New Abstractors Training Colon Cancer Marynell Jenkins, CCRP, CTR Regional Coordinator.

New Abstractor’s Training

Colon Cancer

Marynell Jenkins, CCRP, CTRRegional Coordinator

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Class of Case Anatomy Topography / Morphology Histology Grade

Differentiation

What we are covering today:

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According to the 2015 Abstractor’s manual

Class of Case

Class of case reflects the facility's role in managing this cancer, whether the cancer is required to be reported to ACoS by approved facilities, and whether the case was diagnosed after the program's reference date. Enter the two digit code that describes the patient's relationship to the facility.

• Analytic (must abstract) Classes 00-22

• Non-analytic (send to KCR) Classes 30-99* Not required to abstract non-analytic cases Hospitals are required to submit info to KCR for

review * Non-analytic class 38 MUST be abstracted!

Class of Case: 2 major classes

Analytic: Class of case 10-14Diagnosed at reporting facility or in staff physician office AND

all or part of first course therapy performed at reporting facility

Class 10 Initial diagnosis at the reporting facility or in a staff

physician’s office AND part or all of first course of treatment was done at the

reporting facility, or decision not to treat was done at the reporting facility

Class 11 Initial diagnosis in staff physician’s office AND part

of first course of treatment was done at the reporting facility

Non-analytic: Class of case 30-37Pt appears in person at reporting

______facility

Class 30 Initial diagnosis and all first course treatment

elsewhere AND reporting facility participated in diagnostic workup (Ex: consult only, staging workup after initial diagnosis elsewhere)

Class 31 Initial diagnosis and all first course treatment

elsewhere AND reporting facility provided in-transit care

Non-analytic: Class of case 30-37 – Con’t

Class 34 Type of case not required by CoC to be

accessioned (Ex: A benign colon tumor) AND initial diagnosis AND part or all of first course treatment by reporting facility

Class 35 Case diagnosed before program’s Reference

Date AND initial diagnosis AND all or part of first course treatment by reporting facility

Non-analytic: Class of case 38Diagnosed on autopsy

Class 38 Initial diagnosis established by autopsy at the

reporting facility, cancer not suspected prior to death

Required to be abstracted by your facility.

Ex: Pt admitted with congestive heart failure, expires as inpatient, and autopsy shows thyroid carcinoma

Non-analytic: Class of case 40-99 – Con’t

Class 49 Death certificate only

Class 99 Non-analytic case of unknown relationship to

facility (not for use by CoC-accredited cancer programs for analytic cases)

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Let’s look at some examples

Class of Case: Examples

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Polyp Structures - Pedunculated FlatPolyp “Behavior” – Non-invasive/ In-situ Invasive (including intramucosal) [*”Polypoid” is not a polyp, it is polyp-like. Do not code histology for a polyp if description is polypoid.]

Types of Colon Cancer

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Polyp on a short stalk , approximately 1 cm in size

Photo of Polyp in Sigmoid

Stephen Holland, M.D., Naperville Gastroenterology, Naperville, IL, USA.

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Polyps: Pedunculated & Flat

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Polyp Names: Adenomatous or Tubular adenoma (8210) Villous adenoma (8261) Tubulovillous adenoma (8263)

Malignant colon masses or tumors: Histologies: Adenocarcinoma Mucinous Adenocarcinoma Signet Ring Adenocarcinoma Behaviors: In-situ (non-invasive) Invasive

From Polyp to Cancer…

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Cecum (proximal right colon)6 x 9 cm pouch covered with peritoneum

AppendixA vermiform (wormlike) diverticulum located in the lower cecum

Ascending colon20-25 cm long, located behind the peritoneum

Hepatic flexureLies under right lobe of liver

Colon Module, U. S. National Institutes of Health, National Cancer Institute, 1/13/12. <http://training.seer.cancer.gov/>.

Colon Anatomy

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Transverse colonLies anterior in abdomen, attached to gastrocolic ligament

Splenic flexureNear tail of pancreas and spleen

Descending colon10-15 cm long, located behind the peritoneum

Sigmoid colonLoop extending distally from border of left posterior major psoas muscle

Colon Anatomy

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Rectosigmoid segmentBetween 10 and 15 cm from anal verge

Rectum12 cm long; upper third covered by peritoneum; no peritoneum on lower third which is also called the rectal ampulla. About 10 cm of the rectum lies below the lower edge of the peritoneum (below the peritoneal reflection), outside the peritoneal cavity

Anal canalMost distal 4-5 cm to anal verge

Rectosigmoid, Rectum & Anus

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Colorectal Segments

SEER Training Modules, Colon Module , U S National Institutes of Health, National Cancer Institute. 1/13/12 <http://training.seer.cancer.gov/>.

C18.3

C18.4

C18.2

C18.0

C18.1

C18.5

C18.6

C18.7

C20.9

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Layers from inside out… Lumen (interior surface of colon "tube") Mucosa Surface epithelium Lamina propria or basement membrane

—dividing line between in situ and invasive lesions

Muscularis mucosae Submucosa—lymphatics; potential for

metastases increases Muscularis propria

Layers of colon wall

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Circular layer Longitudinal layer—in three bands called

taenia coli Subserosa—sometimes called pericolic fat

or subserosal fat Serosa—present on ascending, transverse,

sigmoid only (also called the visceral peritoneum)

Retroperitoneal fat (also called pericolic fat) Mesenteric fat (also called pericolic fat)SEER Training Modules, Colon Module, U. S. National Institutes of Health, National Cancer Institute, 1/13/12. <http://training.seer.cancer.gov/>.

Layers of colon wall (cont’d)

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Diagram of wall layers

SEER Training Modules, Colon Module , U S National Institutes of Health, National Cancer Institute. 1/13/12 <http://training.seer.cancer.gov/>.

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Segment Regional Lymph Nodes Cecum - Pericolic, anterior cecal, posterior cecal,

ileocolic, right colic Ascending colon - Pericolic, ileocolic, right colic,

middle colic Hepatic flexure - Pericolic, middle colic, right colic Transverse colon - Pericolic, middle colic Splenic flexure - Pericolic, middle colic, left colic,

inferior mesenteric Descending colon - Pericolic, left colic, inferior

mesenteric, sigmoid

Regional Lymph Nodes

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* Sigmoid colon - Pericolic, inferior mesenteric, superior rectal, superior hemorrhoidal, sigmoidal, sigmoid mesenteric Rectosigmoid - Perirectal, left colic, sigmoid

mesenteric, sigmoidal, inferior mesenteric, superior rectal, superior hemorrhoidal, middle hemorrhoidal

Rectum - Perirectal, sigmoid mesenteric, inferior mesenteric, lateral sacral, presacral, internal iliac, sacral promontory (Gerota's) superior hemorrhoidal, inferior hemorrhoidal

Anus - Perirectal, anorectal, superficial inguinal, internal iliac, hypogastric, femoral, lateral sacral

Regional Lymph Nodes

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Presenting SymptomsPhysical ExamScansLabsScopesBiopsies

Diagnosing Colon Cancer

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Which report contains the earliest documentation of cancer, using the “right” terminology?

Refer to diagnostic Ambiguous Terminology in Abstractor’s Manual for list of “Yes” or “No” terms.

Date of 1st contact CANNOT precede Dx Dt!

Locating the Diagnosis Date!

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Selecting a Site Code

Determining colon cancer primary site….

Different physicians may document different sites!

Operative Report takes top priority for colon….

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Review Colon Histology Rules in MP/H (Colon Chapter)

Review Rectosigmoid/Rectum/Anus Histology Rules in MP/H (Other Sites Chapter)

Determining Histology for Colon

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Determining Topography

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Patient undergoes colonoscopy with biopsy of a large polyp in the sigmoid colon. Resection reveals adenocarcinoma of sigmoid, arising in a tubulovillous adenoma.

What is the histology code?

Let’s work this together!

Grade/Differentiation, Grade Path Value, and Grade Path

System

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An expression of the tumor’s aggressiveness and an estimate of its prognosis.

Grade

A system used to classify cancer cells in terms of how abnormal they look under a microscope and how quickly the tumor is likely to grow and spread.

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Describes how much or how little a tumor resembles the normal tissue from which it arose. A well-differentiated tumor looks more like the

normal cells of that same tissue. An undifferentiated, or anaplastic, tumor bears

virtually no resemblance to the normal tissue in which it started.

Differentiation

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Differentiation correlates with grade: The less differentiated the tumor: the higher the

grade and the more aggressive the tumor. The more differentiated the tumor: the lower the

grade and the less aggressive the tumor.

This sounds backwards, but remember less differentiated actually means it looks less like the cells from the original tissue.

Differentiation Continued

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The grade/differentiation of a tumor is coded in the 6th digit of the morphology code and is only one digit*.

Location in Coding

M - _ _ _ _ / _ X* In CPDMS.net the grade is separated from the histology so it is not seen the 6th digit format.

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Grade/Differentiation is usually expressed in a 2, 3, or 4 code range in either numbers (1-4) or Roman numerals (I – IV).*

Only colon, rectosigmoid junction, rectum, and heart use the 2 grade system.

Peritoneum, endometrium, fallopian tubes, bladder, brain and spinal cord, prostate, kidney, DCIS Breast, and soft tissue sarcomas use a Three-Grade system.

The remaining solid tumors utilize the Four-Grade system.

Grade/Differentiation Expression

* This applies to solid tumors only.

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Two-Grade systems apply to colon, rectosigmoid junction, rectum, and heart.

Code these sites using a two-grade system; Low Grade (2) or High Grade (4). If the grade is listed as 1/2 or asLow Grade, then code 2. If the grade is listed as 2/2 or as High Grade, then code 4.

Two-Grade System

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Three-Grade systems apply to peritoneum, endometrium, fallopian tubes, bladder, brain and spinal cord, and soft tissue sarcomas.

DCIS Breast, kidney, and prostate use site specific three grade systems.

Three-Grade System

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For sites other than DCIS breast, kidney, and prostate code the tumor grade using the following priority order: (1) Terminology, (2) Histologic Grade, and (3) Nuclear Grade as shown in the following table.

Three-Grade System General

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For invasive breast cancers, code the tumor grade using the following priority order: (1) Bloom-Richardson(Nottingham) Scores, (2) Bloom-Richardson Grade, (3) Nuclear Grade (4) Terminology, and (5)Histologic Grade.

Refer to the abstractor and FORDS manuals for appropriate schema.

Grade System for Breast

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Ductal carcinoma in situ (DCIS) is not always graded. When DCIS is graded, it is generally divided into three grades: low grade, intermediate grade, and high grade.

Refer to the abstractor and FORDS manuals for appropriate schema.

Grade System for Breast (cont.)

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For prostate cancers, code the tumor grade using the table below following priority order: (1) GleasonScore (this is the sum of the patterns, for example, if the pattern is 2+4 the score is 6), (2) Terminology,(3) Histologic Grade, and (4) Nuclear Grade.

Tumor Grade for Prostate

2, 3, 4, 5, 678, 9, 10

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For kidney cancers, code the tumor grade using the following priority rules: (1) Fuhrman Grade, (2)Nuclear Grade, (3) Terminology (well differentiated, moderately differentiated), (4) Histologic Grade.These prioritization rules do not apply to Wilms tumor (M-8960).

Tumor Grade for kidney

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Solid tumors not otherwise defined should be graded using the Four-Grade system.

Code the tumor grade using the following priority order: Terminology Histologic Grade Nuclear Grade

Refer to the abstractor manual for schema.

Four-Grade System

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Used to designate cell lineage Use when given in the diagnostic statement

Refer to the abstractor manual for schema.

Coding Lymphomas and Leukemias

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Refer to the abstractor manual for full instructions.

Grade astrocytomas according to ICD-O-3. Do not automatically code glioblastoma

multiforme as Grade IV. For primary tumors of the brain and spinal cord

do not record the WHO grade. All benign and borderline intracranial tumors

should be coded as grade 9.

Coding CNS Tumors

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Special Note: You cannot code a grade from a metastatic site. Code as a ‘9’.

Often for in situ no tumor grade is provided, code as a ‘9’.

More information on tumor grade/differentiation can be found in your FORDS and abstractor manuals.

Grade/Differentiation Comments

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Time for the Exercises

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Example Exercise

Given the following information, provide the Tumor Grade to code in CPDMS.net

03/22/2012 : BX Mass of transverse colon: path states: Invasive colonic adenocarcinoma with ulceration, high grade 4/2

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Example Exercise

What were your answers?

Field ValueTumor Grade

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Example Exercise

What were your answers?

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C 18.7 M-8481/3 2

The codes above tell us the same amount of information as the wording below, but in a lot less space.

The splenic flexure (topography) of the colon has invasive (behavior) mucin producing adenocarcinoma (histology) with a low tumor grade

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Class of Case Anatomy Topography / Morphology Histology Grade

Differentiation

What we covered today