SSDI and Grade Lookup

Notes

1. Grade Clinical must not be blank.

   • Grade Clinical must not be blank.

2. Assign the highest grade from the primary tumor assessed during the clinical time frame.

   • Assign the highest grade from the primary tumor assessed during the clinical time frame.

3. If there are multiple tumors with different grades abstracted as one primary, code the highest grade.

   • If there are multiple tumors with different grades abstracted as one primary, code the highest grade.

4. Code 9 (unknown) when

   • Grade from primary site is not documented
   • Clinical workup is not done (for example, cancer is an incidental finding during surgery for another condition)
   • Grade checked "not applicable" on CAP Protocol (if available) and no other grade information is available

5. If there is only one grade available and it cannot be determined if it is clinical or pathological, assume it is a Grade Clinical and code appropriately per Grade Clinical categories for that site, and then code unknown (9) for Grade Pathological, and blank for Grade Post Therapy Clin (yc) and Grade Post Therapy Path (yp).

   • If there is only one grade available and it cannot be determined if it is clinical or pathological, assume it is a Grade Clinical and code appropriately per Grade Clinical categories for that site, and then code unknown (9) for Grade Pathological, and blank for Grade Post Therapy Clin (yc) and Grade Post Therapy Path (yp).

Code Table

Notes

1. Grade Pathological must not be blank.

   • Grade Pathological must not be blank.

2. Assign the highest grade from the primary tumor.

   • Assign the highest grade from the primary tumor.

3. If there are multiple tumors with different grades abstracted as one primary, code the highest grade.

   • If there are multiple tumors with different grades abstracted as one primary, code the highest grade.

4. Use the grade from the **clinical work up** from the primary tumor in different scenarios based on behavior or surgical resection

   • **Behavior**
   • - Tumor behavior for the clinical and the pathological diagnoses are the same AND the clinical grade is the highest grade
   • - Tumor behavior for clinical diagnosis is invasive, and the tumor behavior for the pathological diagnosis is in situ
   • **Surgical Resection**
   • - Surgical resection is done of the primary tumor and there is no grade documented from the surgical resection
   • - Surgical resection is done of the primary tumor and there is no residual cancer
   • **No surgical resection**
   • - Surgical resection of the primary tumor has not been done, but there is positive microscopic confirmation of distant metastases during the clinical time frame

5. Code 9 (unknown) when

   • Grade from primary site is not documented
   • No resection of the primary site (see exception in Note 4, Surgical resection, last bullet)
   • Neo-adjuvant therapy is followed by a resection (see Grade Post Therapy Path (yp))
   • Grade checked “not applicable” on CAP Protocol (if available) and no other grade information is available
   • Clinical case only (see Grade Clinical)
   • There is only one grade available, and it cannot be determined if it is clinical, pathological, post therapy clinical or post therapy pathological

Code Table

Notes

1. Leave Grade Post Therapy Clin (yc) blank when

   • No neoadjuvant therapy
   • Clinical or pathological case only
   • Neoadjuvant therapy completed, no microscopic exam is done prior to surgery/resection of primary tumor
   • There is only one grade available, and it cannot be determined if it is clinical, pathological, post therapy clinical or post therapy pathological

2. Assign the highest grade from the microscopically sampled specimen of the primary site following neoadjuvant therapy or primary systemic/radiation therapy.

   • Assign the highest grade from the microscopically sampled specimen of the primary site following neoadjuvant therapy or primary systemic/radiation therapy.

3. If there are multiple tumors with different grades abstracted as one primary, code the highest grade.

   • If there are multiple tumors with different grades abstracted as one primary, code the highest grade.

4. Code 9 (unknown) when

   • Microscopic exam is done after neoadjuvant therapy and grade from the primary site is not documented
   • Microscopic exam is done after neoadjuvant therapy and there is no residual cancer
   • Grade checked “not applicable” on CAP Protocol (if available) and no other grade information is available

Code Table

Notes

1. Leave Grade Post Therapy Path (yp) blank when

   • No neoadjuvant therapy
   • Clinical or pathological case only
   • Neoadjuvant therapy completed; surgical resection not done
   • There is only one grade available, and it cannot be determined if it is clinical, pathological, post therapy clinical or post therapy pathological

2. Assign the highest grade from the resected primary tumor assessed after the completion of neoadjuvant therapy.

   • Assign the highest grade from the resected primary tumor assessed after the completion of neoadjuvant therapy.

3. If there are multiple tumors with different grades abstracted as one primary, code the highest grade.

   • If there are multiple tumors with different grades abstracted as one primary, code the highest grade.

4. Use the grade from the post therapy **clinical work up** from the primary tumor in different scenarios based on behavior or surgical resection

   • **Behavior**
   • Tumor behavior for the post therapy clinical and the post therapy pathological diagnoses are the same AND the post therapy clinical grade is the highest grade
   • Tumor behavior for post therapy clinical diagnosis is invasive, and the tumor behavior for the post therapy pathological diagnosis is in situ
   • **Surgical Resection**
   • Surgical resection is done of the primary tumor after neoadjuvant therapy is completed and there is no grade documented from the surgical resection
   • Surgical resection is done of the primary tumor after neoadjuvant therapy is completed and there is no residual cancer

5. Code 9 (unknown) when

   • Surgical resection is done after neoadjuvant therapy and grade from the primary site is not documented and there is no grade from the post therapy clinical work up
   • Surgical resection is done after neoadjuvant therapy and there is no residual cancer and there is no grade from the post therapy clinical work up
   • Grade checked "not applicable" on CAP Protocol (if available) and no other grade information is available

Code Table

Description

Breslow Tumor Thickness, the measurement of the thickness of a melanoma as defined by Dr. Alexander Breslow, is a prognostic factor for Melanoma of the Skin. A measure of how deeply a melanoma tumor has grown into the skin. The tumor thickness (depth) is usually measured from the top of the tumor to the deepest tumor cells. If the tumor is ulcerated (the skin is broken), it is measured from the base of the ulcer to the deepest tumor cells. Breslow thickness is used to help determine the stage of cancer. Thicker tumors are linked with lower survival rates.

Notes

1. **Physician Statement**

   • Physician statement of Breslow Tumor Thickness can be used to code this data item when no other information is available, or the available information is ambiguous.

2. **Breslow's depth**

   • Code a measurement specifically labeled as **thickness** or **depth** or **Breslow depth of invasion** from the pathology report.
   • In the absence of this label, a measurement described as taken from the cut surface of the specimen may be coded. And in the absence of either of these labels, the third dimension in a statement of tumor size can be used to code this field.

Code Table

Description

Ulceration, the absence of an intact epidermis overlying the primary melanoma based upon histopathological examination, is a prognostic factor for melanoma of the skin. Ulceration is the formation of a break on the skin or on the surface of an organ. An ulcer forms when the surface cells die and are cast off. Ulcers may be associated with cancer and other diseases. Primary tumor ulceration has been shown to be a dominant independent prognostic factor, and if present, changes the pT stage from T1a to T1b, T2a to T2b, etc., depending on the thickness of the tumor. The presence or absence of ulceration must be confirmed on microscopic examination. Melanoma ulceration is defined as the combination of the following features * Full-thickness epidermal defect (including absence of stratum corneum and basement membrane) * Evidence of reactive changes (i.e., fibrin deposition, neutrophils); and thinning, effacement, or reactive hyperplasia of the surrounding epidermis in the absence of trauma or a recent surgical procedure * Ulcerated melanomas typically show invasion through the epidermis, whereas nonulcerated melanomas tend to lift the overlying epidermis

Notes

1. **Physician Statement**

   • Physician statement of microscopically confirmed ulceration (e.g., based on biopsy or surgical resection) can be used to code this data item when no other information is available.

2. **Ulceration defined**

   • Melanoma ulceration is the absence of an intact epidermis overlying the primary melanoma based upon microscopic (histopathological) examination.
   • Ulceration can only be confirmed by microscopic examination. Do not use findings from physical exam.
   • It is possible for a patient to present with an ulcerated lesion noted on physical exam, but this is not the same thing as ulceration seen on a microscopic exam

Code Table

Description

Mitotic Rate Melanoma, the number of mitoses per square millimeter based on pathological evaluation, is a prognostic factor for melanoma of the skin. Mitotic count is a way of describing the potential aggressiveness of a tumor. Record the number of cells actively dividing as determined by the pathologist. The count will vary according to the type of tumor.

Code Table

Description

LDH (Lactate Dehydrogenase) Lab Value, measured in serum, is a predictor of treatment response, progression-free survival, and overall survival for patients with Stage IV melanoma of the skin. When cells (normal or tumor) are damaged or destroyed, an enzyme called lactate dehydrogenase (LDH) is released into the bloodstream. LDH is an indirect indication of possible tumor burden or damage to an organ, which may be caused by metastatic involvement of liver or lung, or a myocardial infarction. The total LDH should be the test value that is coded, but there are five fractions of LDH that measure tissue specific cellular damage: LD1 and LD2: heart, red blood cells and kidneys; LD3: lung; LD4 and LD5: liver, skin, and skeletal muscles. LDH is elevated in 60% of patients with non-seminomatous germ cell tumors of the testis. LDH is not a screening test, nor is it diagnostic of melanoma, ocular adnexal lymphoma, or testicular cancer. LDH is important in melanoma staging in the setting of DISTANT metastasis. LDH level might only be ordered after re-excision/wide excision and/or nodal evaluation indicates a higher risk of distant metastasis. Imaging may then be performed and if distant metastasis are identified, LDH is ordered.

Notes

1. **Physician Statement**

   • Physician statement of LDH Lab Value can be used to code this data item when no other information is available.

2. **Pre systemic treatment results**

   • Record the lab value of the highest serum LDH test results documented in the medical record either before or after surgical resection of the primary tumor with or without regional lymph node dissection.
   • The LDH must be taken prior to systemic (chemo, immunotherapy, hormone), radiation therapy or surgery to a metastatic site.

3. **Related data item**

   • The same laboratory test should be used to record the related data items 3869: LDH Level and 3870: LDH Upper Limits of Normal.

Code Table

Description

LDH (Lactate Dehydrogenase), an enzyme involved in converting sugars to energy in the body, is elevated in some malignancies. LDH level is a prognostic factor for patients with Stage IV melanoma. This data Item refers to the Upper Limit of Normal in the laboratory test used to interpret the Serum LDH result. When cells (normal or tumor) are damaged or destroyed, an enzyme called lactate dehydrogenase (LDH) is released into the bloodstream. LDH is an indirect indication of possible tumor burden or damage to an organ, which may be caused by metastatic involvement of liver or lung, or a myocardial infarction. The total LDH should be the test value that is coded, but there are five fractions of LDH that measure tissue specific cellular damage: LD1 and LD2: heart, red blood cells and kidneys; LD3: lung; LD4 and LD5: liver, skin, and skeletal muscles. LDH is elevated in 60% of patients with non-seminomatous germ cell tumors of the testis. LDH is not a screening test, nor is it diagnostic of melanoma, ocular adnexal lymphoma, or testicular cancer.

Notes

1. **Physician Statement**

   • Physician statement of LDH (Lactate Dehydrogenase) Upper Limit of Normal can be used to code this data item when no other information is available.

2. **Recording upper limits**

   • Record the value of the highest serum LDH test results documented in the medical record either before or after surgical resection of the primary tumor with or without regional lymph node dissection. The LDH must be taken prior to systemic (chemo, immunotherapy, hormone), radiation therapy or surgery to a metastatic site. The lab value may be recorded in a lab report, history and physical, or clinical statement in the pathology report.

3. **Related data items**

   • The same laboratory test should be used to record the related data items 3932: LDH Lab Value and 3869: LDH Level.

Code Table

Description

LDH (Lactate Dehydrogenase) is an enzyme involved in conversion of sugars to energy and present in most cells in the body. Elevated LDH is an adverse prognostic factor for plasma cell myeloma and melanoma of the skin.

Notes

1. **Physician Statement**

   • Physician statement of LDH Level can be used to code this data item when no other information is available.

2. **Coding criteria**

   • Record the interpretation of the highest serum LDH test results documented in the medical record either before or after surgical resection of the primary tumor with or without regional lymph node dissection
   • The LDH must be taken prior to systemic (chemo, immunotherapy, hormone), radiation therapy or surgery to a metastatic site
   • Use the reference ranges from your lab to determine if LDH is normal

3. **Related data item**

   • The same laboratory test should be used to record the related data items 3869: LDH Level and 3870: LDH Upper Limits of Normal

Code Table

Description

Clinical margin width describes the margins from a wide excision for a melanoma primary. The margin width is measured by the surgeon prior to the procedure. The measurement is taken, in centimeters, from the edge of the lesion or the prior excision scar to the peripheral margin of the specimen.

Notes

1. **Effective years**

   • This SSDI is effective for diagnosis years 2021+
   • For cases diagnosed 2018-2020, this SSDI must be blank

2. **Measuring the margins**

   • “The appropriate [wide local excision] margins are measured from the periphery of any gross residual tumor or the edges of the entire previous biopsy scar (shave or excisional).” Operative Standards for Cancer Surgery, Volume 2, page 392.

3. **Code peripheral surgical margins from the operative report from a wide excision**

   • + Do not use the pathology report to code this data item.
   • + Margins from wide excision-Measured from the edge of the lesion or the prior excision scar to the peripheral margin of the specimen, do not use deep margin
   • + Do not add margins together
   • + If multiple wide excisions are performed, code the clinical margin width from the procedure with the largest margin
   • + If a range is listed, code the lower range
   • + *Example:* Clinical Width Margin documented as 1-1.2 cm. Code 1 cm

4. **Physician statement**

   • Physician statement of clinical margin width can be used to code this data item when no other information is available, or the available information is ambiguous
   • + Order of priority:
   • - Operative Note
   • - Physician statement in medical record

5. **Code formats**

   • Record stated margin in centimeters. Include decimal point.
   • Examples:*
   • + 0.5 cm - 0.5
   • + 1 cm- 1.0
   • + 2.5 cm - 2.5

Code Table