Lab Test and Tumor Markers in SSF Objective 7/13/2010. Part I Section 2: Site Specific Notes

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1 LAB TESTS AND TUMOR MARKERS Part I Section 2: Site Specific Notes 2 Lab Test and Tumor Markers in SSF Objective To review and understand: Where and what to look for lab test results What does SI mean Prefixes and abbreviation Common Codes in Site Specific Factors Tumor Markers to site or histology specific schemas 3 1

2 Recording lab test and Tumor Markers Guide to registrars how to code lab test results Lab test should be coded in the CS SSFs Tumor markers and laboratory test may vary according to the lab and/or manufacturer When ever possible code the clinician s or pathologist s interpretations of the lab test In the absence of a doctor s interpretation of the test, if the reference range is available use this information to assign the code 4 Recording lab test and Tumor Markers Only when there is no clinician/pathologist interpretation of the lab test and no description of the reference range in the medical record should the registrar use background information listed in the tumor marker notes to code the SSF 5 Recording lab test and Tumor Markers Refer to the CS Manual for allowable codes Refer to the CS Manual for additional coding choices when the test results are not in the Medical Record 6 2

3 Lab Tests & Tumor Markers What does SI mean? French abbreviation for International System for standard units of measure Most SI values are based on kilogram, liter, or standard unit of time (seconds) A nanogram (ng) is one thousandth of a microgram (μg) A milliliter (ml) is one thousandth of a liter 7 Lab Tests & Tumor Markers What does SI mean? Lab value expressed in μg/l is equivalent to the same value expressed in ng/ml Some lab values, such as hormone levels, are recorded in International Units per Liter (IU/L) This is equivalent to miu/ml The equivalence of miu to ng varies according to what is measured SI Conversion: 1 μg/l = 1 ng/ml. For example, 1 ng of AFP is approximately equal to 1 miu Micrograms (μg) per liter may be shown as ug/l 8 urement_files/image021.jpg 3

4 Lab Tests & Tumor Markers Prefixes and abbreviations Units of Measure described and written in various ways in the medical record Unit of Measure dependent on the printer used to report Prefix micron (one millionth of a unit) scientific notation by the Greek Letter mu(μ) 10 Abbreviations for units of measurement Number Prefix Written 1,000,000 Mega M 1000 Kilo k 10 Deka da 1 (baseline) 1/10 Deci d 1/100 Centi c 1/1000 Milli m One millionth Micro m, u, or mc One billionth Nano n One trillionth Pico p One quadrillionth Femto f 11 Abbreviations for units of measurement Unit Abbrev Gram: gr Liter : L, l Unit : U Meter: M milli Equivalent meq Unit of substance: Mole, mol Examples Femtomole : fmol Microgram: ugr mcg μgr Milliliter : ml, ml 12 4

5 Common Codes in SSF Numeric Site Specific factor : Code 000 CEA, Chromogranin, CA 125, means a zero value on the test itself Code 979 (depending on the test) = 97.9 Code 980 Means that the true value was higher Code 988 Test was not performed (Remember Do not assume test was done Code 997 Ordered but no report in the MR Code 999 No information in the MR about the lab value 13 CA 19 9 Lab Value Appears in Schema: Stomach, Appendix, Ampulla of vater, Intraheptatic bile ducts, perihilar bile duct, Distal bile duct, all subsites of pancreas Normal reference range <37 U/mL FCDS & CoC Not Required in SSF s 14 CA 19 9 Lab Value Note 1: Carbohydrate Antigen 19 9 is a tumor marker that has value in the management of certain malignancies. Note 2: Record in Units/milliliter the highest CA 19 9 lab value recorded in the medical record prior to treatment. Example: A pretreatment CA 19 9 of 60 Units/milliliter (U/ml) would be recorded as

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7 CEA (CARCINOEMBRYONIC ANTIGEN) Normal reference range Used in schemas: Stomach; Small Nonsmoker: < 2.5 ng/ml (SI: < intestine; Appendix carcinoma; 2.5 μg/l) Colon; Rectum; Ampulla of Vater; Perihilar bile ducts; Distal bile SI Conversion: 1 μg/l = 1 ducts; Ampulla of Vater ng/ml. Smoker: < 5 ng/ml (SI: < 5 Source documents: clinical lab μg/l) 1 μg/ml = 1 mg/l report, sometimes pathology or cytology report; H&P, operative report; consultant report; Ex: Colon/Rectal/Appendix SSF 1 Discharge summary FCDS NOT required CoC required 19 CEA (CARCINOEMBRYONIC ANTIGEN) Record both the reported value and the clinician s interpretation of the highest value prior to treatment. Code in nanograms per milliliter (ng/ml) the highest preoperative CEA lab value documented. If multiple CEA tests were performed prior to treatment, record the highest value. CEA Interpretation Code the corresponding interpretation of the CEA lab value as stated by the clinician. Use code 000 if there is a statement in the record that If there is no statement that the CEA is positive/elevated, ii negative/normal or the like, code the interpretation as Positive/elevated 020 Negative/normal 030 Borderline; undetermined whether positive or negative Notes: CEA is not a screening test and is not specific to colorectal cancer. Unlikely to be benign if > 10 ng/ml. Distant metastasis most likely if >100 ng/ml. 20 CHROMOGRANIN A (CGA) SSF 3 digit field implied decimal point Protein released by neuroendocrine cells Appears in Schemas: Pancreas (endocrine, all subsites); Neuroendocrine tumors Stomach; Small intestine; Appendix; Colon; Rectum; Ampulla of Vater Source documents: pathology report (immunohistochemistry stain) or clinical lab report (blood serum) Other names: Serum chromogranin A, CGA, chromogranin Chromagranin A is positive more often for WD NET (Carcinoid) than PD Record the higest CgA value prior to treatment Normal reference range Path report: Positive/negative Lab: ng/ml Results vary by laboratory Ex: NET Ampulla SSF 5 FCDS NOT required CoC required 21 7

8 HPV (HUMAN PAPILLOMA VIRUS) STATUS Appears in Schemas: All head and neck sites (carcinoma and melanoma) except major salivary glands and Other Pharynx ; Anus; Penis Source documents: pathology report (immunohistochemical staining), molecular analysis FCDS & CoC Not Required in SSF s Other names: human papillomavirus, HPV, HPV DNA test, human papillomavirus in situ hybridization, HPV hybrid capture test; high risk types: hr HPV, HRHPV 22 LDH, LDH VALUE, LDH UPPER LIMIT OF NORMAL Appears in Schemas: Melanoma Skin, Testis, Lymphoma Ocular Adnexa Source documents: clinical laboratory report; may be included in a liver or hepatic panel/profile, a cardiac panel, or a general metabolic panel of tests Other names: LD, Lactate dehydrogenase, lactase dehydrogenase, lactic acid dehydrogenase Normal reference range varies widely by laboratory, patient age, and the units of measurement Examples of reference range lab values: Lab A Total LDH U/L Lab B Total LDH U/L Lab C Total LDH U/L Lab D Total LDH U/L 23 LDH (MelanomaSkin)& Preorchiectomy LDH Interpretation (Testis) Melanoma Skin Testis Description Test not done; test not ordered and not performed Within normal limits Range 1: less than 1.5 times the upper limit of normal for that lab; for melanoma only: stated as elevated, NOS Range 2: 1.5 to 10 times the upper limit of normal for that lab Range 3: more than 10 times the upper limit of normal for that lab Test ordered, but results not in chart See schema for additional code choices Melanoma skin SSF 4 Required by FCDS & CoC Testis SSF 10 Preorchiectomy LDH Interpretation Required by FCDS & CoC 24 8

9 LDH (Melanoma Skin) SSF4 For melanoma, an abnormal value (SSF4 codes ) MUST be documented by at least two separate tests obtained more than 24 hours apart, according to the AJCC Cancer Staging Manual Note: LDH may not be done for early stage melanomas. If so, code as

10 MITOTIC COUNT Appears in Schemas: FCDS & CoC Required GIST Appendix GIST Colon GIST Esophagus GIST Peritoneum GIST Rectum GIST Small Intestine GIST Stomach Melanoma Skin FCDS & CoC NOT Required NET Ampulla NET Colon NET Small Intestine NET Stomach NET Rectum Pancreas Head, Pancreas Body Tail, Pancreas Other Source documents: pathology report Other names: Mitotic rate, mitotic index (a ratio do not record this measurement), mitotic activity CoC Required Melanoma Choroid Melanoma Ciliary Body Melanoma Iris 28 Record the number of cells actively dividing as determined by the Pathologist The Count will vary according o the type of tumor Follow the Instructions in the SSF notes NET (ampulla, colon, rectum, small intestine, stomach): count per 10 high power fields (HPF*) or 2 square millimeters GIST (appendix, colon, esophagus, peritoneum, rectum, small intestine, stomach): count per 50 HPF* or 5 square millimeters Melanoma of skin: count per square millimeter Ocular melanoma (choroids, ciliary body, iris): count per 40 HPF* or 4 square millimeters * The usual high power is 40x magnification 29 This site specific factor is a three digit field with an implied decimal point between the second and third digits For example: Mitotic count is reported as.8 mitoses per 50 HPF for a GIST Colon tumor, record as 008 Mitotic rate is reported as 11 mitoses per 50 HPF for a GIST Colon, record as

11 31 32 Reference Collaborative Stage Data Collection System Coding Manual and Instructions Part I Section 2: Site Specific Notes VERSION INCORPORATING UPDATES THROUGH JANUARY 1,