SHRI Video Training Series Recorded 1/2020 Colorectal .

1/21/2020SHRI Video Training Series2018 dx and forwardRecorded 1/2020Colorectal Primary Site & HistologyPresented by Lori Somers, RNIowa Cancer Registry20201Colorectal AnatomyPrimary Site ICD‐O Codes for Colon and RectumHep. FlexC18.3AscendingC18.2Cecum C18.0TransverseC18.4LargeIntestine,NOS C18.9Splen. FlexC18.5DescendingC18.6Sigmoid C18.7Appendix C18.1Rectum C20.9Rectosigmoid C19.91

1/21/2020Determining Primary SiteCoding Guidelines Priority Order for Coding Primary SiteResected cases Operative report with surgeon’s description Pathology report ImagingPolypectomy or excision without resection Endoscopy report Pathology reportDetermining Primary SiteSubsites: Code the subsite with the most tumorwhen the tumor overlaps two subsites. Code C188 when both subsites areequally involved Colonoscopy measurement asindication of tumor location2

1/21/2020Colonoscopy Measurements*Transverse 82‐132 cmAscending132‐147 cmDescending57‐82 cmSigmoid 17‐57 cmCecum at 150cmRectum 4‐16cmRectosigmoid 15‐17 cmAnus 0‐4 cm* from anal verge Approximations only.Source: AJCC Cancer Staging Manual, fifth edition, page 85, 1997.USESolid Tumor Rule Manual3

1/21/2020Review ManualIntroductionChanges from 2007 MPH RulesEquivalent or Equal TermsTable 1Table 2 (Not reportable)IllustrationsIntroduction 98% colon cancers are adenocarcinoma and adenocasubtypes Mixed histologies rare Terms: NET, NEC, GISTo NET (Neuroendocrine tumor) replacing the term carcinoid;some path still uses carcinoido NEC (Neuroendocrine carcinoma) includes small cell, largecell and PD neuroendocrine carcinomao GIST (gastrointestinal stromal tumor) 60% stomach; 30% smallintestine About 25% are malig; often difficult to determine behavior4

1/21/2020Changes from 2007 MPH RulesEffective 1/1/2018 dx and later:Code most specific histology from biopsy or resection.o If discrepancy, code from most representativespecimen (greater amt of tumor)NET (formerly carcinoid) arising in appendix arereportable 1/1/2015 and forward.Pseudomyxoma peritoneio High grade is malig /3o Low grade is NOT malig /1Terminology Equivalent Terms: pg 57-58 Not Equivalent or Equal: pg 58-595

1/21/2020ChangesDysplasia /2 not reportable in U.S. Pathologists often use severe dysplasia or high grdysplasia in place of CIS. Code CIS ONLY ifpathologist states CIS.Disregard polypso Adenocarcinoma in a polyp now coded to 8140.Table 1Specific Histologies, NOS and Subtypes/Variants Rare histologies may not be listed in table If code specific to /2 or /3, means only one possiblebehavior If not specified can be /2 or /3 Columns & Rows6

1/21/2020HeadersUnknown if single or multiple M1Single Tumor M2Multiple Tumors M3-M157

1/21/2020STR ExamplesMultiple Primary Sites?Example 1: Malignant mass found in transversecolon C18.4, and another malignant mass foundin descending colon C18.6. Biopsy showed adenocarcinoma (8140) ofboth lesions. How many primaries?8

1/21/2020Multiple TumorsM3 polyposisM4 Abstract mult pri when there areseparate non-contiguous tumors insites with ICDO site codes that differat the CXxx and or CxXx characterC18.4 and C18.6. Do not stop. YET.Multiple Tumors M5 histology subtypes in Table 1M6 different rows Table 1M7 anastomotic site (new)M8 anastomotic siteM9 Mult pri separate non-continuous tumors inICDO site that differ at 4th character C18X.C18.4 and C18.69

1/21/2020Multiple cancersExample 2: Patient with Colon cancer in 2000 and on yourdatabase with Site: C18.2 Ascending colon PD invasiveadenocarcinoma. 8140/3 on hemicolectomy. In 2018 found to have recurrence at the anastomoticsite dx exactly as mucinous adenocarcinoma (8480).10

1/21/2020Histologyfor Colorectal CancerSolid Tumor RulesIncludes Colon, Rectum andRectosigmoidPriority Order for usingDocumentation to Identify Histology1. Code histology prior to neoadjuv treatment.2. Code histology assigned by physician. Don’t change to stage.Code most specific pathology/tissue from resection or biopsy Term ‘Most specific’ subtype/variant Code invasive if both in situ and invasive If discrepancy between biopsy and resection, code from mostrepresentative spec (greater amt of tumor). Use tissue from path, addendum, final, CAP. Tissue from metastatic site Scan Clinical Cytology11

1/21/2020Multiple HistologiesCode Histology when:A. Exact term is documentedB. Histology described as Subtype Type VariantCoding Histology Code most specific (do not use breast rules for thissite) Use Histology Rules, not just this section1. Code most specific histology, subtype/variant,regardless if stated as majority or predominant;minority; component2. Code histology described as differentiation,features/features of only when there is specific codefor “features” or “differentiation”12

1/21/20203. Code specific histology described by ambiguousterms ONLY when A or B is true:A. Only dx available described by ambig term Case accessioned based on ambig terms (noother histology available)B. NOS histology and a more specific described byambig terms Code specific hist confirmed by MD or pt rec’vtreatment based on specific hist described by ambigterm.4. Do not code hist described as: architecture, foci,focus, focal, pattern.13

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1/21/2020NET (Carcinoid) cancer Look for schemas starting with NET All NET tumors are considered malig,/3. Effective 2015, carcinoid tumor, NOS ofappendix (C18.1) is reportable, 8240/3. Keep it simple: Code all to /3 unlessdesignated benign.FAP (8220) Familial adenomatous polyposis (FAP)o also known as familial polyposis coli subtype: Gardner syndrome (with other neoplasms)o genetic defecto patients have 100 colon polyps (usually thousands); most aretubular adenomaso 100% progress to colon carcinomao prophylactic colectomy by age 20-25Reportable only when cancer in a polypRule M3 single primaryRule H10 822017

1/21/2020Anus Histology Squamous cell carcinoma (8070/3)o Arises in the anus Cloacogenic transitional cell carcinoma (8124/3)o Arises at anorectal junctionPrimary Site :C21.0 Anus NOSC21.1 Anal CanalC21.2 Cloacogenic zoneC21.8 Overlap rectum & anusHistology Example18

1/21/2020Example #1Pathology: 3-1-19 Left colon resection:Final DX Splenic flexure MD adenocarcinoma,mucinous ( 75%). Tumor invades through bowelwall. 1 out of 13 mesenteric LNs pos. StageT3N1M0.Primary Site C:Histology/behavior:Primary Site and Morphology ExercisesSTOPforEXERCISES19

1/21/2020Case #1Final Pathology: 3-1-19 Sigmoid resection: Infiltrating PDadenocarcinoma with mucinous features. Tumor invades through bowelwall. 1 out of 13 mesenteric LNs pos.Primary SiteHistology/BehaviorCase #2FINAL Pathology: 3-1-19 L colon resection: Infiltrating well diffadenocarcinoma and signet ring cell carcinoma ( 75%). Tumor invadesthrough bowel wall. 1 out of 13 mesenteric LNs pos.Primary SiteHistology/Behavior20

1/21/2020Case #3Scope: Colonoscopy shows tumor 10cm from dentate line.FINAL Pathology: 3-1-19 Rectosigmoid resection: Gross A 1.5 cm rectalmass showing dysplasia, high grade, intraepithelial neoplasia.Primary SiteHistology/BehaviorTable 221

1/21/2020Case #4Surgery: 10-10-19 R Hemicolectomy: Adenoma in Hepatic flexureFINAL Pathology: 10-10-19 Tubulovillous adenoma with infiltratingmucinous adenocarcinoma, invasion into submucosa. All 10 pericolic LNsnegative. Margins free.Primary SiteHistology/BehaviorCase #5Surgery: 10-30-19 Right hemicolectomy: liver palpated WNL.FINAL Pathology: 10-30-19 Right colon, terminal ileum and appendix. DX Two separate lesions are all mod diff adenoCA; Largest tumor inascending colon is 3.7cm, infiltrates the muscularis propria andpericolonic fat. Margins negative. 5/14 LNs positive. Second tumor inhepatic flexure is 0.9 cm polyp which invades submucosa.How many abstracts?Primary SiteHistology/Behavior22

1/21/2020HomeworkSEER Solid Tumor Rules on SEER*Edu https://educate.fredhutch.org/LandingPage.aspx Practical application sectiono Select DX 2018 Solid Tumor Rules Colon and rectum 01-0545QuestionsContact InfoLori Somers, RNTraining & Quality ImprovementState Health Registry of Iowalori‐somers@uiowa.edu4623

Colorectal Anatomy Primary Site ICD‐O Codes for Colon and Rectum Transverse C18.4 Sigmoid C18.7 Descending C18.6 Rectum C20.9 Rectosigmoid C19.9 Ascending C18.2 Cecum C18.0 Splen. Flex C18.5 Hep. Flex C18.3 Appendix C18.1 Large Intestine, NOS C18.9