NAACCR Webinar Series 1

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1 Collecting Cancer Data: Skin Malignancies 2/4/2010 NAACCR Webinar Series Questions Please use the Q&A panel to submit your questions Send questions to All Panelist Collecting Cancer Data: Skin Malignancies 1 2 Fabulous Prizes Agenda 2010 Updates Overview CSv2 Merkel cell carcinoma Melanoma of the skin Mulitple Primary Rules 3 4 Implementation guidelines 2010 Update NAACCR 2010 Implementation Guidelines and Recommendations on_guidelines_and_recommendations.pdf Posted August 2009 CSv2 Implementation Guide for Registries and Vendors Posted January NAACCR Webinar Series 1

2 Collecting Cancer Data: Skin Malignancies 2/4/2010 CSv2 Manual Part 1 (two sections) Section 1 has been posted p1s1.pdf Section 2 should be posted soon (if not already) Part 2 Standard Setter Requirements CoC has documented what they will require for 2010 cases in the FORDS manual Preface outlines changes A table is included in the definitions for each SSF that lists what sites are required for that variable FORDS is available for download at: CSv2 requirements also in appendix E of the implementation guidelines 7 8 Standard Setter Requirements NPCR 2010 requirements are included in the implementation guidelines. CSv2 requirements also documented at Reporting.Requirements.pdf Standard Setter Requirements SEER The CSV2 requirements are still a draft awaiting final approval The 2010 Manual is scheduled to be on the website April Standard Setter Requirements To determine their final requirements state central cancer registries will have to review: Requirements fromthevarious standard setters Their legislative mandates Their own research needs Hematopoietic The Hematopoietic and Lymphoid Neoplasm Case Reportability and Coding Manual The Hematopoietic Database NAACCR Webinar Series 2

3 Collecting Cancer Data: Skin Malignancies 2/4/2010 CSv2 Update CoC Schema: MerkelCellSkin Site Specific factors required by CoC SSF 1 Measured Thickness (Depth) SSF3 Clinical Status of Lymph Node Mets SSF 16 Size of Metastasis in Lymph Nodes SSF 17 Extracapsular Extension of Regional Lymph Nodes SSF 18 Isolated Tumor Cells (ITCs) in Regional Lymph Node(s) SSF 22 Profound Immune Suppression CSv2 Update CoC Schema: MerkelCellSkin Site Specific factors not required by CoC 19 Tumor Base Transection Status 20 Tumor Infiltrating Lymphocytes (TIL) 21 Growth Pattern of Primary Tumor CSv2 Update CoC Schema: MelanomaSkin Site Specific factors required by CoC SSF 1 Measured Thickness (Depth), Breslow's Measurement SSF 2 Ulceration SSF 3 Clinical Status of Lymph Node Mets. SSF 4 LDH SSF 5 LDH Value SSF 6 LDH Upper Limits of Normal SSF 7 Primary Tumor Mitotic Count/Rate CSv2 Update CoC Schema: MelanomaSkin Site Specific factors not required by CoC SSF 8 Primary Tumor Regression SSF 9 Vertical Growth Phase Anatomy Overview Skin Malignancies NAACCR Webinar Series 3

4 Collecting Cancer Data: Skin Malignancies 2/4/2010 Histology Melanoma Superficial spreading melanoma 70% Grows horizontally first Nodular melanoma 15% Most aggressive Lentigo maligna melanoma 10% Least aggressive Acral lentiginous melanoma 5% Most common in dark skinned people Desmoplastic melanoma rare Characterized by non pigmented lesions Regression Melanoma regression does not refer to a specific histology Itis thesize andphysical appearance of thelesion Shrinking in size is the immune system s reaction to the melanoma It may indicate a poor prognosis Regression Only code regressing melanoma (8723/3) if it is the final diagnosis Regressiondoesnot not affect staging Regression is a prognostic factor and is collected in SSF 8 Synonyms for In Situ Melanoma Basement membrane of epidermis intact Behaviorcode 2 Clark level I Hutchinson freckle Intrapepidermal Intraepithelial Lentigo maligna Noninvasive Precancerous melanosis Radial growth phase melanoma Stage 0 Tis Synonyms for Hutchinson Freckle (8742/2) Circumscribed precancerous melanosis Intraepidermal malignant melanoma Lentigo maligna Precancerous melanosis of Dubreuilh Non reportable Skin Conditions Atypical melanocytic hyperplasia (dysplasia) Evolving melanoma Giant pigmented pg nevus (8761/1) Junctional nevus (8740/0) Proliferation of atypical melanocytes confined to epidermis Severe melanotic dysplasia NAACCR Webinar Series 4

5 Collecting Cancer Data: Skin Malignancies 2/4/2010 Histology Merkel cell carcinoma 8247/3 Merkel cell tumor Primary cutaneous neuroendocrine carcinoma Laterality Skin sites for which laterality is recorded Skin of eyelid C44.1 Skin of external ear C44.2 Skin of face C44.3 Skin of trunk C44.5 Skin of upper limb and shoulder C44.6 Skin of lower limb and hip C Source: FORDS p Update: Laterality Code 5 was added to this variable Use Code 5 for a midline tumor in a paired site Use code 9 only when the laterality is truly unknown Example: Patient had a malignant melanoma in the middle of his back. Use code 5 For analysis using data with diagnoses before January 1, 2010, code 5 should be grouped with code 9. Question If a biopsy said "metastatic melanoma," is primary site an unknown primary site (C80.9) or skin, NOS (C44.9)? Answer FORDS, Revised 2009, page 9 and 10 Overview of Coding Principles under Primary Site: Melanoma, code to Skin, NOS (C44.9) if a patient is diagnosed with metastatic melanoma and the primary site is not identified. (I & R Team) /2/2007 Question A patient had a biopsy of the liver positive for Merkel cell carcinoma. No skin lesions were found. Is primary site unknown primary (C80.9) or skin, NOS (C44.9)? NAACCR Webinar Series 5

6 Collecting Cancer Data: Skin Malignancies 2/4/2010 Answer Merkel cell (neuroendocrine carcinoma of the skin) is a primary that arises only in the skin. Code to skin, NOS (C44.9) (I & R Team) /3/2009 Question A patient presents with a history of numerous melanomas and prostate carcinoma. All were diagnosed and treated elsewhere. At our facility two melanomas are removed from the back: One on the left and one on the right. These are two primaries per the Multiple Primary & Histology Coding Rules. Since sequence is unknown, I used code 99 for our first primary. However, I cannot enter a second primary since our system will not allow two 99 codes. What is the sequence number for our second primary? Answer The patient has a history of more than one melanoma (exact number unknown) and prostate, which is equal to at least three primary sites with sequence numbers 01, 02, and 03. Two more melanomas were resected at your hospital and they would be sequenced to 04 and 05. You may change these numbers later if you get more information about the number of melanomas the patient had prior to admission at your facility. (I & R Team) /23/2009 CSv2 MerkelCellSkin MelanomaSkin MP/H Rules MP/H Rules Merkel Cell Carcinoma Other rules Melanoma of the Skin (C44.0 C44.9) Melanoma of Skin module NAACCR Webinar Series 6

7 Collecting Cancer Data: Skin Malignancies 2/4/2010 Multiple Primary Rules Melanoma of the Skin Multiple Primary Rules Rule M1 Unknown if single or multiple melanoma s When it is not possible to determine if there is a single melanoma or multiple melanomas, opt for a single melanoma and abstract as a single primary. Rule M2 Single Tumor A single melanoma is always a single primary Multiple Primary Rules Rule M3 Melanomas in sites with ICD O 3 topography codes that are different at the second (Cxxx), third (Cxxx) or fourth (C44x) character are multiple primaries. Rule M4 Melanomas with a different laterality are multiple primaries. A midline melanoma is a different laterality than right or left. Multiple Primary Rules Rule M5 Melanomas with ICD O 3 histology codes that are different at the first (xxxx), second (xxxx) or third number (xxxx) are multiple primaries. Rule M6 An invasive melanoma that occurs more than 60 days after an in situ melanoma is a multiple primary Multiple Primary Rules Rule M7 Melanomas diagnosed more than 60 days apart are multiple primaries. Rule M8 Melanomas that do not meet any of the above criteria are abstracted as a single primary. Histology Coding Rules NAACCR Webinar Series 7

8 Collecting Cancer Data: Skin Malignancies 2/4/2010 Histology Coding Rule H1 Code the histology documented by the physician when there is no pathology/cytology specimen or the pathology/cytology report is not available. Rule H2 Code the histology from the metastatic site when there is no pathology/cytology specimen from the primary site. Rule H3 Code the histology when only one histologic type is identified. Histology Rules Rule H4 Code the invasive histologic type when there are invasive and in situ components. Rule H5 Code the histologic type when the diagnosis is regressing melanoma and a histologic type. Rule H6 Code 8723 (Malignant melanoma, regressing) when the diagnosis is regressing melanoma Histology Rules Rule H7 Code the histologic type when the diagnosis is lentigo maligna melanoma and a histologic type. Rule H8 Code 8742 (Lentigo maligna melanoma) when the diagnosis is lentigo maligna melanoma. Histology Rules Rule H9 Code the most specific histologic term when the diagnosis is melanoma, NOS (8720) with a single specific type. Rule H10 Code the histology with the numerically higher ICD O 3 code Question A patient had two skin lesions removed at our facility. Leftupperlateral calf (C44.7) Superficial spreading melanoma (8743/3) Left anterior upper shin (44.7) Melanoma in situ (8720/2) Is this one or two primaries and what rule did you use? Answer Per Melanoma Rule M5, this is two primaries. Code superficial spreading as 8473/3 and melanoma in situ 8720/2 per Melanoma Histology Rule H3. (I & R Team) /9/ NAACCR Webinar Series 8

9 Collecting Cancer Data: Skin Malignancies 2/4/2010 Question A patient presented with a previously excised T1 malignant melanoma. Is here for a wide excision. The surgeon noted a 1.0 cm pre existing junctional nevus in the field of excision, not related to the melanoma. Pathology Residual malignant melanoma in situ Second malignant melanoma in situ arising in the Clark type nevus, completely excised Are these multiple primaries? If so, what histology is used for the 2nd malignant melanoma in situ? Answer Per Melanoma Rule M8, T1 (invasive) melanoma and in situ melanoma arising in the field of excision (assuming same subsite) would be a single primary. Per Melanoma Rule H4, it would be coded to the invasive melanoma. Based on answer from: Curator (I & R Team) /9/ Next Month Questions? Collecting Cancer Data: Kidney March 4, NAACCR Webinar Series 9

10 Skin Malignancies Merkel Cell Carcinoma Education & Training Team Collaborative Stage Data Collection System Version 2.01 Learning Objectives Understand Merkel cell carcinoma Learn the CS codes Learn the site specific factors Able to correctly abstract and stage a Merkel cell carcinoma patient s chart Overview CS Tumor Size and Extension CS Lymph Nodes CS Mets at Dx Site Specific Factors 3 4 Merkel Cell Carcinoma What is it? A rare aggressive type of skin cancer Incidence 1200 new cases annually Presentation MCC Presentation Usually a firm painless lump that resembles a cyst, but is fixed It can be red, pink or blue-violet It grows rapidly 5 6

11 Merkel Cell Carcinoma Merkel Cell Carcinoma Image courtesy of Paul Nghiem, MD, PhD Image courtesy of Paul Nghiem, MD, PhD 7 8 MCC Risk Factors MCC Incidence by Age Age >65 Caucasian Prolonged sun exposure M F Arsenic exposure Immunosuppression Ultraviolet-A light (PUVA) Image courtesy of Paul Nghiem, MD, PhD 9 10 MCC Pathology Intermediate Type of MCC 3 subtypes Intermediate (most common) Small cell Trabecular (least common) Image courtesy of Paul Nghiem, MD, PhD 11 12

12 Small Cell Type of MCC Trabecular Type of MCC Image courtesy of Paul Nghiem, MD, PhD Image courtesy of Paul Nghiem, MD, PhD MCC Treatment CS Tumor Size Wide excision with 1 to 2.5 cm margins Depending on site 000 No mass found mm, code exact size 15 Sentinel node biopsy If nodes are not palpable Bx of palpable lymph nodes & lymphadenectomy Radiotherapy Primary site Draining lymph node basin mm or larger Microinvasion; micro focus or foci only, no size of focus given Described as <1 cm Inexact size special codes CS Tumor Size CS Extension 992 <2 cm but >1 cm OR between 1-2 cm OR Stated ast1 with no other info on size 000 In situ, non-invasive 993 <3 cm but >2 cm OR between 2-3 cm 100 Confined to dermis 994 <4 cm but >3 cm OR between 3-4 cm 400 Localized NOS <5 cm but >4 cm OR between 4-5 cm OR Stated as T2 with no other info on size >5 cm or stated as T3 with no other info on size Sub Q tissue - through the entire dermis

13 600 Stated as T1 CS Extension CS Tumor Size/Extension Eval Unchanged from standard table 610 Stated as T2 620 Stated as T3 700 Underlying cartilage, bone, skeletal muscle, fascia 800 Further contiguous extension 950 No evidence of primary tumor CS Lymph Nodes CS Lymph Nodes 000 No regional node involvement 360 Stated as N1 NOS Regional nodes by primary site 200 Head and neck nodes 300 Code Stated at N1a with no other information 340 Stated as N1b with no other information In-transit met WITHOUT nodal met or involvement of nodes not stated 420 In-transit met WITH nodes in code In-transit met WITH nodes in code Lymph nodes NOS 999 Unknown; not stated CS Lymph Node Eval MX Eliminated New rules for AJCC 7 th Edition necessitated changes MX has been eliminated from 7 th Edition Clinical M0 Unless clinical or pathologic evidence of mets cm only requires history and physical Infer cm0 unless known cm

14 25 00 None 10 Distant node(s) CS Mets at Dx 15 Mets to skin or subq tissue 20 Stated as M1a with no other information 30 Lung or Stated as M1b with no other information 26 CS Mets at Dx 40 All other visceral sites. Carcinomatosis. Distant mets except as listed before any of 10, 15 or Stated as M1c with no other information 60 Distant mets NOS Stated as M1 NOS 99 Unknown CS Mets Eval Unchanged from standard table Mets at Dx-Metastatic Sites 4 new fields Bone excluding marrow Lung excluding pleura and pleural fluid Brain excluding spinal cord and other CNS Liver Code 0 when CS Mets at Dx is Code structure 0 No 1 Yes 8 Not applicable 9 Unknown SSF1 Measured Thickness (Depth) Code exact size in TENTHS of mm mm SSF 3 Clinical Assessment Positive Nodes 000 No nodal mets or in-transit mets WITHOUT regional node involvement 010 Clinically occult nodes only (micromets) mm or larger 020 Clinically apparent nodal mets (macromets) No histologic exam of primary site Microinvasion; microscopic focus or foci only, and no size given Unknown, not stated, not documented in chart

15 SSF 16 Size of Mets in Nodes Record largest mets in node in hundredths of mm mm mm or larger Mets or tumor nests in regional nodes, size cannot be assessed No histologic exam of primary site SSF 17 Path Nodal Extracapsular Extension 010 No extracapsular extension clinically AND extracapsular extension present on pathology 020 No extracapsular extension clinically AND not present or not stated on pathology 030 No extracapsular extension clinically AND nodes not assessed pathologically SSF 17 Path Nodal Extracapsular Extension 040 Extracapsular extension clinically AND extracapsular extension on path 050 Extracapsular extension clinically AND not present or not stated on path 060 Extracapsular extension clinically AND nodes not assessed pathologically SSF 17 Path Nodal Extracapsular Extension 070 Extracapsular extension clinically unknown AND extracapsular extension present on path 080 Extracapsular extension clinically unknown AND extracapsular extension not present or not stated on path 090 Extracapsular extension clinically unknown AND nodes not assessed pathologically SSF 17 TABLE SSF 18 Isolated Tumor Cells (ITC) in Nodes CODE Clinical Pathologic Extracapsular Extracapsular Extension Extension 010 Neg Pos 000 Negative on H&E, ITC not present by IHC, unknown if tested by IHC. Nodes clinically negative, not examined pathologically. IHC stains used are CK20, CAM5.2, pancytokeratins 020 Neg Neg/not stated 030 Neg Not assessed 040 Pos Pos '050 Pos Neg/not stated 010 Nodes negative on H&E and IHC and ITCs not present Pos Not assessed 070 Unknown Pos 080 Unknown Neg/not stated 090 Unknown Not assessed Nodes negative on H&E, + on IHC, and ITCs are present

16 SSF 18 Isolated Tumor Cells (ITCs) in Nodes 090 Regional nodes negative on H&E, positive for tumor detected by IHC, size of tumor cells not stated 100 Regional nodes positive with ITCs on H&E 200 Regional nodes positive with ITCs NOS method of detection not stated 300 Regional nodes positive other than ITCs (tumor cells > 0.2 mm) SSF19 Tumor Transection Status 000 No mass/tumor found 010 Tumor base transected 020 Tumor base not transected 998 No histologic exam of primary site 999 Unknown, not documented in chart SSF20 Tumor Infiltrating Lymphocytes (TIL) SSF 21 Growth Pattern of Primary Tumor TIL in the primary tumor Special cancer-fighting cells of immune system Level of infiltrates at base of vertical growth phase 010 TIL present, non-brisk 020 TIL present, brisk 010 Circumscribed/nodular 020 Diffusely infiltrative 030 Sample inadequate to evaluate or comment as stated the path report 030 TIL present NOS No histologic specimen 40 SSF 22 Profound Immunosuppression 000 No immune suppression conditions 010 HIV/AIDS 020 Solid organ transplant recipient 030 CLL SSF 22 Profound Immunosuppression 040 Non-Hodgkin lymphoma 050 More than one of the above 060 Other specified diagnosis resulting in profound immunosuppression 070 Profound immunosupression present, diagnosis not recorded 41 42

17 Merkel Cell Carcinoma A rare but aggressive tumor Incidence is increasing Specific stains to determine the diagnosis Melanoma Clinical lymph node status an important prognostic factor 43 Learning Objectives Learn the differences between CSv1 and CSv2 Be able to correctly abstract and stage a melanoma patient s chart Overview Changes from CSv1 to CSv2 CS Tumor Size and Extension CS Lymph Nodes CS Mets at Dx Site Specific Factors CS Tumor Size mm (exact size in mm) mm or larger 990 Micro focus or foci, no size of focus given CS Tumor Size 993 <3 cm or >2 cm or between 2-3 cm T2 NOS with no documentation of tumor size 994 <4 cm or >3 cm or between 3-4 cm 991 Described as <1 cm 995 <5 cm or >4 cm or between 4-5 cm <2 cm or >1 cm or between 1-2 cm T1 NOS with no documentation of tumor size 48 CS Tumor Size Eval unchanged

18 CS Extension Clark s Level 000 In situ, non-invasive, intradermal, Clark level I 100 Papillary dermis invaded, Clark level II Papillary-reticularreticular dermal interface invaded, Clark level III 300 Reticular dermis invaded, Clark level IV 400 Skin/dermis NOS, Localized NOS 500 SubQ tissue invaded, Clark level V Clarks Level I Clarks Level II Clarks Level III Clarks Level IV 50 Clarks Level V CS Extension 800 Further contiguous extension, Underlying cartilage, bone, skeletal muscle 950 No evidence of primary tumor 999 Unknown extension, Primary tumor cannot be assessed (e.g. shave biopsy or regressed melanoma) CS Lymph Nodes 100 Regional nodes by primary site 120 Head and neck nodes 130 Satellite nodules or in-transit mets NOS (distance from primary site not stated) WITHOUT regional node involvement or regional node involvement not stated 51 CS Tumor Size/Extension Eval unchanged 52 IIN-TRANSIT METASTASIS In-Transit Mets CS Lymph Nodes 140 Satellite nodule(s) or in-transit mets < 2 cm from primary WITHOUT regional node involvement or node involvement not stated 150 Satellite nodule(s) or in-transit mets >2 cm from primary WITHOUT regional node involvement or involvement not stated 54

19 CS Lymph Nodes 170 Matted nodes in code Matted nodes in code Satellite nodule(s) or in-transit mets WITH regional nodes in code Satellite nodule(s) or in-transit mets WITH regional nodes in code 120 MX Eliminated MX has been eliminated from 7 th Edition Clinical M0 Unless clinical or pathologic evidence of mets cm only requires history and physical Infer cm0 unless known cm Lymph nodes NOS 56 CS Mets at Dx CS Mets at Dx 05 Underlying cartilage, bone, skeletal muscle 10 Distant lymph nodes 44 All other visceral sites Carcinomatosis Other distant sites 40 Distant metastasis NOS Mets to skin or subq tissue beyond regional nodes Lung 58 Mets at Dx-Metastatic Sites SSF1-3 Unchanged 4 new fields Bone excluding marrow Lung excluding pleura and pleural fluid Brain excluding spinal cord and other CNS Liver SSF1 Depth of Invasion Code exact size in hundredths of mm SSF2 Ulceration Code 0 when CS Mets at Dx is 00 No mention of ulceration in path report assume no ulceration 59 Code structure 0 No 1 Yes 8 Not applicable 9 Unknown 60 SSF3 Clinical Status of Lymph Node Mets Code 000 No lymph node mets OR Code 000 Satellite lesion or in-transit mets without nodes

20 SSF4 LDH SSF5 LDH Value 000 Test not done 002 Within normal limits Code value of LDH Prior to treatment or within 6 weeks of diagnosis Give priority to the earliest tests performed Range1 1.5 x normal limit OR elevated NOS 005 Range x normal limit 006 Range 3 more than 10 normal limit 008 Test ordered, results not in chart 62 Code value from same test used in SSF 4 Record actual value for values 001 through 800 Record range for values 801 and greater Codes are ranges in intervals of 20 Codes are ranges in intervals of 50 Codes are ranges in intervals of 100 Code 922 is a value of or greater SSF5 LDH Value SSF6 LDH Upper Limits of Normal 63 Code Description 060 Actual value of Value 801 to Value 3201 to Value 7701 to Value is or greater 995 Stated as within normal limits, no other info 996 Stated as elevated, no other info 997 Test ordered, results not in chart 998 Test not done 64 Record upper limits of normal for LDH Upper limit of normal varies based on the lab Upper limit i of normal is Upper limit of normal not in chart 998 Test not done 999 Unknown, no documentation SSF7 Primary Tumor Mitotic Count/Rate SSF8 Primary Tumor Regression 000 Mitotic rate <1 per millimeter squared Not identified should be coded as absent per millimeter squared millimeter squared or greater 000 No regression Regression not identified Regression absent No histologic exam of primary site Unknown, not stated, not documented 001 Regression present 999 Unknown, not stated, not documented 65 66

21 SSF9 Vertical Growth Phase Not identified should be coded as absent 000 No vertical growth phase present Vertical growth phase not identified Vertical growth phase absent 001 Vertical growth phase present Melanoma Addition of 5 new site specific factors T category is now based on Depth of invasion Ulceration Mitotic rate 999 Unknown, not stated, not documented Inquiry & Response System American Joint Committee on Cancer Contact Information Submit questions to Inquiry & Response System Allows tracking for educational purposes Karen A. Pollitt Manager kpollitt@facs.org phone: Provides information for all Donna M. Gress, RHIT, CTR Technical Specialist dgress@facs.org phone: General Inquiries can be directed to AJCC@facs.org AJCC Web Site