Below are just a few examples of common scenarios of when a physical exam is enough to assign a cN0 and sometimes when it is not. Be sure to document in your text the justification needed to substantiate your coding. Make your text count- Cover Your Abstracting!
| Field | Example of text-to substantiate coding | Can cN0 be assigned for this field/scenario? | Rationale |
| Clinical Category N -for Glottis Larynx) cN0 | Physical Exam Text: Oral cavity/oropharynx: Full oral exam, no palpable tonsillar masses Neck: There is no asymmetry or masses. Lymphatics: There is no palpable lymphadenopathy along the jugulodiagastric, submental, or posterior cervical chains. *No scans available during clinical timeframe | Yes- The regional lymph nodes for this primary site are accessible, per AJCC Chapter 1 cN0 may be assigned based solely on physical exam. *Be sure to document the physical exam of the neck positive or negative findings. | AJCC 8th Edition Chapter 1 Page 15 “Clinical regional lymph node assessment may be performed by physical examination and imaging. Clinical nodal category cN0 may be assigned based solely on physical examination. Imaging to assess regional lymph nodes is not required to assign clinical stage. “ |
| Path Category N-In Situ Breast Primary- no nodes removed. cN0 | Physical Exam: PE: Breasts-no palpable mass, no axillary adenopathy Pathology Text: 02/01/2023 @Hospital XYZ Lumpectomy: RUOQ DCIS, Intermediate grade. 4.0 cm, margins negative, no nodes examined | Yes-per AJCC 8th Edition Breast Chapter-Lumpectomy meets requirement for pathological stage and per Chapter 1 Stage 0 does not require node evaluation for pathological classification. | AJCC 8th Edition Chapter 1 Page 26In situ neoplasia, Stage 0 does not require node evaluation for pathological classification… The primary tumor surgical resection criteria for pathological stage must be met in order to assign pathological Stage 0. Lymph node microscopic assessment is not necessary to assign pathological Stage 0 for in situ neoplasia; for example, pTis cN0 cM0 is staged as pathological Stage 0. AJCC Critical Clarifications In situ neoplasia document https://www.facs.org/quality-programs/cancer-programs/american-joint-committee-on-cancer/staging-education/registrar/ “Lymph node microscopic assessment is not necessary to assign pathological Stage 0 for in situ neoplasia; for example, pTis cN0 cM0 is staged as pathological Stage 0.” |
| Clinical Category N for biopsy proven Corpus Uteri-Endometrial Adenocarcinoma primary-no scans cN0 | Physical Exam: External- Inspection normal including urethra, urethral meatus, hair distribution. On palpation no masses noted, non-tender. Speculum Exam- Vaginal mucosa is pale pink and healthy in appearance without rugae, brown discharge, cervix without lesions Bimanual- Bladder non tender, cervix smooth, no CMT, uterus is normal size and mid position, adnexa without masses or tenderness. Lymph- No enlarged groin nodes *No scans available in the clinical timeframe | NO. The regional nodes for the Corpus Uteri are not palpable on physical exam, so you must have imaging to access. to assign a clinical N category. This case will be assigned a: *cNX if you are absolutely certain no imaging was performed during the clinical timeframe *cN BLANK if you are uncertain if imaging was performed | AJCC 8th Edition Corpus Uteri-Carcinoma and Carcinosarcoma Chapter Rules for Clinical Classification refer to the section on Imaging CAnswer Forum Post https://cancerbulletin.facs.org/forums/forum/ajcc-tnm-staging-8th-edition/female-reproductive-organs-chapters-49-56/corpus-uteri-carcinoma-and-carcinosarcoma-chapter-53/95483-endometrial-staging-with-limited-information |
| Path Category N Endometrial Adenocarcinoma-surgically resected No Nodes Removed cN0 | Physical Exam: External- Inspection normal including urethra, urethral meatus, hair distribution. On palpation no masses noted, non-tender. Speculum Exam- Vaginal mucosa is pale pink and healthy in appearance without rugae, brown discharge, cervix without lesions Bimanual- Bladder non tender, cervix smooth, no CMT, uterus is normal size and mid position, adnexa without masses or tenderness. Lymph- No enlarged groin nodes Path Text: 2-1-2023@Hospital XYZ TAH/BSO: Endometrium, Endometrioid carcinoma, NOS, FIGO grade 1, Myometrial Invasion: Not identified. Adenomyosis: Present, uninvolved by carcinoma. Uterine Serosa involvement: Not identified. Lower Uterine Segment Involvement: Not identified. Cervical Stromal Involvement: Not identified. Other Tissue / Organ Involvement: Not identified. Lymphovascular Invasion: Not identified. Margins Negative. No lymph nodes submitted or found. Primary Tumor (pT): pT1a Xray/Scan Text: 2-12-2022 CT Ab/Pelvis Indication: uterine/cervical cancer, staging. Impression: Post-surgical changes. Pelvis: no adenopathy noted | Yes. The TAH/BSO meets the requirement for pathological stage. A physical exam is not enough to assign a cN0, however a CT was done after surgery to complete the pathologic staging and that supports no pelvic lymph node mets. Although no nodes were examined pathologically, there are those rare instances for some sites whose nodes are pathologically examined can be designated as cN0. Be sure to refer to the AJCC Critical Clarifications-Node Status Not Required for more information. | AJCC Critical Clarifications for Registrars Node Status Not Required in Rare Circumstances document [TIP PRINT THIS and put in your AJCC Manual] https://www.facs.org/quality-programs/cancer/ajcc/staging-education/registrar AJCC 8th Edition Chapter 1 page 18 under Criteria for assigning pathological stage “Imaging studies used in assigning pathological stage: Imaging studies performed after surgery are included in the pathological staging if they are within the time frame or staging window.” CAnswer Forum Posts http://cancerbulletin.facs.org/forums/forum/ajcc-tnm-staging-8th-edition/female-reproductive-organs-chapters-49-56/corpus-uteri-carcinoma-and-carcinosarcoma-chapter-53/113723-timing-and-cn0-for-path-stage-endometrial-cancer |
AJCC Cancer Registrar Education:
- Critical Clarifications
- AJCC Curriculum for Registrars
- Webinars
- Principles of Cancer Staging
Text Resources:
- Abbreviations: Use NACCR Recommended Abbreviations for Abstractors (Appendix G) http://datadictionary.naaccr.org/?c=17
- NCRA Informational Abstracts (These site-specific abstracts provide an outline to follow when determining what text to include.) http://www.cancerregistryeducation.org/rr
- AJCC Cancer Staging Manual-Registry Data Collection Variables (Each Chapter in the AJCC has a list of Registry Data Collection Variables which should be documented in text if available.)
- Site-Specific Data Item (SSDI) Manual https://www.naaccr.org/
- College of American Pathology Cancer Protocol Templates https://www.cap.org/