01-23-2026
Scenario:
- Physician states patient presents with 3cm Base of Tongue HPV Associated squamous cell carcinoma Stage T2 N2
- Physical exam- Rt side neck mass that has been present for past month per pt. Mass causing some hoarseness.
- CT Neck: Matted clustered right level 2a lymphadenopathy at the site of the localized swelling and palpable abnormality
Question: How would you assign the SSDI Extranodal Extension Head and Neck Clinical?
- 0 Regional lymph node(s) involved, ENE not present/not identified during diagnostic workup
- 1 Regional lymph node(s) involved, ENE present/identified during diagnostic workup, based on physical exam and/or imaging
- 7 No lymph node involvement during diagnostic workup (cN0)
- 9 Not documented in medical record
Answer: 1 Regional lymph node(s) involved, ENE present/identified during diagnostic workup, based on physical exam and/or imaging
SSDI Manual v3.3
Note 2: Clinical assessment criteria
- The assessment of ENE must be based on evidence acquired prior to definitive surgery of the primary site, chemotherapy, radiation, or other type of treatment, i.e., the clinical timeframe for staging.
- The assessment for ENE may include imaging and/or physical examination.
- Biopsy of the regional lymph node or surrounding tissue can be used to confirm the presence of metastatic carcinoma and thus verify the clinical assessment, but cannot be used in isolation to determine ENE during clinical staging
- Fixed nodes are clinical indications of cENE
- Matted nodes are indications of iENE
- iENE is identified exclusively on imaging
- ENE during clinical staging is considered present when cENE and/or iENE are present
- Note that the rules for coding ENE for head and neck sites compared to non-head and neck sites are different
REVIEW SSDI Change Log 3.3 https://apps.naaccr.org/ssdi/list/?_gl=1*1k9sirh*_ga*MTQ2NzY5OTExLjE3NTE1NDYzNTU.*_ga_V7J8GWYK5P*czE3Njg1ODk5OTIkbzEwMyRnMSR0MTc2ODU5NDI3MyRqNjAkbDAkaDA
