TNM Supplement: A Commentary on Uniform Use

2nd ed, edited by Ch. Wittekind, D. E. Henson, R. V. P. Hutter, and L. H. Sobin, Wiley-Liss, John Wiley and Sons, Inc, 2001.Throughout every facility that studies and treats patients with cancer, there are copies—in departments of pathology, surgical and medical oncology, diagnostic and radiation oncology, surgical oncology, and cancer registries—of the 5th edition of the American Joint Committee on Cancer (AJCC) Cancer Staging Manual. There should also be a copy of the International Union Against Cancer (UICC) TNM Supplement: A Commentary on Uniform Use, 2nd edition, edited by Wittekind, Henson, Hutter, and Sobin, UICC, 2001. The AJCC manual does not differ from the TNM Classification of Malignant Tumours manual; they were formulated together but are published as separate books. Both manuals are in their 5th editions and were most recently published in 1997.As well written as the 5th edition of the AJCC Cancer Staging Manual is, this commentary is virtually essential for its optimal use, as was the 1st edtion of the supplement, which was published in 1993. The supplement is a short 140-page book that is divided into the following sections: explanatory notes, both general and specific (anatomic); site-specific recommendations for pT and pN; new tumor-node-metastasis (TNM) classifications recommended for testing; and optional proposals for testing new “telescopic” ramifications of TNM. An additional section featuring 14 pages dedicated to answering frequently asked questions on the TNM Web site is possibly the most valuable section of the book. This supplement is a warehouse of information. Among the topics discussed are how to code gastrointestinal sarcomas and malignant lymphomas, as well as malignant thymomas. In many institutions, there are arguments regarding subdivisions of existing standard TNM categories, some based on anecdote, others on solid analyzed data. The chapter on telescopic ramifications is very instructive, full of suggestions on how to collect additional data without altering the definitions of existing TNM code sets.If you read only one chapter in the supplement, it should be the “Frequently Asked Questions” chapter. Even experienced coders will profit from reading this text. Questions answered include how does one use the R classification? If there is residual tumor after surgery, is it always stage IV? If I am not sure of the correct TNM category (because of unclear measurements), which TNM do I select? If tumor is spilled into the abdomen or pleural cavity during surgery, how does this affect classification? The 4th edition of the TNM manual had a classification for brain tumors; why doesn't the 5th edition? Who is ultimately responsible for TNM coding?Simply stated, if we do not code, collect, collate, and study TNM coding data sets, we will not know whether our diagnostic and therapeutic modalities are any improvement on the old. That is why this book is so important.I have 2 final comments. There is a related classification of neoplasms, the World Health Organization International Classification of Disease for Oncology (ICD-O), 2nd edition, first published in 1958. The morphology nomenclature is identical to that of the M field for neoplasms in the Systematized Nomenclature of Medicine (SNOMED), published by the College of American of Pathologists. To facilitate appropriate comparison of data, I recommend that ICD-O classification also be performed.Lastly, this reviewer would like to observe that even with widespread uniform TNM and ICD coding, we shall still be a considerable way from where we need to be to truly analyze the information in the charts of our patients with cancer. When, and until, there is a method to code the entire medical record for its clinical content—linked to or “cross-walked” to all of the other classifications, such as TNM, ICD, nursing, pharmacologic, and other classifications—we will not be in a position to truly “mine” the record for its most precious gems. The Veterans Administration System, with its electronic medical record, and the Kaiser-Permanente system, with its SNOMED-CT project, are leaders in this area. Let us hope that in the near future we will have a way for all of us to move toward the goal of a clinically coded, electronic medical record.