Coding Tumor Extension
- Record the farthest documented extension of the primary tumor.
- Do not include discontinuous metastases to distant sites except for ovary and corpus uteri.
- Distant metastasis must be coded in the CS Mets at Dx field.
- Record extension information in the following order:
- Record extension from the pathology report, when no neoadjuvant radiation or systemic therapy is given.
- If neoadjuvant therapy is given, code farthest extension whether prior to or following treatment.
- Imaging/radiographic information can be used when no pathology or operative report information is available and takes priority over physical exam information.
- Physical examination information may be used when no path, operative or imaging information is available.
- Microscopic residual disease or positive tumor margins does not increase extension code.
- If an involved organ is not listed, approximate the location and code with similar tissues.
- Refer to the ambiguous terminology list for terms that constitute involvement or extension.
- If information in the medical record is ambiguous or incomplete regarding the extent of tumor spread, this may be inferred from the T category stated by the physician. If only indication for extension is the physician's statement of T category, record the numerically lowest equivalent extension code for that T category.
- If there is nodal or metastatic involvement, extension can not be "in situ." Use the code for "Localized, NOS" if there is no better information.