Note 1 Leave Grade Post Therapy Path (yp) blank when

• No neoadjuvant therapy
• Clinical or pathological case only
• Neoadjuvant therapy completed; surgical resection not done
• There is only one grade available and it cannot be determined if it is clinical, pathological, post therapy clinical or post therapy pathological

Note 2 There is a preferred grading system for this schema. If the post therapy clinical grade given uses the preferred grading system and the post therapy pathological grade does not use the preferred grading system, do not record the Grade Post Therapy Clin (yc) in the Grade Post Therapy Path (yp) field. Assign Grade Post Therapy Path (yp) using the applicable generic grade codes (A-D).

• Example Neoadjuvant therapy completed. Breast biopsy, invasive ductal carcinoma, Nottingham grade 2. Lumpectomy, invasive ductal carcinoma, nuclear grade 3
• Code Grade Post Therapy Clin (yc) 2 (G2) since Nottingham is the preferred grading system
• Code Grade Post Therapy Path (yp) as C (nuclear Grade 3), per the Coding Guidelines for Generic Grade Categories

Note 3 Assign the highest grade from the resected primary tumor assessed after the completion of neoadjuvant therapy.

Note 4 If there are multiple tumors with different grades abstracted as one primary, code the highest grade.

Note 5 Priority order for codes

• Invasive cancers codes 1-3 take priority over A-D.
• In situ cancers codes L, M, H take priority over A-D

Note 6 Scarff-Bloom-Richardson (SBR) score is used for grade. SBR is also referred to as Bloom-Richardson, Nottingham, Nottingham modification of Bloom-Richardson score, Nottingham modification, Nottingham-Tenovus grade, or Nottingham score.

Note 7 All invasive breast carcinomas should be assigned a histologic grade. The Nottingham combined histologic grade (Nottingham modification of the SBR grading system) is recommended. The grade for a tumor is determined by assessing morphologic features (tubule formation, nuclear pleomorphism, and mitotic count), assigning a value from 1 (favorable) to 3 (unfavorable) for each feature, and totaling the scores for all three categories. A combined score of 3-5 points is designated as grade 1; a combined score of 6-7 points is grade 2; a combined score of 8-9 points is grade 3.

• Do not calculate the score unless all three components are available

Note 8 Grade from nodal tissue may be used ONLY when there was never any evidence of primary tumor (T0). Grade would be coded using G1, G2, or G3, even if the grading is not strictly Nottingham, which is difficult to perform in nodal tissue. Some of the terminology may include differentiation terms without some of the morphologic features used in Nottingham (e.g., well differentiated (G1), moderately differentiated (G2), or poorly/undifferentiated (G3)).

• Example No breast tumor identified, but 2/3 axillary nodes were positive. Determined to be regional node metastasis from breast primary. Nodes were described as poorly differentiated with a high mitotic rate
• Code G3 based on the poorly differentiated (which is a high grade) although the terminology used is for nuclear grading

Note 9 Use the grade from the post therapy clinical work up from the primary tumor in different scenarios based on behavior or surgical resection

• Behavior
• Tumor behavior for the post therapy clinical and the post therapy pathological diagnoses are the same AND the post therapy clinical grade is the highest grade
• Tumor behavior for post therapy clinical diagnosis is invasive, and the tumor behavior for the post therapy pathological diagnosis is in situ
• Surgical Resection
• Surgical resection is done of the primary tumor after neoadjuvant therapy is completed and there is no grade documented from the surgical resection
• Surgical resection is done of the primary tumor after neoadjuvant therapy is completed and there is no residual cancer

Note 10 Code 9 (unknown) when

• Surgical resection is done after neoadjuvant therapy and grade from the primary site is not documented
• Surgical resection is done after neoadjuvant therapy and there is no residual cancer
• Grade checked "not applicable" on CAP Protocol (if available) and no other grade information is available

Note 11 If you are assigning an AJCC 8th edition stage group

• Grade is required to assign stage group
• Codes A-D are treated as an unknown grade when assigning AJCC stage group
• An unknown grade may result in an unknown stage group