Multiple Primary and Histology Rules 101

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Multiple Primary and Histology Rules 101

• Introductory Workshop
• May 23, 2006
• Pamela Moats, RHIT CTR
• NCRA-SEER
• HISTOLOGY LIASION

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Overview

• The problem with current rules
• Overview of changes
• Format of new rules
• When and how to use the rules
• Why site-specific rules are necessary

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Whats the Problem?

• 25 year old rules
• Site-specific exceptions
• Difficult to train
• Could not flowchart
• ICD-O-3
• New terms and new codes
• Non standard usage of nomenclature

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Whats the Problem?

• Changes in clinical practice
• Technology advances
• More histology characteristics descriptors
• Electron microscopy to immunohistochemistry

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Purpose of New Rules

• Clarify rules
• Prioritize sequence of rules
• Explain, define terms
• Promote consistency in coding
• Same answer from registrar to registrar
• Preserve integrity of incidence count
• Improve quality of data overall

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Major Changes

• Multiple Primaries
• Time frame
• 2 months 1 year or 3 years
• Histology
• Take information only from the FINAL diagnosis
  and not the microscopic description
• Rules for use of complex/combination codes

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Primary Sites

• Lung
• Colon
• Breast

• Kidney
• Renal pelvis, ureter, and bladder
• Head and neck
• Melanoma
• Brain

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How often do new rules apply?

• Varies by site
• Multiple Primaries lt10
• gt 90 of cases are single primaries
• Histology 15-25
• 75-85 of cases are basic NOS terms
• adenocarcinoma, ductal carcinoma, etc.

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Content of Rules Documents

• General Instructions
• Site-Specific Rules
• Equivalent Terms and Definitions
• Multiple Primary Rules--three formats
• Notes and examples
• Histology Rules--three formats
• Notes and examples
• General rules
• Same content and formats as site-specific rules

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General Terms and Definitions

• Read and know!
• Use for all cases with the exception of
  hematopoietic primaries (leukemia and lymphoma)
• Use only for multiple primary and histology rules
• Not for casefinding

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General Terms and Definitions

• Bilateral
• Clinical Diagnosis
• Contiguous tumor
• Contralateral
• Different histology
• Different (multiple) primaries
• Focal
• Foci
• Focus

• Ipsilateral
• Most representative specimen
• Multiple primaries
• Overlapping tumor
• Recurrence
• Paired organ/site
• Single histology
• Single (one) primary
• Unilateral

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General Terms and Definitionscontinued

• Focal-Foci-Focus
• Focal limited to one specific area
• May be microscopic or macroscopic
• NOT a synonym of (microscopic) focus
• Foci plural form of focus
• Focus group of cells that can only be seen
  through a microscope

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General Terms and Definitionscontinued

• Most representative specimen
• The pathologic specimen from the surgical
  procedure that removed the most tumor tissue.
• Might be excisional biopsy rather than
• -ectomy specimen

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General Terms and Definitionscontinued

• Recurrence
• 1. A new or another occurrence, incidence,
  episode, or report of the disease in a more
  general sense a new occurrence of cancer.
• 2. The reappearance of disease that was thought
  to be cured or inactive (in remission).
  Recurrent cancer starts from cancer cells that
  were not removed or destroyed by the original
  therapy.

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General Terms and Definitionscontinued

• Recurrence continued
• Do not use a physicians statement to decide
  whether the patient has a recurrence of a
  previous cancer or a new primary.
• Use the multiple primary rules as written
• unless a pathologist compares the present tumor
  to the original tumor and states that this
  tumor is a recurrence of the previous primary.

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In Addition

• Read the site-specific Equivalent Terms and
  Definitions before using the site-specific
  multiple primary rules.

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How to Use the Rules

• Read equivalent terms and definitions
• Choose a format of new rules to use
• Text
• Matrix
• Flowchart

The rules are identical, only the formats differ.
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Text

• Multiple Primaries example
• M2. A single independent non-metastatic tumor is
  always a single primary.
• Note The tumor may overlap onto or extend
• into adjacent/contiguous site or subsite.
• Histology example
• H4. Code the invasive histologic type when a
  single tumor has invasive and in situ components.

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Matrix
Multiple Primaries example
Histology example
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Flowchart--multiple primaries example
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Flowchart--histology example
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Flowchart
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Learning Styles

• Text
• Flowchart
• Matrix

• Visual
• Auditory
• Read/Write
• Kinesthetic

Use what works for you!
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Warning!

• Dont try to use all three rules formats!
• Dont combine new rules with old rules!

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Using the Rules

• Notes and examples are included with some of the
  rules to highlight key points or to add clarity
  to the rules.
• They are not exclusive.
• They do not replace the rules.

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Using the Rules

• Use multiple primary rules first
• Three independent modules
• Unknown number of tumors
• Single or multiple in primary site
• Single tumor (primary site)
• Multiple tumors (primary site)
• Ask how many tumors does this case have?

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Independent Modules

• Start with rules in appropriate module.
• Do not use rules from any other module.

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Rules are Hierarchical

• Within each section
• Use the first rule that applies and STOP.

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Histology Coding Rules

• Two independent modules
• Single Tumor (one primary site)
• Multiple Tumors abstracted as a single primary
  site
• Rules are hierarchical within each module.

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Multiple Pathology Reports

• Code from the pathology report
• from the most representative specimen examined
• from the final diagnosis

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Pathology Reports

• Note 1 A revised/amended diagnosis replaces the
  original final diagnosis. Code the histology from
  the revised/amended diagnosis.
• Note 2 The new rules limit the information to
  the final diagnosis. The old rules allowed
  coding from information in the microscopic
  description.

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If No Pathology

• Cytology report
• Documentation in the medical record that
  references pathology or cytology

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Ambiguous Terms-No Longer Utilized

• Apparent(ly)
• Appears
• Comparable with
• Compatible with
• Consistent with
• Favor(s)
• Most likely
• Presumed
• Probable
• Suspect(ed)
• Suspicious (for)
• Typical (of)

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No Negative Lists

• If it isnt listed, dont code it.
• No Do not use ambiguous terms list
• No Terms that do not represent the majority of
  the tumor list

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When?

• The rules are effective for cases diagnosed
  January 1, 2007 and after.
• Do not use these rules to abstract cases
  diagnosed prior to January 1, 2007.

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Important!

• The 2007 multiple primary rules replace all
  previous multiple primary rules.

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Why Site-Specific Rules?

• General rules cannot address site-specific issues
• Histologies
• Disease process for that site
• Valid mixed and combination histology codes

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Colon

• Multiple tumors/polyps
• Contiguous/overlapping sites
• Time between diagnoses
• NOS versus specific histology
• Mucinous adenocarcinoma
• Neuroendocrine carcinoma
• Signet ring cell adenocarcinoma
• Undifferentiated carcinoma
• Adenocarcinoma with mixed subtypes

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Head and Neck

• What is the primary site?
• Complex anatomy
• Laterality
• Paired site
• Upper/lower
• Field effect
• Multiple tumors
• Contiguous/overlapping sites

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Head and Neck

• Site Group new concept
• Multiple reports
• Multiple biopsies
• Biopsy versus resection
• Multiple resections
• In situ and invasive
• Time between diagnoses
• Histology Group new concept

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Lung

• Laterality
• Multiple tumors
• Tumors with/without biopsy
• Multiple reports
• Contiguous/overlapping sites
• Time between diagnoses

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Lung (continued)

• Multiple tumors in same lung but only one
  biopsied
• Rules default to abstracting case as a single
  primary with metastatic disease when only one
  tumor is biopsied.
• Three or more tumors in one or both lungs are
  usually a single lung primary with metastatic
  disease.

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Lung (continued)

• NOS versus specific histology
• Histology codes the same at 3 digit level
• Small cell (8041-8045) / non-small cell (8046)
• Bronchoalveolar (8250-8254) / mixed (8255)
• Histology Group new concept Chart I
• Mixed histologies Table I

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Melanoma

• ICD-O-3 topography codes
• Laterality-related issues
• Right/left/midline
• Front/back
• Upper/lower
• Precancerous lesions
• Atypical melanocytic hyperplasia
• Melanocytic intraepithelial neoplasia
• Evolving melanoma

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Melanoma

• In situ melanoma
• In situ and invasive melanoma
• Time between diagnoses
• Regressing melanoma
• Recurrence
• Effect on incidence counts and rates
• Histology coding is pretty simple

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Breast

• TOO MANY TERMS
• In situ subtypes
• Invasive subtypes
• In situ and invasive together
• Recurrence
• NOS versus specific histology
• Combination histologies

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Breast

• Paget disease
• Lobular and ductal carcinoma
• Inflammatory carcinoma

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Kidney

• Similar to lung
• Laterality
• Easy to understand
• Renal pelvis clearly part of lower urinary tract
• Histology coding is pretty simple
• NOS versus specific histology

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Renal Pelvis, Ureter, Bladder

• Laterality
• Field effect or implantation
• Multiple tumors
• Transitional epithelium / urothelium
• Papillary CA of low malignant potential
• Papillary carcinoma - grade I/III
• Papilloma

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Renal Pelvis, Ureter, Bladder

• Papillary versus flat tumor
• In situ versus non-invasive
• In-situ and invasive
• Non-invasive and invasive
• Time interval between diagnoses

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Brain and Central Nervous System

• What is the primary site?
• Complex anatomy
• Site Group new concept
• Time between diagnoses
• Benign/borderline/malignant

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Brain and Central Nervous System

• TOO MANY TERMS
• Progression of disease histologic type
• Histology Group new concept
• Mixed histology

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Highlights of General Rules
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General Rules

• Similar to site-specific rules
• Address remaining combination and mixed histology
  issues
• Cover all malignant solid tumors without
  site-specific rules
• Exclude hematopoietic
• Exclude Kaposi sarcoma
• Exclude benign

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General Rules

• Multiple primary and histology
• Three formats
• Text, flowchart, matrix
• Independent modules
• Unknown Number of Tumors (MP only)
• Single Tumor (primary site)
• Multiple Tumors (primary site)

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General Multiple Primary Rules

• A single tumor is a single primary
• Prostate single primary
• Kaposi sarcoma single primary
• Retinoblastoma single primary
• Ovary bilateral at diagnosis single primary
• Thyroid papillary and follicular at diagnosis
  single primary

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General Histology Rules

• In situ tumor only
• Invasive and in situ tumor
• Invasive tumor only
• NOS and specific histology
• Combination histology codes table

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Project Timeline

• February 2006 New Rules Field Trial
• September 2006 Train the Trainers II
• January 1, 2007 Implementation
• The 2007 rules will replace all previous rules

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Further Education 2006-2007

• Additional training materials published on web
• Webcasts
• State meetings
• NCRA meetings