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

Lymph Nodes Isolated Tumor Cells (ITC), the presence of isolated tumor cells in regional lymph node(s) that may be detected by hematoxylin and eosin or by immunohistochemical staining, is a potential prognostic factor for Merkel Cell Carcinoma. Isolated tumor cells (ITCs) for Merkel cell carcinoma are defined as single tumor cells or small clusters of tumor cells not more than 0.2 mm in greatest dimension. ITCs are usually detected by immunohistochemistry on sentinel lymph node biopsies. * Note: Examples of immunohistochemical staining methods are Cytokeratin 20 (CK20), CAM 5.2, pancytokeratin, and AE1/3. ITCs may be detected by routine H&E stains. ITCs may be identified in lymph nodes by hematoxylin and eosin staining or by specialized pathological techniques, such as IHC for cytokeratin proteins for carcinomas. Specialized pathology techniques such IHC and molecular techniques are not recommended for routine examination of lymph nodes. These cells usually are found in the subcapsular nodal sinuses but may be seen within the nodal parenchyma.

Code Table

Description

Profound Immune Suppression suppressed immune status that may be associated with HIV/AIDs, solid organ transplant, chronic lymphocytic leukemia, non-Hodgkin lymphoma, multiple conditions, or other conditions, increases the risk of developing Merkel Cell Carcinoma and is an adverse prognostic factor. Profound immune suppression may greatly increase the risk of developing Merkel cell carcinoma. Immune suppression is suppression of the body's immune system and its ability to fight infections and other diseases. Immune suppression may be deliberately induced with drugs, as in preparation for bone marrow or other organ transplantation, to prevent rejection of the donor tissue. It may also result from certain diseases such as Acquired Immune Deficiency Syndrome (AIDS) or lymphoma, and from the use of anti-cancer drugs.

Notes

1. **Physician statement**

   • Physician statement of Profound Immune Suppression must be used to code this data item.
   • Do not assume that a patient is immune suppressed just because the patient has one of the conditions listed below in the table.

2. **Two-year limitation and exceptions**

   • Per AJCC experts, this data item is limited to the conditions in the table below occurring within two years of the diagnosis of Merkel cell carcinoma.
   • ***Exceptions***: For the following conditions ONLY, these patients will experience chronic immunosuppression. These are no time limits for these conditions. If a patient has a history (regardless of when diagnosed or treatment status), code as present
   • Human Immunodeficiency Virus (HIV)/acquired immunodeficiency syndrome (AIDS) (Code 1)
   • Solid organ transplant recipient (Code 2)
   • Chronic lymphocytic leukemia (Code 3)

Code Table

Description

Extranodal Extension (ENE) Clinical is defined as “the extension of a nodal metastasis through the lymph node capsule into adjacent tissue” during the diagnostic workup. This data item defines clinical ENE for sites other than Head and Neck. The presence of extranodal extension (ENE) from regional lymph nodes is an important prognostic factor in some cancers because these patients are rarely cured without some type of systemic chemotherapy or radiation. Extranodal extension is defined as metastatic tumor growing from within the lymph node outward through the lymph node capsule and into surrounding connective tissues. * "A regional node extending into a distant structure or organ is categorized as ENE and is not recorded as distant metastatic disease." **Clinical ENE is described as** "Unambiguous evidence of gross ENE on clinical examination (e.g., invasion of skin, infiltration of musculature, tethering to adjacent structures, or cranial nerve, brachial plexus, sympathetic trunk, or phrenic nerve invasion with dysfunction)" * The terms 'fixed' or 'matted' are used to describe lymph nodes This data item is for ENE that is detected clinically.

Notes

1. **Physician Statement**

   • Physician statement of Extranodal Extension (ENE) Clinical or physician clinical staging can be used to code this data item when there is no other information available.

2. **Criteria for coding**

   • Code the status of extranodal extension assessed during the diagnostic working for the assignment of the clinical stage for the most involved regional lymph node(s)
   • This is mainly determined by physical examination and included statements such as fixed or matted nodes
   • The assessment for ENE **in addition to physical examination** may include imaging, biopsy of the regional lymph node, and/or biopsy of tissues surrounding the regional lymph node
   • Do not code ENE for any distant nodes
   • Be aware that the rules for coding ENE for head and neck sites compared to non-head and neck sites are different.

Code Table

Description

Extranodal Extension (ENE) Pathological is defined as “the extension of a nodal metastasis through the lymph node capsule into adjacent tissue." This data item defines pathological ENE for sites other than Head and Neck. Extranodal extension is defined as metastatic tumor growing from within the lymph node outward through the lymph node capsule and into surrounding connective tissues. * "A regional node extending into a distant structure or organ is categorized as ENE and is not recorded as distant metastatic disease." This data item is for ENE that is detected pathologically.

Notes

1. **Physician Statement**

   • Physician statement of Extranodal Extension (ENE) Pathological or physician pathological staging can be used to code this data item when there is no other information available.
   • Note that the rules for coding ENE for head and neck sites compared to non-head and neck sites are different.

2. **Criteria for Coding**

   • Code the status of extranodal extension assessed on the **surgical resection** specimen for the most involved regional lymph node(s)
   • Do not code ENE for any distant lymph nodes.
   • Be aware that the rules for coding ENE for head and neck sites compared to non-head and neck sites are different.

Code Table