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New Abstractor’s Training
Colon Cancer
Marynell Jenkins, CCRP, CTR
Regional Coordinator
What we are covering today:





Class of Case
Anatomy
Topography / Morphology
Histology
Grade
 Differentiation
2
Class of Case
 According to the 2015 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.
3
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!
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
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
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
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
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)
Class of Case: Examples
Let’s look at some examples
10
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.]
11
Photo of Polyp in Sigmoid
 Polyp on a short
stalk ,
approximately 1
cm in size
Stephen Holland, M.D., Naperville Gastroenterology, Naperville, IL, USA.
12
Polyps: Pedunculated & Flat
13
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
14
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
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/>.
15
Colon Anatomy
 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
16
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
17
Colorectal Segments
C18.4
C18.5
C18.3
C18.6
C18.2
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 <http://training.seer.cancer.gov/>.
18
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
19
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. <http://training.seer.cancer.gov/>.
20
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
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
22
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
23
Diagnosing Colon Cancer
Presenting Symptoms
Physical Exam
Scans
Labs
Scopes
Biopsies
24
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!
25
Selecting a Site Code
Determining colon cancer
primary site….
Different physicians may
document different sites!
Operative Report takes top
priority for colon….
26
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)
27
Determining Topography
28
Let’s work this together!
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?
29
Grade/Differentiation, Grade Path
Value, and Grade Path System
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.
31
Differentiation
 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.
32
Differentiation Continued
 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.
33
Location in Coding
 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 the 6th digit format.
34
Grade/Differentiation Expression
 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.
*
This applies to solid tumors only.
35
Two-Grade System
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.
36
Three-Grade System
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.
37
Three-Grade System General
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.
38
Grade System for Breast
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.
39
Grade System for Breast (cont.)
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.
40
Tumor Grade for Prostate
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.
2, 3, 4, 5, 6
7
8, 9, 10
41
Tumor Grade for kidney
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 (M8960).
42
Four-Grade System
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.
43
Coding Lymphomas and Leukemias
 Used to designate cell lineage
 Use when given in the diagnostic statement
Refer to the abstractor manual for schema.
44
Coding CNS Tumors
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.
45
Grade/Differentiation Comments
 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.
46
Time for the Exercises
47
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
Example Exercise
What were your answers?
Field
Tumor Grade
Value
49
Example Exercise
What were your answers?
50
 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
What we covered today





Class of Case
Anatomy
Topography / Morphology
Histology
Grade
 Differentiation
52