VI.2.2 Scope of Regional Lymph Node Surgery

This field is used to record surgeries performed on regional lymph nodes. Refer to the AJCC Staging Manual for nodes identified as regional by the AJCC. Record the removal of distant lymph node(s) in Surgical Procedure of Other Site.

Coding Instructions:

Effective January 1, 2012 and forward the following instructions apply:

Record the farthest regional lymph node removed regardless of involvement with disease.

There is no minimum number of nodes that must be removed.

If a regional lymph node was aspirated or biopsied, code regional lymph node(s) removed, NOS (1).For counting regional lymph nodes for a core needle biopsy or aspiration followed by a dissection, see Section Special Rules for Counting Lymph Nodes.

The following instructions should be applied to all surgically treated cases for all types of cancers. The treatment of breast and skin cancer is where the distinction between sentinel lymph node biopsies (SLNBx) and more extensive dissection of regional lymph nodes is most frequently encountered. For all sites, non-sentinel regional node dissections are typical, and codes 2, 6, and 7 are infrequently used.

Please reference http://www.facs.org/cancer/coc/fordsmanual.html for additional background on the origin and scope of the issue.

Codes:

Code

Label

General Instruction Applying to All Sites

Additional Notes Specific to Breast (C50.x)

Use the operative report as the primary source document to determine whether the operative procedure was a sentinel lymph node biopsy (SLNBx), or a more extensive dissection of regional lymph nodes, or a combination of both SLNBx and regional lymph node dissection. The operative report will designate the surgeon's planned procedure as well as a description of the procedure that was actually performed. The pathology report may be used to complement the information appearing in the operative report, but the operative report takes precedence when attempting to distinguish between SLNBx and regional lymph node dissection or a combination of these two procedures. Do not use the number of lymph nodes removed and pathologically examined as the sole means of distinguishing between a SLNBx and a regional lymph node dissection.

Use the operative report as the primary source document to determine whether the operative procedure was a sentinel lymph node biopsy (SLNBx), an axillary node dissection (ALND), or a combination of both SLNBx and ALND. The operative report will designate the surgeon's planned procedure as well as a description of the procedure that was actually performed. The pathology report may be used to complement the information appearing in the operative report, but the operative report takes precedence when attempting to distinguish between SLNBx and ALND, or a combination of these two procedures. Do not use the number of lymph nodes removed and pathologically examined as the sole means of distinguishing between a SLNBx and a ALND.

No regional lymph node surgery

No regional lymph node surgery.

Biopsy or aspiration of regional lymph node(s)

Review the operative report of to confirm whether an excisional biopsy or aspiration of regional lymph nodes was actually performed. If additional procedures were performed on the lymph nodes, use the appropriate code 2-7.

Excisional biopsy or aspiration of regional lymph nodes for breast cancer is uncommon. Review the operative report of to confirm whether an excisional biopsy or aspiration of regional lymph nodes was actually performed; it is highly possible that the procedure is a SLNBx (code 2) instead. If additional procedures were performed on the lymph nodes, such as axillary lymph node dissection, use the appropriate code 2-7.

Sentinel Lymph Node Biopsy

The operative report states that a SLNBx was performed.
Code 2 SLNBx when the operative report describes a procedure using injection of a dye, radio label, or combination to identify a lymph node (possibly more than one) for removal/examination.
When a SLNBx is performed, additional non-sentinel nodes can be taken during the same operative procedure. These additional non-sentinel nodes may be discovered by the pathologist or selectively removed (or harvested) as part of the SLNBx procedure by the surgeon. Code this as a SLNBx (code 2). If review of the operative report confirms that a regional lymph node dissection followed the SLNBx, code these cases as 6.

If a relatively large number of lymph nodes, more than 5, are pathologically examined, review the operative report to confirm the procedure was limited to a SLNBx and did not include an axillary lymph node dissection (ALND).
Infrequently, a SLNBx is attempted and the patient fails to map (i.e. no sentinel lymph nodes are identified by the dye and/or radio label injection) and no sentinel nodes are removed. Review the operative report to confirm that an axillary incision was made and a node exploration was conducted. Patients undergoing SLNBx who fail to map will often undergo ALND. Code these cases as 2 if no ALND was performed, or 6 when ALND was performed during the same operative event. Enter the appropriate number of nodes examined and positive in the data items Regional Lymph Nodes Examined (NAACCR Item #830) and Regional Lymph Nodes Positive (NAACCR Item #820).

Number of regional lymph nodes removed unknown or not stated; regional lymph nodes removed, NOS

The operative report states that a regional lymph node dissection was performed (a SLNBx was not done during this procedure or in a prior procedure).
Code 3 (Number of regional lymph nodes removed unknown, not stated; regional lymph nodes removed, NOS). Check the operative report to ensure this procedure is not a SLNBx only (code 2), or a SLNBx with a regional lymph node dissection (code 6 or 7).
Code 4 (1-3 regional lymph nodes removed) should be used infrequently. Review the operative report to ensure the procedure was not a SLNBx only.
Code 5 (4 or more regional lymph nodes removed). If a relatively small number of nodes were examined pathologically, review the operative report to confirm the procedure was not a SLNBx only (code 2). If a relatively large number of nodes were examined pathologically, review the operative report to confirm that there was not a SLNBx in addition to a more extensive regional lymph node dissection during the same, or separate, procedure (code 6 or 7).
Infrequently, a SLNBx is attempted and the patient fails to map (i.e. no sentinel lymph nodes are identified by the dye and/or radio label injection). When mapping fails, surgeons usually perform a more extensive dissection of regional lymph nodes. Code these cases as 2 if no further dissection of regional lymph nodes was undertaken, or 6 when regional lymph nodes were dissected during the same operative event.

Generally, ALND removes at least 7-9 nodes. However, it is possible for these procedures to remove or harvest fewer nodes. Review the operative report to confirm that there was not a SLNBx in addition to a more extensive regional lymph node dissection during the same procedure (code 6 or 7).

1-3 regional lymph nodes removed

4 or more regional lymph nodes removed

Sentinel node biopsy and code 3, 4, or 5 at same time, or timing not stated

SLNBx and regional lymph node dissection (code 3, 4, or 5) during the same surgical event, or timing not known
Generally, SLNBx followed by a regional lymph node completion will yield a relatively large number of nodes. However it is possible for these procedures to harvest only a few nodes.
If relatively few nodes are pathologically examined, review the operative report to confirm whether the procedure was limited to a SLNBx only.
Infrequently, a SLNBx is attempted and the patient fails to map (i.e. no sentinel lymph nodes are identified by the dye and/or radio label injection.) When mapping fails, the surgeon usually performs a more extensive dissection of regional lymph nodes. Code these cases as 6.

Generally, SLNBx followed by ALND will yield a minimum of 7-9 nodes. However it is possible for these procedures to harvest fewer (or more) nodes.
If relatively few nodes are pathologically examined, review the operative report to confirm whether the procedure was limited to a SLNBx, or whether a SLNBx plus an ALND was performed.

Sentinel node biopsy and code 3, 4, or 5 at different times

SLNBx and regional lymph node dissection (code 3, 4, or 5) in separate surgical events.
Generally, SLNBx followed by regional lymph node completion will yield a relatively large number of nodes. However, it is possible for these procedures to harvest only a few nodes.
If relatively few nodes are pathologically examined, review the operative report to confirm whether the procedure was limited to a SLNBx only.

Generally, SLNBx followed by ALND will yield a minimum of 7-9 nodes. However, it is possible for these procedures to harvest fewer (or more) nodes.
If relatively few nodes are pathologically examined, review the operative report to confirm whether the procedure was limited to a SLNBx only, or whether a SLNBx plus an ALND was performed.

Unknown or not applicable

The status of regional lymph node evaluation should be known for surgically-treated cases (i.e., cases coded 19-90 in the data item Surgery of Primary Site [NAACCR Item #1290]). Review surgically treated cases coded 9 in Scope of Regional Lymph Node Surgery to confirm the code.

Starting with cases diagnosed January 1, 2003 forward, RX Summ, Scope of Reg LN Surg is not to be coded according to site. It is coded using a single scheme for all sites. The three procedure fields must continue to be coded for 2003 forward cases.

The codes for Scope of Regional LN's are as follows:

Code

Description

NONE

No regional lymph node surgery. No lymph nodes found in the pathologic specimen.

Diagnosed at autopsy.

BIOPSY OR ASPIRATION OF REGIONAL LYMPH NODE, NOS

Biopsy or aspiration of regional lymph node(s) regardless of the extent of involvement of disease.

SENTINEL LYMPH NODE BIOPSY

Biopsy of the first lymph node or nodes that drain a defined area of tissue within the body. Sentinel node(s) are identified by the injection of a dye or radio label at the site of the primary tumor.

NUMBER OF REGIONAL NODES REMOVED UNKNOWN OR NOT STATED; REGIONAL LYMPH NODE REMOVED, NOS

Sampling or dissection of regional lymph node(s) and the number of nodes is unknown or not stated. The procedure is not specified as sentinel node biopsy.

1-3 REGIONAL LYMPH NODES REMOVED

Sampling or dissection of regional lymph node(s) with fewer than four lymph nodes found in the specimen. The procedure is not specified as sentinel node biopsy.

4 OR MORE REGIONAL LYMPH NODES REMOVED

Sampling or dissection of regional lymph nodes with at least four lymph nodes found in the specimen. The procedure is not specified as sentinel node biopsy.

SENTINEL NODE BIOPSY AND CODE 3, 4, OR 5 AT SAME TIME, OR TIMING OUT NOT STATED

Code 2 was performed in a single surgical event with code 3, 4, or 5. Or, code 2 and 3, 4, or 5 was performed, but timing was not stated in patient record.

SENTINEL NODE BIOPSY AND CODE 3, 4, OR 5 AT DIFFERENT TIMES

Code 2 was followed in a subsequent surgical event by procedures coded as 3, 4, or 5.

UNKNOWN OR NOT APPLICABLE

It is unknown whether regional lymph node surgery was performed; death certificate-only; for lymphomas with a lymph node primary site; an unknown or ill-defined primary; primaries of the brain, meninges, spinal cord, cranial nerves and other part of the CNS (including the pituitary gland, craniopharyngeal duct, and pineal gland) , or for leukemia/lymphoma histologies, hematopoietic, reticuloendothelial, immunoproliferative, or myeloproliferative disease.

Code	Description
0	NONE No regional lymph node surgery. No lymph nodes found in the pathologic specimen. Diagnosed at autopsy.
1	BIOPSY OR ASPIRATION OF REGIONAL LYMPH NODE, NOS Biopsy or aspiration of regional lymph node(s) regardless of the extent of involvement of disease.
2	SENTINEL LYMPH NODE BIOPSY Biopsy of the first lymph node or nodes that drain a defined area of tissue within the body. Sentinel node(s) are identified by the injection of a dye or radio label at the site of the primary tumor.
3	NUMBER OF REGIONAL NODES REMOVED UNKNOWN OR NOT STATED; REGIONAL LYMPH NODE REMOVED, NOS Sampling or dissection of regional lymph node(s) and the number of nodes is unknown or not stated. The procedure is not specified as sentinel node biopsy.
4	1-3 REGIONAL LYMPH NODES REMOVED Sampling or dissection of regional lymph node(s) with fewer than four lymph nodes found in the specimen. The procedure is not specified as sentinel node biopsy.
5	4 OR MORE REGIONAL LYMPH NODES REMOVED Sampling or dissection of regional lymph nodes with at least four lymph nodes found in the specimen. The procedure is not specified as sentinel node biopsy.
6	SENTINEL NODE BIOPSY AND CODE 3, 4, OR 5 AT SAME TIME, OR TIMING OUT NOT STATED Code 2 was performed in a single surgical event with code 3, 4, or 5. Or, code 2 and 3, 4, or 5 was performed, but timing was not stated in patient record.
7	SENTINEL NODE BIOPSY AND CODE 3, 4, OR 5 AT DIFFERENT TIMES Code 2 was followed in a subsequent surgical event by procedures coded as 3, 4, or 5.
9	UNKNOWN OR NOT APPLICABLE It is unknown whether regional lymph node surgery was performed; death certificate-only; for lymphomas with a lymph node primary site; an unknown or ill-defined primary; primaries of the brain, meninges, spinal cord, cranial nerves and other part of the CNS (including the pituitary gland, craniopharyngeal duct, and pineal gland) , or for leukemia/lymphoma histologies, hematopoietic, reticuloendothelial, immunoproliferative, or myeloproliferative disease.