Scenario:
3/25/2022 Presented to ER w/ scrotal pain swelling. A scrotal U/S identifies 0.6cm area in the left testicle suspicious for neoplasm. No CT or any other imaging done to assess regional lymph nodes prior to Orchiectomy. AFP elevated 40,000, LDH 398 [upper limit of normal 267], HCG less than 2
4/1/2022 Radical Orchiectomy: 1.0cm Germ Cell Neoplasia, pTis pNX
4/10/2022 CT: 14cm Lt retroperitoneal mass displacing the left kidney suspicious for mets adenopathy
04-11-2022 AFP elevated 40,000, HCG less than 2, no LDH done
4/15/2022 Oncologist stage: cTis cN3 cM0 S3 and is started on adjuvant chemotherapy BEP
8/10/2022 Para-aortic LND: 8 LN’s negative
Rules for Clinical Classification per AJCC 8th Edition
“Clinical examination & histologic assessment are required for clinical staging. Radiographic assessment of the chest, abdomen, and pelvis is necessary to determine the N and M Status of disease. Serum tumor markers-including AFP, hCG and LDH-should be obtained prior to orchiectomy and are s used to assign the clinical stage S category. These pretreatment markers also are needed for comparison when assigning the pathological stage S category, but levels after orchiectomy are used to complete the status of the serum tumor marks (S) for pathological staging.”
Rules for Pathologic Classification per AJCC 8th Edition
“Histologic evaluation of the radical orchiectomy specimen must be used for the pT classification….
The clinical serum markers are needed for comparison when assigning the pathological stage S category, but levels after orchiectomy are used to complete the status of the serum tumor markers (S) for pathological staging. Serum tumor markers are measured immediately after orchiectomy and, if elevated, should be measured serially after orchiectomy to determine whether normal decay curves are followed and the absolute nadir levels of the tumor markers….
The specimens from a defined node-bearing area (such as retroperitoneal lymph node dissection) must be used for the pN classification.”
| Field(s) | Value | Rationale |
| AJCC TNM Clinical Stage | cTX cNX cM0 Stage 99 | cTX, cNX, cM0 (Enter an X because the patient eligible for staging, but the physician did not assess or have the information-no biopsy or CT scans done) [Enter cM0-only requires H&P, imaging is not necessary to assign cM0 AJCC Curriculum for Registrars Module IV: Advanced Lesson 23 & 24 Diagnostic workup did not provide info needed to assess and assign T/N Category -assign an X AJCC Curriculum for Registrars Module II: Beginning Lesson 11 cM0 only requires H&P, imaging is not necessary to assign cM0, Infer status as cM0 unless known clinical M1 https://www.facs.org/quality-programs/cancer-programs/american-joint-committee-on-cancer/staging-education/registrar/curriculum/ CAnswer Forum Post https://cancerbulletin.facs.org/forums/forum/ajcc-tnm-staging-8th-edition/male-genital-organs-chapters-57-59/testis-chapter-59/128136-ctx-or-ct-blank-do-i-use-info-from-ajcc-curriculum-or-canswer-forum-posts#post128175 |
| AJCC TNM Pathologic Stage | pTis pNX cM0 Stage 99 | pTis [Orchiectomy path+Germ Cell Neoplasia] pNX [Case did meet criteria for path staging, an orchiectomy was done, however no lymph nodes were removed, thus enter pNX to indicate Surgical resection primary but no nodes examined. Cannot use the information from the Para-aortic LND because it was done AFTER the most definitive surgery & adjuvant chemotherapy] Even though the pT was in situ, cannot assign a cN0 because of the lymph node involvement on CT. See AJCC Chapter 1 page 18 Imaging studies performed after surgery are included in the pathological staging if they are within the time frame or staging window. AJCC Curriculum for Registrars Nodule IV: Advanced Lesson 24 Surgical resection primary but no nodes examined code X https://www.facs.org/quality-programs/cancer-programs/american-joint-committee-on-cancer/staging-education/registrar/curriculum/ CAnswer Forum Post https://cancerbulletin.facs.org/forums/forum/ajcc-tnm-staging-8th-edition/male-genital-organs-chapters-57-59/testis-chapter-59/127760-testis-clinical-path-staging#post127822 cM0 Oncologist States cM0 |
| AJCC TNM Post Therapy Clinical | ALL BLANK | This patient had adjuvant chemo, not neoadjuvant. Therefore, this patient will have pathological staging, not post therapy staging. The patient does not meet the criteria for Post Therapy Stage. |
| AJCC TNM Post Therapy Pathological | ALL BLANK | |
| Summary Stage | 3 | The Clinical Interpretation prior to chemotherapy was LN involvement w/ the pathology from the LND showing a complete response. SEER Stage is the summary of all findings during 1st course work-up through the end of first course treatment. SEER Summary Stage 2018 pg 11 Code 3: Regional Lymph Nodes Only: 3. If the patient receives neoadjuvant (preoperative) systemic therapy (chemotherapy, immunotherapy) or radiation therapy, code the clinical information if that is the most extensive lymph node involvement documented. If the post-neoadjuvant surgery shows more extensive lymph node involvement, code the regional nodes based on the post-neoadjuvant information. |