1. New Abstractor’s Training Colon Cancer Marynell Jenkins, CCRP, CTR Regional Coordinator

2.  Class of Case  Anatomy  Topography / Morphology  Histology  Grade  Differentiation What we are covering today: 2

3.  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. 3

4. 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

5. Analytic: Class of case 10-14 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

6. Non-analytic: Class of case 30-37 Pt 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

7. 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

8. Non-analytic: Class of case 38 Diagnosed 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

9. 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)

10. Let’s look at some examples 10 Class of Case: Examples

11. 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.] Types of Colon Cancer 11

12.  Polyp on a short stalk, approximately 1 cm in size Photo of Polyp in Sigmoid Stephen Holland, M.D., Naperville Gastroenterology, Naperville, IL, USA. 12

13. Polyps: Pedunculated & Flat 13

14. 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… 14

15.  Cecum (proximal right colon) 6 x 9 cm pouch covered with peritoneum  Appendix A vermiform (wormlike) diverticulum located in the lower cecum  Ascending colon 20-25 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..http://training.seer.cancer.gov/ Colon Anatomy 15

16.  Transverse colon Lies anterior in abdomen, attached to gastrocolic ligament  Splenic flexure Near tail of pancreas and spleen  Descending colon 10-15 cm long, located behind the peritoneum  Sigmoid colon Loop extending distally from border of left posterior major psoas muscle Colon Anatomy 16

17.  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 Rectosigmoid, Rectum & Anus 17

18. 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 18

19. 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 19

20.  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) 20

21. 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/ 21

22. 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 22

23. * 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 23

24. Presenting Symptoms Physical Exam Scans Labs Scopes Biopsies Diagnosing Colon Cancer 24

25. 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 1 st contact CANNOT precede Dx Dt! Locating the Diagnosis Date! 25

26. Selecting a Site Code Determining colon cancer primary site…. Different physicians may document different sites! Operative Report takes top priority for colon…. 26

27.  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 27

28. Determining Topography 28

29. 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! 29

30. Grade/Differentiation, Grade Path Value, and Grade Path System

31.  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. 31

32.  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 32

33.  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 33

34.  The grade/differentiation of a tumor is coded in the 6 th 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 6 th digit format. 34

35.  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. 35

36. 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 as Low Grade, then code 2. If the grade is listed as 2/2 or as High Grade, then code 4. Two-Grade System 36

37. 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 37

38. 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 38

39. 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 39

40. 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.) 40

41. For prostate cancers, code the tumor grade using the table below following priority order: (1) Gleason Score (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 41 2, 3, 4, 5, 6 7 8, 9, 10

42. 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 42

43. 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 43

44.  Used to designate cell lineage  Use when given in the diagnostic statement Refer to the abstractor manual for schema. Coding Lymphomas and Leukemias 44

45. 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 45

46.  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 46

47. Time for the Exercises 47

48. 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 48

49. Example Exercise What were your answers? FieldValue Tumor Grade 49

50. Example Exercise What were your answers? 50

51.  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 51

52.  Class of Case  Anatomy  Topography / Morphology  Histology  Grade  Differentiation What we covered today 52