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New Abstractor’s Training
Colon Cancer Welcome to “New Abstractor’s Training”! Marynell Jenkins, CCRP, CTR Regional Coordinator
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What we are covering today:
Class of Case Anatomy Topography / Morphology Histology Grade Differentiation
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Class of Case According to the 2016 Abstractor’s manual
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. You should have a handout from the Abstractor’s manual that lists the various two digit codes use to identify the class of case. The complete Abstractors Manual is also available on the KCR website. *Verify everyone has a handout listing Class of Case Codes*
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Class of Case: 2 major classes
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! All cases accessioned (abstracted) are assigned a Class of Case based on the type of care provided by your facility. Definition of analytic: Cases initially diagnosed and/or received all or part of first course of therapy at the accessioning facility after the registry’s reference date are analytic. *Exception to not abstracting non-analytic cases – Cases diagnosed on autopsy – we will discuss this scenario a little later. Code the class of case that most precisely describes the patient’s relationship to the facility. Follow the guides for your institution to determine which class of case your site chooses to abstract.
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Analytic: Class of case Diagnosed 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 Lets start be defining a staff physician. A Staff physician = A physician who is employed by the reporting facility, under contract with the reporting facility, or who has routine practice privileges at the reporting facility. Classes of case must be diagnosed at either the reporting facility or in a staff physician’s office. Classes of case must receive all or part of first course of therapy at the reporting facility. Cases diagnosed at the reporting facility that undergo first course therapy in a staff physician’s office and NO therapy at the reporting facility are class of case 00 – this is a change in the class of case rules starting with cases diagnosed on or after 1/1/10.
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Non-analytic: Class of case 30-37 Pt appears in person at reporting ______facility
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 Definition of non-analytic: Classes of case not required by CoC to be abstracted (may be required by cancer committee, state or regional registry or other entity). Definition of in-transit care: Treatment provided by your facility to prevent interruption of planned therapy (Ex 1: patient diagnosed and started tx at Florida facility and transferring to hometown in another state to continue tx – During transit from one facility to the next, comes to your facility for a tx to prevent disruption of planned tx; Ex 2: pt diagnosed and began first course of tx in home state, comes to your facility in your state while on vacation to continue planned tx)
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Non-analytic: Class of case 30-37 – Con’t
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 Definition of Reference Date: To ensure a valid statistical database, the Commission on Cancer requires that a start date be established for CoC-accredited registries. This date is known as the reference date. It should be set as January 1 of a given year. Once this date is established, all cases diagnosed and/or treated at the facility on or after this date must be entered into the registry.
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Non-analytic: Class of case 38 Diagnosed on autopsy
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 Class of Case 38 is an exception to the statement I made earlier that Only Analytic cases must be abstracted per KCR quidelines. Class of Case 38 are cases Dia by autopsy at the reporting facility and the cancer was not suspected prior to death.
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Non-analytic: Class of case 40-99 – Con’t
Death certificate only Class 99 Non-analytic case of unknown relationship to facility (not for use by CoC-accredited cancer programs for analytic cases) Note, that classes of case 49 and 99 are for the central registry level only, not for use in hospital cancer registries.
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Class of Case: Examples
Let’s look at some examples Example #1 Pt has a prostate Bx done at Dr Smith’s office (which is not owned or affiliated with your facility). The urologist sends the sample to your pathologist who states specimen is positive for prostate adenocarcinoma. Dr Smith reviews the pathology and after discussion with the patient decides to treat with Hormone injections, which will be administered in Dr Smith’s office. What class of case would you choose ? Answer coc = 43 Example #2 Pt has a colonoscopy at your facility. Pathologist states sample is positive for adenocarcinoma. Pt decides to have surgery (hemicolectomy) at another hospital in town. What class of case would you choose ? Answer coc =00 Example #3 Pt is Dia with breast cancer at another hospital in town, then comes to your facility for a mastectomy. The Pt had no other surgery. What class of case would you choose ? Answer coc =22
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Types of Colon Cancer Polyp Structures - Pedunculated Flat
Polyp “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.] Now lets discuss Colon Cancer. The American Cancer Society Estimates that in 2016 there will be over 140,000 new cases of colon/rectum cancer dia. This cancer is one of the major sites here in Kentucky. Colon cancer is sometimes found growing in a polyp. There are two types of colon polyps; Pedunculated and Flat. A pedunculated polyp has a long thin stalk separating the head of the polyp from the colon wall. A flat polyp, also called “sessile”, does not have a stalk. Polyps may be either totally benign, or they may exhibit in-situ behavior, or they may even contain invasive cancer. Colon polyps can be either non invasive or invasive.
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Photo of Polyp in Sigmoid
Polyp on a short stalk , approximately 1 cm in size This picture of a polyp in the sigmoid colon was taken during a routine colonoscopy. It was removed via snare biopsy. It would be classified as a peduculated polyp, due to the presence of a stalk. Stephen Holland, M.D., Naperville Gastroenterology, Naperville, IL, USA.
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Polyps: Pedunculated & Flat
On this diagram, we can see both general types of colon polyps: the flat one on the bottom right-hand wall, and the pedunculated one hanging from the top of the wall by a stalk. If left in place, colorectal polyps can grow into invasive cancers…. That is the reason it is so important for people to undergo screening colonoscopies. Removing polyps early-on can actually PREVENT the development of cancer!
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From Polyp to Cancer… 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 Three basic polyp diagnoses are shown on this slide. If cancer arises in any of these, the appropriate histology code is shown in parentheses. It is important to note if a colon cancer arises from a polyp. Colonoscopy may reveal a colon mass that is found to be adenocarcinoma. If it is unknown whether the mass arose from a polyp, you would code the type of carcinoma specified on the path report. Most colon masses turn out to be some form of adenocarcinoma. Some contain extra-cellular mucin and are called “mucinous adenocarcioma”. Some colon tumors are diagnosed as “signet ring carcinoma”; these have intra-cellular mucin. Carefully read your colonoscopy reports and path reports to determine if the tumor originated in a polyp, the type of polyp or adenocarcinoma, and whether the tumor is in-situ (code 2) or invasive (code 3). We abstract both behaviors.
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Colon Anatomy Cecum (proximal right colon) 6 x 9 cm pouch covered with peritoneum Appendix A vermiform (wormlike) diverticulum located in the lower cecum Ascending colon cm long, located behind the peritoneum Hepatic flexure Lies under right lobe of liver Colon Module, U. S. National Institutes of Health, National Cancer Institute, 1/13/12. < Now we will discuss some anatomy basics. Nicole will be going into more detail when she discuss Collaborative Extension…. But these next few slides will give us some general concepts. The 1st segment of the colon, after food leaves the small intestine, is the Cecum…. (Read thru slide)
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Colon Anatomy Transverse colon Lies anterior in abdomen, attached to gastrocolic ligament Splenic flexure Near tail of pancreas and spleen Descending colon cm long, located behind the peritoneum Sigmoid colon Loop extending distally from border of left posterior major psoas muscle Read through the slide
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Rectosigmoid, Rectum & Anus
Rectosigmoid segment Between 10 and 15 cm from anal verge Rectum 12 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 canal Most distal 4-5 cm to anal verge Read through the slide
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Colorectal Segments C18.4 C18.5 C18.3 C18.6 C18.2 C18.0 C18.7 C18.1
Here is a diagram of the colon & rectum. Food leaves the small intestine and enters the large intestine at the Cecum, progresses up the Ascending colon to the Hepatic flexure…. The Rectosigmoid is at the curve between the Sigmoid and Rectum, although SEER left it’s designation off this slide. The topography code for Rectosigmoid is C19.9 . C18.0 C18.7 C18.1 C20.9 SEER Training Modules, Colon Module , U S National Institutes of Health, National Cancer Institute. 1/13/12 <
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Layers of colon wall 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 Nicole will be talking about anatomy and need to review the medical record closely for information that is required for both the MPH rules and collaborative staging. **since Nicole is discussing this later during training…we only briefly look at the slides 19-23** Pay close attention to which layer has been invaded on the pathology report from resected specimens.
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Layers of colon wall (cont’d)
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. < Read layers…
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Diagram of wall layers Nicole is going to talk more about anatomy of the colon when she covers CS Ext and LN, but lets look at this slide. This simple diagram is of a colon cross-section, as if you were looking at a thin slice of colon wall that has been cut through, stained, & mounted on a slide. The inside of the colon “tube” is the lumen. Waste material passes through the lumen on its way out! Tumors most often arise from the inside layer (mucosa) and grow through the wall from the mucosa, then submucosa, then muscularis propria, then subserosa, and may finally penetrate through the serosa. Cancers become more invasive as they penetrate through each level. Different stages of disease are calculated, depending upon the depth of invasion, so it is important to read the resection path report completely & carefully to determine how far down the tumor has invaded. SEER Training Modules, Colon Module , U S National Institutes of Health, National Cancer Institute. 1/13/12 <
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Regional Lymph Nodes 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 There are between 100 and 150 lymph nodes in the mesentery of the colon. Regional lymph nodes are the nodes along the colon, plus the nodes along the major arteries that supply blood to that particular colon segment.
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Regional Lymph Nodes * 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 Lymph node names may also be found in the Collaborative Stage Manual & the AJCC 7th edition Staging Manual (TNM Book). Unfortunately, specifically-named lymph nodes that are removed with a colorectal surgical specimen may not be provided on the path report or the chart. In those situations, we must code them as “regional nodes”, not specific LNs.
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Diagnosing Colon Cancer
Presenting Symptoms Physical Exam Scans Labs Scopes Biopsies Colon cancer may be completely asymptomatic if found at an early stage on screening colonscopy. If it has been growing for awhile, symptoms might include anemia, rectal bleeding, change in bowel habits, weight loss, inability to pass stool, etc. A physical exam may indicate an abdominal mass or possible lymph nodes metastases. Scans may reveal colorectal mass, suspicious lymph nodes, or liver involvement if the cancer has already metastasized. In the case of distant metastasis, surgery may not be performed unless bowel obstruction is imminent. Labs are performed, particularly to locate elevated CEA (carcinoembryonic antigen) levels. Generally, a colonoscopy will be performed to confirm the presence of a malignancy, and usually a biopsy will take place via scope.
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Locating the Diagnosis Date!
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! To find the earliest cancer diagnosis date, look through reports in the patient’s chart for the 1st date a recognized medical practitioner (MD or DO; NOT a nurse practitioner) stated that the mass, nodule, tumor, or lesion was malignant or cancer or metastatic. Use of Ambiguous terminology shown on the “yes” list counts as the 1st or earliest date. For example, you find a colonoscopy report that states “suspicious for carcinoma” even though a biopsy may not have been performed – this date would be the diagnosis date. Dx date may be on a scan showing an obstructing mass “most likely cancerous”, on a path report from a scope with biopsy, on the H&P or Discharge summary of the inpatient chart, on a progress note or consultation by a specialist, or a report from another facility or MD office! Dt of 1st contact should never precede the Dx Dt!
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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…. The surgeon should see & know in which segment the tumor is arising! He or she is the best source for deciding upon the primary site for colon cases. For colon cancer, the surgeon’s determination takes precedence over the path report. Colonoscopy is not a good source for determining primary site, as the endoscopist is literally viewing the colon from the inside out, and it is difficult to determine precisely which segment the scope is in when the tumor is identified. Lymph nodes cannot be examined via colonoscopy. The colon lymph nodes lie on the other side of the colon wall!
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Determining Histology for Colon
Review Colon Histology Rules in MP/H (Colon Chapter) Review Rectosigmoid/Rectum/Anus Histology Rules in MP/H (Other Sites Chapter) Picking the histology code for a colon cancer isn’t simply using the ICD-O-3 book! There are special rules for colon histology coding in the MP/H book that must be reviewed each time you abstract a case. Remember also, that rectosigmoid/ rectum/and anus do NOT use the same schema as the colon Nicole will be discussing the MP/H Rules and CS guidelines.
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Determining Topography
This book is one you will want to keep close at hand as you abstract cases. Remember to stay current on ICD-O-3 Errata and Clarifications, I recommend printing these regularly and keeping them with your ICD-O-3 book. Let’s turn to page 19 in the ICD-O-3 book, pictured here, and discuss the coding guidelines for Topography and Morphology. **Read through the rules in ICD-O book. Get audience participation. Read rules on page 20 and Then mention that pages 24 through 33 goes into much more detail of each of the rules. Point out that page 27 contains information that we collect on every case we abstract—Behavior. Go over each of the codes individually from p 27 Table Point out that page 30 and 31 also contains information collected on every abstract—Tumor grade—which we will discuss in more detail shortly. **Next Slide is a build slide, it will have only the title initially. Notes on that slide detail order.
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Let’s work this together!
Patient undergoes colonoscopy with biopsy of a large polyp in the sigmoid colon. Resection reveals tubulovillous adenocarcinoma of the sigmoid colon What is the histology code? This is a build/animated slide, click again to reveal first paragraph. Click again for “How many primaries” click again for histology code, and click again to advance to the next slide. **Pass out practice quiz. Take a few minutes to find topography and histology codes for these examples on the worksheet using your ICD-O books. We will review the answers together after everyone has had a chance to finish.
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Tumor Grade/Differentiation,
The Abstractor Manual found on the KCR website contains information regarding Tumor Grade. The FORDS manual also provides information for tumor grade. Lets refer to the separate handout titled Tumor Grade. We have a separate Power Point Presentation to share on Tumor Grade.
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Grade An expression of the tumor’s aggressiveness and an estimate of its prognosis. 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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What we covered today Class of Case Anatomy Topography / Morphology
Histology Grade /Differentiation
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