Tumor Grade

General Grade Coding Instructions for Solid Tumors

Listed below are general guidelines for coding all four new grade data items.

1. Code the grade from the primary tumor only

a. Do NOT code grade based on metastatic tumor or recurrence. In the rare instance that tumor tissue extends contiguously to an adjacent site and tissue from the primary site is not available, code grade from the contiguous site

b. If primary site is unknown, code grade to 9

c. If a range is given for a grade (e.g., 1-2 or 2-3), code the higher grade

2. If there is more than one grade available for an individual grade data item (i.e., within the same time frame)

a. Priority goes to the recommended AJCC grade listed in the applicable AJCC system

i. If none of the specified grades are from the recommended AJCC grade system, record the highest grade per applicable alternate grade categories for that site.

b. If there is no recommended AJCC grade for a particular site, code the highest grade per the applicable grade categories for that site.

3. In situ and/or combined in situ/invasive components:

a. If a grade is given for an in-situ tumor, code it. Do NOT code grade for dysplasia such as high-grade dysplasia.

b. If there are both in situ and invasive components, code only the grade for the invasive portion even if its grade is unknown.

4. Priority for grade

a. Synoptic report (including CAP protocol)

b. Pathology report: final diagnosis

c. Physician statement

5. Systemic treatment and radiation can alter a tumor’s grade. Therefore, it is important to code clinical grade based on information prior to neoadjuvant therapy even if grade is unknown during the clinical timeframe. Grade can now be collected in grade post therapy clinical (yc) when grade is available after neoadjuvant therapy and prior to surgical resection and grade post therapy pathological (yp) cases when grade is available from post neoadjuvant surgery.

6. If a case is sent out for consult and the grade results are different than the original case, record the results from the consult

a. Example 1: Patient had biopsy done at a facility which showed a moderately differentiated tumor. Slides were sent out for consult and their review showed a well differentiated tumor.

i. Record the well differentiated grade based on the consult

General Instructions for the Time Frames for Grade

The four new grade data items reflect the points in time in the patient’s care when grade may be assessed. These are similar to the time frames used for assigning AJCC TNM staging.

3838: Grade Clinical: For the Grade Clinical data item, record the grade of a solid primary tumor before any treatment. Treatment may include surgical resection, systemic therapy, radiation therapy, or neoadjuvant therapy. All surgical procedures are not treatment, e.g., TURB and endoscopic biopsies.

1068: Grade Post Therapy Clin (yc): This data item was introduced for cases diagnosed 1/1/2021. For cases diagnosed 2018-2020, this field can be left blank.

For the Grade Post Therapy Clin (yc) data item, record the grade of a solid primary tumor that has been microscopically sampled following neoadjuvant therapy or primary systemic/radiation therapy. If AJCC staging is being assigned, the tumor must have met the neoadjuvant therapy or primary

systemic/radiation therapy requirements in the AJCC manual or according to national treatment guidelines.

This data item corresponds to the yc staging period only

3844: Grade Pathological: For the Grade Pathological data item, record the grade of a solid primary tumor that has been surgically resected and for which no neoadjuvant therapy was administered. If AJCC pathological staging is being assigned, the tumor must have met the surgical resection requirements in the AJCC manual. This may include the grade from the clinical workup, as all information from diagnosis (clinical staging) through the surgical resection is used for pathological staging.

3845: Grade Post Therapy Path (yp): For the Grade Post Therapy Path (yp) data item, record the grade of a solid primary tumor that has been resected following neoadjuvant therapy. If AJCC post therapy path staging is being assigned, the tumor must have met the surgical resection requirements for yp in the AJCC manual. Neoadjuvant therapy must meet guidelines or standards, and not have been given for variable or unconventional reasons as noted in the AJCC manual.

This may include the grade from the post-therapy clinical workup (yc), as all information from the completion of neoadjuvant therapy (post-therapy clinical (yc)) through the surgical resection is used for post-therapy grade (yp).

Grade obtained prior to neoadjuvant therapy (clinical grade obtained during the initial workup) cannot be used after the initiation of neoadjuvant therapy and thus cannot be used to record Grade Posttherapy Path (yp)

This data item corresponds to the yp staging period only.

HISTORICAL:  CODING INSTRUCTION FOR 2014-2017

GRADE, DIFFERENTIATION OR CELL INDICATOR

Grade, Differentiation for solid tumors (Codes 1, 2, 3, 4, 9) and Cell Indicator for Lymphoid Neoplasms (Codes 5, 6, 7, 8, 9)

Note: These instructions pertain to the data item Grade, Differentiation or Cell Indicator. These are coding instructions for cases diagnosed 1/1/2014 and forward.

Hematopoietic and Lymphoid Neoplasms

Cell Indicator (Codes 5, 6, 7, 8, 9)

Cell Indicator (Codes 5, 6, 7, 8) describes the lineage or phenotype of the cell. Codes 5, 6, 7, and 8 are used only for hematopoietic and lymphoid neoplasms. Code 9 indicates cell type not determined, not stated, or not applicable.

Coding Grade for Hematopoietic and Lymphoid Neoplasms

1.   Determine the histology based on the current Hematopoietic and Lymphoid Neoplasm Manual

https://seer.cancer.gov/tools/heme/Hematopoietic_Instructions_and_Rules.pdf

2.   Determine the Cell Indicator by applying the “Grade of Tumor Rules” within the current Hematopoietic and Lymphoid Neoplasm Manual

https://seer.cancer.gov/tools/heme/Hematopoietic_Instructions_and_Rules.pdf to code the grade.

Grade codes for hematopoietic and lymphoid neoplasms

Solid Tumors

Grade, Differentiation (Codes 1, 2, 3, 4, 9)

Pathologic examination determines the grade, or degree of differentiation, of the tumor. For these cancers, the grade is a measurement of how closely the tumor cells resemble the parent tissue (organ of origin). Well-differentiated tumor cells closely resemble the tissue from the organ of origin. Poorly differentiated and undifferentiated tumor cells are disorganized and abnormal looking; they bear little (poorly differentiated) or no (undifferentiated) resemblance to the tissue from the organ of origin. These similarities/differences may be based on pattern (architecture), cytology, nuclear (or nucleolar) features, or a combination of these elements, depending upon the grading system that is used. Some grading systems use only pattern, for example Gleason grading in prostate. Others use only a nuclear grade (usually size, amount of chromatin, degree of irregularity, and mitotic activity). Fuhrman’s grade for kidney is based only on nuclear features. Most systems use a combination of pattern and cytologic and nuclear features; for example Nottingham’s for breast combines numbers for pattern, nuclear size and shape, and mitotic activity. The information from this data item is useful for determining prognosis and treatment.

Pathologists describe the tumor grade using three systems or formats:

1. Two levels of similarity; also called a two-grade system

2. Three levels of similarity; also called a three-grade system (code according to “Coding for solid tumors.”

a. Grade I, well

b. Grade II, moderately

c. Grade III, poorly (undifferentiated carcinoma is usually separated from this system, since “poorly” bears some, albeit little, similarity to the host tissue, while “undifferentiated” has none, e.g. Undifferentiated carcinoma).

3. Four levels of similarity; also called a four-grade system. The four-grade system describes the tumor as

a. Grade I; also called well-differentiated

b. Grade II; also called moderately differentiated

c. Grade III; also called poorly differentiated

d. Grade IV; also called undifferentiated or anaplastic

Breast and prostate grades may convert differently than other sites. These exceptions are noted in “Coding for Solid Tumors”, #7-8 below.

Coding for Solid Tumors

1. Systemic treatment and radiation can alter a tumor’s grade. Therefore, it is important to code grade based on information prior to neoadjuvant therapy even if grade is unknown.

2. Code the grade from the primary tumor only.

a. Do NOT code grade based on metastatic tumor or recurrence. In the rare instance that tumor tissue extends contiguously to an adjacent site and tissue from the primary site is not available, code grade from the contiguous site.

b. If primary site is unknown, code grade to 9.

3. Code the grade shown below (6th digit) for specific histologic terms that imply a grade.

Carcinoma, undifferentiated (8020/34)

Carcinoma, anaplastic (8021/34)

Follicular adenocarcinoma, well differentiated (8331/31)

Thymic carcinoma, well differentiated (8585/31)

Sertoli-Leydig cell tumor, poorly differentiated (8631/33)

Sertoli-Leydig cell tumor, poorly differentiated with heterologous elements (8634/33)

Undifferentiated sarcoma (8805/34)

Liposarcoma, well differentiated (8851/31)

Seminoma, anaplastic (9062/34)

Malignant teratoma, undifferentiated (9082/34)

Malignant teratoma, intermediate type (9083/32)

Intraosseous osteosarcoma, well differentiated (9187/31)

Astrocytoma, anaplastic (9401/34)

Oligodendroglioma, anaplastic (9451/34)

Retinoblastoma, differentiated (9511/31)

Retinoblastoma, undifferentiated (9512/34)

4. In situ and/or combined in situ/invasive components:

a. If a grade is given for an in situ tumor, code it. Do NOT code grade for dysplasia such as high grade dysplasia.

b. If there are both in situ and invasive components, code only the grade for the invasive portion even if its grade is unknown.

5. If there is more than one grade, code the highest grade within the applicable system. Code the highest grade even if it is only a focus. Code grade in the following priority order using the first applicable system:

a. special grade systems for the sites listed in Coding for Solid Tumors #6

b. differentiation: use Coding for Solid Tumors #7: 2-, 3-, or 4- grade system

c. nuclear grade: use Coding for Solid Tumors #7: 2-, 3-, or 4- grade system

d. If it isn’t clear whether it is a differentiation or nuclear grade and a 2-, 3-, or 4- grade system was used, code it.

e. Terminology (use Coding for Solid Tumors #8)

6. Use the information from the special grade systems first. If no special grade can be coded, continue with Coding for Solid Tumors #7-9.

Special grade systems for solid tumors

Grade information based on CS Site-specific factors for breast, prostate, heart, mediastinum, peritoneum, retroperitoneum, soft tissue, and kidney parenchyma is used to code grade. See Special Grade System Rules section below for details on how to use this information to code grade.

7. Use the Two-, Three- or Four-grade system information

a. Two-grade system

In transitional cell carcinoma for bladder, the terminology high grade TCC and low grade TCC are coded in the two-grade system.

b.   Three-grade system

c. Four-grade system: Any four-gradesystem includingEdmondson and Steiner grade for liver.

8. Terminology: use the ‘Description’ column or the ‘Grade’ column to code grade. Breast & Prostate use the same grade code with a few noted exceptions.

9. If no description fits or grade is unknown prior to neoadjuvant therapy, code as a 9 (unknown).

SPECIAL GRADE SYSTEMS RULES

Breast (site: breast excluding lymphomas; CS schema: breast)

Use Bloom Richardson (BR) or Nottingham score/grade to code grade based on CSv2 site-specific factor 7 (SSF) as stated below. If your registry does not collect this SSF, use the description in the table below to determine grade. If you collect this SSF, codes 030-130 could be automatically converted into the grade field.

BR could also be referred to as: Bloom-Richardson, 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, or Nottingham grade.

Code the tumor grade using the following priority order

a. BR scores 3-9

b. BR grade (low, intermediate, high)

BR score may be expressed as a range, 3-9. The score is based on three morphologic features: degree of tubule formation/histologic grade, mitotic activity, nuclear pleomorphism/nuclear grade of tumor cells. If a report uses words such as low, intermediate, or high rather than numbers, use the table below to code grade.

If only a grade of 1 through 4 is given with no information on the score and it is unclear if it is a Nottingham or BR Grade, do not use the table below. Continue with the next priority according to “Coding for Solid Tumors” #7 above.

Code the highest score if multiple scores are reported (exclude scores from tests after neoadjuvant therapy began). Examples: different scores may be reported on multiple pathology reports for the same primary cancer; different scores may be reported for multiple tumors assigned to the same primary cancer.

CS Site-Specific Factor 7

Nottingham or Bloom-Richardson (BR) Score/Grade

Kidney Parenchyma (Site: kidney parenchyma excluding lymphomas; CS schema: KidneyParenchyma): Fuhrman Nuclear Grade

The Fuhrman Nuclear Grade should be used to code grade for kidney parenchyma only based on CSv2 SSF 6 as stated below. Do not use for kidney renal pelvis. If your registry does not collect this SSF, use the description in the table to determine grade. If you collect this SSF, the information could be automatically converted into the grade field if it is coded 010-040. Fuhrman nuclear grade is a four-grade system based on nuclear diameter and shape, the prominence of nucleoli, and the presence of chromatin clumping in the highest grade.

SoftTissue (sites excluding lymphomas: soft tissue, heart, mediastinum, peritoneum, and retroperitoneum; for CS users: SoftTissue, HeartMediastinum, Peritoneum, Retroperitoneum schemas): Grade for Sarcomas

The Grade for Sarcomas should be used to code grade based on CSv2 SSF 1 as stated below. If your registry does not collect this SSF, use the description in the table to determine grade. If you collect this SSF, the information could be automatically converted into the grade field if it is coded 010-200. The grading system of the French Federation of Cancer Centers Sarcoma Group (FNCLCC) is the preferred system.

Record the grade from any three-grade sarcoma grading system the pathologist uses. For terms such as "well differentiated" or "poorly differentiated," go to Coding for Solid Tumors #8.

In some cases, especially for needle biopsies, grade may be specified only as "low grade" or "high grade." The numeric grade takes precedence over “low grade” or “high grade.”

Prostate (site: prostate excluding lymphomas; CS schema: prostate)

Use the highest Gleason score from the biopsy/TURP or prostatectomy/autopsy.  Use a known value

over an unknown value. Exclude results from tests performed after neoadjuvant therapy began. This information is collected in CSv2 SSF 8 (Gleason score from biopsy/TURP) and SSF 10 (Gleason score from prostatectomy/autopsy) as stated below. Use the table below to determine grade even if your registry does not collect these SSFs.  If you collect these SSFs, the information could be converted into the grade field automatically.

Usually prostate cancers are graded using Gleason score or pattern.  Gleason grading for prostate primaries is based on a 5-component system (5 histologic patterns). Prostatic cancer generally shows two main histologic patterns.  The primary pattern, the pattern occupying greater than 50% of the cancer, is usually indicated by the first number of the Gleason grade, and the secondary pattern is usually indicated by the second number. These two numbers are added together to create a pattern score, ranging from 2 to 10.  If there are two numbers, assume that they refer to two patterns (the first number being the primary pattern and the second number the secondary pattern), and sum them to obtain the score.     If only one number is given on a particular test and it is less than or equal to 5 and not specified as a score, do not use the information because it could refer to either a score or a grade. If only one number is given and it is greater than 5, assume that it is a score and use it. If the pathology report specifies a specific number out of a total of 10, the first number given is the score. Example: The pathology report says Gleason 3/10. The Gleason score would be 3.

Historic Perspective

Historical perspective on long term trends in prostate grade: The relationship of Gleason score to grade changed for 1/1/2014+ diagnoses in order to have the grade field in sync with AJCC 7th ed. Analysis of prostate grade before 2014 based solely on the grade field is not recommended. In Collaborative Stage (CS), Gleason score was originally coded in CSv1 in one field (SSF 6) and then it was split into two fields in CSv2 based on the tissue used for the test: needle biopsy/TURP (SSF 8) and prostatectomy/autopsy (SSF 10). For trends using data back to 2004, if one collected the various CS Gleason scores, one could design a recode to have the same criteria as the data collected 2014+. The original grade field would NOT be changed, but for analyses this recode could be based on the CS SSFs and the original grade code.

For tumor grade for cases before 2014 go to Appendix N - Pre-2014 Grade Coding Instructions.