2018 Grade PEGGY ADAMO, RHIT, CTR OCTOBER 11, 2018

Transcription

1 Grade PEGGY ADAMO, RHIT, CTR OCTOBER 11, 2018

2 2 Acknowledgements Donna Hansen, CCR Jennifer Ruhl, NCI SEER

3 Introduction 3

4 Histologic Type vs. Grade Credit: Dr. Kay Washington 4 Histologic classification influenced by matching tumor to a tissue of origin (diagnosis) Differentiation is determined by how closely tumor cells resemble normal cells (grade) Pathologist should make a diagnosis, then grade tumor Different grading systems apply to different tumors Prostate adenocarcinoma & invasive breast carcinoma of no special type both adenocarcinomas, but have different specialized grading schemes Grade has prognostic impact for some but not all tumors

5 5

6 2018 Grade 6 Discontinued Standard Grade/differentiation data item SSFs that collect chapter-specific grades Breast, Kidney, Prostate, Sarcoma Grade (cell type) for heme cases*

7 Grade, cont d New Grade Clinical Clinical time frame Grade Pathological After resection without neoadjuvant therapy Grade Post-therapy After neoadjuvant therapy & resection

8 Grade, cont d Capture grade at three different points in patient care Similar to AJCC timeframes Clinical Grade From diagnostic workup prior to treatment Pathological Grade From surgical resection specimen of primary tumor/organ; or clinical grade if higher Post-therapy Grade From surgical resection specimen of primary tumor/organ after neoadjuvant therapy

9 Grade, cont d 2018 grade data items Incorporate AJCC chapter-specific grading systems (when applicable) May be 2, 3, or 4 grade system No longer convert to 4 grade system Allow for coding of grade at different points of patient care Generic definitions apply when specific grading systems not defined or not applicable

10 10 General Instructions

11 General Instructions for Solid Tumors 11 Code grade from primary tumor only Do NOT code grade based on metastatic tumor or recurrence In rare instance that tumor extends contiguously to adjacent site & tissue from primary site not available, code grade from contiguous site Unknown primary site: Grade = 9 More than one grade available for individual grade data item (i.e. within same time frame) Priority to recommended AJCC grade listed in applicable AJCC chapter If none of specified grades are from recommended AJCC grade system, record highest grade If no recommended AJCC grade for site, code highest grade

12 General Instructions, cont. 12 In situ &/or combined in situ/invasive components Grade specified for in situ tumor: code it Do NOT code grade for dysplasia such as high-grade dysplasia Both in situ & invasive components: code grade for invasive portion even if grade unknown Systemic treatment & radiation can alter tumor s grade Important to code clinical grade based on information prior to neoadjuvant therapy even if grade unknown during the clinical timeframe Grade now collected in grade post-therapy when grade available from postneoadjuvant surgery

13 Grade Table Template Code Grade Description 1 Site-specific grade system category 2 Site-specific grade system category 3 Site-specific grade system category 4 Site-specific grade system category 5 Site-specific grade system category L H M S A B C D Low Grade High Grade Site-specific grade system category Site-specific grade system category Well differentiated Moderately differentiated Poorly differentiated Undifferentiated/Anaplastic 8 Not applicable (Heme neoplasms only) 9 Unknown, cannot be assessed Blank Post-therapy grade only 13

14 Grade Breast 14 Code Grade Description 1 G1: Low combined histologic grade (favorable), SBR score of 3 5 points 2 G2: Intermediate combined histologic grade (moderately favorable); SBR score of 6 7 points 3 G3: High combined histologic grade (unfavorable); SBR score of 8 9 points L Nuclear Grade I (Low) (in situ only) M Nuclear Grade II (intermediate) (in situ only) H Nuclear Grade III (High) (in situ only) A Well differentiated B Moderately differentiated C Poorly differentiated D Undifferentiated, anaplastic 9 Grade cannot be assessed (GX); Unknown

15 2018 Grade 15 Generic grade definitions with new codes used for AJCC chapters with no grading system Primary site/histology combinations not covered in AJCC 2018 Code Code Description Pre-2018 Code A Well differentiated 1 B Moderately differentiated 2 C Poorly differentiated 3 D Undifferentiated, anaplastic 4 9 Unknown 9

16 2018 Grade Sites using generic grade definitions No AJCC preferred grade 16 Cervical lymph nodes & unknown primary Major salivary glands Melanoma Conjunctiva Mucosal melanoma of head & neck Skin Merkle cell carcinoma Nasopharynx NET adrenal gland Oropharynx HPVmediated (p16+) Placenta Testis Thymus Thyroid Thyroid medullary

17 2018 Grade Sites using generic grade definitions No AJCC chapter 17 Adnexa Uterine Other Genital Female Other Genital Male Other Urinary Other Lacrimal Sac Eye Other Endocrine Other Ill-defined Other Pharynx Other Middle Ear Sinus Other Biliary Other Digestive Other Trachea Respiratory Other Skin Other

18 2018 Grade Bladder, Renal Pelvis, Ureter, Urethra 18 Code Grade Description 1 G1: Well differentiated 2 G2: Moderately differentiated 3 G3: Poorly differentiated L LG: Low grade H HG: High grade 9 Grade cannot be assessed (GX); Unknown Blank See Note 1 }1-3 Squamous cell or adenocarcinoma } L & H Urothelial carcinoma

19 Three Grade Fields Code Clinical Grade Code Description 1 G1: Well differentiated 2 G2: Moderately differentiated 3 G2: Poorly differentiated 9 Grade cannot be assessed (GX); Unknown Pathological Grade Code Code Description 1 G1: Well differentiated 2 G2: Moderately differentiated 3 G2: Poorly differentiated 9 Grade cannot be assessed (GX); Unknown Post-therapy Grade Code Code Description 1 G1: Well differentiated 2 G2: Moderately differentiated 3 G2: Poorly differentiated 9 Grade cannot be assessed (GX); Unknown Blank See Note 1 19

20 Site-Specific Notes 20 Grade Clinical Notes Note 1: Clinical grade must not be blank. Note 2: Assign the highest grade from the primary tumor assessed during the clinical time frame. Note 3: Priority order for codes Urothelial cancers: use codes L, H and 9 If only G1-G3 are documented, code 9 Adenocarcinomas and Squamous Cell Carcinomas: use codes 1-3, 9 If only L or H are documented, code 9 Note 4: G3 includes undifferentiated and anaplastic. Note 5: For bladder, a TURB qualifies for a clinical grade only Note 6: Code 9 when Grade from primary site is not documented Clinical workup is not done (for example, cancer is an incidental finding during surgery for another condition) Grade checked not applicable on CAP Protocol (if available) and no other grade information is available Note 7: If there is only one grade available and it cannot be determined if it is clinical or pathological, assume it is a clinical grade and code appropriately per clinical grade categories for that site, and then code unknown (9) for pathological grade, and blank for post therapy grade.

21 21 Site-Specific Notes, cont d Grade Pathological Notes Note 1: Pathological grade must not be blank. Note 2: Assign the highest grade from the primary tumor. If the clinical grade is higher than the grade determined during the pathological time frame, use the grade that was identified during the clinical time frame for both the clinical grade and the pathological grade. (This follows the AJCC rule that pathological time frame includes all of the clinical time frame information plus information from the resected specimen.) If a resection is done of a primary tumor and there is no grade documented from the surgical resection, use the grade from the clinical workup If a resection is done of a primary tumor and there is no residual cancer, use the grade from the clinical workup Note 3: Priority order for codes Urothelial cancers: use codes L, H and 9 If only G1-G3 are documented, code 9 Adenocarcinomas and Squamous Cell Carcinomas: use codes 1-3, 9 If only L or H are documented, code 9 Note 4: G3 includes undifferentiated and anaplastic. Note 5: For bladder, a TURB does not qualify for surgical resection. A cystectomy, or partial cystectomy, must be performed. Note 6 Code 9 when Grade from primary site is not documented No resection of the primary site Neo-adjuvant therapy is followed by a resection (see post-therapy grade) Clinical case only (see clinical grade) There is only one grade available and it cannot be determined if it is clinical, pathological, or after neo-adjuvant therapy Grade checked not applicable on CAP Protocol (if available) and no other grade information is available

22 Site-Specific Notes 22 Grade Post Therapy Notes Note 1: Leave post-therapy grade blank when No neoadjuvant therapy Clinical or pathological case only There is only one grade available and it cannot be determined if it is clinical, pathological or post-therapy Note 2: Assign the highest grade from the resected primary tumor assessed after the completion of neoadjuvant therapy. Note 3: Priority order for codes Urothelial cancers: use codes L, H and 9 If only G1-G3 are documented, code 9 Adenocarcinomas and Squamous Cell Carcinomas: use codes 1-3, 9 If only L or H are documented, code 9 Note 4: G3 includes undifferentiated and anaplastic Note 5: Code 9 when Surgical resection is done after neoadjuvant therapy and grade from the primary site is not documented Surgical resection is done after neoadjuvant therapy and there is no residual cancer Grade checked not applicable on CAP Protocol (if available) and no other grade information is available

23 Three Grade Fields 23 But Usually only two grade fields coded per case Sometimes only one grade field coded per case Never three grade fields coded for a single case Clinical Grade Pathological Grade OR Post-therapy Grade Code path grade and leave post-therapy grade blank Code post-therapy grade and code 9 in path grade

24 Grade Terminology Table 24 Mapping terms for generic grade Only when grade code table includes generic grades coded A-D And no grade documented from AJCC preferred system (when applicable) Do NOT use for generic grades coded 1-4 Description Grade Assigned Grade Code Differentiated, NOS I A Well differentiated I A Only stated as Grade I I A Fairly well differentiated II B Intermediate differentiation II B Low grade I-II B Mid differentiated II B Moderately differentiated II B Moderately well differentiated II B Partially differentiated II B Partially well differentiated I-II B Relatively or generally well differentiated II B Only stated as Grade II II B Medium grade, intermediate grade II-III C Moderately poorly differentiated III C Moderately undifferentiated III C Poorly differentiated III C Relatively poorly differentiated III C Relatively undifferentiated III C Slightly differentiated III C Dedifferentiated III C

25 25 Grade Required for AJCC Stage Group

26 Grade Required for AJCC Stage Group 26 Esophagus & esophagogastric junction Appendix Bone Soft tissue sarcoma of trunk & extremities Soft tissue sarcoma of retroperitoneum Gastrointestinal stromal tumor Breast Prostate

27 AJCC Grade 27 Esophagus & Esophagogastric Junction

28 CAP Protocol 28 Esophagus & Esophagogastric Junction Histologic Grade (required only if applicable) (Note D) # G1: Well differentiated G2: Moderately differentiated G3: Poorly differentiated, undifferentiated GX: Cannot be assessed # Histologic grade is not applicable to adenoid cystic carcinoma, mucoepidermoid carcinoma, welldifferentiated neuroendocrine tumor, and high-grade neuroendocrine carcinoma.

29 Esophagus Stage Groupings: Squamous Cell Carcinoma Stage T N M G Location Stage 0 Tis N0 M0 N/A Any Stage IA T1a N0 M0 1 or X Any Stage IB T1a N0 M0 2 or 3 Any T1b N0 M0 Any Any T2 N0 M0 1 Any Stage IIA T2 N0 M0 2, 3, or X Any T3 N0 M0 Any Lower T3 N0 M0 1 Upper, middle Stage IIB T3 N0 M0 2 or 3 Upper, middle T3 N0 M0 X Any T3 N0 M0 Any location X T1 N1 M0 Any Any Stage IIIA T1 N2 M0 Any Any T2 N1 M0 Any Any Stage IIIB T2 N2 M0 Any Any T3 N1-2 M0 Any Any T4a N0-1 M0 Any Any Stage IVA T4a N2 M0 Any Any T4b N0-2 M0 Any Any Any N3 M0 Any Any Stage IVB Any T Any N M1 Any Any 29

30 AJCC Grade 30 Appendix

31 CAP Protocol 31 Appendix Histologic Grade (Note D) G1: Well differentiated G2: Moderately differentiated G3: Poorly differentiated Other (specify): GX: Cannot be assessed Not applicable

32 AJCC Grade 32 Bone

33 CAP Protocol 33 Bone Histologic Grade (Note D) G1: Well differentiated, low grade G2: Moderately differentiated, high grade G3: Poorly differentiated, high grade GX: Cannot be assessed Not applicable

34 AJCC Stage Groupings 34 Appendicular Skeleton, Trunk, Skull, and Facial Bones Stage IA T1 N0 M0 G1,GX Low grade Stage IB T2 N0 M0 G1,GX Low grade T3 N0 M0 G1,GX Low grade Stage IIA T1 N0 M0 G2,G3 High grade Stage IIB T2 N0 M0 G2,G3 High grade Stage III T3 N0 M0 G2,G3 High grade Stage IVA Any T N0 M1a Any G Any grade Stage IVB Any T N1 Any M Any G Any grade Any T Any N M1b Any G Any grade Spine and Pelvis There are no AJCC prognostic stage groupings for spine and pelvis.

35 AJCC Grade 35 Soft tissue sarcoma of trunk & extremities Soft tissue sarcoma of retroperitoneum

36 CAP Protocol 36 Soft tissue sarcoma of trunk & extremities Soft tissue sarcoma of retroperitoneum Histologic Grade (French Federation of Cancer Centers Sarcoma Group [FNCLCC]) (Note E) Grade 1 Grade 2 Grade 3 Ungraded sarcoma Cannot be assessed

37 AJCC Grade 37 Gastrointestinal stromal tumor

38 CAP Protocol 38 Gastrointestinal stromal tumor Histologic Grade (Note B) G1: Low grade; mitotic rate 5/5 mm 2 G2: High grade; mitotic rate >5/5 mm 2 GX: Grade cannot be assessed

39 AJCC Grade 39 Breast

40 CAP Protocol 40 DCIS Breast Nuclear Grade (Note F) Grade I (low) Grade II (intermediate) Grade III (high)

41 CAP Protocol 41 Invasive Breast Overall Grade Grade 1 (scores of 3, 4, or 5) Grade 2 (scores of 6 or 7) Grade 3 (scores of 8 or 9) Only microinvasion present (not graded) No residual invasive carcinoma Score cannot be determined Note: The grade corresponds to the largest area of invasion. If there are smaller foci of invasion of a different grade, this information should be included under Additional Pathologic Findings.

42 AJCC Grade 42 Prostate

43 CAP Protocol 43 Prostate Histologic Grade (Note C) Gleason Pattern Not applicable Cannot be assessed Gleason Pattern, Score, and Grade Group (only if applicable and if Gleason pattern can be assessed) Note: Gleason patterns and score may be reported on a single line. Primary (Predominant) Gleason Pattern Pattern 1 Pattern 2 Pattern 3 Pattern 4 Pattern 5 Secondary (Worst Remaining) Gleason Pattern # Pattern 1 Pattern 2 Pattern 3 Pattern 4 Pattern 5 # Note: If 3 patterns present, use most predominant pattern and worst pattern of remaining 2. If only 2 patterns are present, Gleason score is the sum of the primary and secondary grades.

44 44

45 CAP Protocol, cont d 45 Prostate Total Gleason Score: Grade Group Grade group 1 Grade group 2 Grade group 3 Grade group 4 Grade group 5 Percentage of Pattern 4 in Gleason Score 3+4=7 Cancer (only if applicable) Specify: % + Percentage Gleason Patterns 4 and 5 (applicable to Gleason score 7) + Percentage pattern 4: % + Percentage pattern 5: %

46 46 Hematopoietic & Lymphoid Neoplasms

47 Hematopoietic & Lymphoid Neoplasms 47 Grade no longer collected* Grade clinical & path = code 8 Grade post-therapy = blank *EXCEPT for Ocular Adnexa Lymphoma, AJCC 8th Ed. Chapter 71 AJCC defined grade system for follicular histologies Sites C441, C690, C695, C696 Follicular lymphomas 9690/3, 9691/3, 9695/3, 9698/3 All other lymphoma histologies in AJCC Chapter 71 Grade clinical, path, post-therapy = code 9

48 Ocular Adnexa Lymphoma 48 Credit: Dr. Khalid Lecture 1 Eyelids and Lacrimal Apparatus, b07fc72a.pdf

49 Follicular Lymphoma Follicular lymphoma 9695 Follicular lymphoma, grade Follicular lymphoma, grade Follicular lymphoma, grade 3A 9698 Follicular lymphoma, grade 3B

50 Ocular Adnexa Follicular Lymphoma Grade 50

51 AJCC Chapter 71 51

52 Resources 52

53 Grade Webinar Free! 53

54 NAACCR Website 54

55 55

56 SEER*RSA 56

57 CoC CAnswer Forum 57

58 58 Thank you! Questions?