Grade Post Therapy Clin (yc)
Notes
**Note 1:** Leave Grade Post Therapy Clin (yc) blank when
* No neoadjuvant therapy
* Clinical or pathological case only
* Neoadjuvant therapy completed, no microscopic exam is done prior to surgery/resection of primary tumor
* There is only one grade available and it cannot be determined if it is clinical, pathological, post therapy clinical or post therapy pathological
**Note 2:** Assign the highest grade from the microscopically sampled specimen of the primary site following neoadjuvant therapy or primary systemic/radiation therapy.
**Note 3:** If there are multiple tumors with different grades abstracted as one primary, code the highest grade.
**Note 4:** There are two major grading systems used for Breast and they are based on the behavior of the primary tumor (in situ or invasive)
**Invasive tumors**
* The preferred grading system for Invasive tumors is the **Nottingham grade/Nottingham Score**, also known as the Scarff-Bloom-Richardson or Bloom Richardson
* The **Nottingham score** is a combined histologic grade in which three components are evaluated to determine the overall grade: **tubule formation, nuclear pleomorphism and mitotic count**. Each of these components is assigned a value from 1 (favorable) to 3 (unfavorable) for each feature and then totaling the scores for all three categories. A combined score of 3-5 points is designated as grade 1; a combined score for 6-7 points is grade 2; a combined score of 8-9 points is grade 3
**Note 5:** If a pathology report for an invasive cancer states, “Grade 1 (or 2, 3)” and there is no further information, assume this is the Nottingham grade and assign the appropriate code.
* If a pathology report for an invasive cancer states, “well differentiated, moderately differentiated, poorly differentiated, low, medium, high,” use grades A-D as appropriate
* ***Example***: Pathology report states invasive ductal carcinoma, well differentiated. Code grade A.
* **Do not use grades L, M, H for invasive tumors**
* *Exception*: Biopsy diagnosis is DCIS; Lumpectomy is invasive ductal carcinoma. The Clinical Grade would be L, M, H or 9 based on the DCIS; the Pathological Grade would be 1, 2, 3, or 9 based on the invasive ductal carcinoma. Behavior would be /3
**Note 6:** **In situ tumors**
* The preferred grading system for in situ tumors is based on a 3 grade Nuclear system, and is defined as Low (L) (Nuclear Grade 1), Intermediate (M) (Nuclear Grade 2), or High (H) (Nuclear Grade 3), or the nuclear component of the Nottingham grade
* Documentation for these grades may be 1/3, 2/3, 3/3. This notation is documenting the nuclear component of the Nottingham grade, not the Nottingham grade (1, 2, 3)
* If a pathologist uses a Nottingham grade (i.e., G2) for an in situ cancer, they are documenting the nuclear component of the Nottingham score. You would still assign L, M, or H as appropriate for the in situ tumor
* **Do not use grades 1, 2, 3 for in situ tumors**
**Note 7:** Grade from nodal tissue may be used **ONLY** when there was **never** any evidence of primary tumor (T0). Grade would be coded using G1, G2, or G3, even if the grading is not strictly Nottingham, which is difficult to perform in nodal tissue. Some of the terminology may include differentiation terms without some of the morphologic features used in Nottingham (e.g., well differentiated (G1), moderately differentiated (G2), or poorly/undifferentiated (G3)).
* *Example:* No breast tumor identified, but 2/3 axillary nodes were positive. Determined to be regional node metastasis from breast primary. Nodes were described as poorly differentiated with a high mitotic rate
- Code G3 based on the poorly differentiated (which is a high grade) although the terminology used is for nuclear grading
**Note 8:** Code 9 (unknown) when
* Microscopic exam is done after neoadjuvant therapy and grade from the primary site is not documented
* Microscopic exam is done after neoadjuvant therapy and there is no residual cancer
* Grade checked “not applicable” on CAP Protocol (if available) and no other grade information is available
**Note 9:** If you are assigning an AJCC Staging System stage group
* Grade is required to assign stage group
* Codes A-D are treated as an unknown grade when assigning AJCC stage group
* An unknown grade may result in an unknown stage group
Metadata
SSDI
| Code |
Description |
| 1 |
G1: Low combined histologic grade (favorable), SBR score of 3-5 points
Stated as Nottingham/Scarff Bloom-Richardson Grade 1 |
| 2 |
G2: Intermediate combined histologic grade (moderately favorable); SBR score of 6-7 points
Stated as Nottingham/Scarff Bloom-Richardson Grade 2 |
| 3 |
G3: High combined histologic grade (unfavorable); SBR score of 8-9 points
Stated as Nottingham/Scarff Bloom-Richardson Grade 3 |
| L |
Nuclear Grade I (Low) (in situ only) |
| M |
Nuclear Grade II (interMediate) (in situ only) |
| H |
Nuclear Grade III (High) (in situ only) |
| A |
Well differentiated |
| B |
Moderately differentiated |
| C |
Poorly differentiated |
| D |
Undifferentiated, anaplastic |
| 9 |
Grade cannot be assessed (GX); Unknown |
| <BLANK> |
See Note 1 |
