C50.0-C50.6, C50.8-C50.9 C50.0 Nipple C50.1 Central portion of breast C50.2 Upper-inner quadrant of breast C50.3 Lower-inner quadrant of breast C50.4 Upper-outer quadrant of breast C50.5 Lower-outer quadrant of breast C50.6 Axillary Tail of breast C50.8 Overlapping lesion of breast C50.9, NOS Note: 편측성만코딩한다. CS Tumor Size (Revised: 11/11/2010) Note 1: 의무기록상에있는세부적인종양크기를코딩한다. 종양크기에관한기록이의사의 T 분류관련기술뿐이라면, 코드 990(T1mi), 991(T1b), 992(T1 or T1c), 995(T2) 로코딩한다. 종양크기관련다른기록은없고 T1a 라는의사기술만있다면, 005로코딩한다. 종양크기관련다른기록은없고 T3 이라는의사기술만있거나종양크기가 5cm 이상이라는기술만있다면 051로코딩한다. Note 2: 병리학적크기를코딩할때, 침범요소를측정한것을코딩한다. 예를들어, 정상소재 (in situ) 부분은크고 ( 예 : 4cm) 침범부분은작을경우, SSF 6을보고보고되는종양크기에더많은정보를이용하여코딩한다. invasive 부분의크기가없다면전체크기를코딩하고 SSF 6에서그것을대표하는것을기록한다. 일부유방암에서종양크기는병리학적으로안나올수도있다. Note 3: 미세침윤 (Microinvasion) 은기저막 (basement membrane) 을넘어주변조직으로암세포가확장된것으로가장큰크기가 0.1cm 이상이되는병소는없다. 미세침윤 (Microinvasion) 의중복병소들이있을때, 가장큰병소의크기를사용하고각각개별적이병소들의합은사용하지않는다. 000 No mass/tumor found 001-001 - millimeters (mm) ( exact size in mm) 989 989 mm or larger 990 Microinvasion Microscopic focus or foci only and no size given Described as "less than 1 mm" 991 992 Stated as T1mi with no other information on tumor size Described as "less than 1 centimeter (cm)" Stated as T1b with no other information on tumor size Described as "less than 2 cm," or "greater than 1 cm," or "between 1 cm and 2 cm" - 1 -
993 994 995 Stated as T1 [NOS] or T1c [NOS] with no other information on tumor size Described as "less than 3 cm," or "greater than 2 cm," or "between 2 cm and 3 cm" Described as "less than 4 cm," or "greater than 3 cm," or "between 3 cm and 4 cm" Described as "less than 5 cm," or "greater than 4 cm," or "between 4 cm and 5 cm" Stated as T2 with no other information on tumor size 996 Mammographic/xerographic diagnosis only, no size given; clinically not palpable 997 Paget disease of nipple with no demonstrable tumor 998 Diffuse Unknown; size not stated Size of tumor cannot be assessed CS Extension (Revised: 11/11/2010) Note 1: 파인피부 (dimpling of the skin), 매듭 (tethering), 오므라든유두 (nipple retraction) 같은변화는실제피부침범이아닌쿠퍼인대의팽창에의한것으로분류하지않는다. Note 2: 피부또는피하조직으로침범된임상적근거로써, 고수 (adherence), 부착 (attachment), 고정 (fixation), 경화 (induration), 두꺼워짐 (thickening) 은 200으로코딩한다. Note 3: 대흉근 (pectoralis muscle) 의침범으로써 " 고정 (fixation), NOS" 는 300으로코딩한다. Note 4: 침범코드가 000이라면, 행태코드는반드시 2이어야한다. 침범코드가 050또는 070이면, 행태코드는 2또는 3일수있다. 침범코드가 100이라면, 행태코드는반드시 3이어야한다. Note 5: 염증성암종 (Inflammatory Carcinoma): AJCC 7판지침에다음과같이포함되어있다. " 염증성암종 (Inflammatory Carcinoma) 은전체적으로유방에널리퍼진홍반 부종 (peau d'orange) 과함께임상병리학적으로발견된다. 이것은종종잠재적으로만져지는덩어리가없을때도있다. 이러한임상적증상은대부분유방의피부까지침범이된것이다. 관행에따르면, 피부변화는종양이있는유방에따라빠르게발생하기때문에염증성암종 (Inflammatory Carcinoma) 이란용어는국소적으로진행된암에적용하지않는다. 영상에서두드러지게두꺼워진피부나덩어리가발견될수있다. 피부림프관내에종양색전때문에임상검사를하는데피부조직검사를할수도있고안할수도있다. 염증성암종 (Inflammatory Carcinoma) 의종양은 T4d로분류되며주로임상진단으로나온다는것을기억하는것이중요하다. 임상적근거없는피부내림프관침습만으로염증성암종 (Inflammatory Carcinoma) 이라하지않는다. 임상적으로확인후, 조직검사로피부내림프관또는유방실질조직안의암이존재하는지확인하는것이필요하다. Note 6: CS을위해, 추출자는염증성암종 (Inflammatory Carcinoma) 진단을기록해야하고임상적특징과피부의침습정도를텍스트로기록해야한다. 염증성암종 (Inflammatory Carcinoma) 진단과피부침범이유방피부의 1/3(33%) 보다적은경우코드 600을준다. 염증성암종 (Inflammatory Carcinoma) 진단과피부침범이유방피부의 1/3(33%) 보다크거나같거나또는 50% 보다작거나같은경우코드 725을준다. 염증성암종 (Inflammatory Carcinoma) 진단과피부침범이유방피부의 - 2 -
50%( 다수또는 diffuse) 보다큰경우코드 730을준다. 염증성암종 (Inflammatory Carcinoma) 진단은내려졌는데임상적기술이없다면코드 750을준다. 염증성암종 (Inflammatory Carcinoma) 진단이없는임상적인기술 (inflammation, erythema, edema, peau d'orange 또는피부변화를묘사하는다른용어들 ) 은침범된정도에따라코드 512-585를주면된다. TNM 7 TNM 6 SS2000 000 050 070 100 In situ: noninfiltrating; intraepithelial Intraductal WITHOUT infiltration Lobular neoplasia Paget disease of nipple WITHOUT underlying tumor Paget Disease disease of nipple WITHOUT underlying invasive carcinoma pathologically Confined to breast tissue and fat including nipple and/or areola Localized, NOS Tis Tis IS Tis Tis ** Tis Tis ** ^ * L 110 Stated as T1mi with no other information on extension ^ * L 120 Stated as T1a with no other information on extension ^ * L 130 Stated as T1b with no other information on extension ^ * L 140 Stated as T1c with no other information on extension ^ * L 170 180 190 200 300 400 Stated as T1 [NOS] with no other information on extension or size Stated as T2 with no other information on extension or size Stated as T3 with no other information on extension or size Invasion of subcutaneous tissue Local infiltration of dermal lymphatics adjacent to primary tumor involving skin by direct extension Skin infiltration of primary breast including skin of nipple and/or areola Attachment or fixation to pectoral muscle(s) or underlying tissue Deep fixation Invasion of (or fixation to) pectoral fascia or muscle Invasion of (or fixation to): Chest wall Intercostal or serratus anterior muscle(s) Rib(s) T1NOS T1NOS L T2 T2 L T3 T3 L ^ * RE ^ * RE T4a T4a RE See codes 610 (obsolete), 612-615, and 620 (obsolete) for combinations with this code - 3 -
TNM 7 TNM 6 SS2000 410 Stated as T4a with no other information on extension T4a T4a RE OBSOLETE DATA RETAINED V0200 Extensive skin involvement, including: Satellite nodule(s) in skin of primary breast Ulceration of skin of breast Any of the following conditions described as involving 510 not more than 50% of the breast, or amount or ERROR T4b RE percent of involvement not stated: Edema of skin En cuirasse Erythema Inflammation of skin Peau d'orange ("pigskin") Extensive skin involvement, including: 512 Satellite nodule(s) in skin of primary breast T4b T4b RE Ulceration of skin of breast Any of the following conditions described as involving less than one-third (33%) of the breast WITHOUT a stated diagnosis of inflammatory carcinoma WITH or WITHOUT dermal lymphatic infiltration: 514 Edema of skin T4b T4b RE En cuirasse Erythema Inflammation of skin Peau d'orange ("pigskin") 516 514 + 512 T4b T4b RE Any of the following conditions described as involving one third (33%) or more but less than or equal to half (50%) of the breast WITHOUT a stated diagnosis of inflammatory carcinoma 518 WITH or WITHOUT dermal lymphatic infiltration: Edema of skin T4b T4b RE En cuirasse Erythema Inflammation of skin Peau d'orange ("pigskin") 519 518 + 512 T4b T4b RE Any of the following conditions described as involving 520 more than 50% of the breast WITHOUT a stated diagnosis of inflammatory carcinoma T4b T4b RE WITH or WITHOUT dermal lymphatic infiltration: - 4 -
TNM 7 TNM 6 SS2000 Edema of skin En cuirasse Erythema Inflammation of skin Peau d'orange ("pigskin") 575 520 + 512 T4b T4b RE 580 Any of the following conditions with amount or percent of breast involvement not stated and WITHOUT a stated diagnosis of inflammatory carcinoma WITH or WITHOUT dermal lymphatic infiltration: Edema of skin T4b T4b RE En cuirasse Erythema Inflammation of skin Peau d'orange ("pigskin") 585 580 + 512 T4b T4b RE 600 Diagnosis of inflammatory carcinoma WITH a clinical description of inflammation, erythema, edema, peau d'orange, etc., involving less than T4b T4d RE one-third (33%) of the skin of the breast, WITH or WITHOUT dermal lymphatic infiltration 605 Stated as T4b with no other information on extension T4b T4d RE 610 OBSOLETE DATA RETAINED V0200 (400) + (510) ERROR T4c RE 612 Any of (512-516) + 400 T4c T4c RE 613 Any of (518-519) + 400 T4c T4c RE 615 Any of (520-585) + 400 T4c T4c RE 620 OBSOLETE DATA RETAINED V0200 (400) + (520) ERROR T4c RE 680 Stated as T4c with no other information on extension T4c T4c RE OBSOLETE DATA RETAINED V0200 710 Diagnosis of inflammatory carcinoma WITH a clinical description of inflammation, erythema, edema, peau d'orange, etc., involving not more than 50% of the skin of the breast, WITH or WITHOUT dermal lymphatic infiltration Inflammatory carcinoma, NOS ERROR T4d RE - 5 -
TNM 7 TNM 6 SS2000 Previous wording (V0100): Diagnosis of inflammatory carcinoma WITHOUT a clinical description of inflammation, erythema, edema, peau d'orange, etc., of more than 50% of the breast. WITH or WITHOUT dermal lymphatic infiltration Inflammatory carcinoma, NOS OBSOLETE DATA RETAINED V0202 715 725 730 Diagnosis of inflammatory carcinoma WITH a clinical description of inflammation, erythema, edema, peau d'orange, etc., involving not more than one-third (33%) of the skin of the breast, WITH or WITHOUT dermal lymphatic infiltration Diagnosis of inflammatory carcinoma WITH a clinical description of inflammation, erythema, edema, peau d'orange, etc., involving one-third (33%) or more but less than or equal to one-half (50%) of the skin of the breast, WITH or WITHOUT dermal lymphatic infiltration Diagnosis of inflammatory carcinoma WITH a clinical description of inflammation, erythema, edema, peau d'orange, etc., involving more than one-half (50%) of the skin of the breast, WITH or WITHOUT dermal lymphatic infiltration Diagnosis of inflammatory carcinoma WITH a clinical description of inflammation, erythema, edema, peau d'orange, etc., but percent of involvement not stated, WITH or WITHOUT dermal lymphatic infiltration. T4b T4d RE T4d T4d RE T4d T4d RE 750 Note: If percentage is known, code to 600, 725, or 730. T4d T4d RE Diagnosis of inflammatory carcinoma WITHOUT a clinical description of inflammation, erythema, edema, peau d'orange, etc., WITH or WITHOUT dermal lymphatic infiltration Inflammatory carcinoma, NOS 780 Stated as T4d with no other information on extension T4d T4d RE 790 State as T4 [NOS] with no other information on extension T4NOS T4NOS RE 950 No evidence of primary tumor T0 T0 U - 6 -
TNM 7 TNM 6 SS2000 Unknown; extension not stated Primary tumor cannot be assessed TX TX U * 이부위의 Extension 코드 100-140, 200, 300에서는 T분류가 CS Tumor Size 값을바탕으로분류 된다. ^ 이부위의 Extension 코드 100-140, 200, 300에서는 T분류가 CS Tumor Size 값을바탕으로분류 된다. ** 이부위의 Extension 코드 050, 070에서 summary stage 2000는 ICD-O-3 행태코드값을바탕으 로분류된다. CS Tumor Size/Ext Eval (Revised: 08/10/2009) 0 1 2 3 AJCC pathologic staging 기준에맞지않음 : 절제수술시행안함. 신체검사, imaging 검사, 기타비외과적인임상검사를근거로평가내림. 부검을시행안함. AJCC pathologic staging 기준에맞지않음 : 절제수술시행안함. 내시경검사, 진단조직검사 (fine needle aspiration biopsy 포함 ), 다른외과적인검사 ( 조직검사안한수술적관찰포함 ) 을근거로평가내림. 부검을시행안함. AJCC pathologic staging 기준에맞음 : 절제수술시행안했지만, 부검을근거로평가내림 ( 부검전에종양을의심받았거나진단받음 ) AJCC pathologic staging에맞음 : 수술전 systemic 치료나방사선치료없이절제수술을시행함. 또는수술전 systemic 치료나방사선치료를시행한지모르고절제수술을시행함. 그리고치료전수술결과로얻은정보, 특히절제한표본의조직검사를근거로평가내림. Staging Basis c c p p 5 절제수술시행안함. 양성결과나온조직검사중가장높은 T 분류를근거로평가내림. AJCC y-pathologic staging 기준에맞지않음 : 수술전치료를받고절제수술을시행하였고수술조직검사 ( 수술전치료시행후 ) 가더진행되지않으며임상정보를근거로평가내림. c - 7 -
6 8 9 AJCC y-pathologic staging 기준에맞음 : 수술전치료를받고절제수술을시행함. 그리고수술조직검사결과가치료전임상검사결과보다더진행되었기때문에조직검사를근거로평가내림. autopsy(a) staging 기준에맞음 : 부검으로만평가내림.( 종양을부검전에의심하거나진단내리지도않음 ) 절제수술시행여부모름평가할수없음평가했는데모름환자기록에정보없음 Staging Basis yp a c CS Lymph Nodes (Revised: 11/12/2010) Note 1: 이항목에서는주변림프절만코딩한다. 경부 (cervical)( 빗장위 (supraclavicular) 제외 ) 또는반대쪽액와 (axillary) 와같은원격림프절은 Mets at DX에서코딩한다. Note 2: 미세전이 (Micrometastases) 는종양침전물직경이 0.2mm 이상이지만 2.0mm를안넘는것을말하며종양침전물이 2.0mm 이상이다. 미세전이 (Micrometastases) 가있는모든림프절은림프절양성개수에포함된다. 하지만적어도하나의림프절이 pn1mi 보다큰병리학적 N 분류를하기위한거대전이 (macrometastasis) 가포함되어야한다. Note 3: 병리보고서에서림프절은양성인데전이크기가기술되어있지않다면, 0.2 mm 이상이라고가정하고림프절양성으로코딩한다. 림프절에대한다른정보가없으면코드 600을준다. Note 4: 신체검진상에서림프절을촉진했을때, 고정된 (fixed) 이라기술되지않는다면, 그림프절은 움직이는 (movable) 이라가정한다. Note 5: 코드 130-600은 leve I 과 level II 동측액와림프절 (axillary lymph nodes) 과동측 intramammary nodes 에만사용한다. 쇄골하 (infraclavicular) 또는첨액와림프절 (apical nodes) 로알려진동측 level III 액와림프절 (axillary lymph nodes) 은코드 750 또는그이상을준다. 액와림프절 (axillary lymph nodes) 은 internal mammary 또는동측빗장위림프절 (supraclavicular lymph nodes) 을포함하지않는다. Note 6: 유방스키마에서, N 분류는 CS Lymph Nodes Eval 필드를바탕으로한다. 림프절을임상적으로평가한경우 (CS Lymph Nodes Eval 코드 = 0, 1, 5, 9) 임상적으로평가 로분류된다. 몇몇 CS Lymph Nodes 코드설명앞에는이런것들은반영하여 임상적평가 (Evaluated clinically) 라고기재되어있는코드들이있다. 병리학적으로평가한경우 (CS Lymph Nodes Eval 코드 = 2, 3, 6, 8) 는 병리학적으로평가 로분류되는데앞의상황과비슷하게 병리학적평가 (Evaluated pathologically) 라고기재되어있는코드들이있다. 이외의다른모든코드들은임상적또는병리학적평가에상관없이사용된다. Note 7: 단일종양세포 (Isolated tumor cells, ITC) 는단일암세포나작은무리들이 0.2 mm 이상이안되는것을말한다. 이것은대게면역조직화학 (IHC) 또는분자검사방법 (H-hematoxylin와 E-eosin 착색제로증명하는 ) 에의해주로발견된다. 단일종양세포 (Isolated tumor cells, ITC) 들은대개악성의행태를보이지않는다.( 예 : 확산또는기질반응 ). 단일종양세포 (Isolated tumor cells, ITC) 만있는림프절은양성림프절로고려하지않는다. 기록이단지 N0(i+) 라고기재되어있는경우, 코드 000을주고 CS SSF 4를확인한다. - 8 -
TNM 7 TNM 6 SS2000 000 No regional lymph node involvement OR isolated tumor cells (ITCs) detected by immunohistochemistry/immunohistochemical (IHC) methods or molecular methods ONLY. (See Note 7 and CS Site-Specific Factors 4 and 5) Evaluated pathologically: ^ * NONE 050 None; no regional lymph node involvement BUT ITCs detected on routine hematoxylin and eosin (H and E) stains. (See Note 7) Evaluated pathologically: N0(i+) N0(i+) NONE 130 Axillary lymph node(s), ipsilateral, micrometastasis ONLY detected by IHC ONLY (At least one micrometastasis greater than 0.2 mm or more than 200 cells AND all micrometastases less than or equal to 2 mm) Evaluated pathologically: N1mi N1mi RN 150 155 Axillary lymph node(s), ipsilateral, micrometastasis ONLY detected or verified on H&E (At least one micrometastasis greater than 0.2 mm or more than 200 cells AND all micrometastases less than or equal to 2 mm ) Micrometastasis, NOS Evaluated pathologically: Stated as N1mi with no other information on regional lymph nodes Evaluated pathologically: N1mi N1mi RN N1mi N1mi RN 250 Movable axillary lymph node(s), ipsilateral, positive with more than micrometastasis (At least one metastasis greater than 2 mm) (See Note 4) Evaluated clinically: ^^ ** RN Clinically movable axillary lymph node(s), ipsilateral, 255 positive N1 N1 RN (Clinical assessment because of neoadjuvant therapy or no pathology) (See Note 44) 257 Evaluated clinically: N1 N1 RN - 9 -
TNM 7 TNM 6 SS2000 Clinically stated only as N1 (Clinical assessment because of neoadjuvant therapy or no pathology Evaluated pathologically: 258 260 280 Pathologically stated only as N1 [NOS], no information on which nodes were involved Stated as N1 [NOS] with no other information on regional lymph nodes OBSOLETE DATA RETAINED V0104 Stated as N2, NOS OBSOLETE DATA RETAINED V0104 ^^ ** RN ^^ ** RN ERROR ** RN 500 Fixed/matted ipsilateral axillary nodes, positive with more than micrometastasis (i.e., at least one metastasis greater than 2 mm) Fixed/matted ipsilateral axillary nodes, NOS Evaluated clinically: ERROR ** RN 510 Fixed/matted ipsilateral axillary nodes clinically (Clinical assessment because of neoadjuvant therapy or no pathology) Stated clinically as N2a (Clinical assessment because of neoadjuvant therapy or no pathology) Evaluated pathologically: ^^ ** RN 520 600 Fixed/matted ipsilateral axillary nodes clinically with pathologic involvement of lymph nodes WITH at least one metastasis greater than 2 mm Axillary/regional lymph node(s), NOS Lymph nodes, NOS Evaluated clinically: ^^ ** RN ^^ ** RN 610 620 630 Clinically stated only as N2 [NOS] (Clinical assessment because of neoadjuvant therapy or no pathology) Evaluated pathologically: Pathologically stated only as N2 [NOS]; no information on which nodes were involved Stated as N2 [NOS] with no other information on regional lymph nodes ^^ ** RN ^^ ** RN ^^ ** RN - 10 -
TNM 7 TNM 6 SS2000 Evaluated pathologically: 710 Internal mammary node(s), ipsilateral, positive on sentinel nodes but not clinically apparent (No positive imaging or clinical exam) WITHOUT axillary lymph node(s), ipsilateral Evaluated pathologically: N1b N1b RN 720 Internal mammary node(s), ipsilateral, positive on sentinel nodes but not clinically apparent (No positive imaging or clinical exam) WITH axillary lymph node(s), ipsilateral Evaluated pathologically: ^^ ** RN 730 Internal mammary node(s), ipsilateral, positive on sentinel nodes but not clinically apparent (No positive imaging or clinical exam) UNKNOWN if positive axillary lymph node(s), ipsilateral Evaluated clinically: N1b N1b RN 735 740 745 748 750 755 760 Internal mammary node(s), ipsilateral, positive on sentinel nodes but primary not resected WITHOUT axillary lymph node(s), ipsilateral OR UNKNOWN if positive axillary lymph node(s), Internal mammary node(s), ipsilateral, clinically apparent (On imaging or clinical exam) WITHOUT axillary lymph node(s), ipsilateral Internal mammary node(s), ipsilateral, clinically apparent (On imaging or clinical exam) UNKNOWN if positive axillary lymph node(s), ipsilateral Stated as N2b with no other information on regional lymph nodes Infraclavicular lymph node(s)(subclavicular) (level III axillary nodes) (apical), ipsilateral WITH or WITHOUT axillary nodes(s) WITHOUT internal mammary node(s) Stated as N3a with no other information on regional lymph nodes OBSOLETE DATA RETAINED AND REVIEWED V0203 See codes 763 and765 Internal mammary node(s), ipsilateral, clinically apparent (on imaging or clinical exam) N2b N2b RN N2b N2b RN N2b N2b RN ^^ ** RN N3a N3a RN N3a N3a RN N3b N3b RN - 11 -
TNM 7 TNM 6 SS2000 763 764 765 768 WITH axillary lymph node(s), ipsilateral, codes 150 to 600 WITH or WITHOUT infraclavicular (level III axillary nodes) (apical) lymph nodes Internal mammary node(s), ipsilateral, clinically apparent (On imaging or clinical exam) WITH axillary lymph node(s), ipsilateral, codes 150 to 600 WITHOUT infraclavicular (level III axillary nodes) (apical) lymph nodes or unknown if infraclavicular (level III axillary nodes) (apical) lymph nodes involved Internal mammary node(s), ipsilateral, clinically apparent (On imaging or clinical exam) WITHOUT axillary lymph node(s), ipsilateral WITH infraclavicular (level III axillary nodes) (apical) lymph nodes involved Internal mammary node(s), ipsilateral, clinically apparent (On imaging or clinical exam) WITH axillary lymph node(s), ipsilateral WITH infraclavicular (level III axillary nodes) (apical) lymph nodes involved Stated as N3b with no other information on regional lymph nodes OBSOLETE DATA RETAINED V0200 N3b N3b RN N3b N3b RN N3b N3b RN N3b N3b RN 770 780 Internal mammary node(s), ipsilateral, clinically apparent (on imaging or clinical exam) UNKNOWN if positive axillary lymph node(s), ipsilateral OBSOLETE DATA RETAINED V0200 (750) + (770) ERROR N2b RN ERROR N3a RN 800 Supraclavicular node(s), ipsilateral N3c N3c D 805 Stated as N3c with no other information on regional lymph nodes N3c N3c D Evaluated clinically: 810 Clinically stated only as N3 [NOS] (Clinical assessment because of neoadjuvant therapy or no pathology) N3NOS N3NOS RN Evaluated pathologically: 815 Pathologically stated only as N3 [NOS]; no information on which nodes were involved N3NOS N3NOS RN 820 Stated as N3, NOS with no other information on regional lymph nodes N3NOS N3NOS RN - 12 -
TNM 7 TNM 6 SS2000 Unknown; regional lymph nodes not stated Regional lymph node(s) cannot be assessed NX NX U ^ 코드 000는이부위의 IHC MOL 표를사용하는 SSF 4와 SSF 5가 N 분류의기본이된다. ^^ 코드 250, 258, 260, 510, 520, 600, 610, 620, 630, 720, 748은 SSF 3( 동측액와림프절양성개수 ) 값과 CS Reg Nodes Eval 값이 N 분류의기본이된다. Eval code가 2(p), 3(p), 6(y), 8(a) 라면, N분류는림프절의병리평가표를참고하여결정된다. Eval code가 0(c), 1(c), 5(c), 9(c) 라면, N 분류는림프절의임상평가표를참고하여결정된다. Eval 항목이코딩되지않으면 N 분류는액와림프절양성표의참고로결정된다. * 코드 000는이부의의 IHC MOL 표를사용하는 SSF 4와 SSF 5가 N 분류의기본이된다. ** 코드 250, 258, 260, 280, 500, 510, 520, 600, 610, 620, 630, 720, 748은 SSF 3( 동측액와림프절양성개수 ) 값과 CS Reg Nodes Eval 값이 N 분류의기본이된다. Eval code가 2(p), 3(p), 6(y), 8(a) 라면, N분류는림프절의병리평가표를참고하여결정된다. Eval code가 0(c), 1(c), 5(c), 9(c) 라면, N분류는림프절의임상평가표를참고하여결정된다. Eval 항목이코딩되지않으면 N 분류는액와림프절양성표의참고로결정된다. CS Lymph Nodes Eval (Revised: 10/26/2009) Note 1: 이항목은주로 TNM system에서 N 분류에바탕이된다. "CS Lymph Nodes" 항목을코딩하는데결정을하게된진단방법에대해기록하는것이다. Note 2: AJCC 7판지침에서, N 분류의임상적, 조직학적분류지침은현재의학분야상황을반영하여변경되었다. N 은의도 ( 정밀검사 vs 치료 ) 에따라임상평가또는조직학적평가인지분류된다. 그의도가정밀검사일때, 병기기본은임상평가이고그의도가치료일때, 병기기본은조직학적평가이다. A. 치료계획을세우기위한정밀검사의일부분으로주변림프절또는감시림프절조직검사를포함한현미경평가는임상병기의한부분이다. 정밀검사의일부라면 T 분류는임상평가로분류되고조직학적인 T 분류를위해원발부위절제 ( 치료의일부로 ) 를하지않는다. B. 치료의일부분으로실행한주변림프절의현미경평가는조직학적병기가된다. 치료의일부라면 T 분류는조직학적평가로분류되고조직학적인 T 분류를위해원발부위절제 ( 치료의모든부분 ) 를한다. Note 3: 가장높은 N 분류의현미경평가는항상조직학적평가로분류된다. ( 코드 3) Note 4: 수술전치료이후에림프절절제가없었다면, 코드 0 또는 1을사용한다. Note 3: 코드 5 와 6은수술전치료이후에림프절에대한평가가실행되지않았을때사용한다. 0 1 AJCC pathologic staging 기준에맞지않음 : 검사를위해 regional lymph node 제거안함. 신체검사, imaging 검사, 기타비외과적인임상검사를근거로평가내림. 부검을시행안함. 다음기준에최소한한가지에기초해 AJCC pathologic staging 기준에맞지않음 : Staging Basis c c - 13 -
검사를위해 regional lymph node 제거안함. 내시경검사, 다른외과적인검사 ( 조직검사안한수술적관찰포함 ) 을근거로평가내림. 부검을시행안함. Staging Basis 2 또는정밀검사의일부로 regional lymph node 또는 sentinel nodes 의 fine needle aspiration, incisional core needle biopsy, excisional biopsy를시행 ( 조직학적으로 T 분류-치료를하기위해원발부위제거를하지않은상태 ) AJCC pathologic staging 기준에맞음 : 검사를위해 regional lymph node 제거안했지만, 부검을근거로평가내림 ( 부검전에종양을의심받았거나진단받음 ) 다음기준에최소한한가지에기초해 AJCC pathologic staging 기준에맞음 : p p 3 조직학적으로 T 분류 ( 치료 ) 를하기위해원발부위를제거하거나가장높은 T 분류를평가하는조직검사를하면서, regional nodes 의현미경적평가 (FNA, incisional core needle bx, excisional bx, sentinel node bx, node resection 포함 ) 5 6 8 9 또는 T 분류정보와상관없이, 가장높은 N 분류를평가하기위한현미경적평가 AJCC y-pathologic staging 기준에맞지않음 : 수술전치료를받고검사를위해 regional lymph node 제거를시행하였고수술조직검사 ( 수술전치료시행후 ) 가더진행되지않으며임상정보를근거로평가내림. AJCC y-pathologic staging 기준에맞음 : 수술전치료를받고검사를위해 regional lymph node 제거를시행함. 그리고수술조직검사결과가치료전임상검사결과보다더진행되었기때문에조직검사를근거로평가내림. autopsy(a) staging 기준에맞음 : 부검으로만평가내림.( 종양을부검전에의심하거나진단내리지도않음 ) 검사를위해 regional lymph node 제거시행여부모름평가할수없음평가했는데모름환자기록에정보없음 c yp a c - 14 -
Reg LN Pos (Revised: 07/28/2010) Note 1: 수술전치료를받았다하더라도이항목은기록한다. Note 2: 단일종양세포 (Isolated tumor cells, ITCs) 만있는림프절은양성림프절로세지않는다. 0.2mm이상 ( 미세전이또는그이상 ) 침범된림프절만양성으로숫자를센다. 병리보고서에림프절이양성이지만전이크기가기재되어있지않다면, 0.2mm 이상으로간주하고양성림프절로코딩한다. Note 3: 이항목에서는모든양성주변림프절을기록한다. 양성동측주변림프절 level I-II 액와림프절의숫자는그에맞는 SSF 항목에따로기재한다. 00 All nodes examined negative. 01-89 1-89 nodes positive (code exact number of nodes positive) 90 90 or more nodes positive 95 Positive aspiration or core biopsy of lymph node(s) 97 Positive nodes - number unspecified 98 No nodes examined 99 Unknown if nodes are positive; not applicable Reg LN Exam (Revised: 07/28/2010) 00 No nodes examined 01-89 1-89 nodes examined (code exact number of regional lymph nodes examined) 90 90 or more nodes examined 95 96 97 98 99 No regional nodes removed, but aspiration or core biopsy of regional nodes performed Regional lymph node removal documented as sampling and number of nodes unknown/not stated Regional lymph node removal documented as dissection and number of nodes unknown/not stated Regional lymph nodes surgically removed but number of lymph nodes unknown/not stated and not documented as sampling or dissection; nodes examined, but number unknown Unknown if nodes were examined; not applicable or negative - 15 -
CS Mets at DX (Revised: 11/12/2010) Note 1: 빗장위 (Supraclavicular( 가로목, transverse cervical)) 림프절침범은 CS Lymph Nodes 항목에서코딩한다. Note 2: 임상적또는방사선적방법으로원격전이가없다고확인된다면 cm0으로분류되고 00 코드를준다. 임상적또는방사선방법으로하나또는그이상의원격전이가발견되었다면 cm1로분류된다. 전이부위에대한조직검사나임상적검사방법에의한증거가기록되어있지않다면임상적으로전이가안된것 (cm0) 으로분류된다. 어떤병기를평가할만한정보가없거나종양이국소침범이아닌것이확실하고원격전이와관련된더이상의정보가없다면코드 99를준다. TNM 7 TNM 6 SS2000 00 No distant metastasis M0 M0 NONE No clinical or radiographic evidence of distant metastasis, but deposits of molecularly or 05 microscopically detected tumor cells in circulating blood, bone marrow or other non-regional nodal M0(i+) M0 NONE tissue that are 0.2 millimeters (mm) or less in a patient without symptoms or signs of metastasis 07 Stated as M0(i+) with no other information on distant metastasis M0(i+) M0 NONE Distant lymph node(s): Cervical, NOS Contralateral/bilateral axillary and/or internal 10 mammary Other than above M1 M1 D 40 42 44 Distant lymph node(s), NOS Distant metastasis except distant lymph node(s) (code 10) Carcinomatosis Further contiguous extension: Skin over: Axilla Contralateral (opposite) breast Sternum Upper abdomen Metastasis: Adrenal (suprarenal) gland Bone, other than adjacent rib Contralateral (opposite) breast - if stated as metastatic Lung Ovary Satellite nodule(s) in skin other than primary breast M1 M1 D M1 M1 D M1 M1 D 50 (40-44) + 10 M1 M1 D - 16 -
TNM 7 TNM 6 SS2000 Distant metastasis, NOS 60 99 Stated as M1 with no other information on distant metastasis Unknown; distant metastasis not stated Distant metastasis cannot be assessed M1 M1 D M0 MX U CS Mets Eval (Revised: 08/10/2009) Note: 이항목은채택된진단방법에따른 CS Mets at DX 분류의유효성을반영한다. 0 1 2 3 5 6 AJCC pathologic staging 기준에맞지않음 : 신체검사, imaging 검사, 기타비외과적인임상검사를근거로평가내림. 전이부위조직에대한조직학적검사를시행하지않았거나조직학적검사가 negative 로나온경우. AJCC pathologic staging 기준에맞지않음 : 내시경검사, 다른외과적인검사 ( 조직검사안한수술적관찰포함 ) 을근거로평가내림. 전이부위조직에대한조직학적검사를시행하지않았거나조직학적검사가 negative 로나온경우. AJCC pathologic staging 기준에맞음 : 사망전에전이조직에대한조직학적검사를시행하지않았지만, 부검을근거로평가내림 ( 부검전에종양을의심받았거나진단받음 ) AJCC pathologic staging에맞음 : 수술전 systemic 치료나방사선치료없이현미경적검사에서 positive 로나온경우또는수술전 systemic 치료나방사선치료시행여부는모르고현미경적검사에서 positive 로나온경우또는수술전치료이전에현미경적검사에서 positive 로나온경우 AJCC y-pathologic staging 기준에맞지않음 : 수술전 systemic 치료나방사선치료를받고현미경적검사에서 positive 로나왔지만, 임상정보를근거로평가내림. AJCC y-pathologic staging 기준에맞음 : 수술전 systemic 치료나방사선치료를받고현미경적검사에서 positive 로나왔고조직검사를근거로평가내림. Staging Basis c c p p c yp - 17 -
8 9 autopsy(a) staging 기준에맞음 : 전이조직검사에서 positivie 나왔고부검으로평가내림. 그리고종양을부검전에의심하거나진단내리지도않음평가할수없음평가했는데모름환자기록에정보없음 Staging Basis a c CS Site-Specific Factor 1 Estrogen Receptor (ER) Assay (Revised: 11/12/2010) Note 1: A. ER이하나이상의종양표본에서보고된경우 ( 아래의 B와 D 경우제외 ), 높은값을기록한다. 표본이양성이면양성으로기록한다. B. 수술전치료를받은경우, 수술전치료받기전종양표본으로부터나온결과를기록한다. C. 수술전치료를받고치료전표본에서 ER 결과가없는경우, 치료후표본의결과를기록한다. D. ER이양성이고림프절이음성이면, 다른 ER 검사로 OncotypeDX 같은다유전자검사를시행했을수도있다. 이항목에서는그검사결과는기록하지않는다. 다유전자검사를받을자격이되는환자에한하여그검사결과만을기록한다. Note 2: 일반적으로에스트로겐수용체 (estrogen receptor, ER) 는하나의표본에서시행된다. 하나이상의표본에서시행된경우, 반드시가장큰종양표본에서시행한것이가장정확한것은아니다. 임상적으로치료는양성검사를기반으로한다. 대부분의환자들은 ER 검사가양성이면호르몬치료를받는다. Note 3: 대부분최근에스트로겐수용체 (estrogen receptor, ER) 지침해석은이쪽도아니고저쪽도아닌결과 (borderline result) 는따르지않으므로코드 030은잘쓰이지않는다. 1% 또는그이상의세포가양성인경우, 결과는양성으로고려된다. 1% 이하의세포가양성이라면그결과는음성으로고려된다. 010 Positive/elevated 020 Negative/normal; within normal limits 030 Borderline; undetermined whether positive or negative 996 Test ordered, results not interpretable 997 Test ordered, results not in chart 998 Test not done (test not ordered and not performed) - 18 -
CS Site-Specific Factor 2 Progesterone Receptor (PR) Assay (Revised: 11/12/2010) Note 1: A. PR이하나이상의종양표본에서보고된경우 ( 아래의 B와 D 경우제외 ), 높은값을기록한다. 표본이양성이면양성으로기록한다. B. 수술전치료를받은경우, 수술전치료받기전종양표본으로부터나온결과를기록한다. C. 수술전치료를받고치료전표본에서 PR의결과가없는경우, 치료후표본의결과를기록한다. D. PR이양성이고림프절이음성이면, 다른 PR 검사로 OncotypeDX 같은다유전자검사를시행했을수도있다. 이항목에서는그검사결과는기록하지않는다. 다유전자검사를받을자격이되는환자에한하여그검사결과만을기록한다. Note 2: 일반적으로프로게스테론수용체 (progesterone receptor, PR) 은하나의표본에서시행된다. 하나이상의표본에서시행된경우, 반드시가장큰종양표본에서시행한것이가장정확한것은아니다. 임상적으로치료는양성검사를기반으로한다. 대부분의프로게스테론수용체 (progesterone receptor, PR) 검사가양성이면호르몬치료를받는다. Note 3: 대부분최근프로게스테론수용체 (progesterone receptor, PR) 지침해석은이쪽도아니고저쪽도아닌결과 (borderline result) 는따르지않는다. 그러므로코드 030은잘쓰이지않는다. 1% 또는그이상의세포가양성인경우, 결과는양성으로고려된다. 1% 이하의세포가양성이라면그결과는음성으로고려된다. 010 Positive/elevated 020 Negative/normal; within normal limits 030 Borderline; undetermined whether positive or negative 996 Test ordered, results not interpretable 997 Test ordered, results not in chart 998 Test not done (test not ordered and not performed) CS Site-Specific Factor 3 Number of Positive Ipsilateral Level I-II Axillary Lymph Nodes (Revised: 11/22/2010) Note 1: 양성동측 level I 과 II, 액와림프절 (axillary lymph node) 과 intramammary lymph node 숫자만포함된다. 유방내위치한 Intramammary node는흉골을따라위치한 internal mammary 와는같지않다. Note 2: 수술전치료를받았다하더라고이항목은기록한다. Note 3: 단일종양세포 (isolated tumor cells, ITCs) 만의림프절은양성림프절로세지않는다. 전이크기가 0.2mm 이상인림프절만양성으로숫자를센다. 병리보고서에림프절은양성이지만전이크기 - 19 -
가기재되어있지않다면, 0.2mm 이상으로간주하여이항목에서양성으로코딩을한다. Note 4: 이항목은병리정보만을바탕으로한다. 동측액와림프절이검사를위해절제되지않았거나동측액와림프절배출지역 (drainage area) 을제거했지만림프절이보이지않았다면코드는 098로준다. Note 5: 양성림프절에대한 Part I 일반코딩지침은이항목에서도적용된다 (Regional Nodes Positive 코드가세자리수보다는두자리일지라도 ). 양성동측액와림프절이이항목에서코딩될때, 그숫자는 Regional Nodes Positive 수와같거나그보다작아야한다.( 예 : 양성동측액와림프절의수는항상양성림프절수의부분집합일것이다.) 000 All ipsilateral axillary nodes examined negative 001-089 1-89 nodes positive (Exact number of nodes positive) 090 90 or more nodes positive 095 Positive aspiration of lymph node(s) 097 Positive nodes, number unspecified 098 No axillary nodes examined 099 998 Unknown if axillary nodes are positive (If this item is required by your standard setter, use of code will result in an edit error.) CS Site-Specific Factor 4 Immunohistochemistry (IHC) of Regional Lymph Nodes (Revised: 11/12/2010) Note 1: 단일종양세포 (Isolated tumor cells, ITCs) 는단일암세포나작은무리들이 0.2 mm 이상이안되는것을말한다. 이것은대게면역조직화학 (IHC) 또는 H and E (CS Lymph Nodes 코드 050 확인 ) 또는분자방법 (RT-PCR: Reverse Transcriptase Polymerase Chain Reaction)(CS SSF-5 확인 ) 에의해주로발견된다. 단일종양세포 (Isolated tumor cells, ITCs) 는대개악성의행태를보이지않는다.( 예 : 확산또는기질반응 ) Note 2: CS Lymph Nodes 코드가 000 일때, 면역조직화학 (IHC) 결과를보고할때는코드 000-009 만사용한다. 그렇지않으면 987을준다. Note 3: 면역조직화학 (IHC) 검사의시행여부를모를경우, 안했다고가정한다. Note 4: N0(i+) 라고기재되어있고다른정보가없는경우, 코드는 009를준다. 000 Regional lymph nodes negative on routine hematoxylin and eosin (H and E), no immunohistochemistry (IHC) OR unknown if tested for isolated tumor cells (ITCs) by IHC studies Nodes clinically negative, not examined pathologically - 20 -
001 002 009 Regional lymph nodes negative on routine H and E, IHC studies done, negative for tumor Regional lymph nodes negative on routine H and E, IHC studies done, positive for ITCs (Tumor cell clusters not greater than 0.2 millimeter (mm)) Regional lymph nodes negative on routine H and E, positive for tumor detected by IHC, size of tumor cell clusters or metastases not stated Stated as N0(i+) with no further information on regional lymph nodes 987 Not applicable: CS Lymph Nodes not coded 000 (If this item is required by your standard setter, use of code will result in an edit error.) CS Site-Specific Factor 5 Molecular (MOL) Studies of Regional Lymph Nodes (Revised: 11/12/2010) Note 1: 단일종양세포 (Isolated tumor cells, ITCs) 는단일암세포나작은무리들이 0.2 mm 이상이안되는것을말한다. 이것은대게면역조직화학 (IHC) 또는 H and E (CS Lymph Nodes 코드 050 확인 ) 또는분자방법 (RT-PCR: Reverse Transcriptase Polymerase Chain Reaction)(CS SSF-5 확인 ) 에의해주로발견된다. 단일종양세포 (Isolated tumor cells, ITCs) 는대개악성의행태를보이지않는다.( 예 : 확산또는기질반응 ) Note 2: CS Lymph Nodes 코드 000 일때, MOL 검사 ((RT-PCR) 결과를보고할때는코드 000-002 만사용한다. 그렇지않으면 987을준다. Note 3: 분자검사의시행여부를모를경우, 안했다고가정한다. 000 001 002 Regional lymph nodes negative on routine hematoxylin and eosin (H and E), no RT-PCR molecular (MOL) studies done OR unknown if RT-PCR studies done Nodes clinically negative, not examined pathologically Regional lymph nodes negative on routine H and E, RT-PCR MOL studies done, negative for tumor Regional lymph nodes negative on routine H and E, RT-PCR MOL studies done, positive for tumor 987 Not applicable: CS Lymph Nodes not coded 000 (If this item is required by your standard setter, use of code will result in an edit error.) - 21 -
CS Site-Specific Factor 6 Size of Tumor-Invasive Component (Revised: 11/12/2010) Note 1: 병리학적종양크기가 CS Tumor Size에어떻게코딩되었는지를기록한다. Note 2: 이항목에서 "mixed" 는악성과상피내암이같이있다는것을말한다. "mixed" 종양은 mixed infiltrating ductal and ductal carcinoma in situ 같이같은조직학일수도있고 mixed infiltrating ductal and lobular carcinoma in situ 같이조합된조직학일수도있다. "Pure" 는오직악성만있거나상피내암만있는것을말한다. Note 3: 종양의크기가주어지고상피내암병변이존재하는악성종양이라고언급된경우, 상피내암요소가적은부분있다고고려하여코드 030 을준다. Note 4: 이정보는분석을목적으로수집하고병기그룹에는영향을미치지않는다. 이항목의다른코드들은같은 T 분류나병기그룹의환자들의예후의차이를설명해줄수있다. 예 : 환자 1 은상피내암크기가 2.5cm 인종양과크기를모르는악성암이 mixed 되어있다. CS Tumor Size 는 025 로코딩하고 T2 로분류된다. SSF 6 은 040 으로코딩한다. 환자 2 는 2.5cm 의순전히악성종양이다. CS Tumor Size 는 025 로코딩하고 T2 로분류된다. 그 러나 SSF 6 은 000 으로코딩한다. 악성의크기를안다면 T1 으로분류될것이기때문에환자 1 은아마도환자 2 보다더생존율이 좋을것이다. 환자 3 은상피내암과악성암이같이존재하는 2.5cm 종양을가지고있다. SSF 6 은상피내암을 최소로생각하여코드 030 을준다. 000 010 020 030 040 050 Entire tumor reported as invasive (No in situ component reported) Entire tumor reported as in situ (No invasive component reported) Invasive and in situ components present, size of invasive component stated and coded in CS Tumor Size Invasive and in situ components present, size of entire tumor coded in CS Tumor Size because size of invasive component not stated AND in situ described as minimal (less than 25%) Invasive and in situ components present, size of entire tumor coded in CS Tumor Size because size of invasive component not stated AND in situ described as extensive (25% or more) Invasive and in situ components present, size of entire tumor coded in CS Tumor Size because size of invasive component not stated AND proportions of in situ and invasive not known - 22 -
060 987 Invasive and in situ components present, unknown size of tumor (CS Tumor Size coded ) Unknown if invasive and in situ components present, unknown if tumor size represents mixed tumor or a "pure" tumor. (See Note 2.) Clinical tumor size coded. (If this item is required by your standard setter, use of code will result in an edit error.) CS Site-Specific Factor 7 Nottingham or Bloom-Richardson (BR) Score/Grade (Revised: 11/12/2010) Note 1: AJCC는조직학적등급이결합된노팅엄 (Nottingham) 을추천한다.(Elston-Ellis modification of the Scarff-Bloom-Richardson grading system) BR의다른이름 : Bloom-Richardson (BR), modified Bloom-Richardson, BR, BR grading, Scarff-Bloom-Richardson, SBR grading, Elston-Ellis modification of Bloom-Richardson score, Nottingham modification of Bloom-Richardson score, Nottingham modification of Scarff-Bloom-Richardson, Nottingham-Tenovus grade, Nottingham grade Note 2: 종양등급코딩하는우선순위 : a) Bloom-Richardson 점수 3-9; b) Bloom-Richardson 등급 (low, intermediate, high) Note 3: BR 코드는 3-9로표현이된다. 이점수는 다른특별한유형이없는악성 특징을가진세가지조직학일때를바탕으로한다 ( 소관형성정도 / 조직학적등급, 유사분열활동, 핵의다형태성 / 핵의등급 ). 숫자보다단어들 (low, intermediate, high) 로기술된보고서라면이단어들을점수 / 숫자로바꾸려하지않고코드 110-130 을사용한다. Note 4: 점수정보가없고등급이 1-4로기재되었거나노팅엄 (Nottingham), BR Grade 가부정확할경우는코드 를준다. Note 5: 여러개의점수가기재되어있다면가장높은점수를코딩한다. 예를들어, 같은원발암의여러개의병리보고서에보고된서로다른점수들이있다면같은원발암내다발성종양들에따라다른점수들이보고될수있다. 030 Score of 3 040 Score of 4 050 Score of 5 060 Score of 6 070 Score of 7 080 Score of 8 090 Score of 9-23 -
110 Low Grade, Bloom-Richardson (BR) grade 1, score not given 120 Medium (Intermediate) Grade, BR grade 2, score not given 130 High Grade, BR grade 3, score not given (If this information is required by your standard setter, use of code may result in an edit error.) 998 No histologic examination of primary site Neither BR grade nor BR score given CS Site-Specific Factor 8 HER2: Immunohistochemistry (IHC) Lab Value (Revised: 11/12/2010) Note 1: 이항목에서는인체상피성장요소감각수용체 2(Human Epidermal Growth Factor Receptor 2, HER2) 를위한면역조직화학 (immunohistochemistry, IHC) 검사값만을코딩한다. 이검사는인체상피성장요소감각수용체 2(Human Epidermal Growth Factor Receptor 2, HER2) 의과다표출이있거나세포표면의인체상피성장요소감각수용체 2(Human Epidermal Growth Factor Receptor 2, HER2) 단백질양이과도한지를밝혀낸다. 점수는세포막얼룩의강도와비율을바탕으로병리의사가결정한다. Note 2: SSF 8 과 SSF 9 는같은검사정보를이용한다. Note 3: 검사가실행되었지만실제점수가기재되어있지않다면코드 997을준다. Note 4: 조직샘플이없다든지등의검사를실행하지못할만한환경이아님에도불구하고검사에관련된언급이의무기록상에없다면코드 를준다. 000 Score 0 010 Score 1+ 020 Score 2+ 030 Score 3+ (If this information is required by your standard setter, use of code may result in an edit error.) 997 Test ordered, results not in chart. 998 Test not done (test not ordered and not performed) - 24 -
CS Site-Specific Factor 9 HER2: Immunohistochemistry (IHC) Test Interpretation (Revised: 11/12/2010) Note 1: 이항목에서는인체상피성장요소감각수용체 2(Human Epidermal Growth Factor Receptor 2, HER2) 를위한면역조직화학 (immunohistochemistry, IHC) 검사결과를코딩한다. Note 2: SSF 8 과 SSF 9 는같은검사정보를이용한다. Note 3: 조직샘플이없다든지등의검사를실행하지못할만한환경이아님에도불구하고검사에관련된언급이의무기록상에없다면코드 를준다. 010 Positive/elevated 020 Negative/normal; within normal limits 030 Borderline; equivocal; indeterminate; undetermined whether positive or negative (If this information is required by your standard setter, use of code may result in an edit error.) 997 Test ordered, results not in chart. 998 Test not done (test not ordered and not performed) CS Site-Specific Factor 10 HER2: Fluorescence In Situ Hybridization (FISH) Lab Value (Revised: 11/12/2010) Note 1: 이항목에서는인체상피성장요소감각수용체 2(Human Epidermal Growth Factor Receptor 2, HER2) 를위한 FISH(Fluorescence In Situ Hybridization) 검사값만을코딩한다. 이검사는종양세포를정상숫자와비교해서부가적인 HER2/neugene 복제가있는지를검사하는것이다. 결과는 17번염색체복제수와 HER2/neugene 복제수의비율로보고된다. Note 2: 실제주어진비율을소수점둘째자리까지입력한다. Note 3: SSF10 과 SSF11 은같은검사정보를이용한다. Note 4: 검사를실행했지만실제비율이기술이되어있지않다면코드 997을준다. Note 5: 조직샘플이없다든지등의검사를실행하지못할만한환경이아님에도불구하고검사에관련된언급이의무기록상에없다면코드 를준다. 100-979 Ratio of 1.00-9.79-25 -
(Enter exact ratio to two decimal places) Examples: 100 1.0 120 1.2 564 5.64 980 Ratio of 9.80 or greater (If this information is required by your standard setter, use of code may result in an edit error.) 991 Ratio of less than 1.00 997 Test ordered, results not in chart 998 Test not done (test not ordered and not performed) CS Site-Specific Factor 11 HER2: Fluorescence In Situ Hybridization (FISH) Test Interpretation (Revised: 11/12/2010) Note 1: 이항목에서는인체상피성장요소감각수용체 2(Human Epidermal Growth Factor Receptor 2, HER2) 를위한 FISH(Fluorescence In Situ Hybridization) 검사값만을코딩한다. Note 2: SSF10 과 SSF11 은같은검사정보를이용한다. Note 3: 조직샘플이없다든지등의검사를실행하지못할만한환경이아님에도불구하고검사에관련된언급이의무기록상에없다면코드 를준다. 010 Positive/elevated; amplified 020 Negative/normal; within normal limits; not amplified 030 Borderline; equivocal; indeterminate; undetermined whether positive or negative (If this information is required by your standard setter, use of code may result in an edit error.) 997 Test ordered, results not in chart 998 Test not done (test not ordered and not performed) - 26 -
CS Site-Specific Factor 12 HER2: Chromogenic In Situ Hybridization (CISH) Lab Value (Revised: 11/12/2010) Note 1: 이항목에서는인체상피성장요소감각수용체 2(Human Epidermal Growth Factor Receptor 2, HER2) 를위한 CISH(Chromogenic In Situ Hybridization) 검사값만을코딩한다. 이검사는종양세포내부가적인 HER2/neugene 복제가있는지를검사하는것이다. 결과는전체 30개또는 60개종양세포안에서 HER2/neugene 복제수를평균값으로보고된다. Note 2: 실제주어진비율을소수점둘째자리까지입력한다. Note 3: SSF 12 와 SSF 13 은같은검사정보를이용한다. Note 4: 검사를실행했지만실제비율이기술이되어있지않다면코드 997을준다. Note 5: 조직샘플이없다든지등의검사를실행하지못할만한환경이아님에도불구하고검사에관련된언급이의무기록상에없다면코드 를준다. Mean of 1.00-9.79 (Enter exact mean to two decimal places) 100-979 Examples: 100 1.0 120 1.2 564 5.64 980 Mean of 9.80 or greater (If this information is required by your standard setter, use of code may result in an edit error.) 991 Mean of less than 1.00 997 Test ordered, results not in chart 998 Test not done (test not ordered and not performed) CS Site-Specific Factor 13 HER2: Chromogenic In Situ Hybridization (CISH) Test Interpretation (Revised: 11/12/2010) Note 1: 이항목에서는인체상피성장요소감각수용체 2(Human Epidermal Growth Factor Receptor 2, HER2) 를위한 CISH(Chromogenic In Situ Hybridization) 검사해석만을코딩한다. Note 2: SSF 12 와 SSF 13 은같은검사정보를이용한다. Note 3: 조직샘플이없다든지등의검사를실행하지못할만한환경이아님에도불구하고검사에관련된언급이의무기록상에없다면코드 를준다. - 27 -
010 Positive/elevated; amplified 020 Negative/normal; within normal limits; not amplified 030 Borderline; equivocal; indeterminate; undetermined whether positive or negative (If this information is required by your standard setter, use of code may result in an edit error.) 997 Test ordered, results not in chart. 998 Test not done (test not ordered and not performed) CS Site-Specific Factor 14 HER2: Result of Other or Unknown Test (Revised: 11/12/2010) Note 1: 이항목에서는인체상피성장요소감각수용체 2(Human Epidermal Growth Factor Receptor 2, HER2) 검사 fluorescent (FISH) 또는 chromogenic (CISH) 가아니거나모르는인체상피성장요소감각수용체 2(Human Epidermal Growth Factor Receptor 2, HER2) 검사를시행한경우결과를기록한다. Note 2: 어떤형태의인체상피성장요소감각수용체 2(Human Epidermal Growth Factor Receptor 2, HER2) 검사를시행했는지모른다면, 이항목에서결과를기록한다. Note 3: 조직샘플이없다든지등의검사를실행하지못할만한환경이아님에도불구하고이름이밝혀지지않은검사에관련된언급이의무기록상에없다면코드 를준다.( 예 : no histologic specimen ) 010 Positive/elevated; amplified 020 Negative/normal; within normal limits; not amplified 030 Borderline; equivocal; indeterminate; undetermined whether positive or negative (If this information is required by your standard setter, use of code may result in an edit error.) 997 Test ordered, results not in chart. 998 Test not done (test not ordered and not performed) - 28 -
CS Site-Specific Factor 15 HER2: Summary Result of Testing (Revised: 11/12/2010) Note 1: 이항목에서는면역조직화학 (Immunohistochemistry, IHC), FISH(Fluorescent In Situ Hybridization), CISH(Chromogenic In Situ Hybridization) 또는다른 / 모르는인체상피성장요소감각수용체2(HER2) 검사결과요약를코딩한다. 이변수는 CS SSF9, 11, 13, 14 의결과로부터온다. Note 2: 면역조직화학 (Immunohistochemistry, IHC) 과유전자증폭검사 (FISH, CISH 등 ) 모두주어져있다면그결과를기록한다. 그러나유전자증폭검사 (gene-amplification test) 가처음주어지고그결과가경계성이거나불분명하며, 이불분명한결과를명확하게하려고 IHC 검사가시행된경우에는, IHC 검사결과를코딩한다. Note 3: 하나의검사결과는기재되어있고두번째검사결과는시행했는데결과가기재되어있지않다면, 코드 997을준다. 010 Positive/elevated; amplified 020 Negative/normal; within normal limits; not amplified 030 Borderline; equivocal; indeterminate; undetermined whether positive or negative (If this information is required by your standard setter, use of code may result in an edit error.) 997 Test ordered, results not in chart. 998 Test not done (test not ordered and not performed) CS Site-Specific Factor 16 Combinations of ER, PR, and HER2 Results (Revised: 11/12/2010) Note 1: 에스트로겐수용체 (estrogen receptors, ER), 프로게스테론수용체 (progesterone receptors,pr), 인체상피성장요소감각수용체 2(Human Epidermal Growth Factor Receptor 2, HER2) 증폭또는과다표출이음성인유방암이나세개모두음성인유방암은임상적으로관심대상이다. Note 2: 이항목은 SSF 1, 2, 15에서비롯된다. Note 3: 에스트로겐수용체 (estrogen receptors, ER) 결과는첫번째자리에코딩한다 : 음성 - 0, 양성 - 1 Note 4: 프로게스테론수용체 (progesterone receptors,pr) 결과는두번째자리에코딩한다 : 음성 - 0, 양성 - 1 Note 5: 인체상피성장요소감각수용체 2(Human Epidermal Growth Factor Receptor 2, HER2) 결과는세번째자리에코딩한다 : 음성 - 0, 양성 - 1 Note 6: 세가지검사중하나또는그이상의결과값을모르거나이용할수없거나세가지검사중하나또는그이상이시행되지않았다면코드를 를준다. - 29 -
000 ER Negative, PR Negative, HER2 Negative (Triple Negative) 001 ER Negative, PR Negative, HER2 Positive 010 ER Negative, PR Positive, HER2 Negative 011 ER Negative, PR Positive, HER2 Positive 100 ER Positive, PR Negative, HER2 Negative 101 ER Positive, PR Negative, HER2 Positive 110 ER Positive, PR Positive, HER2 Negative 111 ER Positive, PR Positive, HER2 Positive (If this information is required by your standard setter, use of code may result in an edit error.) One or more tests not performed One or more tests unknown if performed One or more tests with unknown or borderline results CS Site-Specific Factor 17 Circulating Tumor Cells (CTC) and Method of Detection (Revised: 11/12/2010) Note 1: 순환종양세포 (Circulating tumor cells, CTCs) 는유방에서떨어져있는혈액에서발견된단일종양세포 (isolated tumor cells, ITCs) 를말한다. Note 2: 면역자성분리 (Immunomagnetic separation, IMS) 와역전사중합효소연쇄반응 (reverse transcription polymerase chain reaction, RT-PCR) 은조직내종양세포의매우작은양을감별하는과정의두가지요소이다. 면역자성분리 (Immunomagnetic separation, IMS) 과정에서, 항체로둘러싸인상자성입자는자기장을거침으로써모으고제거하는종양세포내항원을묶는다. 그때, 역전사중합효소연쇄반응 (reverse transcription polymerase chain reaction, RT-PCR) 은탐지가능한수준으로유전자물질을증폭시키는데사용된다. Note 3: 의무기록상표현된검사유형결과를코딩한다. 과다표출된검사유형이여러개이면 " 면역자성분리 (Immunomagnetic separation, IMS)" 를우선으로한다. 010 Positive, Reverse Transcription Polymerase Chain Reaction (RT-PCR) test 020 Positive, immunomagnetic separation (IMS) test 030 Positive, other test type - 30 -
040 Positive, unknown test type 110 Negative/normal, RT-PCR test 120 Negative/normal, IMS test 130 Negative/normal, other test type 140 Negative/normal, unknown test type 210 Borderline; equivocal; indeterminate; undetermined if positive or negative, RT-PCR test 220 Borderline; equivocal; indeterminate; undetermined if positive or negative, IMS test 230 240 Borderline; equivocal; indeterminate; undetermined if positive or negative, other test type Borderline equivocal; indeterminate; undetermined if positive or negative, unknown test type (If this information is required by your standard setter, use of code may result in an edit error.) 997 Test ordered, results not in chart 998 Test not done (test not ordered and not performed) CS Site-Specific Factor 18 Disseminated Tumor Cells (DTC) and Method of Detection (Revised: 11/12/2010) Note 1: 파종종양세포 (Disseminated tumor cells, DTCs) 는골수, 주변조직이나기관이아닌곳에서발견된단일종양세포 (isolated tumor cells, ITCs, 0.2 mm 보다작거나같은미소전이 ) 를말한다. Note 2: 사이토케라틴 (cytokeratin) 착색, 역전사중합효소연쇄반응 (reverse transcription polymerase chain reaction, RT-PCR) 과함께하는면역조직화학 (Immunohistochemistry, IHC) 은조직내매우작은양의종양세포를확인하는검사방법이다. 역전사중합효소연쇄반응 (reverse transcription polymerase chain reaction, RT-PCR) 은탐지가능한수준의종양유전자를조사함으로써유전자물질을증폭시킨다. Note 3: 모든양성반응이나온검사는음성또는경계값결과가나온검사보다우선시된다. 알려진검사정보는다른검사들의알지못하는정보보다우선시된다. 010 Positive, Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) test - 31 -
020 Positive, immunohistochemistry (IHC) test 025 Positive on RT-PCR and IHC 030 Positive, other test type 040 Positive, unknown test type 110 Negative/normal, RT-PCR test 120 Negative/normal IHC test 130 Negative/normal, other test type 140 Negative/normal, unknown test type 210 Borderline; equivocal; indeterminate; undetermined if positive or negative, RT-PCR test 220 Borderline; equivocal; indeterminate; undetermined if positive or negative, test IHC 230 240 Borderline; equivocal; indeterminate; undetermined if positive or negative, other test type Borderline; equivocal; indeterminate; undetermined if positive or negative, unknown test type (If this information is required by your standard setter, use of code may result in an edit error.) 997 Test ordered, results not in chart 998 Test not done (test not ordered and not performed) CS Site-Specific Factor 19 Assessment of Positive Ipsilateral Axillary Lymph Nodes (Revised: 11/12/2010) Note: SSF 3( 같은쪽 level I-II 액와림프절양성개수 ) 에코딩된양성액와림프절 (axillary lymph nodes) 과 intramammary 림프절개수를평가한방법을코딩한다. level III 액와림프절 (axillary lymph nodes) 또는 internal mammary 림프절의평가방법을코딩하지않는다. 000 No ipsilateral axillary lymph nodes positive 010 Positive nodes on clinical assessment only - 32 -
020 Positive fine needle aspiration (FNA) only 030 Positive core biopsy, incisional 040 Positive core biopsy, excisional 050 Positive core biopsy, type not specified 100 110 120 Positive sentinel lymph node biopsy(ies) AND no lymph node dissection Positive sentinel lymph node biopsy(ies) AND negative lymph node dissection Positive sentinel lymph node biopsy(ies) AND positive lymph node dissection 130 Negative sentinel node biopsy(ies) AND positive lymph node dissection 140 No sentinel node biopsy AND positive lymph node dissection 150 Nodes positive, but method of assessment unknown (If this information is required by your standard setter, use of code may result in an edit error.) CS Site-Specific Factor 20 Assessment of Positive Distant Metastases (Revised: 11/12/2010) Note 1: CS Mets at DX, CS Mets at DX - Bone, CS Mets at DX - Brain, CS Mets at DX - Liver, CS Mets at DX - Lung 에서전이의존재를결정하는평가방법을코딩한다. CS Mets at DX 코드가 00( 양성전이없음 ) 이라면이항목은반드시 000 으로코딩되어야한다. Note 2: 양성전이를평가하는방법이여러가지라면적용가능한가장높은코드를사용한다. CSv2 General Rules Part I - 검사유형을참고한다. 000 No positive metastases identified 010 Physical examination or laboratory tests only 020 Radiography,imaging: Ultrasound (US) Computed tomography scan (CT) Magnetic resonance imaging (MRI) - 33 -
Positron emission tomography scan (PET) 030 Incisional biopsy; fine needle aspiration (FNA) 040 Excisional biopsy or resection with microscopic confirmation (If this information is required by your standard setter, use of code may result in an edit error.) CS Site-Specific Factor 21 Response to Neoadjuvant Therapy (Revised: 11/12/2010) Note: 수술전치료반응에대한의사의기술을의무기록에서검토한다. 병리보고서에서잔여종양기술과같이의무기록상다른서류들을바탕으로해석하거나추론하지않는다. 수술전치료에대한정보가없다면코드 를준다. 010 Complete response (CR) 020 Partial response (PR) 030 No response (NR) 987 Not applicable: Neoadjuvant therapy not given (If this information is required by your standard setter, use of code may result in an edit error.) CS Site-Specific Factor 22 Multigene Signature Method (Revised: 11/12/2010) Note 1: 다유전자용법 (Multigene signatures) 또는분류기 (classifiers) 는종양조직으로부터유전자판의순도분석을한다. 이것은화학치료의반응성의양적평가, 예후나원격재발을평가하는데이용한다. Oncotype DX와 MammaPrint(MammoPrint 라고도함 ) 는유전자검사에통상적으로사용된다. Note 2: 시행한검사유형을코딩한다. SSF 22 와 SSF 23 항목에같은검사정보를이용한다. Note 3: 이정보는예후에사용되지않고의사의추적검사에사용될수있다. 010 Oncotype DX 020 MammaPrint (MammoPrint) - 34 -
030 Other 040 Test performed, type of test unknown (If this information is required by your standard setter, use of code may result in an edit error.) 998 Test not done (test not ordered and was performed) CS Site-Specific Factor 23 Multigene Signature Results (Revised: 11/12/2010) Note 1: Oncotype DX 검사결과는 0-100 사이의재발점수비율로 low, intermediate, high 분류의위험도와같이표현된다. Note 2: MammaPrint 검사결과는원격재발의 low risk 와 high risk 로표현된다. Note 3: SSF 22 에기록된다유전자용법검사결과또는점수를코딩한다. Oncotype DX 검사에서위험도보다는비율점수를우선적으로코딩한다. MammaPrint 검사는위험도평가를코딩한다. Note 4: 이정보는예후에사용되지않고의사의추적검사에사용될수있다. 001-100 Score of 000-100 (Actual score with leading zeroes to nearest whole percentage) 200 Low risk of recurrence (good prognosis) 300 Intermediate risk of recurrence 400 High risk of recurrence (poor prognosis) (If this information is required by your standard setter, use of code may result in an edit error.) 997 Test ordered, results not in chart 998 Test not done (test not ordered and not performed) - 35 -
CS Site-Specific Factor 24 Paget Disease (Revised: 11/12/2010) Note 1: 임상적이든병리적이든 Paget disease에대한언급은기록하지만병리학적평가가우선이다. 병리보고서의육안적또는해부학적소견으로부터정보를얻을수있다. 두검사가음성이면 Paget disease 가없다고해석한다. Note 2: 병리기록지에유두 (nipple) 의파제트병모양침범 (pagetoid involvement) 이라고기술되어있다면코드 020을주지만유관 (ducts) 또는소엽 (lobules) 의파제트병모양침범 (pagetoid involvement) 이라고기술되어있다면코드 020을주지않는다. Note 3: 유두검사가임상적이든병리학적이든의무기록상에서이용할만한정보가없었다면코드 (Unknown) 를준다. 000 Paget disease absent 010 Paget disease present 020 Stated as pagetoid involvement of nipple (If this information is required by your standard setter, use of code may result in an edit error.) - 36 -