Collaborative Stage Data Set - Revised 08/07/2013 FINAL
CS Site-Specific Factor 10
Gleason's Score on Prostatectomy/Autopsy
- Note 1: Code the Gleason's score from prostatectomy or autopsy only in this field.
- Note 2: Code the Gleason's score prior to neoadjuvant treatment.
- Note 3: Usually prostate cancers are graded using Gleason's score or pattern. Gleason's grading for prostate primaries is based on a 5-component system (5 histologic patterns). Prostatic cancer generally shows two main histologic patterns. The primary pattern, the pattern occupying greater than 50% of the cancer, is usually indicated by the first number of the Gleason's grade, and the secondary pattern is usually indicated by the second number. These two numbers are added together to create a pattern score, ranging from 2 to 10.
If there are two numbers, assume that they refer to two patterns (the first number being the primary pattern and the second number being the secondary pattern), and sum them to obtain the score.
If only one number is given and it is less than or equal to 5, code the total score to 999, unknown or no information.
If only one number is given and it is greater than 5, assume that it is a score and code as stated.
If the pathology report specifies a specific number out of a total of 10, the first number given is the score. Example: The pathology report says Gleason's 3/10. The Gleason's score would be 3, and coded as 003.
- Note 4: Record the Gleason's score based on the addition of the primary and secondary patterns coded in CS Site-Specific Factor 9.
- Note 5: If prostatectomy and autopsy are not performed, assign code 998. If the Gleason's pattern and score are not documented on prostatectomy or autopsy, assign code 999.
- Note 6: If a tertiary pattern is documented on prostatectomy or autopsy, do not code in either CS Site-Specific Factor 9 or CS Site-Specific Factor 10. Record the tertiary pattern in CS Site-Specific Factor 11.
|002-010||Gleason's Score |
(See Notes 1-5)
|988||Not applicable: Information not collected for this case (If this information is required by your standard setter, use of code 988 may result in an edit error.)|
|998||No prostatectomy/autopsy performed|
|999||No Gleason's score documented on prostatectomy/autopsy|
No residual disease on prostatectomy/autopsy
Unknown or no information
Not documented in patient record