Tumor Size Clinical

Field length: 3

This data item records the size of a solid primary tumor before any treatment (surgical resection or initiation of any treatment including neoadjuvant)

Coding Instructions

Note: Record tumor size only in millimeters (mm). Convert to millimeters from centimeters when size of tumor is measured in centimeters. Often measurements are given in centimeters and must be converted to millimeters, such as 2 cm, which is 20 mm.

1. Code the clinical tumor size using all information (reports) available during the detection and diagnostic confirmation of the tumor. Information prior to the date of diagnosis may be used if it is part of the workup for this primary tumor.

a. The only exception is when there is progression of disease; use the measurements (size) closest to the day of diagnosis for coding clinical tumor size

Example: There is a screening mammography and a diagnosing mammography, and the size from the latter is the largest measurement. Use the value from the diagnosing mammography (the larger size).

2. Document clinical tumor size before any form of treatment, in the priority order that follows

Priority of recording clinical tumor size

a. Operative report from surgical exploration without resection

b. Imaging-guided tissue biopsy (i.e., incisional biopsy done under imaging)

i. Do not use the size from a core biopsy or needle biopsy for clinical tumor size unless you are confident that the size corresponds to the tumor rather than the size of the specimen obtained. Core biopsies and needle biopsies do not necessarily obtain enough tissue to know the actual tumor size.

Example: Prostate biopsy, pathologist states core 1: tumor involves 8 mm of core; core 2: tumor involves 3 mm of core. The sizes reported (8 mm and 3 mm) do not represent the size of the prostate tumor. Look for a tumor size on imaging or elsewhere for this case.

Note: An incisional biopsy that removed the whole tumor is actually an excisional biopsy. Record excisional biopsy tumor size in Tumor Size--Pathologic.

Example: A breast biopsy revealed a 1.3 cm ductal carcinoma. There was no residual carcinoma found in the partial mastectomy specimen. The biopsy removed the whole tumor which makes it an excisional biopsy. Code the clinical tumor size as 999 and the path tumor size as 013.

c. Diagnostic imaging

Use the largest size from available diagnostic imaging procedures in no priority order unless the physician specifies the imaging procedure that is most accurate. Examples include: MRI, ultrasound, mammography, CT, PET, x-ray.

d. Physical exam

Use in the absence of surgical exploration, imaging from incisional biopsy, and diagnostic imaging. Tumor size from an endoscopy (e.g., colonoscopy) is included under physical exam.

3. Use clinical history on a pathology report for clinical tumor size when that is the only information available to code clinical tumor size. Use text field to record the details.

4. Clinical tumor size follows the timing rules for AJCC clinical staging. For clinical tumor size, take into consideration what the physician would use to assign clinical stage. Refer to AJCC TNM guidelines to determine the sources of information that pertain to the clinical staging timeframe.

Example: TURBT for a bladder primary pertains to clinical staging. A size from a TURBT would be a clinical size.

Note 1: Do not infer the tumor size from the T category.

Note 2: For prostate clinical tumor size, size from an operative report is the highest priority. Use the size from imaging if you do not have a size from an operative report.

Note 3: When LEEP is followed by more definitive surgery for a cervical primary, code clinical tumor size based on the LEEP.

5. Code the largest size of the primary tumor before neoadjuvant treatment

Example: Patient has a 2.2 cm (22 mm) mass in the oropharynx; fine needle aspiration of mass confirms squamous cell carcinoma. Patient receives a course of neoadjuvant combination chemotherapy. Pathologic size of tumor after total resection is 2.8 cm (28 mm). Record clinical tumor size as 022 (22 mm) as that is the largest tumor size that was recorded before treatment occurred, since the pathologic resection is after the neoadjuvant therapy.

6. If no treatment is administered, use the size from all information available within four months of the date of diagnosis using the priority order, and in the absence of disease progression

7. Record the size of the invasive component of the tumor, even if it is smaller, when both an in situ and an invasive component are present and the invasive component is measured

8. Record tumor size using the largest dimension of the tumor, not the depth or thickness of the tumor.

9. Do not use endometrial ultrasound reporting endometrial stripe or thickening because this does not represent clinical tumor size

10. Record the size of the primary tumor, including contiguous tumor tissue extension, at the time of diagnosis

11. Always code the size of the primary tumor, not the size of the polyp, ulcer, cyst, or distant metastasis. However, when the tumor is described as a “cystic mass or polypoid mass,” and only the size of the entire mass is given, code the size of the entire mass, since the cysts or polyps are part of the tumor itself.

12. For breast tumors, clinical size may be recorded based on the size of a non-mass enhancement (NME). NME is defined as an enhancing abnormality that is not associated with the three-dimensional volume of a mass, shape and outlining, and it is separate from the Background Parenchymal Enhancement (BPE).

13. Multifocal/multicentric tumors: Code the size of the largest invasive tumor, or the largest in situ tumor if all tumors are in situ, when the tumor is multi-focal or when multiple tumors are reported as a single primary.

14. Code the size of the largest focus when there is microinvasion. Code 990 when there is microinvasion and no size given.

15. Record tumor size only in millimeters (mm). Convert to millimeters from centimeters when size of tumor is measured in centimeters. Often measurements are given in centimeters and must be converted to millimeters, such as 2 cm; code as 020.

16. Record the size stated when tumor size is described as “at least” a certain size. Record 003 for a tumor size of at least 3 mm.

17. Record ‘less than’ OR ‘greater than’ tumor size

a. Record the tumor size as one mm less than stated when tumor size is reported as “less than x mm” or “less than x cm”

Example: If size is < 10 mm, code size as 009.

i. Often measurements are given in centimeters and must be converted to millimeters, such as < 1 cm (< 10 mm), which is coded as 009; or < 2 cm (<20 mm), which is coded as 019

ii. Code 001 when stated as less than 1 mm

b. Record the tumor size as one mm more than stated when tumor size is reported as “more than x mm” or “more than x cm”

Example: If size is > 10 mm, code size as 011.

i. Often measurements are given in centimeters and must be converted to millimeters such as: > 1 cm (> 10 mm), code as 011; or > 2 cm (> 20 mm), code as 021

ii. Code 989 when described as anything greater than 989 mm (98.9 cm)

18. Record “between” tumor sizes as the midpoint between the two measurements when tumor size is reported to be between two sizes; i.e., add the two sizes together and divide by two

Note: The word ‘between’ must be stated to use this instruction.

Example: Tumor size is “between 2 and 3 cm.” Code size as 025 since 2 + 3 = 5 divided by 2 = 2.5 cm (25 mm).

19. Record the higher tumor size when stated as a range

Example: Tumor size is 8-10 mm or tumor size is 8 to 10 mm. Code size as 010 since 10 mm is the higher of the values in the range.

20. Avoid coding tumor size based on a description such as "Mass was present at 22 to 25 cm." Descriptions like this are found on endoscopies. Look for an actual measurement of the mass, or a stated tumor size.

21. Round decimals: Round the tumor size when it is described in fractions (decimals) of millimeters as follows

a. When tumor size is greater than 1 millimeter, round tenths of millimeters in the 1-4 range down to the nearest whole millimeter and round tenths of millimeters in the 5-9 range up to the nearest whole millimeter.

b. Do not round tumor size expressed in centimeters to the nearest whole centimeter; rather, convert the measurement to millimeters by moving the decimal point one space to the right

Note 1: Record tumor size as 001 (do not round down to 000) when the largest dimension of a tumor is less than 1 millimeter (greater than 0 mm and less than 1 mm).

Note 2: Code 001 when tumor size is 1 mm.

Exception to rounding rules for BREAST primaries: Round tumor sizes greater than 1.0 mm and up to 2.4 mm to 2 mm (002). The purpose of this exception is so that the size recorded in the Tumor Size data item will derive the correct AJCC TNM Primary Tumor (T) category for breast primaries. Do not apply this instruction to any other site.

Examples:

• • • Breast cancer described as 6.5 millimeters in size. Round up to 7 mm and code as 007.
    • Breast cancer described as 1.3 mm in size. Round up to 2 mm and code as 002.
    • 2.3 millimeters cancer in a polyp. Round down to 2 mm and code as 002.
    • Hypopharynx: Focus of cancer described as 1.4 mm in size. Round down to 1 mm and code as 001.
    • 5.2 cm breast cancer. Convert to millimeters (52 mm) and do not round; code as 052 millimeters.
    • 2.5 cm rectal cancer. Do not round, record as 025 millimeters.

22. Assign code 000 when

a. Schema is Cervical Lymph Nodes and Unknown Primary 00060

b. EOD Primary Tumor is coded 800 (No evidence of primary tumor) for any schema except for those listed in Coding Instruction 24

23. Assign tumor size for benign and borderline tumors in the schemas Brain, CNS Other, Intracranial Gland, and Medulloblastoma when provided; do not default to 999

24. Assign code 999 when size is unknown and for the following sites and schemas/schema IDs

a. Any case coded to primary site C420, C421, C423, C424, C770-C779, or C809

b. HemeRetic 00830

i. Excluding Spleen (C422)

c. Kaposi Sarcoma 00458

d. Lymphoma 00790

e. Lymphoma-CLL/SLL 00795

f. Melanoma Choroid and Ciliary Body 00672

g. Melanoma Iris 00671

h. Plasma Cell Disorders 00822

i. Plasma Cell Myeloma 00821

25. Assign code 999 for calcifications that span given distance or a cluster of microcalcifications. Do not record the size of calcifications as tumor size. If there is no measurement of the mass or tumor, record 999 for clinical tumor size.

26. Document the information in the appropriate text field of the abstract to support the clinical tumor size

Tumor size is important for staging of tumors in the following schemas. For more information about schemas and schema IDs, go to the SSDI Manual, Appendix A.

Table. Schemas for which Tumor Size Affects Staging