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1 SEER Summary Staging 이현경

2 병기란? - 환자개개인의질병의확장정도에 따라특정하게분류하는방법 - 의학분야종사자들이서로다른암에 관한정보를교환하기위해공통의언 어로개발

3 병기의목적 환자의치료결정 예후암시 생존율의추정치제공 치료결과비교

4 병기의종류 TNM : 거의모든 site에사용 FIGO : 여성의 reproductive site cancers의 staging Clark s Level : Melanoma staging Dukes : Colon과 Rectum의 staging Ann Arbor : 림프종에대한 staging 기타 : Breslow s, National Wilms s Tumor study Group 등

5 Summary Staging - 암이원발부위로부터얼마나멀리퍼져있는지를범주화해놓은가장기초적인방법 - General staging, California staging SEER staging - NCI 의 SEER 프로그램에의해개발 - 임파종과백혈병을포함모든해부학적부위에적용 - TNM 정보와상응하는요약병기코드기록가능

6 3. Summary Staging 의구조 Code Definition 0 In situ 1 Localized only 2 Regional by direct extension only 3 Regional lymph nodes involved only 4 Regional by BOTH direct extension AND lymph node involvement 5 Regional, NOS 7 Distant site(s)/node(s) involved 9 Unknown if extension or metastasis (unstaged, unknown, or unspecified Death certification only case)

7 In situ (code = 0) in place 를의미 조직의기저막 (basement membrane) 이나기질 (stroma) 를침입하지않음. Carcinoma, Melanoma 만이상피내암종으로분류가능 침윤 (Invasion), 림프절전이, 원격전이의증거가있는경우엔상피내암종이아님

8 In situ (code = 0)

9 In situ (code = 0) ** 동의어 non-invasive, pre-invasive, non-infiltrating, intraepithelial, Stage 0, intraductal, intracystic, no stromal invasion, no penetration, below the basement membrane ** 주의 In situ with microinvasion 라고기록된경우 Localized (1)

10 Localized (code = 1) Basement membrane 을침윤하였으나 confined to organ of origin 상태 원발장기를벗어나지않고, 장기내에넓게퍼지거나전이하는경우

11 Localized (code = 1)

12 Localized (code = 1) lamina propria, myometrium, muscularis 원발부위내의혈관침범, perineural lymphatic invasion 다른장기로전이의증거가없어야

13 Regional (code = 2~5) 원발장기의경계를벗어난종양확장 병기가 In situ, local, distant 가아닌경우 (carcinoma) 4가지의세부범주를가진다. 1) 주변으로 extension된경우 (code=2) 2) 림프절에종양포함된경우 (code=3) 3) 1) 과 2) 가모두해당되는경우 (code=4) 4) regional, NOS (code=5)

14 Regional (code = 2~5)

15 Regional (code = 2~5) ** 주의 전이된림프절중가장먼림프절을생각한다. TNM과다른타병기분류에서림프절포함이라면, 림프절전이를고려하여병기를분류한다. 의무기록내용과 TNM 병기에모순이있다면, 의무기록에우선하고, 의사와상의한다. 전이된림프절이메뉴얼상 regional로언급되지않았다면, 원격전이로추정한다.

16 Distant (code = 7) = remote, diffuse, disseminated, metastasis, secondary disease 원발부위에서떨어져서, 신체의다른 장기로이동하고, 새로운장소에서 자라기시작

17 Distant (code = 7) 전이방법 원발부위와인접한조직을넘어선전이 초기림프절을넘어서다른림프절로의전이 혈액성혹은혈액운반전이 신체공동속의유동액을통한전이 (implantation, seeding mets)

18 Distant (code = 7)

19 Distant (code = 7)

20 Distant (code = 7)

21 Distant (code = 7) ** 원격전이가주로일어나는부위 간, 폐, 뇌, 뼈 ** 특별히명명되지않은조직이나림프절은우선원격전이로의심 ** 항상 distant인경우 Hematopoietic 질환 ** 주의 Plasmacytoma, Histiocytosis 중일부

22 Unknown if extension or metastasis (code = 9) C80.9 = code 9 병기분류에필요한충분한증거가 없을때 : 검사전사망, 진단이나치료 거부, 환자나이나금기로인한검사 제한 가능한한이코드를분류하기않기위해 더많은정보를찾도록해야한다. Death certificate only case

23 General Guidelines 임상, 수술 / 조직평가를모두검토하여분류 수술후혹은진단후 4개월이내의정보를포함하여분류 진단확정후에일어난전이는병기분류시제외 수술 / 조직정보가임상정보와반증한다면, 수술 / 조직정보우선

24 General Guidelines 특정부위에관한지침은일반지침보다우선한다. carcinoma와 melanoma는우선 in situ를확인한다. In situ, Distant, Localized, Regional 순으로확인하여분류한다. 만약원격전이가언급되어졌다면 Code는 (7번:distant) 를준다.

25 1. Serosa 2. Tela subserosa 3. Muscularis 4. Oblique fibers of muscle wall 5. Circular muscle layer 6. Longitudinal muscle layer 7. Submucosa 8. Lamina muscularis Mucosae 9. Mucosa 10. Lamina propria 11. Epithelium 12. Gastric glands 13. Gastric pits 14. Villous folds 15. Gastric areas (gastric surface) Layers of Stomach

26 Mucosa, NOS Muscle(muscularis) Submucosa Lamina propria, Stroma, Subepitelial connective tissue, Tunica propria, Subserosa TNM/AJCC T, T2 원발부위별요약병기코딩규칙 Bladder 0 In situ carcinoma in situ, NOS Noninvasive papillary(transitional) cell carcinoma papillary non-infiltrating papillary transitional cell carcinoma, stated to be noninvasive 1. Localized only

27 원발부위별요약병기코딩규칙 Bladder 2 Regional By direct extension only Extension to: Adventitia, Peritoneum, periureteral fat/tissue, prostate Serosa, Ureter, Seminal vesicle 3. Regional by lymph node(s) involved only Lymph nodes(iliac, pelvic, perivesicla, sacral ) 4. Regional by BOTH direct extension AND regional lymph node(s) involved codes (2) + (3)

28 원발부위별요약병기코딩규칙 Bladder 7. Distant site(s)/lymph node(s) involved Distant lymph node(s): common iliac, Other distant lymph nodes Extension to: Abdoninal wall, bone, colon, pelvic wall, rectum Further contiguous extension Metastasis 9. Unknown if extension or metastasis

29 원발부위별요약병기코딩규칙 Bladder ( 예제 ) - 62 세남환, 1 년전건강검진에서 hematuria 있었으나치료없이지내던중 10 일전부터 gross hematuria 있어서외부병원에서 work up - IVP(Intravenous pyelography), ultrasono 시행후 bladder ca 진단하에 외래진료후 op 위해 admission - IVP : upper tract normal - Bladder sono : right lateral wall 에 2cm size mass - OP : bladder, tumor, right lateral wall transurethral resection : papillary transitional cell carcinoma, grade I/III with no stromal invasion

30 원발부위별요약병기코딩규칙 - key word 1) papillary transitional cell carcinoma, 2) no stromal invasion 요약병기 : 0

31 원발부위별요약병기코딩규칙 Breast 0 In situ Noninvasive; intraepithelial Intraductal without infiltration ** M8500/2 Intraductal carcinoma, noninfiltrating, NOS M8500/3 Infiltrating duct carcinoma, NOS 1. Localized only Confined to breast tissue and fat including nipple and/or areola Paget disease WITH or WITHOUT underlying tumor

32 원발부위별요약병기코딩규칙 Breast 2 Regional By direct extension only - Attachment of fixation to pectoral muscle of underlying tissue - Extensive skin involvement En cuirasse, Erythema, Inflammation of skin, Peaud orange Skin edema, Ulceration of skin of breast - Invasion of (or fixation of) Chest wall, Intercostal muscle, Rib, subcutaneous tissue 3. Regional by lymph node(s) involved only Lymph nodes(axillary, Infraclavicular )

33 원발부위별요약병기코딩규칙 Breast 4. Regional by BOTH direct extension AND regional lymph node(s) involved codes (2) + (3) 7. Distant site(s)/lymph node(s) involved Distant lymph node(s): Cervical, Contralateral/bilateral axillary vein, supraclavicular Further contiguous extension Skin over (Axilla, Contralateral breast, sternum, upper abdomen) Metastasis

34 원발부위별요약병기코딩규칙 Breast( 예제 ) - Infiltrating duct carcinoma - Breast, right, modified radical mastectomy - Key word Lymph node : metastasis in 5 out of 14 axillary lymph nodes - Pathology - 요약병기 : 3

35 원발부위별요약병기코딩규칙 Liver 0 In situ Noninvasive;intraepithelial 1. Localized only Confined to one lobe with or without vascular invasion Multiple(satelite)nodules/tumors confined to one lobe Confined to liver, NOS 2 Regional By direct extension only More than one lobe involved by contiguous growth

38 원발부위별요약병기코딩규칙 Ovary 0. Noninvasive, intraepithelial, Preinvasive 1. Localized only FIGO stage IA, IB, I 2. Regional by direct extension only FIGO stage IIB, IIC,II 7. Distant site(s)/lymph node(s) involved FIGO stage IIIA, IIIB, IIIC,III, IV

39 원발부위별요약병기코딩규칙 Ovary ( 예제 ) - clear cell carcinoma - oophorectomy, salpingectomy - Key word stage : T1a, (FIGO IA) 17 lymph node with no tumor involvement - Pathology- 요약병기 : 1

40 Hodgkin and non-hodgkin Lymphoma of all sites

41 원발부위별요약병기코딩규칙 Hodgkin and non-hodgkin Lymphoma of all sites 1. Localized - nodal lymphoma 하나의 Lymph node involve 된경우 (I) - extranodal lymphoma 하나의기관의일부분에국한되어 involve 된경우 (II) 하나의기관에여러부분이 involve 된경우 (II) - spleen 에만 involve 된경우 (IS)

42 1. Localized N Ex-N S 장기 횡격막 Spleen 임파절 I IE IS

43 원발부위별요약병기코딩규칙 Hodgkin and non-hodgkin Lymphoma of all sites 5. Regional, NOS - nodal lymphoma 횡격막을기준으로한쪽부분에있는 lymph node 가둘이상 involve 된경우 (II) - extranodal lymphoma 근접기관이나조직으로 extension(iie) 하나의기관과 regional lymph node, 또는횡격막을기준으로기관과같은부분의 lymph node 들이 involve 된경우 - Spleen 관련 spleen 과횡격막아래에있는하나의기관이 invole 된경우 (with/without 횡격막아래부분 lymph node 의 involve)(iies) spleen 과횡격막아래부분에있는 lymph node 가 involve (IIS)

44 5. Regional N Ex-N S 장기 횡격막 장기 Spleen 장기 IIEs 임파절 IIs II IIE II

45 원발부위별요약병기코딩규칙 Hodgkin and non-hodgkin Lymphoma of all sites 7. Distant - Nodal lymphoma 횡격막을기준으로양쪽부분 lymph node 에 involve(iii) - extranodal lymphoma 하나의기관과횡격막기준으로다른쪽부분에있는 lymph node 들이 involve 된경우 (IIIE) - spleen 관련 spleen 과횡격막윗부분에있는 lymph node, 그리고 Extralymphatic 기관이 involve 된경우 (IIIES) spleen 과횡격막윗부분의 extralymphatic 기관, 그리고 lymph node 가 involve 된경우 (IIIES)

46 7. Distant N Ex-N S 횡격막 Spleen 임파절 장기 III IIIE IIIs

47 7. Distant Ex-N Ex-N 장기 횡격막 Spleen 장기 Spleen 장기 장기 IIIEs IIIEs IV

48 원발부위별요약병기코딩규칙 Hodgkin and non-hodgkin Lymphoma of all sites 7. Distant - 하나이상의 extralymphatic 기관에 disseminate 된경우 (IV) - 둘이상의 extralymphatic 기관이 involve 된경우 (IV) - metastases(bone marrow, Liver)

49 7. Distant 횡격막 Dissemin ation Metastasis (bone marrow Liver)

50 예제풀이여행예제풀이여행

51 Lung 예제 풀이 - 41 세남환, cough, sputum, rhinorrhea - Chest CT A nodule on LUL, sugesting cancer Left Pl thickening with invasion to visceral pleura - Bone scan : Degenerative lesion in L3-4 & L5-S1 - PET CT Lobulated with increased FDG uptake in Left lung apex several protruding lesions in lateral and posterial wall of the bladder, probable bladder diverticula - LUL lobectomy and mediastinal dissection - Path : Adenosquamous carcinoma, 3.7x 2.8cm vascular invasion : present, Pleural invasion : present bronchial margin : clear, lymphatic invasion : present lymph node metastasis in six out of 45 reginoal lymph node

52 Lung 예제 풀이 - Key word invasion to visceral pleura ( chest CT ) Pleura invasion : present ( path ) lymph node metastases in six out of 45 regional lymph node ( path ) 요약병기 : 4

53 Pancreas 예제 풀이 - 59 세남, abdominal pain - CT : pancreatic mass at proximal tail, pancreatic ductal dilation - ERCP(endoscopic retrograde cholangiopancreatography) Bile duct : not remarkable Pancreatic duct : pancreatic cancer, tail - Path soft tissue named pericolon tissue : free from tumor soft tissue named pancreas tumor : Fibrotic wall without lining epithelium showing chroic inflamation pancreas : Adenocarcinoma, poorly differentiated lymphovascula permeation, hypovascula permeation Lymph node : regional(1/10) metastatic carcinoma

54 Pancreas 예제 풀이 - Key word Lymph node : regional(1/10) metastatic carcinoma (Path) 요약병기 : 3

55 예제 풀이 Rectum 56 세, 여성 : melena - CT : Irregular wall thickening involving lower rectum with small regional L/Ns - Colonoscopy : No definite evidence of distant metastasis - OP : Large bowel anterior resection - Path : Adenocarcinoma, moderately differentiated 4.5cm x 3.5cm Extent of invasion : perirectal adipose tissue venous invasion : not identified angiolymphatic invasion : not identified Lymph nodes: no metastasis in 18 lymph node

56 예제 풀이 Rectum - Key word extent of invasion : perirectal adipose tissue lymph node : no metastasis in 18 lymph node - Pathology - 요약병기 : 2

57 예제 풀이 Ovary - 35 세여성, Lower abdomen mass - CEA/CA / Pelvis CT Huge pelvic and lower abdominal mass with solid and cystic component ovarian cancer most likely. Ascites and seeding to mesenteric root, omentum and peritoneum. - Chest CT Hematogenous lung metastasis without interval change. - Kidney sono Bilateral hydronephorosis 가있으며이중 right side 가좀더심한 hydronephorosis 를보임

58 예제 풀이 Ovary Key word - seeding to mesenteric root, omentum and peritoneum.(pelvis CT) - Hematogenous lung metastasis without interval change.(chest CT) 요약병기 : 7

59 예제 풀이 Lymphoma - 64 세여성, 1 week of swelling, left neck, - Chest CT : Lobular right superior mediastinal mass consistent with clinical diagnosis of hodgkins lymphoma in paratracheal node - Bone scan : negative - Liver scan : Within normal limit - OP : staging laparotomy and splenectomy - Path : L cervical node biopsy : Hodgikin lymphoma, mixed cellularity Bone marrow : negative Spleen : Hodgikin lymphoma, mixed cellularity

60 예제 풀이 Ovary Key word - Paratracheal node (above diaphragm-ct) - Cervical lymph node (above diaphragm-path) - Spleen involved (below diaphragm-path) 요약병기 : 7

61 Collaborative Stage 현재주로사용되는 stage는 TNM stage와 Summary stage(1977, 2000) 각각의체계가다르고호환성이부족 세가지병기시스템의분류방식을모두만족시키는단일화된자료수집시스템으로개발 모든암종의병기분류시스템호환가능

62 Collaborative Staging

63 Collaborative staging(cs) Task Force Team American Joint Committee on Cancer National Cancer Registrars Association National Program of Cancer Registries, Centers for Disease control and prevention Statistics Canada American Joint on Cancer Surveillance, Epidemiology, and End Results Program, National cancer Institute North American Association of Central Cancer Registries

64 Dec- current

66 일반적지침 2004년 1월 1일이후에진단받은환자에게적용 모든암이대상 ( 현미경적확진여부와관계없음 ) 현미경적으로확진되지않은경우임상의사가원발부위라고생각하는부위의체계에맞춰코드를줘야함 Staging 하는시기는 TNM, Summary staging이모두같음 ( 첫번째단계로진행된수술치료나진단이후 4개월안에수집된모든정보가기초- 병이진행되지않은경우 ) 진단후진행된전이자료는 staging시배제

67 일반적지침 항목별코드는일반적으로높은번호가종양이더많이진행된것을나타내도록되어있음. 각항목별로가능한가장높은번호를부여할것 코딩시임상적, 병리적정보를모두사용 CS Tumor Size, CS Extension, CS Lymph Nodes, CS Mets at Dx 항목은임상적그리고수술 / 병리적으로얻어진자료를모두종합하여가장멀리진행된상태를기록 모든암조직이절제되지않은경우수술시 Gross observation은중요한정보. 조직병리결과와수술기록이차이가있을경우병리조직결과에근거하여코딩할것

68 일반적지침 환자가수술전에항암치료, 방사선치료, 호르몬치료등의치료를받지않았는데수술 / 병리정보와임상정보에차이가있을경우병리정보를우선으로할것 만일수술전에치료를한경우임상정보에의존하여코딩할것. 임상정보 ( 피부의진행양상묘사, 원발부위크기, 원격림프절전이등은 stage를바꿀수있으므로주의깊게살펴볼것 ) 수술전치료를받았을경우에는임상, 수술 / 병리를종합하여가장진행이많이된경우의정보를사용하여코딩. 특정부위나조직병리진단에한정되는지침은일반적지침에우선.

69 일반적지침 부검에서얻은정보는병리결과에서얻어진정보와같은방법으로사용됨 사망진단서만가지고코딩을하는경우는 9, 99, 888등 ( 모름, 해당없음 ) 에해당하는코드를사용 Regional lymph nodes positive나 Regional lymph nodes examined는병리결과에근거해야함

70 Collaborative Staging Item ITEM Description CS Tumor Size 종양의크기 ( 구체적크기명시 ) CS Extension 종양이퍼진정도 CS TS/Ext Eval CS 크기와퍼진정도의확정방법 CS Lymph nodes 임파선관여여부 ( 관여된종류, 범위 ) Regional Nodes Positive 양성반응결과나온임파선개수 Regional Nodes Exam 총검사한임파선개수 CS Reg Nodes Eval 임파선진단관련사항확정방법 CS Mets at Dx Mets 여부 ( 어느부위전이 ) CS Mets at Dx-Bone CS Mets at Dx-Brain CS Mets at Dx-Liver CS Mets at Dx-Lung CS <Mets Eval Mets 진단확정방법

71 Collaborative Staging Item ITEM CS Site-spec Factors 1-25 Lymph-Vascular Invasion Grade Path Value Grade Path System Description 암종별로 specific 한요소 25항목 Lymph-vascular Invasion 여부 2, 3, 4 grade system일경우 ( 분자 or 첫번째숫자 ) 2,3,4 grade system일경우 ( 분모 or 두번째숫자r) Examples Final pathologic diagnosis listed as grade 1/4. Code Grade Path System as 4. Microscopic description reports high grade III of III. Code Grade Path System as 3.

72 Tumor Size Examples Mammogram shows 2.5 cm breast malignancy 025 CT of chest shows 4 cm mass in RUL 040 Prostate TURP shows 0.6 mm carcinoma 001

73 CS Extension

74 CS Tumor SIZE/EXT Eval

75 CS Mets at Dx

76 CS Mets at Dx-Bone

77 Lymph-vascular invasion

78 Grade path value

87 Testomatic program (CS version 사용 )

88 감사합니다 감사합니다

내시경 conference

내시경 conference 부울경소화기내시경학회 6월집담회 고신대학교복음병원소화기내과전임의서광일 F/63 CASE C.C) epigastric pain for 2 wks P. I) 2014.04.16 EGD at LMC adm via OPD for further evaluation. P. Hx) CASE HTN/DM/Hepatitis/Tbc (+/+/-/-) S. Hx) N-S ROS)