PUBLIC HEALTH DIVISION Oregon State Cancer Registry Abstracting Hematologic Malignancies Stepping Up...
Transcript of PUBLIC HEALTH DIVISION Oregon State Cancer Registry Abstracting Hematologic Malignancies Stepping Up...
PUBLIC HEALTH DIVISIONOregon State Cancer Registry
Abstracting Hematologic MalignanciesStepping Up Your Game
LeeLa Coleman, CTRCancer Data Consultant
Fall Workshop
October 9, 2015
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
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
Overview
SEER•Lead Hematopoietic Working Group
– SEER
– NCRA
– NAACCR
– NPCR
– CoC
– ACOS
– CCR
•Is the authoritative reference•Questions go to SEER (SINQ)
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
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
Heme Manual and DB
8
Heme Manual and DB
• 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– “Version” no longer applicable (2014)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/
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Updated manual published January 14, 2015•“Version” no longer applicable (2014)•Use for all cases diagnosed January 01, 2010 and forward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
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
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
Heme DB
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
Heme DB
Use Multiple Primaries Calculator only when instructed by the M Rules
15
Using Heme Manual & DBSteps 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
It’s differentNot the same as solid tumorsApplies to cases diagnosed 01/01/2010 forward
17
18
Ambiguous Terms
Apparently
Appears
Comparable with
Compatible with
Favor(s)
Malignant appearing
Most likely
Presumed
Probable
Suspect(ed)
Suspicious (for)
Typical (of)
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
Histology
Code histology identified by method(s) listed in Heme DB Definitive Diagnostic Method(s) section. May include•Clinical diagnosis•Genetic test•Immunophenotyping•Cytology•Pathology
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
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
Diagnostic confirmation
Microscopically confirmed
Code Description
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
Diagnostic confirmation
Not Microscopically confirmed
Code Description
5 Positive laboratory test or marker
6 Direct visualization without microscopic confirmation
7Radiology and other imaging techniques without microscopic confirmation
8Clinical diagnosis only (other than 5, 6 or 7)
Confirmation Unknown
9 Unknown whether or not microscopically confirmed; death cert
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
Diagnostic confirmation
Codes that should rarely be used:
Code 2: Positive cytology cautionMostly used when spinal, pleural or peritoneal fluid is the only confirmation
Code 4: Positive microscopic confirmation
Code 5: Positive lab test or marker cautionDon’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
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/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
Pop Quiz 1 – Diagnostic confirmation
Heme DB
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
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
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
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
Pop Quiz 2 - Diagnostic Confirmation
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
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
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
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
Pop Quiz 3 – M Rules
Use the Hematopoietic Multiple Primaries Calculator when instructed by the Heme manual
Mast cell le
ukemia
Mast ce
ll sarco
ma
OOPS!
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
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
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
ExerciseUsing Heme DB and Manual Steps in Priority Order
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
Exercise
Using the steps, determine– Date of diagnosis– Histology(s)– Number of primaries– Primary site– Grade– Diagnostic confirmation
45
Exercise
Step 1 - assign a working histology
Step 2 – apply the MP rules
46
Exercise
Step 3 – verify or revise the working histology (if needed)
47
Exercise
Step 4 – Determine the primary site(s)
48
Exercise
Step 5 – Determine the Grade
49
Exercise
What is the diagnostic confirmation code(s)?
50
Resources
REFERENCES
SEER Hematopoietic Projecthttp://seer.cancer.gov/tools/heme/
SEER Hematopoietic & Lymphoid Database
SEER Hematopoietic & Lymphoid Manual
Multiple Primaries Calculatorhttp://seer.cancer.gov/seertools/hemelymph/
SEER Inquiry System (SINQ)
http://seer.cancer.gov/seerinquiry/index.php
51
Resources
TRAININGFree, CEs provided!
NAACCR WebinarsAvailable on request from OSCaR
SEER*Educatehttps://educate.fhcrc.org/Index.aspx