PUBLIC HEALTH DIVISION Oregon State Cancer Registry Abstracting Hematologic Malignancies Stepping Up Your Game LeeLa Coleman, CTR Cancer Data Consultant

PUBLIC HEALTH DIVISIONOregon State Cancer Registry

Abstracting Hematologic MalignanciesStepping Up Your Game

LeeLa Coleman, CTRCancer Data Consultant

Fall Workshop

October 9, 2015

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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

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Overview

New hematopoietic & lymphoid neoplasm rules •Applies to

– morphology codes 9590 to 9992

– behavior code of /3

– diagnosed on or after January 1, 2010

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Overview

SEER•Lead Hematopoietic Working Group

– SEER

– NCRA

– NAACCR

– NPCR

– CoC

– ACOS

– CCR

•Is the authoritative reference•Questions go to SEER (SINQ)

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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

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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

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Heme Manual and DB

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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– “Version” no longer applicable (2014)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/

http://seer.cancer.gov/tools/heme/

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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

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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

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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

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Heme DB

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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

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Heme DB

Use Multiple Primaries Calculator only when instructed by the M Rules

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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

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It’s differentNot the same as solid tumorsApplies to cases diagnosed 01/01/2010 forward

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Ambiguous Terms

Apparently

Appears

Comparable with

Compatible with

Favor(s)

Malignant appearing

Most likely

Presumed

Probable

Suspect(ed)

Suspicious (for)

Typical (of)

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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

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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

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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

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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

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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

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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

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• 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

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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)

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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

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Pop Quiz 1 – Diagnostic confirmation

Heme DB

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a)1 – histology

b)3 – histology + immunophenotyping/genetic*

c)5 – positive lab test or marker

d)8 – clinical

e)It depends

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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

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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.

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Histology is

a)Malignant neoplasm, NOS – 8000/3

b)Lymphoma, NOS – 9590/3


a)1 – histology

b)7 – imaging

c)8 - clinical

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Histology is

a)Malignant neoplasm, NOS – 8000/3

b)Lymphoma, NOS – 9590/3


a)1 – histology

b)7 – imaging

c)8 - clinical

Reference: SINQ 20120002

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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.

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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

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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

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Use the Hematopoietic Multiple Primaries Calculator when instructed by the Heme manual

Mast cell le

ukemia

Mast ce

ll sarco

ma

OOPS!

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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

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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”.

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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

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ExerciseUsing Heme DB and Manual Steps in Priority Order

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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.

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Exercise

Using the steps, determine– Date of diagnosis– Histology(s)– Number of primaries– Primary site– Grade– Diagnostic confirmation

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Exercise

Step 1 - assign a working histology

Step 2 – apply the MP rules

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Exercise

Step 3 – verify or revise the working histology (if needed)

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Exercise

Step 4 – Determine the primary site(s)

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Exercise

Step 5 – Determine the Grade

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Exercise

What is the diagnostic confirmation code(s)?

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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

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Resources

TRAININGFree, CEs provided!

NAACCR WebinarsAvailable on request from OSCaR

SEER*Educatehttps://educate.fhcrc.org/Index.aspx

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Thank you!

LeeLa Coleman, CTR

[email protected]

T: 971-673-1056

Documents

PUBLIC HEALTH DIVISION Oregon State Cancer Registry Abstracting Hematologic Malignancies Stepping Up Your Game LeeLa Coleman, CTR Cancer Data Consultant