The Anatomy of Collaborative Staging: Colon and Rectum

Presentation developed by April Fritz, RHIT, CTR april.fritz@nih.gov SEER Program National Cancer Institute

Colorectal Cancer
Estimated 10.7% of all 2004 cancer cases Collaborative Stage fields

Tumor Size--special codes Extension TS/Ext Eval--standard Lymph Nodes LN Eval--standard LN Pos--standard LN Exam--standard Mets at Dx Mets Eval--standard Site-specific Factor 1: Carcinoembryonic Antigen Site-specific Factors 2-6: not used

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Colorectal Cancer -- Tumor Size

Not a factor in classifying T category Site-specific (not standard) table Special codes
991-995 less than _ cm

Use if precise size not available

998 Familial or multiple polyposis

(M8220/8221) Hereditary condition in which numerous polyps develop in colon and rectum, increasing the risk of colon cancer

also called familial adenomatous polyposis, familial intestinal polyposis, familial polyposis coli, adenomatous polyposis coli, FAP and other terms
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Colorectal Cancer -- Extension

Critical part of TNM T1 - T3 categories
Codes 00-55: depth of invasion through

wall

Lumen

Mucosa Submucosa Muscularis propria Subserosa Serosa

Peritoneum
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Colorectal Cancer -- Extension

Notes
1. Ignore intraluminal extension 2. Definition of tumor nodule vs. lymph node mets 3. Codes 60-80 code contiguous (direct) extension Discontinous extension is coded in Mets at Dx

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Extension 00 In situ noninvasive; intraepithelial

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Extension codes 05-16 Polyps

Not shown: 10 Mucosa, NOS 15 Polyp, NOS
05 Ca in polyp, (non-invasive) 14 Stalk of polyp 16 Submucosa 20 Muscularis propria
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13 Head of polyp

12 Muscularis mucosa 11 Lamina propria

Adapted from: Atlas of Diagnostic Oncology, 2nd ed., by AT Skarin, Mosby Wolfe, 1996

Extension code 10 Invasive confined to mucosa, NOS

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Extension code 12 Invasive confined to muscularis mucosa

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Extension code 16 Invasive confined to submucosa

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Extension code 20 Invasive muscularis propria invaded

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Extension code 30 Localized, NOS confined to colon, NOS

?
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Colorectal Cancer: Serosal Layer

Hepatic flexure Transverse

Splenic flexure

Ascending front only

Descending front only

Cecum

Sigmoid
Rectosigmoid Rectum no serosa

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Extension code 40 Transmural, NOS invasion through muscularis into (sub)serosal tissue/fat

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Extension code 42 Fat, NOS

?
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Extension code 45 Pericolic fat

extension to adjacent connective tissue Extension code 46 Adherent to but not involving other structures

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Extension code 50 Serosa

Invasion of/through visceral peritoneum

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Extension code 55 Both serosa and adjacent connective tissue

and

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Extension code 60 Adjacent organs

Examples 1. Liver from ascending 2. Stomach from transverse 3. Small intestine from sigmoid

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More Extension Codes

* 57 Adherent to other structures 1. 65 Abdominal wall 2. 66 Kidney 3. 70 Ovary * 80 Ureter from transverse colon

2
3

Code distant mets in CS Mets at DX field

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Colorectal Cancer CS TS/Ext Eval, CS Reg Nodes Eval, CS Mets Eval

All standard tables General structure
0 clinical only 1 invasive techniques, no bx; or needle bx

2 autopsy (known or suspected dx) 3 pathology

bx does not meet criteria for pathologic T

5 6 8 9

meets criteria for pathologic T

pre-op tx, clinical eval pre-op tx, path eval autopsy (dx not suspected) unknown, not assessed
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CS Colorectal Coding 2004

Colorectal Cancer CS Lymph Nodes

Notes
1. Regional nodes only 2. Definition of tumor nodule vs. regional node mets: code smooth nodules here 3. Inferior mesenteric nodes are distant for cecum, appendix, ascending, transverse, hepatic flexure Superior mesenteric nodes are distant for all colon sites

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Colorectal Cancer CS Lymph Nodes

Code 10--all sites Colic Epicolic Mesocolic Para/pericolic Nodule in fat/ mesentery/ mesocolic fat

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Colorectal Cancer CS Lymph Nodes

Code 20--site specific Regional nodes for each segment of colon Cecum Ascending Hepatic flexure Transverse Splenic flexure Descending Sigmoid Code 30--all sites
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Regional nodes, NOS including mesenteric, NOS

Colorectal Cancer Reg LN Pos/Exam

Standard tables TNM N category based on
Reg LN Pos (number) + CS Lymph Nodes (location)

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Colorectal Cancer CS Mets at Dx

Codes 8, 10 are distant nodes
mapping Code 40 is distant mets via bloodstream (hematogenous) discontinuous examples: liver, lung, brain
8, 10 separated due to summary stage

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Rectum, Rectosigmoid and Anus

rectosigmoid junction

sigmoid colon rectum peritoneal reflection

dentate line

anal verge
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Anus has a separate CS schema

Colorectal Cancer Site-Specific Factor 1 Carcinoembryonic antigen (CEA)

Former tumor marker; not used for TNM staging Code the highest pre-operative result
000 010 020 030 Test not done Positive/elevated Negative/normal; within normal limits Borderline; undetermined whether positive or negative Ordered, but results not in chart Unknown or no information; Not documented in record

080 999

SSF2-SSF6 not applicable; code as 888

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