Disability Doc

13.28 Malignant neoplastic diseases treated by bone marrow or stem cell transplantation . (See 13.00L.)

A. Allogeneic transplantation. Consider under a disability until at least 12 months from the date of transplantation. Thereafter, evaluate any residual impairment(s) under the criteria for the affected body system.

OR

B. Autologous transplantation. Consider under a disability until at least 12 months from the date of the first treatment under the treatment plan that includes transplantation. Thereafter, evaluate any residual impairment(s) under the criteria for the affected body system.

Allogeneic transplantation – uses bone marrow stem cells or peripheral blood stem cells from someone else.

Autologous transplantation – uses the patient’s own bone marrow stem cells or peripheral blood stems cells.

“Bone marrow transplantation” refers to stem cells derived from bone marrow.

“Stem cell transplantation” refers to stem cells derived from peripheral blood.

Stem cells from bone marrow or peripheral blood are immature precursors of blood cells; and when they mature, form white blood cells (fight infection), red blood cells (carry oxygen), and platelets (help blood clot).

One reason bone marrow (stem cell) transplantation and (peripheral blood) stem cell transplantation are used in cancer treatment is to make it possible for patients to get very high doses of chemotherapy and/or radiation. This high-dose therapy is a form of very intense cancer treatment above and beyond “standard” therapy.

Chemotherapy and radiation mostly affect cells that divide rapidly, and cancer cells are the main target because they divide more rapidly than most healthy cells.

However, because normal bone marrow cells also divide rapidly, high-dose chemotherapy and/or radiation can damage or destroy the patient’s own bone marrow. Without healthy bone marrow, the patient can no longer make white blood cells to fight infection, red blood cells to carry oxygen, and platelets to help blood clot.

Both bone marrow transplantation and (peripheral blood) stem cell transplantation place stem cells into the blood after the patient has received high-dose chemotherapy and/or radiation. These new transplanted stem cells travel to the bone marrow to restore the bone marrow’s ability to produce new mature blood cells the patient needs to survive.

SSA instructs that in planning autologous (using own stem cells) bone marrow or stem cell transplantation to support high-dose chemotherapy; it is general practice to treat the individual with one or two cycles of “standard” chemotherapy to check for tumor responsiveness.

A cancer that is totally unresponsive to “standard” chemotherapy is unlikely to successfully respond to autologous bone marrow or stem cell transplantation.

If the therapy plan consists of several cycles of “standard” chemotherapy to be followed by bone marrow or stem cell transplantation, the date of “first treatment” is the date of the first “standard” chemotherapy.

If no “standard” chemotherapy is planned prior to bone marrow or stem cell transplantation, the date of “first treatment” is the date of the transplant.

In my opinion, this approach by SSA regarding the onset of “standard” chemotherapy to set the date of “first treatment” as onset for this listing is fraught with ambiguity and complexity. One could argue for an onset based purely on the point at which the severity of the impairment prevented work, not just when the “standard” therapy began. Though establishing an onset prior to transplantation would probably entail invoking a "less than sedentary RFC" or some other form of medical-vocational allowance.

The listing used to evaluate bone marrow or stem cell transplant depends on the specific malignancy. The criteria in listings 13.05C, 13.06A, 13.06B1, 13.06B2a, 13.07B, 113.05C, 113.06A, 113.06B1, or 113.06B2a do not specify the type of transplant. Only listing 13.28 distinguishes between autologous and allogeneic transplants. SSA evaluates any other malignant neoplastic disease treated with bone marrow or stem cell transplantation under listing 13.28, regardless of whether there is another listing that addresses that impairment.

Bone marrow or stem cell transplantation for aplastic anemia is evaluated under listing 7.17.

Bone marrow or stem cell transplantation for severe auto-immune disorders would be considered as a possible equals under listing 13.28.

Regardless, an individual who has received an autologous bone marrow or stem cell transplant for a malignant neoplastic disease has an impairment that meets a listing.

If the impairment is evaluated under listing 13.28 B, the individual is considered disabled until at least 12 months from the date of the “first treatment” under the treatment plan that involves an autologous transplant.

If the impairment is evaluated under another listing for bone marrow or stem cell transplantation, the individual is disabled until at least 12 months from the date of the transplant.

SSA further instructs that a listing for bone marrow or stem cell transplantation can not be met or medically equaled until the claimant has undergone the transplant. Therefore, if a transplant can not be done because there is no match, or because of funding issues, the listings for bone marrow or stem cell transplantation should not be used to evaluate the claim.

Umbilical cord blood contains large numbers of stem cells; therefore, umbilical cord blood transplants are considered stem cell transplants.

13.27 Primary site unknown after appropriate search for primary —metastatic carcinoma or sarcoma, except for solitary squamous cell carcinoma in the neck.

Except for a solitary squamous cell carcinoma found in the neck, any other metastatic carcinoma or sarcoma found in the body; and the primary site of origin of that tumor is unknown after a thorough metastatic work up, will meet this listing.

Under the revised listings, SSA evaluates tumors based on histology. For example, there is no histology for a “primary abdominal neoplasm.” Tumors that have spread to the abdomen should be evaluated under the site of origin, if known. If the primary site is unknown, SSA will use this listing to evaluate this or any similar impairment.

13.26 Penis --carcinoma with metastases to or beyond the regional lymph nodes.

Metastases to regional lymph nodes (or beyond) – will be described in the pathology report (microscopic exam of tissue) or in medical imaging studies, such as MRI or CT scan.

13.25 Testicles— tumor with metastatic disease progressive or recurrent following initial chemotherapy.

“Metastatic disease” is disease that has spread through the blood or lymphatic system.

May be local, regional, or distant metastases.

Progressive – malignancy becomes more extensive after completion of initial chemotherapy.

OR

Recurrent – recurrence of the tumor in any part of the body after completion of initial chemotherapy.

13.24 Prostate gland— carcinoma.

A. Progressive or recurrent despite initial hormonal intervention.

“Hormonal intervention” for prostate cancer is any medical treatment that lowers androgen (male hormone) levels. If carcinoma of the prostate tumor progresses or recurs despite initial hormonal intervention, the prognosis is poor.

Carcinoma of the prostate that progresses or recurs despite chemotherapy or radiation given as the initial treatment my still respond to hormonal therapy. Therefore, failure of prostate cancer to respond to chemotherapy or radiation does not have the same significance as failure to respond to hormonal therapy and cannot be used to equal 13.24 A.

The intent of this listing is that the cancer must be resistant to hormonal therapy before it can be considered of listing-level severity. This is why the listing uses the wording “despite initial hormonal intervention,” rather than “following initial hormonal intervention.”

Often, hormonal therapy for prostate cancer is given on an ongoing basis for an indefinite period. The listing is met when the disease progresses or recurs while on initial hormonal therapy. To meet this listing, the person must be receiving hormonal treatment. Or the listing would be met if the tumor continues to progress if the initial hormonal therapy was stopped and restarted for some reason.

Progression of prostate carcinoma should be decided based on the evaluation of all appropriate signs and symptoms. SSA opines that serial PSA (prostate-specific antigen) levels can help assess disease activity, but cannot be used to document progression without additional corroborating evidence, such as radiologic studies or findings on physical examinations. While a rise in serial PSA level reflects does reflect ongoing disease activity, be sure the medical evidence corroborates progression or recurrence. If this issue is not clear, contact the treating source for clarification.

OR

B. With visceral metastases.

“Visceral metastases” is metastases to non-bone structures, such as the liver or lung.

“Metastatic disease” is disease that has spread through the blood or lymphatic system. For prostate cancer, extension to the intestines or rectum is usually through direct extension; and, if so, SSA opines this does not necessarily represent metastatic disease. Though I think this opinion is wrong, and it could easily be argued that direct extension of prostate cancer to structures, such as the intestines, represents “visceral metastases.”

13.23 Cancers of the female genital tract --carcinoma or sarcoma .

A. Uterus (corpus), as described in 1, 2, or 3:

Corpus – body of the uterus.

1. Invading adjoining organs.

Spread to the pelvic wall equals 13.23 A.1.

OR

2. With metastases to or beyond the regional lymph nodes.

Metastases to regional lymph nodes (or beyond) – will be described in the pathology report (microscopic exam of tissue) or in medical imaging studies, such as MRI or CT scan.

OR

3. Persistent or recurrent following initial antineoplastic therapy.

Persistent – failure to achieve complete remission after completion of initial antineoplastic therapy.

OR

Recurrent – recurrence of the tumor in any part of the body after completion of initial antineoplastic therapy.

OR

B. Uterine cervix, as described in 1 or 2:

Cervix – mouth of the uterus

1. Extending to the pelvic wall, lower portion of the vagina, or adjacent or distant organs.

Will be described in the physical exam, operative report, pathology report (microscopic exam of tissue), or in medical imaging, such as MRI or CT scan.

OR

2. Persistent or recurrent following initial antineoplastic therapy.

Persistent – failure to achieve complete remission after completion of initial antineoplastic therapy.

OR

Recurrent – recurrence of the tumor in any part of the body after completion of initial antineoplastic therapy.

OR

C. Vulva, as described in 1, 2, or 3:

1. Invading adjoining organs.

Spread to the pelvic wall equals 13.23 C.1.

OR

2. With metastases to or beyond the regional lymph nodes.

Metastases to regional lymph nodes (or beyond) – will be described in the pathology report (microscopic exam of tissue) or in medical imaging studies, such as MRI or CT scan.

OR

3. Persistent or recurrent following initial antineoplastic therapy.

Persistent – failure to achieve complete remission after completion of initial antineoplastic therapy.

OR

Recurrent – recurrence of the tumor in any part of the body after completion of initial antineoplastic therapy.

OR

D. Fallopian tubes, as described in 1 or 2:

1. Extending to the serosa or beyond.

Serosa – membrane that lines the organs.

Will be described in the operative report or pathology report (microscopic exam of tissue). Entails extension through the fallopian tube wall to its lining or beyond.

OR

2. Persistent or recurrent following initial antineoplastic therapy.

Persistent – failure to achieve complete remission after completion of initial antineoplastic therapy.

OR

Recurrent – recurrence of the tumor in any part of the body after completion of initial antineoplastic therapy.

OR

E. Ovaries, as described in 1 or 2:

1. All tumors except germ-cell tumors, with at least one of the following:

a. Tumor extension beyond the pelvis; for example, tumor implants on peritoneal, omental, or bowel surfaces.

Peritoneum - membrane that lines the walls of the abdominal cavity

Omentum - folds of the peritoneum that connect the stomach with other abdominal organs 

Will be described in the operative report, pathology report (microscopic exam of tissue), or in medical imaging, such as MRI or CT scan.

OR

b. Metastases to or beyond the regional lymph nodes.

Metastases to regional lymph nodes (or beyond) – will be described in the pathology report (microscopic exam of tissue) or in medical imaging studies, such as MRI or CT scan.

OR

c. Ruptured ovarian capsule, tumor on the serosal surface of the ovary, ascites with malignant cells, or positive peritoneal washings.

Serosa - membrane that lines the organs.

Ascites - fluid in the abdominal cavity.

Peritoneal washings - the intraabdominal cavity is bathed with fluid during the surgical procedure; the fluid is suctioned and sent for examination by a pathologist. If tumor cells are present, the washing is considered "positive."

These findings will be described best in the operative report or pathology report (microscopic exam of tissue).

OR

d. Recurrent following initial antineoplastic therapy.

Recurrent – recurrence of the tumor in any part of the body after completion of initial antineoplastic therapy.

OR

2. Germ-cell tumors--progressive or recurrent following initial antineoplastic therapy.

Germ-cell tumors form in the reproductive cells (egg) of the ovary. Usually occurs in teenage girls and young women. These include dysgerminoma, yolk sac tumors, embryonal carcinoma, immature teratoma, choriocarcinoma, polyembryomas, and mixed germ cell tumors.

In adults, the most majority of germ cell tumors are benign, such as the benign cystic teratoma.

Progressive – malignancy becomes more extensive after completion of initial antineoplastic therapy.

OR

Recurrent – recurrence of the tumor in any part of the body after completion of initial antineoplastic therapy.

13.22 Urinary bladder --carcinoma .

A. With infiltration beyond the bladder wall.

The pathology report (microscopic exam of tissue) or medical imaging, such as MRI or CT scan will show this.

OR

B. Recurrent after total cystectomy.

Tumor recurs after surgical removal of the entire bladder.

OR

C. Inoperable or unresectable.

Inoperable - surgery is of no therapeutic value or cannot be performed due to risk to the patient.

OR

Unresectable - operation was performed but all of the tumor could not be removed.

OR

D. With metastases to or beyond the regional lymph nodes.

Metastases to regional lymph nodes (or beyond) – will be described in the pathology report (microscopic exam of tissue) or in medical imaging studies, such as MRI or CT scan.

13.21 Kidneys, adrenal glands, or ureters-- carcinoma .

A. Inoperable, unresectable, or recurrent.

Inoperable - surgery is of no therapeutic value or cannot be performed due to risk to the patient.

OR

Unresectable - operation was performed but all of the tumor could not be removed.

OR

Recurrent – recurrence of the tumor in any part of the body after completion of initial antineoplastic therapy.

OR

B. With metastases to or beyond the regional lymph nodes.

Similar to stomach (gastric) cancer, requiring metastases to regional lymph nodes (or beyond) – will be described in the pathology report (microscopic exam of tissue) or in medical imaging studies, such as MRI or CT scan.

13.20 Pancreas.

A. Carcinoma (except islet cell carcinoma).

OR

B. Islet cell carcinoma that is inoperable or unresectable and physiologically active.

Islet (pronounced eye-let) cell carcinoma is rare and may either be functional (physiologically active) or non-functional.

Functional (physiologically active) islet cell tumors produce different clinical manifestations depending on the type of hormone it produces in excess.

If it is unclear whether the tumor is physiologically active, contact the treating source.

Keep in mind that to meet Listing 13.20 B, the islet cell tumor must be physiologically active and either inoperable (surgery is of no therapeutic value or cannot be performed due to risk to the patient) or unresectable (operation was performed but all of the tumor could not be removed).

13.19 Liver or Gallbladder-- tumors of the liver, gallbladder, or bile ducts.

As stated in 13.00C, SSA applies the criteria in a specific listing to a malignancy originating from that site. Listing 13.19 should be used to evaluate primary tumors of the liver, and not tumors that metastasize to the liver.

13.18 Large intestine (from ileocecal valve to and including anal canal).

A. Adenocarcinoma that is inoperable, unresectable, or recurrent.

Inoperable - surgery is of no therapeutic value or cannot be performed due to risk to the patient.

OR

Unresectable - operation was performed but all of the tumor could not be removed.

OR

Recurrent – recurrence of the tumor in any part of the body after completion of initial antineoplastic therapy.

OR

B. Squamous cell carcinoma of the anus, recurrent after surgery.

In many cases, anal squamous cell carcinoma that recurs after treatment with radiation and chemotherapy can be successfully removed by surgery. Listing 13.18 B. is met if the surgery is unsuccessful. If squamous cell carcinoma of the anus is deemed inoperable or unresectable, Listing 13.18 B. is equaled.

OR

C. With metastases beyond the regional lymph nodes.

Notice how this listing differs from stomach (gastric) cancer but is similar to small intestine cancer in that metastases must be beyond regional lymph nodes. This will be described in the pathology report (microscopic exam of tissue) or in medical imaging studies, such as MRI or CT scan. Listing 13.18 C. applies to either adenocarcinoma of the large intestine (colon) or squamous cell carcinoma of the anus.

13.17 Small intestine --carcinoma, sarcoma, or carcinoid.

A. Inoperable, unresectable, or recurrent.

Inoperable - surgery is of no therapeutic value or cannot be performed due to risk to the patient.

OR

Unresectable - operation was performed but all of the tumor could not be removed.

OR

Recurrent – recurrence of the tumor in any part of the body after completion of initial antineoplastic therapy.

OR

B. With metastases beyond the regional lymph nodes.

Notice how this listing differs from stomach (gastric) cancer in that metastases must be beyond regional lymph nodes. This will be described in the pathology report (microscopic exam of tissue) or in medical imaging studies, such as MRI or CT scan.

Malignant tumors of the small intestine are very rare, making up only 2% of all gastrointestinal cancers.

Adenocarcinoma is the most common tumor type.

Carcinoid tumor is a neuroendocrine tumor, and usually follows a more benign course with a low incidence of metastases. Carcinoid tumors that metastasize to the liver meet Listing 13.17 B., and may result in carcinoid syndrome, which produces flushing and diarrhea.

13.16 Esophagus or stomach.

A. Carcinoma or sarcoma of the esophagus.

Esophageal carcinoma or sarcoma must simply be present to meet Listing 13.16 A.

There are two types of esophageal carcinoma – squamous cell carcinoma and adenocarcinoma.

Adenocarcinoma of the esophagus is linked with gastroesophageal reflux disease (GERD), also known as “heartburn.”

Sarcomas of the esophagus are very rare.

OR

B. Carcinoma or sarcoma of the stomach, as described in 1 or 2:

1. Inoperable, unresectable, extending to surrounding structures, or recurrent.

2. With metastases to or beyond the regional lymph nodes.

Malignant stomach (gastric) carcinoma has a 5-year survival rate of only 20%.

95% of all malignant gastric tumors are adenocarcinomas.

Stomach (gastric) sarcomas are rare and make up part of the remaining 5%.

Listing 13.16 B. requires stomach (gastric) carcinoma or sarcoma to be:

Inoperable - surgery is of no therapeutic value or cannot be performed due to risk to the patient.

OR

Unresectable - operation was performed but all of the tumor could not be removed.

OR

Extending to surrounding structures – filtration of tumor through the stomach wall, touching or invading local structures, including vessels and other organs.

OR

Recurrent – recurrence of the tumor in any part of the body after completion of initial antineoplastic therapy.

OR

With metastases to regional lymph nodes (or beyond) – will be described in the pathology report (microscopic exam of tissue) or in medical imaging studies, such as MRI or CT scan.

13.15 Pleura or Mediastinum.

A. Malignant mesothelioma of pleura.

Mesothelium lines the body’s internal organs.

Mesothelioma is a rare malignancy of this lining.

Pleura covers the lungs.

Mediastinum is the area between both lungs and contains the heart.

Malignant peritoneal (lining the abdominal cavity) mesothelioma shares many features with malignant pleural mesothelioma and medically equals listing 13.15A.

OR

B. Tumors of the mediastinum, as described in 1 or 2:

1. With metastases to or beyond the regional lymph nodes.

2. Persistent or recurrent following initial antineoplastic therapy.

Common primary mediastinal malignancies include choriocarcinoma, embryonal carcinoma, teratocarcinoma, and yolk sac carcinoma.

SSA considers that pleural involvement by direct extension of a mediastinal tumor may still be operable; therefore, SSA does not recommend that these tumors automatically equal this listing.

Lymphoma is not considered a primary mediastinal tumor, and is evaluated under Listing 13.05.

13.14 Lungs.

A. Non-small-cell carcinoma--inoperable, unresectable, recurrent, or metastatic disease to or beyond the hilar nodes.

“Non-small cell carcinoma” of the lung includes adenocarcinoma and squamous cell carcinoma.

Involvement of the mediastinal and hilar (area between both lungs and contains the heart) or supraclavicular (above the clavicle) nodes meets the listing.

Involvement of peribronchial nodes (lymph nodes surrounding individual bronchi) would not meet the listing, unless hilar or mediastinal lymph nodes are also involved.

SSA considers that pleural (lining of the lungs) involvement by direct extension of a pulmonary tumor may still be operable, and does not recommend that these tumors automatically equal this listing.

OR

B. Small-cell (oat cell) carcinoma.

Small cell carcinoma, also known as oat cell carcinoma, is the most aggressive of any primary lung malignancy. Most often, distant metastases already exist at the time of diagnosis.

13.13 Nervous system. (See 13.00K6.)

A. Central nervous system neoplasms (brain and spinal cord), as described in 1 or 2:

1. Highly malignant tumors, such as Grades III and IV astrocytomas, glioblastoma multiforme, ependymoblastoma, medulloblastoma or other primitive neuroectodermal tumors (PNETs) with documented metastases, diffuse intrinsic brain stem gliomas, or primary sarcomas.

Tumor grade is usually reported in the pathology report of a tissue biopsy. Grades I and II are “low grade,” whereas III and IV are “high grade.” If grade is unclear, contact the treating source for clarification.

Whether a brain stem glioma is “diffuse” is a clinical judgment made by treating sources based on imaging studies. Most highly malignant brain stem gliomas are considered “diffuse.” If there is any question, the treating source should be contacted for clarification.

2. Any central nervous system neoplasm progressive or recurrent following initial antineoplastic therapy.

To determine if the malignant central nervous system neoplasm meets the listing, it must be documented if it progresses or recurs following initial antineoplastic therapy. Therapy could consist of a single modality, such as surgical resection alone, or multimodal therapy, such as surgery and radiation. If the initial treatment plan calls for surgery alone, and the tumor recurs after this surgery, then the listing is met. If the initial treatment plan calls for multimodal therapy, SSA cannot determine whether the impairment meets or equals the listing until it can determine the effects of the entire treatment plan.

OR

B. Peripheral nerve or spinal root neoplasm, as described in 1 or 2:

1. Metastatic.

Local or regional metastases fulfill this requirement of this listing.

2. Progressive or recurrent following initial antineoplastic therapy.

13.12 Maxilla, orbit, or temporal fossa.

A. Sarcoma or carcinoma of any type with regional or distant metastases.

OR

B. Carcinoma of the antrum with extension into the orbit or ethmoid or sphenoid sinus.

OR

C. Tumors with extension to the base of the skull, orbit, meninges, or sinuses.

Maxilla - upper jaw

Orbit - cavity in the skull containing the eye

Temporal fossa - area on the side of the skull anterior to and above the ears

Sarcoma or carcinoma with regional or distal metastases

Sarcomas of the skull – may include chondrosarcoma, rhabdomyosarcoma, and Ewing’s sarcoma

Carcinomas of these regions of the skull with “extension” to local structures including the skull, orbit, and meninges (lining of the brain) is the same as “regional metastases”

13. 11 Skeletal system --carcinoma or sarcoma.

Refers to primary (originates in bone) malignant bone tumors.

NOTE: “Carcinoma” is an error in this listing. It should only state “sarcoma.”

A. Inoperable or unresectable.

“Inoperable” malignant bone tumors – surgery is of no therapeutic value or cannot be performed due to risk to the patient.

“Unresectable” malignant bone tumors – operation was performed but all of the tumor could not be removed.

OR

B. Recurrent tumor (except local recurrence) after initial antineoplastic therapy.

“Local recurrence” - recurrence at the site of the original tumor after completion of initial antineoplastic therapy.

OR

C. With distant metastases.

“Distant metastases” - metastases beyond local tissue or local lymph nodes.

OR

D. All other tumors originating in bone with multimodal antineoplastic therapy. Consider under a disability for 12 months from the date of diagnosis. Thereafter, evaluate any residual impairment(s) under the criteria for the affected body system.

Types of primary bone tumors requiring multimodal therapy include osteosarcoma and Ewing’s sarcoma.

13.10 Breast (except sarcoma—13.04) (See 13.00K4.)

A. Locally advanced carcinoma (inflammatory carcinoma, tumor of any size with direct extension to the chest wall or skin, tumor of any size with metastases to the ipsilateral internal mammary nodes.

Inflammatory breast carcinoma, considered locally advanced, is a rare breast cancer that shows inflammation in pathology reports and produces an “orange peel” appearance of the skin overlying the tumor.

Tumors with direct extension to the chest wall or skin, and tumors with metastases to the ipsilateral (same-side) internal mammary nodes are also considered locally advanced.

These examples of “locally advanced carcinoma” in this listing correspond to tumors categorized as Stage IIIB in the “American Joint Committee on Cancer” (AJCC) staging manual, 5th edition (edition in effect when SSA developed these listings).

However, SSA says it did not simply choose them because they are Stage IIIB, but because the characteristics of these tumors, and the effects of treatment for them are indicative of listing level severity. SSA says it uses the particular criteria, not the stage of tumor, to determine listing level severity because staging systems, such as the AJCC, change intermittently.

SSA instructs that not all Stage III breast carcinomas are as medically severe as the ones in the listing. By this, they mean that Stage IIIA breast carcinomas are not of listing level severity. This suggests a change in program policy because before the new malignant neoplastic listings came out, Central Office was approving equaling Stage IIIA breast carcinomas [with either a tumor size greater than 5.0 cm or metastases to ipsilateral (same-side) axillary lymph nodes fixed to one another] to old listing 13.09 B. This change in policy is most likely due to the fact that Stage IIIA breast tumors are generally considered operable, and Stage IIIB, inoperable.

Currently, breast cancer surgeons do not usually remove ipsilateral (same-side) internal mammary nodes (found along the breast bone). If a pathology report does not specify otherwise, nodes described are usually axillary nodes; and, if so, a finding of "positive nodes" does not indicate that the listing is met. Internal mammary nodes should be specifically mentioned in the pathology report if they were examined.

SSA further instructs, “although (estrogen and progesterone) receptor status has therapeutic and prognostic importance, it does not serve as a specific entity in the determination of whether a listing is met or medically equaled.”

OR

B. Carcinoma with distant metastases.

This includes breast carcinomas with metastases to ipsilateral (same-side) supraclavicular (above the clavicle) lymph nodes and beyond.

OR

C. Recurrent carcinoma, except local recurrence that remits with antineoplastic therapy.

Local recurrence for breast carcinoma is either:

• recurrence in the remaining tissue in the same breast status post lumpectomy OR
• recurrence in the mastectomy scar line status post mastectomy.

Recurrence in ipsilateral (same-side) axillary nodes is considered a regional recurrence and meets listing 13.10C.

Bottom line: If it is not clear, have the treating physician clarify the stage of the breast tumor.

13.09 Thyroid Gland.

A. Anaplastic (undifferentiated) carcinoma.

Anaplastic carcinoma of the thyroid is very aggressive with early metastases.

OR

B. Carcinoma with metastases beyond the regional lymph nodes progressive despite radioactive iodine therapy.

If thyroid carcinoma is neither progressive nor responsive to treatment, but rather simply persists despite treatment, SSA considers this “stable,” and recommends evaluating the claim at steps 4 and 5 of the sequential evaluation process.

SSA did not include medullary carcinoma of the thyroid in the listings because it is a rare form of thyroid cancer—less than 10 percent of all thyroid cancers. Also, since medullary carcinoma of the thyroid is not treated with radioactive iodine, it cannot meet listing 13.09B. Medullary carcinoma of the thyroid can medically equal listing 13.09B when it has metastasized beyond the regional (neck) lymph nodes.