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Record size in specified order:

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  1. Size measured on the surgical resection specimen, when surgery is administered as the first definitive treatment, i.e., no pre-surgical treatment administered.

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        1. If there is a discrepancy among tumor size measurements in the various sections of the pathology report, code the size from the synoptic report (also known as CAP protocol or pathology report checklist). If only a text report is available, use: final diagnosis, microscopic, or gross examination, in that order. 
        • Example: Chest x-ray shows 3.5 cm mass; the pathology report from the surgery states that the same mass is malignant and measures 2.8 cm. Record tumor size as 028 (28 mm).
        • Example: Pathology report states lung carcinoma is 2.1 cm x 3.2 cm x 1.4 cm. Record tumor size as 032 (32 mm).

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      1. If neoadjuvant therapy followed by surgery, do not record the size of the pathologic specimen. Code the largest size of tumor prior to neoadjuvant treatment; if unknown code size as 999. 
        • Example: Patient has a 2.2 cm mass in the oropharynx; find needle aspiration of mass confirms squamous cell carcinoma. Patient receives a course of neoadjuvant combination chemotherapy. Pathologic size after total resection is 2.8 cm. Record tumor size as 022 (22mm).

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      1. If no surgical resection, then largest measurement of the tumor from physical exam, imaging, or other diagnostic procedures prior to any other form of treatment.

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      1. If 1, 2, and 3 do not apply, the largest size from all information available within four months of the date of diagnosis, in the absence of disease progression.


      Code

      Description

      000

      No mass/tumor found

      001

      1 mm or described as less than 1 mm

      002-988

      Exact size in millimeters (2mm-988mm)

      989

      989 millimeters or larger

      990

      Microscopic focus or foci only and no size of focus is given

      998

      SITE-SPECIFIC CODES

      Alternate descriptions of tumor size for specific sites:

      Familial/multiple polyposis:

           Rectosigmoid and rectum (C19.9, C20.9)

           Colon (C18.0, C18.2-C18.9)

      If no size is documented:

      Circumferential:

           Esophagus (C15.0-C15.5, C15.8 C15.9)

      Diffuse; widespread: 3/4s or more; linitis plastica:

           Stomach and Esophagus GE Junction (C16.0-C16.6, C16.8-C16.9)

      Diffuse, entire lung or NOS:

           Lung and main stem bronchus (C34.0-C34.3, C34.8-C34.9)

      Diffuse:

           Breast (C50.0-C50.6, C50.8-C50.9)

      999

      Unknown; size not stated; Not documented in patient record; Size of tumor cannot be assessed; Not applicable