비뇨병리연구회공청회 조남훈 연세대학교병리학교실

비뇨병리연구회공청회 조남훈 연세대학교병리학교실

종양분류코드 - 방광암 표재성방광암 근층비침윤암 (Ta, Tis/ T1) 종양분류코드 진단서 ICD vs. ICO 사보험지급기준 중증질환분류 암등록사업 공보험 80-90% 지급기준 0 기암 -pta, ptis 특이한유형 면역 / 항암치료필요 재발과병기진행 다발성여부 진단확정주체 병리진단서 임상소견서 의무기록사

종양분류코드의변천사 1946 1965 1968 Tumor coding SNOP/CAP ( 미국병리학자협의회 )/ACS 1967 ICD-8/WHO 형태학적 code+ 해부학적 code MONTAC/ACS/IARC ICD 에종양편삽입 (ICD-9) 1976 ICD-O 1975 ICD-9/WHO chapter II Neoplasm 1977 SNOMED/CAP 1990 ICD-O 2 nd 해부학적 code(c00-c80)+ 형태학적 code 1992 ICD-10/WHO chapter II Neoplasm 1993 SNOMED III/CAP 2000 ICD-O 3 rd / WHO 2000 SNOMED RT/CAP MONTAC: manual of tumor nomenclature and coding SNOP: systematized nomenclature of pathology SNOMED: systematized nomenclature of medicine CAP: College of American Pathologists ACS: American cancer society ICD: International statistical classification of disease, injuries and cause of death IARC: International agency for research on cancer

ICD-10 vs. ICD-O ICD C XY (site).z (subsite): Anatomy C67.9 (urinary bl) C68.9 (urinary system) ICD-O M-abcd (cell type)/0,1,2,3 (behavior) 1,2,3 (grade): Pathology M-8130/3 (papillary Uca) M-8130/2 (Pca, non-invasive) M-8120/2 (UCIS) 실제 Anatomy,Pathology C67.9, M-8130/3 ICD-O C67.9, M-8130/2 Malignant metastatic In situ benign Uncertain malignant ICD Neoplasm C80 C80 D09.9 D36.9 D48.9 UB C67.9 C79.1 D09.0 D30.3 D41.4 ICD-O UB M8130/3 M8130/6 M8130/2 M8130/0 M8130/1 M8145/3 (AC)

Confusing point in Naming-I 진단서의코드경우대부분 ICD 만사용 ICD-O 경우도해부학적구분이필요하므로 ICD code 를표기한다. 이표기는단지해부학적표시에불과하며 ICD 본래의악성과양성을구분하는기준과는다른개념이다. C67.9, M-8130/3 : urinary bladder papillary urothelial carcinoma, invasive C67.9, M-8130/2: urinary bladder papillary urothelial carcinoma, non-invasive C67.9, M-8120/2: urinary bladder urothelial carcinoma in situ

Confusing point in Naming-II ICD ICD-O pt Papillary UC, invasive C67.9 C67.9, M-8130/3 pt1+ Papillary UC, noninvasive D09.0 >C67.9 C67.9, M-8130/2 pta UC in situ D09.0 >C67.9 C67.9, M-8120/2 ptis Papillary Urothelial neoplasm, low malignant potential D41.4 or D09.0 >C67.9 C67.9, M-8120/1 In case of uncertain invasion: only papillary mass-commonly found: D09.0 questionable LP invasion ( /2; D09.0) In case of uncertain malignancy (LMP) D41.4

Issues to be issued 1. ICD vs. ICD-O 용어의혼동 2. TUR bladder (bx) 진단의대표성 Invasiveness 불분명의경우 Deep biopsy 유무 Multiplicity 무시 Grading 비고려 3. 타암종과의임상적차이 0 기암의 2 유형존재 In Situ 의예후및치료특이성 4. 임상적예후일치여부 Recur Progression Multiplicity ICD 문제점 해부학적용어 vs. 신생물구분 임상의문제점 BX algorithm 부재 Subepithelial CT or Deep muscle biopsy 여부 Stomach/colon EMR Excision Conization Case-sensitive issue 보험사문제점 ICD & ICD-O 요구 임상과병리의이견시임상우선 Case-sensitive issue 병리의문제점 Muscle 아닌경우 Bx 에서침윤여부파악어려움 Thermal Artifact Gray zone 해결필요

Meta-analysis of pta UC Materials and Methods: 2007-present for original article, review article for pta blader cancer and recurrence via PubMed, Cochrane, Google, EMBASE, SCOPUS. No language or geographic restriction Full paper reviewed 226 papers 130 papers with exclusion of clinical trial 10 papers with high priority Results Meta-analysis for recurrence in pta 30.5% (151 cases recurred / total 495 cases) Meta-analysis for progression in pta 3.4% (2 per 59 cases)

Recommendations for the diagnosis of non muscle-invasive bladder cancer Recommendations The renal and bladder US may be used during initial workup in patients with haematuria. GR C At the time of initial diagnosis of bladder cancer, CT urography or IVU should be performed only in selected cases (eg, tumours located in the t rigone). Cystoscopy is recommended in all patients with symptoms suggestive of bladder cancer. It cannot be replaced by cytology or by any ot her noninvasive test. Cystoscopy should describe all macroscopic features of the tumour (site, size, number, and appearance) and mucosal abnormalities. A bladder d iagram is recommended. Voided urine cytology or urinary markers are advocated to predict high-grade tumour before TUR. It is recommended to perform TUR in one piece for small papillary tumours (<1 cm), including part of the underlying bladder wall. It is recommended to perform TUR in fractions (including muscle tissue) for tumours >1 cm in diameter. It is recommended to take biopsies from abnormal-looking urothelium. Biopsies from normal-looking mucosa (trigone, bladder dome, and from right, left, anterior, and posterior bladder walls) are recommended only when cytology is positive or when exophytic tumour has a nonpapillary appearance. B A C C B B C Biopsy of the prostatic urethra is recommended for cases of bladder neck tumour, when bladder CIS is present or suspected, when there is posi tive cytology without evidence of tumour in the bladder, or when abnormalities of prostatic urethra are visible. If biopsy is not performed durin g the initial procedure, it should be completed at the time of the second resection. The biopsy should be taken from the precollicular area betw een 5 and 7 o clock positions using a resection loop. C If equipment is available, fluorescence-guided biopsy when bladder CIS is suspected (eg, positive cytology, recurrent tumour with previous histo ry of a high-grade lesion. B A second TUR should be performed 2 6 wk after the initial resection when the latter is incomplete (in large and multiple tumours, no muscle in the specimen) or when an exophytic high-grade and/or T1 tumour is detected. A The pathologic report should specify the grade, the depth of tumour invasion, and whether the lamina propria and muscle are present i n the specimen. Eur Urol 2011, 59:997 A

Weighting used to calculate recurrence and progression scores Factor Recurrence Progression No. of tumours Single 0 0 2 7 3 3 8 6 3 Tumour diameter <3 cm 0 0 3 cm 3 3 Prior recurrence rate Primary 0 0 1 recurrence per year 2 2 >1 recurrence per year 4 2 Category Ta 0 0 T1 1 4 Concomitant CIS No 0 0 Yes 1 6 Grade (1973 WHO) G1 0 0 G2 1 0 G3 2 5 Total score 0 17 0 23

Prob. of recurrence/progression ac/to total score Recurrence score Probability of recurrence at 1 yr Probability of recurrence at 5 yr Recurrence risk group % (95% CI) % (95% CI) 0 15 (10 19) 31 (24 37) Low risk 1 4 24 (21 26) 46 (42 49) Intermediate risk 5 9 38 (35 41) 62 (58 65) 10 17 61 (55 67) 78 (73 84) High risk Progression score Probability of progression at 1 yr Probability of progression at 5 yr Progression risk group % (95% CI) % (95% CI) 0 0.2 (0 0.7) 0.8 (0 1.7) Low risk 2 6 1 (0.4 1.6) 6 (5 8) Intermediate risk 7 13 5 (4 7) 17 (14 20) High risk 14 23 17 (10 24) 45 (35 55)

Summary of Results in Metaanalysis -High risk pta/ptis- 1. Multiplicity in all 2. >3cm in size in almost all 3. Grade 3 in almost all 4. Outcome of initial cystoscopy

Further issues-minor Inverted papilloma Inverted papilloma 8120/0 Sinonasal inverted papilloma 8121/1 Testis nodule Pick cell adenoma 8640/1 Sertoli cell adenoma 8640/1

One example in code-remodelling by KPS-GIT Colon Low grade dysplasia ( 대부분 ICO/1) High grade dysplasia ( 대부분 ICO/2) Adenoca, in situ ( 대부분 ICO/2) Adenocarcinoma intramucosal ( 대부분 ICO/2) Adenoca, SM invasion (ICO/3) Appendix carcinoid (/3) <1cm, no invasion (/1) Any size, invasion (/3) Pancreas islet cell tumor (/0) Well diff (/1) Poor diff (/3) KPS-GIT only by questionarre No meta 분석 Comparative cases in other sys Cervix CIN I (ICO/0) CIN II (ICO/0) CIN III (ICO/2) CIS (ICO/2) Invasive SCC (ICO/3) PIN (8148/2) Ovary borderline tumor (/1) psuedomyxoma perotonei (/3) Struma ovari/carcinoid (/1) Granulosa cell tm (/1) malignant GCT (/3) Paraganglioma (/1) malignant (/3) Breast intraductal papillary ca-noninvasive (/2)

Ideal Goal to Discussion Looking for the most fair and appropriate decision For reasonable theory, not for just patients or clinicians For aligned outcome, not for deviated scope Remembering always, without exception, based on Pathology For final ruler or last judgment absolutely based on the current findings