RX Summ--Scope Reg LN Sur [1292]

Field Length:  1

Scope of Regional Lymph Node Surgery describes the procedure of removal, biopsy, or aspiration of regional lymph nodes performed during the initial work-up or first course of therapy.

Instructions for coding sentinel lymph node biopsies (SLNBx) have been clarified for 2012 and later, diagnoses.

Additional instructions for breast primaries (C500-C509) are described below, following the general coding

Coding Instructions

1. Use the entire operative report as the primary source document to determine whether the operative procedure was a SLNBx, or a more extensive dissection of regional lymph nodes, or a combination of both SLNBx and regional lymph node dissection. The body of the operative report will designate the surgeon’s planned procedure as well as a description of the procedure that was actually performed. The pathology report may be used to complement the information appearing in the operative report, but the operative report takes precedence when attempting to distinguish between SLNBx and regional lymph node dissection or a combination of these two procedures. Do not use the number of lymph nodes removed and pathologically examined as the sole means of distinguishing between a SLNBx and a regional lymph node dissection.

2. Code regional lymph node procedures in this data item. Record distant lymph node removal in Surgical Procedure of Other Site.

a. Include lymph nodes that are regional in the current AJCC Staging Manual or EOD 2018

3. Record all surgical procedures that remove, biopsy, or aspirate regional lymph node(s) whether or not there were any surgical procedures of the primary site. The regional lymph node surgical procedure(s) may be done to diagnose cancer, stage the disease, or as a part of the initial treatment.

Example: Patient has a sentinel node biopsy of a single lymph node. Assign code 2 (Sentinel lymph node biopsy [only]).

4. Include lymph nodes obtained or biopsied during any procedure within the first course of treatment. A separate lymph node surgery is not required.

a. Code the removal of intra-organ lymph nodes in Scope of Regional Lymph Node Surgery

Example: Local excision of breast cancer. Specimen includes an intra-mammary lymph node. Assign code 4 (1 to 3 regional lymph nodes removed).

5. Add the number of all of the lymph nodes removed during each surgical procedure performed as part of the first course of treatment. The Scope of Regional Lymph Node Surgery data item is cumulative.

Example: Patient has excision of a positive cervical node. The pathology report from a subsequent node dissection identifies three cervical nodes. Assign code 5 (4 or more regional lymph nodes removed).

a. Lymph node aspirations

i. Do not double-count when a regional lymph node is aspirated and that node is in the resection field. Do not add the aspirated node to the total number.

ii. Count as an additional node when a regional lymph node is aspirated and that node is NOT in the resection field. Add it to the total number.

iii. Assume the lymph node that is aspirated is part of the lymph node chain surgically removed and do not include it in the count when its location is not known

6. Code the removal of regional nodes for both primaries when the patient has two primaries with common regional lymph nodes

Example: Patient has a cystoprostatectomy and pelvic lymph node dissection for bladder cancer. Pathology identifies prostate cancer as well as the bladder cancer and 4/21 nodes positive for metastatic adenocarcinoma. Code Scope of Regional Lymph Node Surgery to 5 (4 or more regional lymph nodes removed) for both primaries.

7. Assign the appropriate code for occult head and neck primaries with positive cervical lymph nodes (schema 00060). Do not default to code 9 for this schema.

8. Assign code 0 when

a. Regional lymph node removal procedure was not performed

Note: Excludes all sites and histologies that would be coded 9. (See Coding Instruction #13 below.)

OR

b. First course of treatment was active surveillance/watchful waiting

OR

c. The operative report lists a lymph node dissection, but no nodes were found by the pathologist

9. Assign code 2 when

a. The operative report states that a SLNBx was performed

OR

b. The operative report describes a procedure using injection of a dye, radio label, or combination to identify a lymph node (possibly more than one) for removal/examination

Note: When a SLNBx is performed, additional non-sentinel nodes can be taken during the same operative procedure. These additional non-sentinel nodes may be discovered by the pathologist or selectively removed (or harvested) as part of the SLNBx procedure by the

surgeon. Code this as a SLNBx (code 2). If review of the operative report confirms that a regional lymph node dissection followed the SLNBx, code these cases as 6.

10. Codes 3, 4, and 5: The operative report states that a regional lymph node dissection was performed (a SLNBx was not done during this procedure or in a prior procedure)

a. Code 3: Check the operative report to ensure this procedure is not a SLNBx only (code 2), or a SLNBx with a regional lymph node dissection (code 6 or 7)

b. Code 4 should be used infrequently. Review the operative report to ensure the procedure was not a SLNBx only.

c. Code 5: If a relatively small number of nodes was examined pathologically, review the operative report to confirm the procedure was not a SLNBx only (code 2). If a relatively large number of nodes was examined pathologically, review the operative report to confirm that there was not a SLNBx in addition to a more extensive regional lymph node dissection during the same, or separate, procedure (code 6 or 7).

Note: Infrequently, a SLNBx is attempted and the patient fails to map (i.e., no sentinel lymph nodes are identified by the dye and/or radio label injection). When mapping fails, surgeons usually perform a more extensive dissection of regional lymph nodes. Code these cases as 2 if no further dissection of regional lymph nodes was undertaken, or 6 when regional lymph nodes were dissected during the same operative event.

11. Code 6: SLNBx and regional lymph node dissection (code 3, 4, or 5) during the same surgical event, or timing not known

a. Generally, SLNBx followed by a regional lymph node completion will yield a relatively large number of nodes. However, it is possible for these procedures to harvest only a few nodes.

b. If relatively few nodes are pathologically examined, review the operative report to confirm whether the procedure was limited to a SLNBx only

c. Infrequently, a SLNBx is attempted and the patient fails to map (i.e., no sentinel lymph nodes are identified by the dye and/or radio label injection). When mapping fails, the surgeon usually performs a more extensive dissection of regional lymph nodes. Code these cases as 6.

12. Code 7: SLNBx and regional lymph node dissection (code 3, 4, or 5) in separate surgical events

a. Generally, SLNBx followed by regional lymph node completion will yield a relatively large number of nodes. However, it is possible for these procedures to harvest only a few nodes.

b. If relatively few nodes are pathologically examined, review the operative report to confirm whether the procedure was limited to a SLNBx only

13. Code 9: The status of regional lymph node evaluation should be known for surgically treated cases (i.e., cases coded A190-A900 or B190-B900 in the data item Surgery of Primary Site 2023 (NAACCR Item #1291). Review surgically treated cases coded as 9 in Scope of Regional Lymph Node Surgery to confirm the code.

a. Assign code 9 for

i. Any case coded to primary site: C420, C421, C423, C424, C589, C700-C709, C710-C729, C751-C753, C761-C768, C770-C779, or C809

Coding Instructions – Sentinel lymph node biopsy (SLNBx), breast primary C500-C509

1. Use the entire operative report as the primary source document to determine whether the operative procedure was a SLNBx, an axillary node dissection (ALND), or a combination of both SLNBx and ALND. The body of the operative report will designate the surgeon’s planned 

procedure as well as a description of the procedure that was actually performed. The pathology report may be used to complement the information appearing in the operative report, but the operative report takes precedence when attempting to distinguish between SLNBx and ALND, or a combination of these two procedures. Do not use the number of lymph nodes removed and pathologically examined as the sole means of distinguishing between a SLNBx and an ALND.

2. Code 1

a. Excisional biopsy or aspiration of regional lymph nodes for breast cancer is uncommon. Review the operative report to confirm whether an excisional biopsy or aspiration of regional lymph nodes was actually performed; it is highly possible that the procedure is a SLNBx (code 2) instead. If additional procedures were performed on the lymph nodes, such as axillary lymph node dissection, use the appropriate code 2-7.

3. Code 2

a. If a relatively large number of lymph nodes, more than 5, are pathologically examined, review the operative report to confirm the procedure was limited to a SLNBx and did not include an axillary lymph node dissection (ALND)

b. Infrequently, a SLNBx is attempted and the patient fails to map (i.e., no sentinel lymph nodes are identified by the dye and/or radio label injection) and no sentinel nodes are removed. Review the operative report to confirm that an axillary incision was made and a node exploration was conducted. Patients undergoing SLNBx who fail to map will often undergo ALND. Use code 2 if no ALND was performed, or 6 when ALND was performed during the same operative event. Enter the appropriate number of nodes examined and positive in the data items Regional Nodes Examined (NAACCR Item #830) and Regional Nodes Positive (NAACCR Item #820).

4. Codes 3, 4, and 5: Generally, ALND removes at least 7-9 nodes. However, it is possible for these procedures to remove or harvest fewer nodes. Review the operative report to confirm that there was not a SLNBx in addition to a more extensive regional lymph node dissection during the same procedure (code 6 or 7).

5. Code 6

a. Generally, SLNBx followed by ALND will yield a minimum of 7-9 nodes. However, it is possible for these procedures to harvest fewer (or more) nodes.

b. If relatively few nodes are pathologically examined, review the operative report to confirm whether the procedure was limited to a SLNBx, or whether a SLNBx plus an ALND was performed

6. Code 7

a. Generally, SLNBx followed by ALND will yield a minimum of 7-9 nodes. However, it is possible for these procedures to harvest fewer (or more) nodes.

b. If relatively few nodes are pathologically examined, review the operative report to confirm whether the procedure was limited to a SLNBx only, or whether a SLNBx plus an ALND was performed