VI.2.10 Diagnostic or Staging Procedures

Record surgical procedures performed solely for establishing a diagnosis and or determining stage of disease. If there is more than one surgical diagnostic or staging procedure, record the first one performed. Some of the procedures should be recorded in the Operative Findings field.

January 1, 2003 and Forward

Beginning with cases diagnosed January 1, 2003 forward, this field does not include palliative treatment/procedures. Palliative treatment/procedures are recorded in a separate field. The CCR does not require that palliative treatment/procedures be recorded but the CoC does require this field. Please consult the FORDS Manual for instructions regarding the palliative procedure field.

Surgical diagnostic or staging procedures include:

• Biopsy, incisional or NOS (if a specimen is less than or equal to 1 cm, assume the biopsy to have been incisional unless otherwise specified)

Note: If a lymph node is biopsied or removed to diagnose or stage lymphoma, and that node is NOT the only node involved with lymphoma, used code 02.  If there is only a single lymph node involved with lymphoma, use the data item Surgical Procedure of Primary Site to code these procedures.

• Dilation and curettage for invasive cervical cancer
• Dilation and curettage for invasive or in situ cancers of the corpus uteri, including choriocarcinoma
• Surgery in which tumor tissue is not removed, for example
• Bypass surgery—colostomy, esophagostomy, gastrostomy, nephrostomy, tracheostomy, urethrostomy, stent placement

Note: Removal of fluid (paracentesis or thoracentesis) even if cancer cells are present is not a surgical procedure. Do not code brushings, washings, or hematologic findings(peripheral blood smears). These are not considered surgical procedures.

• Exploratory surgery—celiotomy, cystotomy, gastrotomy, laparotomy, nephrotomy, thoracotomy

Note: If both an incisional biopsy of the primary site and an incisional biopsy of a metastatic site are done, use code 02 (Incisional biopsy of primary site).

Do Not Code

• Brushings, washings, cell aspirations and hematologic findings (peripheral smears), as they are NOT considered surgical procedures and should not be coded in the Diagnostic or Staging Procedures field. Code positive brushings, washings and cell aspirations, and hematologic findings (peripheral smears) as cytologic diagnostic confirmation in the Diagnostic Confirmation field.
• Surgical procedures which aspirate, biopsy, or remove regional lymph nodes in effort to diagnose and/or stage disease in this data item. Use the data item Scope of Regional Lymph Node Surgery to code these procedures. Do not record the date of surgical procedures which aspirate, biopsy, or remove regional lymph nodes in the data item Date of Surgical Diagnostic and Staging Procedure.
• Excisional biopsies with clear or microscopic margins in this data item. Use the data item Surgical Procedure of Primary Site to code these procedures.
• Palliative surgical procedures in this data item.

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