OSCaR Update. Manager s Update. Upcoming Events. Donald Shipley, MS

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1 Volume 8, Quarter 1 Winter 2007 Oregon State Cancer Registry OSCaR Update In this Issue: Update on New MPH Rules Bladder Cancer Incidence and Mortality Focus on Abstracting, Coding, and Staging Bladder Cancer OSCaR Staff Donald Shipley, MS Program Manager donald.k.shipley@state.or.us Cathy Riddell Senior Research Analyst catherine.a.riddell@state.or.us Joan Pliska, RHIT, CTR Research Analyst joan.m.pliska@state.or.us Claudia Feight, RHIT, CTR Quality Assurance Specialist Training Coordinator claudia.f.feight@state.or.us Deborah Towell, CTR Senior Cancer Data Specialist deborah.j.towell@state.or.us Nancy Henderson, CTR Cancer Data Specialist nancy.l.henderson@state.or.us LeeLa Coleman, CTR Cancer Data Specialist leela.j.coleman@state.or.us Rebecca Gould, CTR Cancer Data Specialist rebecca.s.gould@state.or.us Alyssa J. Elting Database Specialist alyssa.elting@state.or.us Jeffrey Soule Administrative Assistant jeffrey.a.soule@state.or.us Manager s Update Donald Shipley, MS There s rarely a dull moment around here! Since the last newsletter, OSCaR has submitted files for two calls for data: one to NAACCR in December, and one to CDC in January. OSCaR staff is now knee-deep in writing the application for the next 5-year funding cycle. At the same time, the OCRA Spring Workshop and the annual NCRA meeting are just around the corner, and OSCaR s new web-based reporting system is ready for testing. Work is beginning on production of the 2004 annual report and the 2005 data file is nearing completion. They tell me it all constitutes job security. We have received very positive feedback on the last few newsletters, each one being focused on a cancer site. This issue focuses on bladder cancer. The Cancer Data Specialists have worked hard to provide summarized coding and staging information in a format they hope will be useful to you when abstracting these cases. If you have any questions or comments, please contact your state registry representative or any member of the quality assurance team. This quarter marks the beginning of a series of articles in which Claudia will be providing information and tips on the new histology and multiple primary rules (MPH). As we move into our new funding cycle, Claudia will be taking on additional responsibilities in providing training for our staff, and training for reporting registrars in the field. As training plans develop, we will share those plans with you and ask for suggestions on how we can make training available to you in the most valuable ways. Because of the hard work that goes on in cancer registries across the state, Oregon s cancer data will once again be included in Cancer in North America, United States Cancer Statistics, and for the first time, in Cancer Incidence on Five Continents published by the World Health Organization. Keep up your good work! Upcoming Events National Cancer Registrars Week: April 9-12, 2007 OCRA s Spring Educational Workshop Spring in the Valley: Blooming with Knowledge April 13, 2007 in Salem NCRA s 33rd Annual Educational Conference Rolling Out Advances through Research, Professionalism, Education and Advocacy April 22-25, 2007 in Las Vegas

2 Page 2 C LAUDIA S QA CORNER C LAUDIA FEIGHT, RHIT, CTR Talk from the Trainer 2007 Multiple Histology and Primary Rules Greetings Registrars! I hope everyone had a wonderful holiday and is hopping into Spring! As Donald noted in his update, the central registry is going in a lot of different directions. Some days I am not sure which direction I am headed! With the implementation of the 2007 Multiple Histology and Primary rules, many of you are now suspending cases and dealing with the new rules on a daily basis. The MPH rules are creating some havoc out there in some of the facilities. I will be talking about the top ten principles that go along with using the new rules. I think you will all find something that will be helpful in your day-to-day work. I decided to present this topic because there were times when I did not strictly adhere to the rules myself. Obviously, I didn t get the correct answer that I was looking for! I figured stepping back a bit and reviewing some of the principles of the rules would be a good thing! As Donald noted, my role has changed at OSCaR to include continuing education training in Oregon. CDC has mandated that all NPCR central registries designate a CTR for this role. I will be responsible for providing local and statewide educational trainings to registrars on a regular basis. I am still adjusting to my new role, so I am hoping that this training will be beneficial to all of you in the registry field. Donald and I are currently writing an implementation plan, but it will take time for all the pieces to fall into place. I figured stepping back a bit and reviewing some of the principles of the rules would be a good thing! If you have any ideas, or other areas of interest, please let me know, via or phone. Thank you for your support and assistance. See you at the Spring workshop! Claudia Feight, CTR, RHIT Quality Assurance/Training Coordinator A NALYST S ANGLE C ATHY RIDDELL; JOAN PLISKA, CTR; ALYSSA ELTING Bladder Cancer in Oregon 2004 Incidence and Mortality Summary Bladder Cancer: Stage at Diagnosis, Oregon Residents, 2004 Age-adjusted incidence rate per 100,000 Number of new invasive cases Total Male Female local 29% regional 8% distant 4% unstaged 2% Number of new in situ cases Number of deaths in situ 57%

3 Inside St ory Headline Volume 8, Quarter 1 Page 3 CTR NEWS DEBORAH TOWELL, CTR; NANCY HENDERSON, CTR; LEELA COLEMAN, CTR; BECKY GOULD, CTR Focus on abstracting, coding, and staging bladder cancer Adapted from: ANATOMY The empty bladder is about the size and shape of a pear. It is located in the lower pelvic cavity. Urine drains from the kidneys into the bladder through the ureters. From the bladder, urine is excreted through a tube called the urethra. In women, this tube is about 1.5 inches long and exits the body at the upper aspect of the vaginal opening. In men, the urethra is about 8 inches long and passes through the penis, opening at its tip. Bladder Anatomy and ICD-O-3 ICD-O-3 Codes ICD-O-3 Term C67.0 Trigone of bladder C67.1 Dome of bladder C67.2 Lateral wall of bladder C67.3 Anterior wall of bladder C67.4 Posterior wall of bladder C67.5 Bladder neck C67.6 Ureteric orifice C67.7 Urachus C67.8 Overlapping lesion of bladder C67.9 Bladder, NOS Equvalent Terms Mucosa epithelium urothelium mucosal surface transitional mucosa Muscle muscularis muscularis propria muscularis externa smooth muscle Submucosa lamina propria suburothelial connective tissue subepithelial tissue stroma muscularis mucosa Perivesical fat adventitia serosa Regional Lymph Nodes Common iliac internal iliac (hypogastric) external iliac Obturator sacral (lateral, presacral, promontory {Gerota's}) perivesical and pelvic not otherwise specified (NOS) Continued on Page 4

4 Page 4 Continued from Page 3 ABSTRACTING, CODING, and STAGING ICD-O-3 Morphology Code Transitional cell carcinoma (8120/3); most common morphology. Papillary carcinoma (8130/3); Papillary and transitional cell carcinomas comprise 90-95% of all bladder cancers. Squamous cell carcinoma (8070/3); occurs in 8% of all bladder carcinomas. Adenocarcinoma (8140/3); of the bladder--very rare (2%) and almost impossible to distinguish from primary prostate carcinoma which has extended into the bladder. Leiomyosarcoma (8890/3); rare tumor arising in the muscle layer of the bladder. Common Metastatic Sites Spread Primary Site/Mets Lymphatic Spread Hematogenous Spread Common iliac lymph nodes are second station (metastatic) nodes. Lung, bone, liver ABSTRACTING KEYS The terms lamina propria and submucosa can be used interchangeably because these structures tend to merge when there is no muscularis mucosae. Invasion of the mucosa may be interpreted by the pathologist as either in situ or invasive; determine whether the pathologist is describing in situ or localized tumor. It is important to have a deep resection in order to adequately assess involvement of the bladder wall muscle. Superficial muscle invasion is defined as less than half-way through the muscle coat (three layers). Deep muscle invasion is considered half-way or more through the muscle coat. If the depth of muscle invasion is not stated by the surgeon or pathologist, stage as T2, invasion of superficial muscle. There is a high degree of correlation between the grading (differentiation or aggressiveness) of the tumor and the stage (invasiveness). It is important to differentiate between negative nodes and no information on nodes. There must be some kind of examination beyond a TUR to determine if regional nodes are negative. Continued on Page 5

5 Volume 8, Quarter 1 Page 5 Continued from Page 4 Distinguishing Noninvasive and Invasive Bladder Cancer The two main types of bladder cancer are the flat (sessile) variety and the papillary type. Only the flat (sessile) variety is called in situ when the tumor has not penetrated the basement membrane. The papillary tumor that has not penetrated the basement membrane is called non-invasive, and pathologists use many different descriptive terms for noninvasive papillary transitional cell carcinoma. Frequently, the pathology report does not contain a definite statement of noninvasion; however, noninvasion can be inferred from the microscopic description. The more commonly used descriptions for noninvasion are listed below. All are considered summary stage in situ. Statements of Non-invasion (applies to bladder cases only) Definite Non-infiltrating; non-invasive No evidence of invasion No extension into lamina propria No stromal invasion No extension into underlying supportive tissue Negative lamina propria and superficial muscle Negative muscle and (subepithelial) connective tissue No infiltrative behavior/component Inferred No involvement of muscularis propria and no mention of subepithelium/submucosa No statement of invasion (microscopic description present) (Underlying) Tissue insufficient to judge depth of invasion No invasion of bladder wall; no involvement of muscularis propria Benign deeper tissue Microscopic description problematic for pathologist (non-invasion versus superficial invasion) Frond surfaced by transitional cells No mural infiltration No evidence of invasion (no sampled stroma) Excerpts from Multiple Primary & Histology Coding Rules (Renal Pelvis, Ureter, Bladder & Other Urinary) NEW FOR CASES DIAGNOSED JANUARY 1, 2007, OR LATER: Tumors diagnosed more than three (3) years apart are multiple primaries. When an invasive tumor follows an in situ tumor within 60 days, abstract as a single primary. Equivalent or Equal Terms Flat transitional cell, flat urothelial, in situ transitional cell, and in situ urothelial Tumor, mass, lesion, neoplasm Urothelial and transitional Urothelium and transitional epithelium Intramucosal and in situ Definitions Contiguous Sites: Renal pelvis Ureter Bladder Urethra/prostatic urethra Field effect: Widespread changes in normal or relatively normal tissue that predispose a person to cancer. Flat Tumor (bladder)/noninvasive flat TCC: A flat tumor is a non-papillary bladder tumor that lies flat against the bladder tissue. Flat tumors usually have a poor prognosis. Noninvasive flat TCC (also called carcinoma in situ, or CIS) grows in the layer of cells closest to the inside of the bladder and appears as flat lesions on the inside surface of the bladder. Flat, invasive TCC may invade the deeper layers of the bladder, particularly the muscle layer. In situ: A tumor confined to epithelium (intraepithelial) with no penetration below the basement membrane. Intraluminal (Ureter): Within the lumen of a tubular or hollow structure. Urinary tumors may spread intraluminally to adjacent urinary organs. Intramucosal: Within the mucosal surface. Continued on Page 6

6 Continued from Page 5 Invasive: A tumor that penetrates beyond the basement membrane. Most invasive: The tumor with the greatest continuous local/ regional extension (see focal and foci/focus definitions). Bladder The walls of the bladder in order from least to greatest extension are: Mucosa Lamina propria (some pathologists equate this to submucosa) Muscularis mucosae (this layer not always present, may not be mentioned) Submucosa Muscular layer (muscularis propria, detrusor muscle) Serosa, adventitia Multicentric, multifocal, and polycentric are often used as synonyms. The tumor has multiple centers. The foci are not contiguous. Non-invasive tumor: A tumor confined to epithelium (intraepithelial) with no penetration below the basement membrane. Papillary tumor: A papillary bladder, ureter, or renal pelvis tumor is a warty growth that is attached to the wall by a stalk. Papillary and Flat Carcinomas: Urothelial carcinomas may be either flat or papillary. The terms papillary and flat describe the structure or architecture of the tumor, not a specific histologic type. Both are transitional cell/urothelial carcinoma, although there are behavioral differences between the two. Prostatic Urethra: Adenocarcinoma of the prostatic urethra is usually an extension of adenocarcinoma of the prostate. Transitional cell/urothelial carcinoma in the prostatic urethra may be an extension from the bladder or may be primary in the prostatic urethra. Satellite lesion or metastasis: Metastatic lesion within the immediate vicinity of the primary tumor. Transitional cell carcinoma usually begins in the renal pelvis, not in the kidney. The cancer cells are different from renal cell carcinoma. Transitional epithelium: A highly expandable epithelium that has a layered appearance with large cube-shaped cells in the relaxed state that transform and stretch into broad and flat cells in the expanded or distended state. Urinary tract: Structures lined by transitional epithelium also known as urothelium. Urothelium: The transitional epithelium lining the wall of the bladder, ureter, and renal pelvis, external to the basement membrane. Oregon State Cancer Registry 800 NE Oregon Street, Suite 730 Portland, OR Phone: Fax: oscar.ohd@state.or.us The purpose of the registry shall be to provide information to design, target, monitor, facilitate, and evaluate efforts to determine the causes or sources of cancer among the residents of Oregon and to reduce the burden of cancer and benign brain tumors in Oregon." V ISIT US ON THE WEB! WWW. HEALTHOREGON. ORG/ OSCAR