive (CD-ROM), Wiley-Liss Pathologic Lymph Nodes 000 No extracapsular extension 005 Extracapsular extension

17. CS Head and Neck Coding 2005 Site-Specific Factors 3-6 Definitions of levels are the same for all applicable head and neck sites. SSF 3 Levels I-III SSF 4 Levels IV and V and the retropharyngeal nodes SSF 5Levels VI and VII and the facial nodes SSF 6 Other groups as defined by AJCC

18. CS Head and Neck Coding 2005 Lymph Node Levels Image source: voice-center.com (The Voice Center, Norfolk, VA) I Submental and submandibular II Upper jugular III Middle jugular IV Lower jugular and supraclavicular V Superficial cervical (along spinal accessory nerve) VI Anterior compartment (prelaryngeal and paratracheal) VII Upper mediastinal VII

19. CS Head and Neck Coding 2005 Coding Site-Specific Factors 3-6 SSF 3 Levels I-III_________ I II III SSF 4 Levels IV-V, _________ retropharyngeal (RP) IV V RP SSF 5Levels VI-VII,_________ Facial (F) VI VII F SSF 6 Other groups_________ Parapharyngeal (PP), PP PA S Parotid (PA), Suboccipital (S)  Default is 0, not involved.  If any level/chain is involved, code as 1, involved.

20. CS Head and Neck Coding 2005 Coding Site-Specific Factors 3-6 Example: Buccal Mucosa LRND: 2 positive parotid nodes (< 3 cm with extracapsular exten.), 1 positive buccal (facial) node (2 cm), and 1 positive 2 cm submandibular (Level I) node. SSF 3 Levels I-III_1__0__0_ I II III SSF 4 Levels IV-V, _0__0__0_ Retropharyngeal (RP) IV V RP SSF 5Levels VI-VII,_0__0__1_ Facial (F) VI VII F SSF 6 Other groups_0__1__0_ Parapharyngeal (PP), PP PA S Parotid (PA), Suboccipital (S)

21. CS Head and Neck Coding 2005 Coding Site-Specific Factors 1-6 Example -- Full Coding of Nodes--Buccal Mucosa LRND: 2 positive parotid nodes (< 3 cm with extracapsular exten.), 1 positive buccal (facial) node (2 cm), and 1 positive 2 cm submandibular node. CS Lymph Nodes20Multiple ipsilateral LN positive CS Reg Nodes Eval3Based on dissection Reg LN Pos042+1+1 = 4 positive nodes Reg LN Exam97Dissection, number not stated SSF 1Size of node993Described as < 3 cm SSF 2Extracaps. exten005Pathologic extension SSF 3Levels I-III100Level 1 only SSF 4Levels IV-V, RP000All nodes neg SSF 5Levels VI-VII, F001Facial nodes only SSF 6Other groups010 Parotid nodes only Computer derived N: pN2b

22. CS Head and Neck Coding 2005 Head and Neck -- CS Mets at Dx  Code 10 revision March 2005 Delete Supraclavicular (transverse cervical) Supraclavicular nodes are REGIONAL--code in CS Lymph Nodes and SSF4. Review and recode any cases coded 10 or 50 (should be very few)

23. CS Head and Neck Coding 2005 Classification of Neck Dissections (1)  Standardized terminology of American Academy of Otolaryngology/Head and Neck Surgery  Radical Neck Dissection Standard basic procedure for cervical lymphadenectomy En bloc clearance of all fibrofatty tissue from one side of neck Includes lymph nodes from Levels I-V plus those around tail of parotid Removes spinal accessory nerve (SAN), internal jugular vein (IJV), and sternocleidomastoid muscle (SCM)

24. CS Head and Neck Coding 2005 Classification of Neck Dissections (2)  Modified Radical Neck Dissection Removal of same lymph node groups (I-V) but with preservation of 1 or more of non- lymphatic structures:  spinal accessory nerve (SAN)  internal jugular vein (IJV)  sternocleidomastoid muscle (SCM)  Comprehensive Neck Dissection Non-standard term referring to any dissection removing node Levels I-V, i.e., radical or modified radical

25. CS Head and Neck Coding 2005 Classification of Neck Dissections (3)  Selective Neck Dissection Removal of certain lymph node groups and preservation of other groups Supraomohyoid  selective removal of Levels I, II, and III  preservation of SAN, SCM, and IJV  sometimes includes Level IV Lateral  selective removal of Levels II, III, and IV  preservation of SAN, SCM, and IJV

26. CS Head and Neck Coding 2005 Classification of Neck Dissections (4)  Selective Neck Dissections, continued Anterior Compartment  selective removal of Level VI  usually bilateral, may be unilateral Posterolateral  used for cutaneous scalp malignancies  removal of suboccipital, postauricular, and upper, middle, and lower jugular nodes, and posterior triangle nodes

27. CS Head and Neck Coding 2005 Classification of Neck Dissections (5)  Extended Neck Dissection Refers to any type of above types of dissection, but involving the removal of additional lymph node groups or nonlymphatic structures beyond what is normally included. Examples:  Extended modified radical neck dissection  Extended selective anterior compartment neck dissection

28. CS Head and Neck Coding 2005 TNM Supplement Guidelines  Tumor involving two sites Classify to site in which greater part of tumor is located Consider only invasive component if tumor has associated carcinoma in situ  Extension Superficial  spread limited to mucosa  not sufficient for T4 Deep  muscles, bones or other deep structures (vertical or horizontal invasion)

29. CS Head and Neck Coding 2005 Head and Neck Cancer Case Study 1: “Accessible site”  1.5 cm tumor, confined to lateral hard palate; negative nodes clinically; no nodes removed. Remainder of exam negative. Referred for chemo. Tumor size 0151.5 cm Extension30Localized, NOS TS/Ext Eval0Physical exam Lymph nodes 00 Negative Reg LN Eval 0Physical exam Reg LN Pos 98None examined Reg LN Exam 00None removed Mets at Dx 00None Mets Eval0Clinical only SSF1 (LN size)000No nodes involved SSF2 888No LN involvement SSF3 = 000 SSF4 = 000 All levels of lymph SSF5 = 000 SSF6 = 000 nodes negative

30. CS Head and Neck Coding 2005 Head and Neck Cancer Case Study 2: Positive nodes  Mobile tongue primary 2.5 cm; firm submental node palpable. Excision and node dissection: tumor in deep (extrinsic) muscle and 1 of 2 submental nodes positive, no extracapsular extension. PE: WNL Tumor size 0252.5 cm Extension 75Deep muscle TS/Ext Eval 3Based on excision Lymph nodes10 Single level I node involved Reg LN Eval 3Based on node dissection Reg LN Pos 01One node positive Reg LN Exam 02Two nodes removed Mets at Dx 00Physical exam normal Mets Eval0Based on physical exam SSF1 999Size not stated SSF2 000No extracapsular extension SSF3 100Level I node involved SSF4 = 000 SSF5 = 000 SSF6 = 000 All other LN neg.

31. CS Head and Neck Coding 2005 Head and Neck Cancer Case Study 3: Preoperative therapy  Hard mass in floor of mouth 3 cm size attached to mandible. Rest of exam neg. Pt given chemo. prior to wide excision and radical neck dissection. At surgery, 1 level IV and 2 level V nodes positive (largest size < 3 cm). TS 1.3 cm. Tumor size 0303 cm Extension 70Mandible involved TS/Ext Eval 5Clinical info pre-Rx Lymph nodes 22Multiple nodes listed in code 12 Reg LN Eval 6Residual positive nodes post-Rx Reg LN Pos 031 + 2 = 3 nodes involved Reg LN Exam 97Dissection, number of nodes unknown Mets at Dx 00“Rest of exam neg.” Mets Eval0Based on physical exam SSF1 = 993 SSF2 = 999 Size < 3 cm; unknown exten. SSF3 = 000 SSF4 = 110 Level IV and V nodes positive SSF5 = 000 SSF6 = 000 All other nodes negative

32. CS Head and Neck Coding 2005 Head and Neck Cancer Case Study 4: Inaccessible site  Pt hoarse. ENT exam (endoscopy): 1.5 cm supraglottic mass extending into pyriform sinus; cords fixed. Modified radical neck dissection: 8/20 paralaryngeal and retropharyngeal nodes pos. Tumor size0151.5 cm mass Extension 62Pyriform sinus + fixation TS/Ext Eval 1Based on endoscopy Lymph nodes 21Multiple positive ipsilateral nodes Reg LN Eval 3Based on dissection Reg LN Pos 08Eight nodes positive Reg LN Exam20Twenty nodes examined Mets at Dx 00 Inaccessible sites rule--presumed neg. Mets Eval0Based on non-invasive clinical evidence SSF1 999 Size not stated SSF2 999Extracaps. exten not documented SSF3 = 000 SSF4 = 001 Retropharyngeal LN pos. SSF5 = 100 SSF6 = 000 Level VI (paralaryngeal) LN pos.