1. PUBLIC HEALTH DIVISION Oregon State Cancer Registry Abstracting Hematologic Malignancies Stepping Up Your Game LeeLa Coleman, CTR Cancer Data Consultant Fall Workshop October 9, 2015

2. 2 Agenda Overview Heme Manual and Database overview It’s different –Ambiguous Terminology –Histology –Grade –Diagnostic Confirmation –M Rules –Grade Steps in Priority Order for Using Heme DB and Coding Manual –Focus on multiple primary rules Resources

3. 3 Overview New hematopoietic & lymphoid neoplasm rules Applies to –morphology codes 9590 to 9992 –behavior code of /3 –diagnosed on or after January 1, 2010

4. 4 Overview SEER Lead Hematopoietic Working Group –SEER –NCRA –NAACCR –NPCR –CoC –ACOS –CCR Is the authoritative reference Questions go to SEER (SINQ)

5. 5 Overview Why change? 2008 WHO Classification of Tumors of Hematopoietic and Lymphoid Neoplasms –Basic principle - classification for all neoplasms based on Morphology and biologic features Genetic Immunophenotype Clinical features ICD-O-3 not keeping up –Focused on tissue biopsy and morphology Old rules were not adequately capturing transformation

6. 6 Overview Diagnostic process is different than for solid tumors Path report is usually start of the diagnostic workup –Usually results in provisional diagnosis NOS histology or ambiguous term histology Most often additional testing is required –Genetic –Immunophenotyping Some diagnoses are arrived at after excluding other causes

7. 7 Heme Manual and DB

8. 8 Heme manual –Updated manual published January 14, 2015 –“Version” no longer applicable (2014) –Use for all cases diagnosed January 01, 2010 and forward Heme DB –Web-based and stand-alone –Web-based version is updated as information becomes available Revision history and conversion documents available at http://seer.cancer.gov/tools/heme/ http://seer.cancer.gov/tools/heme/

9. 9 Heme Manual and DB Work together to determine Reportability Multiple primaries Histology Primary site Grade Updated manual published January 14, 2015 “Version” no longer applicable (2014) Use for all cases diagnosed January 01, 2010 and forward Database updated as information becomes available

10. 10 Heme Manual “Rule” book with instructions on: Case reportability First course of treatment Diagnostic Confirmation (NAACCR # 490) M Rules (multiple primary) Histology (NAACCR #522) Primary site (NAACCR # 400) Primary site & Histology (PH rules) –Rule PH1 to Rule PH31 –Arranged in 9 Modules Much more

11. 11 Heme Manual M Rules and Instructions (manual pages 25-29) Clarification to use M rule references in DB as guide only. Start with M1 for each case, move through the rules, stop at first rule that applies For M Rules that have corresponding PH rules, links were added

12. 12 Heme DB

13. 13 Heme DB – Transformations Field Transformations are used with M Rules M8-M13 to help determine number of primaries Transformations To –Only applicable to chronic diseases that may transform to a more acute phase –If no histologies are listed, not a chronic disease that transforms Transformations From –Only applicable acute diseases will have histologies listed –If no histologies are listed, not an acute disease that transforms

14. 14 Heme DB Use Multiple Primaries Calculator only when instructed by the M Rules

15. 15 Using Heme Manual & DB Steps in Priority Order 1.Assign a “working” histology code 2.Determine the number of primaries using M Rules 3.Use Definitive Diagnostic Method (DB) to verify or revise the “working” histology 4.Determine the primary site 5.Determine the grade

16. 16

17. It’s different Not the same as solid tumors Applies to cases diagnosed 01/01/2010 forward 17

18. 18 Ambiguous Terms Apparently Appears Comparable with Compatible with Favor(s) Malignant appearing Most likely Presumed Probable Suspect(ed) Suspicious (for) Typical (of)

19. 19 Ambiguous Terms Use: Reportability Date of diagnosis Don’t use: Coding specific histology NOS histology takes priority over specific histology when preceded by ambiguous term. Heme manual Histology Coding Instructions #3 – 5 contain instructions and clarifications for coding histology with ambiguous terms

20. 20 Histology Code histology identified by method(s) listed in Heme DB Definitive Diagnostic Method(s) section. May includeDefinitive Diagnostic Method(s) Clinical diagnosis Genetic test Immunophenotyping Cytology Pathology

21. 21 Histology NAACCR #522 When test or report lists a specific histology with an ambiguous term (NOS histology) Code the NOS histology Specific histology can be assigned if –Later testing definitively identifies specific histology (timing not a factor) –Physician definitively states the diagnosis –Record states patient is being treated for a specific histology –Abstractor notes identify additional information that can be used

22. 22 Diagnostic Confirmation NAACCR #490 New schema for cases diagnosed 01/01/2010 or later –Don’t use for cases diagnosed prior to 2010 No priority or hierarchy for coding Code result that definitively diagnoses the case Review Heme DB to determine definitive diagnostic method Use positive findings for the neoplasm being abstracted

23. 23 Diagnostic confirmation Microscopically confirmed CodeDescription 1Positive histology Peripheral blood smear can be used for all heme histologies 9590/3 – 9992/3 CBC & WBC can be used for leukemias only 9800-9948 2Positive cytology 3Positive histology PLUS: –Positive immunophenotyping and/or positive genetic testing –DB is continually updated

24. 24 Diagnostic confirmation Not Microscopically confirmed CodeDescription 5Positive laboratory test or marker 6Direct visualization without microscopic confirmation 7Radiology and other imaging techniques without microscopic confirmation 8Clinical diagnosis only (other than 5, 6 or 7) Confirmation Unknown 9Unknown whether or not microscopically confirmed; death cert

25. 25 Diagnostic confirmation Clinical confirmation is a valid diagnostic method –Some cases are a diagnosis of exclusion, made after other causes are ruled out Use Code 8 when –the DB lists it as a definitive diagnostic method –there are no other results that are definitively positive –physician states the overall findings are [histology] –Diagnosis of exclusion

26. 26 Diagnostic confirmation Codes that should rarely be used: Code 2: Positive cytology caution Mostly used when spinal, pleural or peritoneal fluid is the only confirmation Code 4: Positive microscopic confirmation Code 5: Positive lab test or marker caution Don’t use to code immunophenotyping and/or genetic testing Code 6: Direct visualization without microscopic confirmation Coding tips: Review heme manual, pages 14-16 and DB before using codes 2, 4, 5, 6 Positive CBC or peripheral blood smears should be coded 1 (or 3 if positive immunophenotyping and/or genetic testing)

27. 27 Pop Quiz 1 - Diagnostic Confirmation Peripheral blood flow cytometry: B-cell population with co-expression of CD19/CD5. Positive for CD20, 22,23 & 200 but negative for CD10 & FMC-7. Expression of CD38 not detected. Compatible with CLL/SLLCLL/SLL The diagnostic confirmation is: a)1 – histology b)3 – histology + immunophenotyping/genetic c)5 – positive lab test or marker d)8 – clinical e)It depends

28. 28 Pop Quiz 1 – Diagnostic confirmation Heme DB

29. 29 Pop Quiz 1 - Diagnostic Confirmation The diagnostic confirmation is: a)1 – histology b)3 – histology + immunophenotyping/genetic* c)5 – positive lab test or marker d)8 – clinical e)It depends

30. 30 Pop Quiz 1 - Diagnostic Confirmation The diagnostic confirmation is: d)It depends… It could be 3 – immune/genetic if Physician made a definitive diagnosis Patient was treated for a specific diagnosis Follow-back with physician strongly advised

31. 31 Pop Quiz 2 - Diagnostic Confirmation CT scan: extensive bilateral cervical and retroperitonal lymphadenophathy FNA biopsy cervical LN – malignant neoplasm Flow cytometry – no definitive CD45+ events for informative analysis FISH analysis – no evidence of rearrangement in limited number of cells available Physician statement – patient presents with extensive lymphoma, chooses hospice, no further workup.

32. 32 Pop Quiz 2 - Diagnostic Confirmation Histology is a)Malignant neoplasm, NOS – 8000/3 b)Lymphoma, NOS – 9590/3 Diagnostic confirmation a)1 – histology b)7 – imaging c)8 - clinical

33. 33 Pop Quiz 2 - Diagnostic Confirmation

34. 34 Pop Quiz 2 - Diagnostic Confirmation Histology is a)Malignant neoplasm, NOS – 8000/3 b)Lymphoma, NOS – 9590/3 Diagnostic confirmation a)1 – histology b)7 – imaging c)8 - clinical Reference: SINQ 20120002

35. 35 M Rules – Multiple Primaries Use M rule references in Heme DB as guide only In Heme Manual, start with M1 (page 25) –move through the rules –stop at first rule that applies Reminder - physician may start with provisional diagnosis(s) and identify more specific diagnosis as testing is completed Use the Heme DB Multiple Primary Calculator only when instructed to do so.

36. 36 Pop Quiz 3 – M Rules 05/15/12 - Patient diagnosed with acute myeloid leukemia 07/30/15 – Patient diagnosed with myeloid sarcoma How many primaries? a)1 b)2

37. 37 Pop Quiz 3 – M Rules Step 1 - assign a working histology Mast cell leukemia – 9742/3 Mast cell sarcoma – 9740/3 Step 2 – apply the MP rules M3 –Abstract as a single primary when a sarcoma is diagnosed simultaneously or after a leukemia of the same lineage

38. 38 Pop Quiz 3 – M Rules Use the Hematopoietic Multiple Primaries Calculator when instructed by the Heme manual Mast cell leukemia Mast cell sarcoma OOPS!

39. 39 Grade NAACCR #440 Based on cell lineage, not differentiation Grade of Tumor Rules in Heme Manual pages 49 - 52 –When applicable, Heme DB can be used for quick reference Codes in heme Manual or DB take priority over grade descriptions in path report

40. 40 Grade Only valid grade codes for heme neoplasms are 5, 6, 7, 8 and 9 Do not code based on descriptions “low grade”, “intermediate grade” or “high grade”.

41. 41 Pop Quiz 3 – Grade Final path report: Follicular lymphoma, grade 2 - 3 What histology should be coded? Extra credit a)9691/3 - follicular lymphoma, grade 2 b)9698/3 - follicular lymphoma, grade What is the grade code for this primary? a)2 - moderately differentiated b)3 – poorly differentiated c)6 - B-cell

42. 42 Exercise Using Heme DB and Manual Steps in Priority Order

43. 43 Exercise Physical Exam –01/03/2014 - HPI: Patient was diagnosed w/ follicular lymphoma of the tonsil in 01/2010. A tonsillectomy and adenoidectomy was performed. FISH showed BCL2 gene rearrangements. The patient has been disease and symptom free since 2010. Now presents w/ no appetite, weight loss, and digestive problems. Scans –01/03/2014 - MRI Abd: Mass lesion in the duodenum. Probably malignant. Path Text –01/04/2014 - Bx duodenal mass: Final Diagnosis: Lymphoma, large B- cell. –01/04/2014 - Flow Cytometry on duodenal tissue: CD10 positive, CD79a positive. Impression: Diffuse large B-cell lymphoma.

44. 44 Exercise Using the steps, determine –Date of diagnosis –Histology(s) –Number of primaries –Primary site –Grade –Diagnostic confirmation

45. 45 Exercise Step 1 - assign a working histology Step 2 – apply the MP rules

46. 46 Exercise Step 3 – verify or revise the working histology (if needed)

47. 47 Exercise Step 4 – Determine the primary site(s)

48. 48 Exercise Step 5 – Determine the Grade

49. 49 Exercise What is the diagnostic confirmation code(s)?

50. 50 Resources REFERENCES SEER Hematopoietic Project http://seer.cancer.gov/tools/heme/ SEER Hematopoietic & Lymphoid Database SEER Hematopoietic & Lymphoid Manual Multiple Primaries Calculator http://seer.cancer.gov/seertools/hemelymph/ SEER Inquiry System (SINQ) http://seer.cancer.gov/seerinquiry/index.php

51. 51 Resources TRAINING Free, CEs provided! NAACCR Webinars Available on request from OSCaR SEER*Educate https://educate.fhcrc.org/Index.aspx

52. 52 Thank you! LeeLa Coleman, CTR leela.j.coleman@state.or.us T: 971-673-1056