1. Tumor Grade

2. Coding grade
Grade has long been a source of confusion…

3. Coding grade Several issues complicate matters: in situ vs invasive
terminology vs numbers
special rules for many sites
FORDS and SEER manual have different instructions
2) Trying to decide whether to go with terminology or numbers
3) Many sites have their own special rules (breast, prostate, kidney, etc.)
4) CoC and SEER disagree

4. Changes in coding grade
SEER, CDC, and CoC formed a work group to address the problem
No new codes; only clarifications and changes to instructions
New rules apply to cases diagnosed January 1, forward

5. Changes in coding grade
Instructions for coding cell indicator in hematopoietic and lymphoid neoplasms (codes 5, 6, 7, 8, 9) have not changed
Determine cell indicator using the “Grade of Tumor Rules” in Hematopoietic and Lymphoid Neoplasm Manual

6. Changes in Coding Grade
For solid tumors, grade is a measurement of how closely the tumor cells resemble the tissue from the organ of origin
Similarities and differences may be based on pattern (architecture), cytology, nuclear features, or a combination of these
Depends upon which grading system is used
1) Well differentiated tumor cells closely resemble the tissue from which they originated
Poorly differentiated and undifferentiated tumor cells are disorganized and abnormal; they look very different from the their tissue of origin
3) For example, Gleason grading for prostate uses only pattern; Fuhrman’s for kidney uses only nuclear features; most use a combo

7. Coding grade Pathologists describe tumor grade using three systems:
Two levels of similarity (two-grade system)
Three levels of similarity (three-grade system)
Four levels of similarity (four-grade system)

8. Rules for coding solid tumors
1) Code grade based on information prior to neoadjuvant therapy, even if grade is unknown 2) Code grade from the primary tumor only- NOT mets or recurrence; in the rare instance that the tumor extends contiguously to an adjacent site and tissue from the primary site is not available, code grade from the contiguous site
Systemic treatment and XRT can alter a tumor’s grade
2) For example, a pancreatic cancer in which the tumor is extending DIRECTLY into the liver, and the liver tumor was bx’d

9. Rules for coding solid tumor
3) Code the grade (6th digit) for specific histologic terms that imply a grade (i.e., undifferentiated sarcoma 8805/34) 4) For in situ or combined in situ/invasive tumors- if a grade is assigned for an in situ tumor, code it. Do NOT code grade for dysplasia. If there are both in situ and invasive components, code only the grade for the invasive portion, even if it is unknown
3) Full list in manual
4) i.e., high grade dysplasia

10. Rules for coding solid tumors
5) If more than one grade is given, code the highest grade, even if it is only a focus. Code grade in the following priority order using the first applicable system:
Special grade system for the sites listed in #6
Differentiation, using instructions in #7 (2, 3, or 4 grade system)
Nuclear grade, using instructions in #7 (2, 3, or 4 grade system)
If it isn’t clear whether the grade assigned is differentiation or nuclear, but a 2, 3, or 4 grade system was used, code it using instructions in #7
Terminology
Special grade sites- breast, prostate, kidney, etc.

11. Rules for coding solid tumors
6) Use information from the special grade system first; if no special grade can be coded, go on to #7 Grade information based on CS SSF’s for breast, prostate, heart, mediastinum, peritoneum, retroperitoneum, soft tissue, and kidney parenchyma is used to code grade

12. Rules for coding solid tumors
See the rules for each of these SSF’s for details on how to code grade for these sites:
CS Schema
Special grade system
Breast
Nottingham or Bloom-Richardson (BR) Score/Grade (SSF7)
Prostate
Gleason's Score on Needle Core Biopsy/Transurethral Resection of Prostate (TURP) (SSF 8)
Gleason's Score on Prostatectomy/Autopsy (SSF 10)
Heart, Mediastinum
Grade for Sarcomas (SSF 1)
Peritoneum
Retroperitoneum
Soft Tissue
Kidney Parenchyma
Fuhrman Nuclear Grade (SSF 6)
DO NOT use SSF’s for sites other than those listed here to code grade (for example, WHO grade for CNS tumors, FIGO for gyn, etc.)

13. Rules for coding solid tumors
7) Use the two, three, or four grade system information Two grade system
Term
Description
Grade Code
Exception for Breast and Prostate Grade Code
1/2, I/II
Low grade 2 1
2/2, II/II
High grade 4 3
If the site isn’t one of the ones mentioned in the table in #6, go to rule #7. This is similar to the MPH rules, where you find the rules that fits, then stop.
Two grade system is commonly used for TCC of the bladder

14. Rules for coding solid tumors
Three grade system
Term
Description
Grade Code
Exception for Breast and Prostate Grade Code
1/3
Low grade 2 1
2/3
Intermediate grade 3
3/3
High grade 4

15. Rules for coding solid tumors
Four grade system
Term
Description
Grade Code
1/4
Grade I; Well differentiated 1
2/4
Grade II; Moderately differentiated 2
3/4
Grade III; Poorly differentiated 3
4/4
Grade IV; Undifferentiated 4

16. Rules for coding solid tumors
8) When coding grade from terminology, use the “description” column or the “grade” column. Breast and prostate use the same grade code with a few noted exceptions.
If the grade you have isn’t using a special grading system and is not specified to be a two, three, or four grade system, use terminology to code grade

17. Rules for coding solid tumors
Description
Grade
Assign Grade Code
Exception for Breast and Prostate Grade Code
Differentiated, NOS I 1
Well differentiated
Only stated as ‘Grade I’
Fairly well differentiated II 2
Intermediate differentiation
Low grade
I-II
Mid differentiated
Moderately differentiated
Moderately well differentiated
Partially differentiated
Partially well differentiated
Relatively or generally well differentiated
Only stated as ‘Grade II’

18. Rules for coding solid tumors
Description
Grade
Assign Grade Code
Exception for Breast and Prostate Grade Code
Medium grade, intermediate grade
II-III 3 2
Moderately poorly differentiated
III
Moderately undifferentiated
Poorly differentiated
Relatively poorly differentiated
Relatively undifferentiated
Slightly differentiated
Dedifferentiated
Only stated as ‘Grade III’
High grade
III-IV 4
Undifferentiated, anaplastic, not differentiated IV
Only stated as ‘Grade IV’
Non-high grade 9

19. Rules for coding solid tumors
9) If no description fits or grade is unknown prior to neoadjuvant therapy, use code 9 (unknown)

20. Special grade system rules
Breast uses Bloom Richardson (BR) or Nottingham
Coded in SSF7
Code in priority order
BR scores 3-9
BR grade (low, intermediate, high)

21. Special grade systems rules
BR score is expressed as a range, 3-9.
Based on three morphologic features: degree of tubule formation/histologic grade, mitotic activity, nuclear pleomorphism/nuclear grade of tumor cells

22. Special grade system rules
If a pathology report uses words such as low, intermediate, or high rather than numbers, use this table to code grade
Description CS
Code
Grade Code
Score of 3
030 1
Score of 4
040
Score of 5
050
Score of 6
060 2
Score of 7
070
Score of 8
080 3
Score of 9
090
Low Grade, Bloom-Richardson (BR) grade 1, score not given
110
Medium (Intermediate) Grade, BR grade 2, score not given
120
High Grade, BR grade 3, score not given
130

23. Special grade system rules
If only a grade of 1 through 4 is given with no information on the score, and it is unclear if it is a Nottingham or BR grade, do not use the conversion table.
Instead, continue on to #7 in the grading rules
If multiple scores are reported, code the highest score

24. Special grade system rules
Kidney uses Fuhrman nuclear grade
Parenchyma ONLY- not renal pelvis!
Coded in SSF6
Fuhrman nuclear grade is a four-grade system based on nuclear diameter and shape, the prominence of nucleoli, and the presence of chromatin clumping
C64.9, never C65.9

25. Special grade system rules
Description CS
Code
Grade Code
Grade 1
010 1
Grade 2
020 2
Grade 3
030 3
Grade 4
040 4
If you code SSF 6 = 030, but code grade = 1, you will get an error message

26. Special grade system rules
Soft tissue sarcoma uses a three-grade system
French Federation of Cancer Centers Sarcoma Group (FNCLCC)
Coded in SSF1
In some cases (especially for needle bxs), grade may be specified only as “high grade” or “low grade”
Numeric grade take precedence over high or low

27. Special grade system rules
Description CS
Code
Grade Code
Specified as Grade 1 [of 3]
010 2
Specified as Grade 2 [of 3]
020 3
Specified as Grade 3 [of 3]
030 4
Grade stated as low grade, NOS
100
Grade stated as high grade, NOS
200

28. Special grade system rules
Prostate uses Gleason grade
Coded in SSF8 (bx/TURP) and SSF10 (prostatectomy/autopsy)
Gleason grade is based on a 5-component system and generally shows two main histology patterns
Prostate –Gleason Grade was a change in 2014
Exclude results from tests performed after neoadjuvant tx

29. Special grade system rules
The primary pattern occupies >50% of the cancer
It is usually the first number of the Gleason grade
Secondary pattern is indicated by the second number
These two numbers are added together to create the score, ranging from 2-10

30. Special grade system rules
If there are two numbers, assume they refer to patterns, and add them together to obtain the score
If only one number is given, and it is < 5, and not specified as a score, do not use the information, because it could refer to either a score or a grade
If only one number is given, and it is >5, assume that is the score and use it

31. Special grade system rules
Change in prostate grading
Gleason
Description
SEER
score
CS Code
Grade Code
AJCC 7th
2003-
2013
AJCC 6th
prior
2003 2
002 1 G1 3
003 4
004 5
005 G2 6
006 7
007 G3 8
008 9
009 10
010
Basically, lower grades (2-4) and higher grades (8-10) have never changed
Middle grades have mutated to bring them into line with AJCC 7th Ed
Gleason scores of 5 and 6, which used to be 2, is now 1.
Gleason 7, which used to translate to grade 3, is now 2.

32. Special grade system rules
Due to coding changes in Gleason Grade 7 in 2014, analysis of prostate grade for cases diagnosed prior to based solely on the grade field is not recommended
Standard setters were trying to balance continuity through time with advances in staging and prognosis
As a results, prostate grading over time is a bit of mess

33. Special grade system rules
SSF 8
Code
SSF 10
Grade Code
002
003
004
005
006
007
008
009
010
988
998
999 1 2 3 *
Conversion table for SSF 8 and SSF10 to grade

34. Changes in coding grade
The new grading instructions can be found at
CoC and SEER has incorporated these instructions in their respective coding manual for 2014
KCR Abstractor’s Manual has been updated

35. Summary 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

36. Location for Coding Tumor Grade
The grade/ differentiation of a tumor is coded in the 6th digit of the morphology code and is only one digit*
M- _ _ _ _ /_X
In CPDMS.net the grade is separated from the histology so it is not seen in the 6th digit format.

37. Example
Given the following information, provide the Tumor Grade to code in CPDMS.net
3/22/16: Mass of transverse colon: Path states: Invasive colonic adenocarcinoma with ulceration, high grade 4/2.
Which code would you record ?

38. Changes in coding grade
Questions?