Colon and Rectum 5/1/14

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1 Collecting Cancer Data: Colon and Rectum NAACCR Webinar Series May 1, 2014 Q&A Please submit all questions concerning webinar content through the Q&A panel. Reminder: If you have participants watching this webinar at your site, please collect their names and s. We will be distributing a Q&A document in about one week. This document will fully answer questions asked during the webinar and will contain any corrections that we may discover after the webinar. Fabulous Prizes 3 NAACCR Webinar Series 1

2 Agenda Overview Quiz 1 Staging Quiz 2 Treatment Quiz 3 Case Scenarios Overview Colon/Rectum Key Statistics Estimated new cases and deaths from colon and rectal cancer in the United States in 2014: New cases: 96,830 (colon) 40,000 (rectum) Deaths: 50,310 (colon and rectal combined) Estimated new cases and deaths from colon and rectal cancer in Canada in 2013: New Cases 23,900 (colon and rectum combined) Deaths 9,200 (colon and rectum) 6 NAACCR Webinar Series 2

3 Hepatic Flexure Transverse Colon Splenic Flexure Ascending Cecum Rectosigmoid 15-17cm Descending Sigmoid 17-57cm 7 Mesentery Small bowel mesentery (mesentery proper): suspends the jejunum and the ileum Mesoappendix: peritoneum of the vermiform appendix Transverse mesocolon: peritoneum of the transverse colon Sigmoid mesocolon: peritoneum of the sigmoid colon 8 Layers of the Colon Pericolic Fat Subserosal Fat Muscularis Propria Lamina Propria Lumen 9 NAACCR Webinar Series 3

4 Layers of the Colon Confined to the mucosa Invasion into the submucosa Invasion of muscularis propria Invasion into subserosa Invasion through serosa Tumor penetrates the visceral peritoneum Tumor directly invades or is adherent to other organs or structures T1 Tis T2 Subserosal Fat T3 T4 10 Lymph Vascular Invasion Blood Vessel Lymphatic Vessel Tumor 11 Polyps Pedunculated Stalk Head Sessile 12 NAACCR Webinar Series 4

5 Terminology Frank Adenocarcinoma No indication of a polyp Sessile Polyp Polyp without a stalk Pedunculated Polyp Polyp with a stalk Exophytic Nodular or polypoid Pedunculated or sessile Endophytic Ulcerative 13 Tumor Configurations Exophytic (nodular or polypoid) {pedunculated or sessile} Ulcerative (endophytic) Multicentric Diffusely infiltrative Annular (multifocal) (apple core) Polyps Tubular Tubulovillous Villous 15 NAACCR Webinar Series 5

6 Histology Adenocarcinoma in an adenomatous polyp (8210) Adenocarcinoma in a tubular adenoma Carcinoma in adenomatous polyp Adenocarcinoma in a polyp, NOS Carcinoma in a polyp, NOS Adenocarcinoma in villous adenoma (8261) Adenocarcinoma in tubulovillous adenoma (8263) 16 Coding Adenocarcinoma in a polyp (MP/H Rules) Code 8210 (adenocarcinoma in adenomatous polyp), 8261 (adenocarcinoma in villous adenoma), or 8263 (adenocarcinoma in tubulovillous adenoma) when: The final diagnosis is adenocarcinoma and the microscopic description or surgical gross describes polyps or The final diagnosis is adenocarcinoma and there is reference to residual or pre existing polyps or The final diagnosis is mucinous/colloid or signet ring cell adenocarcinoma in polyps or There is documentation that the patient had a polypectomy There is documentation that the patient had a polypectomy 17 Exception Note1: It is important to know that the adenocarcinoma originated in a polyp. Note 2: Code adenocarcinoma in a polyp only when the malignancy is in the residual polyp (adenoma) or references to a pre existing polyp (adenoma) indicate that the malignancy and the polyp (adenoma) are the same lesion. 18 NAACCR Webinar Series 6

7 Terminology Exophytic Nodular or polypoid Pedunculated or sessile Endophytic Ulcerative 19 Histology Adenocarcinoma Ninety eight percent of colon cancers are adenocarcinoma Ten to fifteen percent of these cases produce enough mucin to be categorized as mucinous/colloid Mixed histologies and specific types other than mucinous/colloid or signet ring cell are rare (2007 MPH Manual pg 29) 20 Histology Mucinous/colloid adenocarcinoma (8480) An adenocarcinoma containing extra cellular mucin comprising more than 50% of the tumor Note that mucin producing and mucin secreting are not synonymous with mucinous Signet ring cell carcinoma (8490) An adenocarcinoma containing intra cellular mucin comprising more than 50% of the tumor 21 NAACCR Webinar Series 7

8 Histology Carcinoid, NOS (8240) Also called typical carcinoid or low grade or well differentiated neuroendocrine carcinoma Neuroendocrine carcinoma, NOS (8246) Composite carcinoid (8244) Single tumor containing both carcinoid and adenocarcinoma Adenocarcinoid (8245) Specific type usually found in appendix Atypical carcinoid tumor (8249) 22 Histology Familial adenomatous polypoid/fap (8220) Familial polyp or polypoid syndromes are caused by a hereditary genetic defect that increases the risk for developing colorectal cancer. Malignant Gastrointestinal Stromal Tumors/GIST (8936/3) GIST NOS is not reportable (8936/1) 23 Grade Two Grade system 2 Low grade Well differentiated and moderately differentiated 4 High grade Poorly differentiated and undifferentiated Four Grade System 1 Well Differentiated 2 Mod Differentiated 3 Poorly differentiated 4 Undifferentiated 24 NAACCR Webinar Series 8

9 Colon Blood Supply SMA IMA Superior mesenteric artery branches 1 Ileocolic 2 Right colic 3 Middle colic Inferior mesenteric artery branches 4 Ascending left colic 5 Left colic 6 Sigmoid branches 7 Superior rectal artery 8 Middle rectal artery 9 Inferior rectal artery 10 Inferior mesenteric vein 25 Lymph Nodes of Colon 26 Common Metastatic Sites Liver Lung Abdominal seeding 27 NAACCR Webinar Series 9

10 Staging Systems Colon and Rectum Collaborative Stage Data Collection System V02.05 Colon and Rectum 29 CS Tumor Size: Colon Record largest dimension of primary colon tumor Tumor size is not a determinant in AJCC T category or Summary Stage Special code Code 998: Familial/multiple polyposis NAACCR Webinar Series 10

11 CS Extension: Colon Code the greatest extent of invasion of primary colon tumor Ignore intraluminal extension to adjacent segments of colon/rectum Adherence to other organs or structures Use code 565 for macroscopic adhesions without pathologic confirmation AND for pathologically confirmed tumor in adhesions Assign code based on extent of tumor invasion through wall if no tumor in adhesions upon microscopic exam 31 CS Extension: Colon AJCC T category Tis: Intraepithelial or invasion of lamina propria Intraepithelial: Confined within glandular basement membrane CS Extension = 000, 050 Intramucosal: Confined within lamina propria with no extension through muscular mucosae into submucosa CS Extension = 100, 110, 120 T1: Invades submucosa CS Extension = 130, 140, 150, 160, 170, 300 CS Extension: Colon AJCC T category T2: Invades muscularis propria CS Extension = 200 T3: Invades through muscularis propria into pericolorectal tissues CS Extension = 400, 450, 458, 470 T4a: Penetrates to surface of visceral peritoneum CS Extension = 500, 550, 560 T4b: Directly invades or is adherent to other organs or structures CS Extension = 565, 570, 600, 655, 660, 675, 700, 750, 800, 850 NAACCR Webinar Series 11

12 Pop Quiz Segmental resection path report: Splenic flexure tumor, adenocarcinoma, penetrates into the pericolic fat and extends to the free serosal surface. What is the code for CS Extension? a. 450: Extension to pericolic fat b. 458: Fat NOS c. 500: Invasion of/through serosa (mesothelium) (visceral peritoneum); Tumor penetrates to surface of visceral peritoneum d. 550: (450 or 458) 34 CS Lymph Nodes: Colon Code involvement of regional nodes Malignant satellite peritumoral nodules (tumor deposits) Use code 050 if tumor deposits WITHOUT lymph node involvement Code involvement of lymph nodes if both lymph node involvement and peritumoral nodules Code number of tumor deposits in SSF4 Number of positive regional nodes required to calculate N category If CS Lymph Nodes = and CS Lymph Nodes Eval = 0, 1, 5, or 9, N category is determined by SSF2 If CS Lymph Nodes = and CS Lymph Nodes Eval = 2, 3, 6, 8 or not coded, N category is determined by Regional Nodes Positive CS Lymph Nodes: Colon Mesenteric nodes Code 300 for mesenteric nodes NOS Code 210 for inferior mesenteric nodes with primary site of splenic flexure, descending colon, or sigmoid colon Code inferior mesenteric nodes in CS Mets at DX for primary site of cecum, ascending colon, transverse colon, or hepatic flexure Code superior mesenteric nodes in CS Mets at DX for all colon sites 36 NAACCR Webinar Series 12

13 CS Lymph Nodes: Colon AJCC N Category N1: Metastasis in 1 3 regional lymph nodes CS Lymph Nodes = 430, 800 N1a: Metastasis in 1 regional lymph node CS Lymph Nodes = 410 N1b: Metastasis in 2 3 regional lymph nodes CS Lymph Nodes = 420 N1c: Tumor deposits without regional nodal metastasis CS Lymph Nodes = CS Lymph Nodes: Colon AJCC N Category N2: Metastasis in 4 or more regional lymph nodes CS Lymph Nodes = 480 N2a: Metastasis in 4 6 regional lymph nodes CS Lymph Nodes = 460 N2b: Metastasis in 7 or more regional lymph nodes CS Lymph Nodes = Regional Nodes Positive Regional Nodes Examined Record even if patient has preoperative treatment Value of Regional Nodes Positive is a factor in determining pathologic N category 39 NAACCR Webinar Series 13

14 Pop Quiz Hemicolectomy path report: 2 cm adenocarcinoma of sigmoid colon invades muscularis propria; malignant peritumoral deposit distance to margin 1 cm; mesenteric margin distance 3.0 cm; 0/17 nodes positive. What is the code for CS Lymph Nodes? a. 000: No regional lymph node involvement and no tumor deposits (TD) b. 050: TD in the subserosa, mesentery, or nonperitonealized pericolic or perirectal tissues WITHOUT regional nodal metastasis c. 110: Colic NOS; Epicolic; Mesocolic; Paracolic/pericolic d. 300: Mesenteric NOS; Regional lymph nodes NOS 40 Pop Quiz What is the code for Regional Nodes Positive? a. 00: All nodes examined negative b. 01 c. 98: No nodes examined d. 99: Unknown What is the code for Regional Nodes Examined? a. 00: No nodes examined b. 17 c. 18 d. 99: Unknown 41 CS Mets at DX: Colon Record distant metastasis at time of diagnosis Use codes 08, 16 or 18 for involvement of single distant lymph node chain Use codes 31 or 33 for involvement of multiple distant lymph node chains NAACCR Webinar Series 14

15 CS Mets at DX: Colon AJCC M Category M1: Distant metastasis CS Mets at DX = 60 M1a: Metastasis confined to 1 organ or site CS Mets at DX = 08, 16, 18, 26, 27 M1b: Metastases in more than 1 organ/site or the peritoneum CS Mets at DX = 31, 33, 36, 45, CS Tumor Size: Rectum Record largest dimension of primary rectal or rectosigmoid tumor Tumor size is not a determinant in AJCC T category or Summary Stage Special code Code 998: Familial/multiple polyposis CS Extension: Rectum Code the greatest extent of invasion of primary rectal or rectosigmoid tumor Ignore intraluminal extension to adjacent segments of colon/rectum Adherence to other organs or structures Use code 565 for macroscopic adhesions without pathologic confirmation AND for pathologically confirmed tumor in adhesions Assign code based on extent of tumor invasion through wall if no tumor in adhesions upon microscopic exam 45 NAACCR Webinar Series 15

16 CS Extension: Rectum AJCC T category Tis: Intraepithelial or invasion of lamina propria Intraepithelial: Confined within glandular basement membrane CS Extension = 000, 050 Intramucosal: Confined within lamina propria with no extension through muscular mucosae into submucosa CS Extension = 100, 110, 120 T1: Invades submucosa CS Extension = 130, 140, 150, 160, 165, 170, 300 CS Extension: Rectum AJCC T category T2: Invades muscularis propria CS Extension = 200, 210, 250 T3: Invades through muscularis propria into pericolorectal tissues CS Extension = 400, 415, 455, 458, 470 T4a: Penetrates to surface of visceral peritoneum CS Extension = 500, 555, 560 T4b: Directly invades or is adherent to other organs or structures CS Extension = 565, 570, 610, 700, 800, 850 Pop Quiz Patient has rectal carcinoma with invasion of levator ani muscle complex. What is the code for CS Extension? a. 570: Adherent to other organs or structures NOS b. 610: For rectum Skeletal muscle of pelvic floor c. 800: Further contiguous extension d. 999: Unknown 48 NAACCR Webinar Series 16

17 CS Lymph Nodes: Rectum Code involvement of regional nodes Malignant satellite peritumoral nodules (tumor deposits) Use code 050 if tumor deposits WITHOUT lymph node involvement Code involvement of lymph nodes if both lymph node involvement and peritumoral nodules Code number of tumor deposits in SSF4 Number of positive regional nodes required to calculate N category If CS Lymph Nodes = and CS Lymph Nodes Eval = 0, 1, 5, or 9, N category is determined by SSF2 If CS Lymph Nodes = and CS Lymph Nodes Eval = 2, 3, 6, 8 or not coded, N category is determined by Regional Nodes Positive CS Lymph Nodes: Rectum Rectal nodes Code 100 for rectal nodes NOS Code 200 for middle or superior rectal nodes Code 200 for inferior rectal nodes for rectum Code inferior rectal nodes in CS Mets at DX for rectosigmoid Hemorrhoidal nodes Code 200 for middle or superior hemorrhoidal nodes Code 200 for inferior hemorrhoidal nodes for rectum Code inferior hemorrhoidal nodes in CS Mets at DX for rectosigmoid Mesenteric nodes Code 300 for mesenteric nodes NOS Code 200 for inferior or sigmoid mesenteric nodes Code superior mesenteric nodes in CS Mets at DX CS Lymph Nodes: Rectum AJCC N Category N1: Metastasis in 1 3 regional lymph nodes CS Lymph Nodes = 430, 800 N1a: Metastasis in 1 regional lymph node CS Lymph Nodes = 410 N1b: Metastasis in 2 3 regional lymph nodes CS Lymph Nodes = 420 N1c: Tumor deposits without regional nodal metastasis CS Lymph Nodes = NAACCR Webinar Series 17

18 CS Lymph Nodes: Rectum AJCC N Category N2: Metastasis in 4 or more regional lymph nodes CS Lymph Nodes = 480 N2a: Metastasis in 4 6 regional lymph nodes CS Lymph Nodes = 460 N2b: Metastasis in 7 or more regional lymph nodes CS Lymph Nodes = Regional Nodes Positive Regional Nodes Examined Record even if patient has preoperative treatment Value of Regional Nodes Positive is a factor in determining pathologic N category 53 CS Mets at DX: Rectum Record distant metastasis at time of diagnosis Use codes 08, 16 or 18 for involvement of single distant lymph node chain Use codes 29, 31 or 33 for involvement of multiple distant lymph node chains NAACCR Webinar Series 18

19 CS Mets at DX: Rectum AJCC M Category M1: Distant metastasis CS Mets at DX = 60 M1a: Metastasis confined to 1 organ or site CS Mets at DX = 08, 16, 18, 26, 27 M1b: Metastases in more than 1 organ/site or the peritoneum CS Mets at DX = 29, 31, 33, 36, 45, SSF1: Carcinoembryonic Antigen (CEA) SSF3: CEA Lab Value CEA Is a protein molecule Is a tumor marker for colorectal cancer SSF1 Record interpretation of highest CEA test result prior to treatment SSF3 Record to the nearest tenth in ng/ml the highest CEA lab value prior to treatment Use same test to record SSF1 and SSF3 56 Pop Quiz Patient had routine colonoscopy with polypectomy which diagnosed adenocarcinoma. Hemicolectomy was performed a month later, and there was no residual malignancy. CEA was drawn after the polypectomy but before the resection. The results were 7 with normal being <5. 57 NAACCR Webinar Series 19

20 Pop Quiz What is the code for SSF1? a. 010: Positive/elevated b. 020: Negative/normal c. 998: Test not done d. 999: unknown What is the code for SSF3? a. 050 b. 070 c. 998: Test not done d. 999: Unknown 58 SSF2: Clinical Assessment of Regional Lymph Nodes Record clinical lymph node involvement based on diagnostic workup Physical exam, imaging, diagnostic lymph node biopsy, exploratory surgery WITHOUT resection Exclude endoscopy without ultrasound Use code 999 (unknown) if there is no diagnostic workup to assess regional node involvement Handles mapping to clinical N category 59 Pop Quiz Patient had colonoscopy with polypectomy, adenocarcinoma in tubular adenoma. After the polypectomy, patient had abdominal/pelvic CT scan that documented no lymphadenopathy. No other treatment was given. What is the code for SSF2? a. 000: Nodes not clinically evident; imaging of regional nodes performed and nodes not mentioned b. 999: Unknown 60 NAACCR Webinar Series 20

21 SSF4: Tumor Deposits Are 1 or more satellite peritumoral nodules in pericolorectal adipose tissue without evidence of lymph node Record exact number of tumor deposits in SSF4 Assign code 000 (none) if resection of primary site is performed and no mention of tumor deposits Assign code 998 if no surgical resection of primary site Polypectomy is not resection of primary site 61 Pop Quiz Polypectomy diagnosed adenocarcinoma in a tubular adenoma involving submucosa. No other treatment. What is the code for SSF4? a. 000: None b. 998: No surgical resection of primary site c. 999: Unknown 62 SSF6: Circumferential Resection Margin (CRM) Is the measurement from deepest invasion of tumor to closest soft tissue margin Radial margin, mesenteric resection margin Record to nearest tenth in mm exact measurement of CRM Assign code 998 if no surgical resection of primary site Polypectomy is not resection of primary site 63 NAACCR Webinar Series 21

22 Pop Quiz Patient had hemicolectomy for ascending colon adenocarcinoma. Resection margins were: Radial margin, serosal aspect: 0.3 cm Radial margin, mesocolic aspect: 1.5 cm What is the code for SSF6? a. 003 b. 015 c SSF8: Perineural Invasion Is infiltration of nerves by tumor cells or spread of tumor along nerve pathway Is a prognostic factor for colorectal cancer Code presence or absence of perineural invasion in SSF8 Assign code 000 (none) if histologic exam of primary site is performed and no mention of perineural invasion 65 Pop Quiz Colonoscopy with polypectomy: Adenocarcinoma in situ in adenomatous polyp. Abdominal/pelvic CT scan: No organomegaly or lymphadenopathy. No further treatment. What is the code for SSF8? a. 000: No perineural invasion present b. 010: Perineural invasion present c. 999: Unknown 66 NAACCR Webinar Series 22

23 SSF9: KRAS Is an oncogene that when mutated may turn a normal cell into a cancer cell Patients with mutated KRAS may not respond to antiepidermal growth factor receptor drugs Record status of KRAS in SSF9 Abnormal (mutated) or Normal (wild type) 67 Pop Quiz Colonoscopy with polypectomy: Adenocarcinoma in situ in adenomatous polyp. Abdominal/pelvic CT scan: No organomegaly or lymphadenopathy. No further treatment. What is the code for SSF9? a. 010: Abnormal (mutated); Positive for mutations b. 020: Normal (wild type); Negative for mutations c. 998: Test not done d. 999: Unknown 68 AJCC Cancer Stage Colon and Rectum Chapter NAACCR Webinar Series 23

24 AJCC Cancer Stage: Colon and Rectum Classification Clinical staging Based on medical history, physical exam, sigmoidoscopy, and colonoscopy with biopsy Pathologic staging Based on surgical exploration of the abdomen, cancer directed surgical resection, and pathologic exam of resected specimen 70 AJCC Cancer Stage: Colon and Rectum Stage T N M 0 Tis 0 0 I T1 T IIA T3 0 0 IIB T4a 0 0 IIC T4b 0 0 IIIA T1 T2 T1 N1/N1c N2a AJCC Cancer Stage: Colon and Rectum Stage T N M IIIB T3 T4a T2 T3 T1 T2 N1/N1c N2a N2b IIIC T4a T3 T4a T4b N2a N2b N1 N2 IVA Any T Any N M1a IVB Any T Any N M1b NAACCR Webinar Series 24

25 Pop Quiz Colonoscopy with biopsy: Adenocarcinoma of splenic flexure with polypoid architecture Abdominal/pelvic CT scan: No organomegaly or lymphadenopathy Segmental resection path report: Splenic flexure tumor, adenocarcinoma, penetrates into the pericolic fat and extends to the free serosal surface. Metastasis in 0/16 lymph nodes. 73 Pop Quiz What is the AJCC clinical cancer stage? What is the AJCC pathologic cancer stage? 74 Summary Stage NAACCR Webinar Series 25

26 Summary Stage 2000: Colon In situ (0) Noninvasive; intraepithelial CS Extension = 000 Noninvasive adenocarcinoma in a polyp CS Extension = 050 Summary Stage 2000: Colon Localized (1) Invasive tumor confined to: Intramucosal NOS, lamina propria, mucosa NOS, muscularis mucosae, muscularis propria, perimuscular tissue invaded, polyp NOS, submucosa, subserosal tissue/fat, transmural NOS, wall NOS Confined to colon NOS Extension through wall NOS Invasion through muscularis propria or muscularis NOS Localized NOS CS Extension = 100, 110, 120, 130, 140, 150, 160, 170, 200, 300, Summary Stage 2000: Colon Regional by Direct Extension (2) All colon sites Invasion of/through serosa Extension into/through: Abdominal wall, adjacent tissue NOS, connective tissue, fat NOS, greater omentum, mesenteric fat, mesentery, mesocolon, pericolic fat, retroperitoneum, small intestine By colon subsite CS Extension = 450, 458, 470, 500, 550, 560, 565, 570, 600, 655, 660, NAACCR Webinar Series 26

27 Summary Stage 2000: Colon Regional lymph nodes(s) involved only (3) All colon subsites: Colic NOS, epicolic, mesenteric NOS, paracolic/pericolic By colon subsite Regional lymph nodes NOS CS Lymph Nodes = 110, 210, 220, 300, 410, 420, 430, 460, 470, 480, 800 Nodule(s) in pericolic fat CS Lymph Nodes = 050 Regional by BOTH direct extension AND regional lymph node(s) involved (4) Summary Stage 2000 codes Regional NOS (5) 79 Summary Stage 2000: Colon Distant site(s)/lymph node(s) involved (7) Lymph nodes All colon subsites: Para aortic, retroperitoneal, superior mesenteric, other distant By colon subsite CS Mets at DX = 08, 16, 18, 31, 33 Further contiguous extension All colon subsites: Adrenal, bladder, diaphragm, fallopian tube, fistula to skin, gallbladder, other segment of colon via serosa, ovary, uterus By colon subsite CS Extension = 700, 750, Summary Stage 2000: Colon Distant site(s)/lymph node(s) involved (7) Metastasis CS Mets at DX = 26, 27, 36, 48, 60 Metastasis + distant lymph nodes CS Mets at DX = NAACCR Webinar Series 27

28 Pop Quiz Colonoscopy with biopsy: Adenocarcinoma of splenic flexure with polypoid architecture Abdominal/pelvic CT scan: No organomegaly or lymphadenopathy Segmental resection path report: Splenic flexure tumor, adenocarcinoma, penetrates into the pericolic fat and extends to the free serosal surface. Metastasis in 0/16 lymph nodes. 82 Pop Quiz What is the Summary Stage 2000? a. 0 In situ b. 1 Localized only c. 2 Regional by direct extension only d. 3 Regional lymph nodes involved only e. 4 Regional by both direct extension and regional lymph nodes involved f. 5 Regional NOS g. 7 Distant sites/nodes involved 83 Summary Stage 2000: Rectosigmoid Junction, Rectum In situ (0) Noninvasive; intraepithelial CS Extension = 000 Noninvasive adenocarcinoma in a polyp CS Extension = 050 NAACCR Webinar Series 28

29 Summary Stage 2000: Rectosigmoid Junction, Rectum Localized (1) Invasive tumor confined to: Intramucosal NOS, lamina propria, mucosa NOS, muscularis mucosae, muscularis propria, perimuscular tissue invaded, polyp NOS, submucosa, subserosal tissue/fat, transmural NOS, wall NOS Confined to colon NOS Extension through wall NOS Invasion through muscularis propria or muscularis NOS Localized NOS CS Extension = 100, 110, 120, 130, 140, 150, 160, 165, 170, 200, 210, 250, 300, 400, Summary Stage 2000: Rectosigmoid Junction, Rectum Regional by Direct Extension (2) Invasion of/through serosa Extension to/through: Adjacent tissue NOS, connective tissue, fat NOS, perirectal fat Rectosigmoid Cul de sac, mesenteric fat, mesentery, mesocolon, pelvic wall, pericolic fat, small intestine Rectum Anus, bladder (males only), cul de sac, pelvic wall, prostate, rectovaginal septum, rectovesical fascia (males only), seminal vesicle(s), skeletal muscle of pelvic floor CS Extension = 455, 458, 470, 500, 555, 560, 565, 570, 610, 850, Summary Stage 2000: Rectosigmoid Junction, Rectum Regional lymph nodes(s) involved only (3) Rectosigmoid Colic NOS, left colic, hemorrhoidal (superior or middle), inferior mesenteric, mesenteric NOS, paracolic/pericolic, perirectal, rectal, sigmoidal, superior rectal Rectum Hemorrhoidal (superior, middle, or inferior), inferior mesenteric, internal iliac, mesenteric NOS, perirectal, rectal, sacral NOS (lateral, middle sacral, presacral), sigmoidal Regional lymph nodes NOS CS Lymph Nodes = 110, 200, 300, 410, 420, 430, 460, 470, 480, 800 Nodule(s) in pericolic fat CS Lymph Nodes = NAACCR Webinar Series 29

30 Summary Stage 2000: Rectosigmoid Junction, Rectum Regional by BOTH direct extension AND regional lymph node(s) involved (4) Summary Stage 2000 codes Regional NOS (5) 88 Summary Stage 2000: Rectosigmoid Junction, Rectum Distant site(s)/lymph node(s) involved (7) Lymph nodes Rectosigmoid Internal iliac NOS, obturator Rectum Left colic Other distant nodes CS Mets at DX = 08, 16, 18, 29, 31, Summary Stage 2000: Rectosigmoid Junction, Rectum Distant site(s)/lymph node(s) involved (7) Further contiguous extension Rectosigmoid Bladder, colon via serosa, fallopian tube(s), ovary (ies), prostate, ureter(s), uterus Rectum Bladder (females only), bone(s) of pelvis, urethra, uterus CS Extension = 700, NAACCR Webinar Series 30

31 Summary Stage 2000: Rectosigmoid Junction, Rectum Distant site(s)/lymph node(s) involved (7) Metastasis CS Mets at DX = 26, 27, 36, 48, 60 Metastasis + distant lymph nodes CS Mets at DX = Questions? Quiz Treatment NAACCR Webinar Series 31

32 Colonoscopy Colonoscopy with biopsy Diagnostic/Staging Procedure Colonoscopy with polypectomy Surgical procedure The area that is biopsied is often tattooed for future reference 94 Clinical Staging Endoscopic ultrasound Can be used to determine the depth of invasion Can be used to assess the status of regional lymph nodes MRI Can be used to assess depth of invasion Can be used to assess status of regional lymph nodes. 95 Treatment for Polyps Polypectomy may be only treatment necessary if Tis or T1 Grade 1 or 2 No lymph vascular invasion Negative surgical margins Sessile polyps may require additional surgery even with favorable histologic features T1 Tis NAACCR Webinar Series 32

33 Treatment Colon or Rectum Tis, T1 or T2 with no further mets (Stage 1) Surgery Open Laparoscopic Surveillance Tis T1 T2 97 Treatment Colon Low risk stage II Surgery Possibly chemotherapy Surveillance High risk stage II Surgery (If resectable) Chemotherapy Surveillance T3 Subserosal Fat T4 98 Stage II Poor Prognostic Features T4A or T4B Histologic grade 3 or 4 Lymphvascular invasion (LVI) Perineural invasion Bowel obstruction Lesions with perforation Close or positive surgical margins Inadequate lymph node sampling (fewer than 12 lymph nodes) NAACCR Webinar Series 33

34 Treatment Colon Stage III (lymph nodes positive, but no distant mets) Surgery Chemotherapy 5 fu/leucovorin/oxaliplatin Stage IV Surgery of the colon primary with resection of liver or lung mets. Neoadjuvant chemotherapy followed by surgery to the colon and to the liver or lung If unresectable, chemotherapy. Reassessment for surgical candidacy after 2 months. Surgical Procedures Colon Polypectomy Endoscopic Surgical Excision Partial/ Segmental Resection Hemicolectomy Colectomy Treatment Rectum ct3 or cn1 2 Neoadjuvant radiation and /or neoadjuvant chemo Resection Adjuvant chemo ct4 or distant mets Neoadjuvant radiation and /or neoadjuvant chemo Resection (if resectable) Adjuvant chemo Subserosal Fat T3 T4 102 NAACCR Webinar Series 34

35 Neoadjuvant Treatment Rectum Chemotherapy/ Radiation 5 fu and radiation therapy for about 5 ½ weeks Radiation to the tumor, pre sacral nodes and internal iliac nodes. Surgery May be 5 10 weeks after completion of chemo/radiation. Adjuvant Chemotherapy 5-fu and leucovorin FOLFOX Surgical Resection Rectum Transanal Endoscopic Microsurgery (TEM) Low Anterior Resection (LAR) Performed for lesions in the rectum and rectosigmoid 4 5cm from the anal verge Total Mesorectal Excision (TME) Coloanal anastomosis Abdominoperitoneal Resection (APR) Coming Up Collecting Cancer Data: Liver June 5, 2014 Topics in Survival Data July 10, 2014 NAACCR Webinar Series 35

36 And the winners are. 106 CE Certificate Quiz/Survey Phrase Link Thank You!!!! Please send any questions to: Jim Hofferkamp Shannon Vann NAACCR Webinar Series 36

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