02-06-2026
Scenario: Patient underwent TURP for BPH. The path report revealed an incidental finding of focal adenocarcinoma in .05% of the TURP specimen.
Question: How would you assign the Summary Stage?
- 1 Local
- 9 Unknown
Answer: 1 Local
Discussion: Although there was no documentation or imaging of the lymph node status, or distant mets, the Summary Stage manual, follow the instructions in the Summary Stage Manual- be sure to read those General Instructions!
Summary Stage 2018 Coding Manual v3.3 General Instructions page 21 -22
- 5. Although Summary Stage is based on all information, the evaluation of the following is still needed to determine the correct Summary Stage
- a. Extent of primary tumor
- i. Tumor size does not affect Summary Stage
- ii. For most schemas, the status of SSDIs does not affect Summary Stage
- iii. If there is no information on the extent of the tumor, but there is known regional lymph node involvement or distant metastasis, code based on those
- 1. Default to code 3 when the status of the primary tumor is not known, but there is regional lymph node involvement
- 2. Default to code 7 when the status of the primary tumor is not known, but there is distant metastasis
- iv. In situ tumors with nodal or metastatic involvement: In the event of an in-situ tumor with nodal or metastatic involvement, Summary Stage will be 3 (for regional lymph node involvement) or Summary Stage 7 (if mets are involved).
- Note: Behavior would be /3 for these tumors. The primary tumor is in situ; however, there is evidence of an invasive component due to the positive lymph nodes or metastatic involvement
- b. Regional lymph node status
- i. If there is no information on the status of regional lymph nodes, code based on the primary tumor or distant metastasis. The Summary Stage algorithm treats unknown lymph node status as NONE
- ii. For most schemas, the status of SSDIs does not affect Summary Stage
- 1. If there are SSDIs that evaluate the status of regional lymph nodes, those SSDIs and Summary Stage should agree
- iii. The number of regional lymph nodes does not affect Summary Stage; however, if Regional Nodes Positive = 01-90, 95, 97, this indicates that regional lymph nodes are involved. Summary Stage must be 3, 4, or 7 and cannot be 0, 1, 2 or 9
- c. Metastatic disease status
- i. If there is no information on distant metastasis, assume there are none
