1 international classification of diseases for oncology (3 rd edition)

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International Classification of Diseases for Oncology

(3rd Edition)

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History

Brief History leading to ICD-O- 1893 WHO responsible for publishing

international classification of Mortality 1948 6th Revision of International Statistical

Classification of Diseases, Injuries, and cause of death ICD) (9) Used to code mortality and Morbidity data

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History cont’d

Classification of Neoplasm was based on site and behavior (whether malignant benign or not otherwise specified).

1951- 1st coding manual for Morphology by American Cancer Society

1971 Recommendation for ICDO was approved by WHO- 2nd edition of ICDO published in 1990 to be used by cancer registries

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What is ICD-O?

Not a true classification system Includes codes from multiple classification

systems

Actually a coded nomenclature for : Topography (primary site of origin) Morphology (histology, behavior, grade)

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To standardize cancer data collection

To compare data Regional National International

Rationale for ICD-O

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Why a new edition?

Immense changes over the past decade in techniques for diagnosing neoplasms

Science has evolved (cytogenetics, immunophenotyping, etc)

1998 – IARC task force

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ICD-10 vs ICD-O

ICD-10 topography code describes the behavior of the neoplasm

Ex) Lung neoplasm (ICD-10)

C34.9 malignant D02.2 in situ D14.3 benign

Ex) Lung neoplasm (ICD-O-3), carcinoma

C34.9 lung, NOS

8010 / __ (3, 2, 0 )

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ICD-10 vs ICD-O

Behavior ICD-10 Category Term

/0 D10-D36 Benign

/1 D37-D48Borderline

/2 D00-D09 In situ

/3 C00-C76, Invasive

C80-C97

/6 C77-C79Metastatic

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pp. 001-044) Introduction & Instructions for Use

pp. 045-068) Topography (site) - Numerical List

pp. 069-104) Morphology (type) - Numerical List

pp. 105-218) Alphabetic Index (site & type)

pp. 219-240) Appendices

Contents of ICD-O-3

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Topography – Numerical List

Structure C__ __ . __ Example) LIP

Range : C00.0 – C80.9 Grouped by systems / common organs Numerical order

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Major Topography Groups

C00-14 Lip, Oral Cavity, Pharynx C15-26 Digestive Organs C30-39 Respiratory System C40-41 Bones, Joints, Cartilage C44 Skin C47 Nerves C49 Soft Tissues C50 Breast

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Major Topography Groups

C51-58 Female Genital Organs C60-63 Male Genital Organs C64-68 Urinary Tract C69-72 Eye, Brain, CNS C73-75 Thyroid and Endocrine Glands C76 Other Ill defined sites C77 Lymph Nodes C80 Unknown

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Topography – Numerical List Preferred terms in boldface Synonyms indented Equivalent terms not indented

--subdivision of preferred term not sufficiently different to warrant own code

Example) C07 Parotid Gland --- page 46

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Morphology - Numerical List

Structure __ __ __ __ / __ Example) Neoplasm

Range : 8000/0 to 9989/3 Grouped by common cell types Numerical order

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Major Morphology Groups

800 Unspecified 801-867 Carcinomas 872-879 Melanomas 880-899 Sarcomas 906-909 Germ Cell 938-948 Gliomas 959-972 Lymphomas 980-994 Leukemias

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Morphology – Numerical List Preferred terms in boldface Synonyms indented Equivalent terms not indented

--subdivision of preferred term not sufficiently different to warrant own code

Example) 8045/3 Combined small cell carcinoma --- page 70

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Behavior, Grade/Differentiation

Located on pages between numerical topography and morphology lists

Place purple ribbon here for quick reference!

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Behavior is the fifth digit (after the “/”) of the morphology code

Behavior code indicates the pathologic behavior of the neoplasm - benign, in situ, malignant

Most registries in the world only collect cancer with behavior codes 2 (in situ) and 3 (malignant)

Morphology - Behavior

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Grade/Differentiation is the sixth digit (after the /) of the morphology code

Describes how much or how little a tumor resembles the normal tissue from which it arose

Code the grade of the primary tumor. Do code the grade if given for an in situ neoplasm. Do not code grade for intraepithelial neoplasias

Morphology – Grade/Differentiation

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ICD-O-3 Code = 10 Digit Code TOPOGRAPHY 4 Digits

+ MORPHOLOGY 4 Digits

+ BEHAVIOR 1 Digit

+ GRADE 1 Digit

10 Digits

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Alphabetic Index Topography (C) and morphology (M)

terms listed together alphabetically but not mixed. Space before and after each group.

Boldface header for any word that appears as part of 3 or more terms (terms indented)

NOS terms listed first

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Not Otherwise Specified Printed after a term when it :

lacks a modifying or more explicit word or phase

contains an adjective that is not listed used in a general sense

Examples) Adenocarcinoma & Endocrine Gland

Meaning and Use of NOS

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General Coding Guidelines -Topography Code the site in which the primary tumor

originated, even if it extends to an adjacent subsite.

Code subsite to .9 for single primaries when multiple tumors arise in different subsites of the same anatomic site. Infiltrating duct carcinoma in UOQ of

R Breast and infiltrating duct carcinoma in LIQ R Breast

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General Coding Guidelines - Site If a tumor is metastatic and the primary site

is unknown, code primary site to C80.9 If the medical record does not contain

enough info to code site: Consult physician advisor Use NOS for organ system or ILL

defined site code Code unknown C80.9

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Coding Guidelines

Topography – p23-24 Where the tumor arose No changes from ICD-O-2 Noun form appears in manual

Glioma of pons vs pontine glioma Special Codes

Esophagus Branchial Cleft, Meckel diverticulum

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Codes C76._ If the diagnosis specifies the tissue of

origin, code to the tissue suggested in the alphabetic index in preference to NOS

C76._ codes should be used very rarely as the histology usually will allow you to use a more specific code

Topography - Ill-Defined Sites (A)

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NeckC76.0 NOS

C44.4 NOS (carcinoma, melanoma, nevus)

C49.0 NOS (sarcoma, lipoma)

C49.0 adipose tissue

C47.0 autonomic nervous system

C49.0 connective tissue

C44.4 skin

C49.1 tendon

Example of Possible Codes Use of NOS for Ill-defined Sites

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Example of Rule A

Code : Malignant carcinoma of the arm

Answer : C44.6 (skin of upper limb)

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Prefixes are often used to describe topographic sites and various organs (ex. peri-, para-, pre-, supra-, etc)

Some prefixes modify the topographic site and are listed with specific codes (ex. C77.2 Para-aortic lymph node)

Use Ill-defined site code C76._ for terms such as those above if not specifically listed in ICD-O (only if Rule A does not apply)

Topography – Prefixes (B)

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Example of Rule B

Code : periabdominal cystadenocarcinoma

Answer : C76.2 (abdomen, NOS)

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A single neoplasm that overlaps two contiguous sites and whose point of origin cannot be determined is coded to

‘C__ __ .8’ unless..

The combination is listed elsewhere

Carcinoma of tip and ventral surface of the tongue

C02.8 Overlapping lesion of the tongue

Carcinoma of esophagus and stomach

C16.0 Cardioesophageal junction

Topography - Overlapping Sites (C)

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Example of Rule C

Code : Carcinoma overlapping the stomach and small intestine?

Answer : C26.8 (overlapping digestive)

Code : Overlapping tumor of the cervix and uterus?

Answer : C57.8 (overlapping female genital)

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Topography – Lymphomas (D)

Always code site of origin (extranodal/nodal) malignant lymphoma of the stomach = C16.9 malignant lymphoma of lymph node = C77._ spleen and splenic lymph nodes = C42.2 spleen and non-regional nodes =

consult(C77.9)

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Topography – Lymphomas (D)

If no site of origin is given, code to lymph nodes, NOS (C77.9);– C80.9 if suspected to be extranodal but site is not stated.

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Topography – Lymphomas (D)

When multiple lymph node chains are involved: Code where originated If all involved chains are in the same

lymph node region, code to C77.__ If involved chains are in different lymph

node regions, code to C77.8

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Example of Rule D

Code : Lymphoma of inguinal and iliac lymph nodes

Answer : C77.8 (multiple regions)

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Topography - Bone Marrow C42.1 (E)

All leukemias have a site-specific code of bone marrow (C42.1) except: Myeloid sarcoma (rare) – leukemic

deposit in an organ and should be coded to that organ

Multiple myeloma – code site to C42.1

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Ascending Colon

Group Exercise - Topography

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Ascending colon C18.2

Axillary lymph node

Group Exercise - Topography

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Ascending colon C18.2

Axillary lymph node C77.3

UOQ right breast

Group Exercise - Topography

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Ascending colon C18.2

Axillary lymph node C77.3

UOQ right breast C50.4

Temporal and parietal lobes (1 tumor)

Group Exercise - Topography

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Ascending colon C18.2

Axillary lymph node C77.3

UOQ right breast C50.4

Temporal and parietal lobes (1 tumor) C71.8

Group Exercise - Topography

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Individual Exercises

Practice Topography Coding

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General Coding Guidelines - Histology

Histology can only be coded after multiple primary determination has been made

If there is no tissue, code the histology the medical practitioner uses to describe the tumor

Use the histology stated in the final diagnosis from the pathology report, unless a more specific histology is definitively described elsewhere (i.e. micro, comment)

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General Coding Guidelines - Behavior Collect in situ and malignant always Collect benign and borderline intracranial

and CNS effective 1/1/2004 Code the behavior as /3 if any portion of the

primary tumor is invasive

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General Coding Guidelines - Grade

Code the grade from the final diagnosis of the pathology report.

Code grade from primary tumor, not from a metastasis or recurrence

If tumor has invasive and in situ components, code grade of invasive component of tumor. If invasive component unknown then code 9

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Morphology – Matrix Concept (F)

Use the appropriate 5th digit behavior code even if the exact term is not listed in ICD-O

It is okay to over-ride suggested code if pathology report says something different (“Matrix Principle”)

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Example of Rule F

Code : Benign chordoma

Answer : 9370/0

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If a pathology report gives more than one grade/diff, code to the highest grade/diff

If the morphology code includes grade, repeat grade code as sixth digit

Morphology-Grade/Differentiation (G)

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Example of Rule G

Code : moderately to poorly differentiated ` adenocarcinoma

Answer : 8140/33

Code : anaplastic malignant teratoma

Answer : 9082/34

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Codes for cell lineage take precedence over grade/diff codes 1-4. Based on path/lab report.

Do not borrow from bold face headers (9680/3)

Grade - Description

5 T-cell

6 B-cell,Pre-B,B-precursor

7 Null cell, non T or non B

8 N K cell (natural killer)

9 Unknown, Undetermined

Morphology - 6th Digit for Lymphomas and Leukemias

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Leukemias and Lymphomas

ICD-O-2 Classification based on Working Formulation (means of translating terminology among various other classification schemes – grouped by morphologic characteristics)

low grade – slow progressing, most favorable

intermediate grade

high grade – fast progressing, least favorable

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Using grade to assign 6th digit

Errata # 1 – Read Clarifications! Certain instances, term grade does not

represent diff. but instead is a syn for “category”. 6th digit should not be coded as grade 1,2,3 for these cases Ex. Follicular lymphomas (don’t use

grade) Ex. Low grade endometrial stromal

sarcoma (do use grade)

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More on Grade

Lymphomas and Leukemias Do not use the terms “high grade”, “low

grade” and “intermediate grade” to code differentiation. These terms refer to histology in the Working Formulation.

Lymphomas Do not use the descriptions “grade 1”,

“grade 2” and “grade 3” to code differentiation. These represent lymphoma types

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Lymphoma grades

Code : Follicular Lymphoma, grade 1

Answer : 9695/39

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Bold face headers

Code : Diffuse centroblastic lymphoma

Answer : 9680/39 NOT 9680/36

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Some site specific morphology terms have suggested primary site codes in the index

If no specific primary site is listed in the diagnosis, default to the suggested code Disregard suggested code if tumor is

known to arise at another primary site

Morphology - Site Specific (H)

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Example of Rule H

Code : Pathology reports states infiltrating duct carcinoma with no

mention of primary site

Answer : C50.9 (Breast, nos)

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Some tumors have more than one histologic pattern

Common combinations are listed and given a specific code Two new codes for mixed breast subtypes

(8523/_ And 8524/_) If any part of the tumor is invasive, the

behavior must be coded to 3

Morphology – Compound Terms (J)

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Morphology – Compound Terms (J)

Code : Mixed adenocarcinoma & squamous cell carcinoma

Answer : 8560/3 (adenosquamous carcinoma)

Code : Papillary and follicular carcinoma

Answer : 8340/3

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Morphology – Compound Terms (J)

Compound terms with multiple prefixes may not be in the index - check for alternate permutations of the prefix(es) and the base term

Myxofibrosarcoma vs. Fibromyxosarcoma Look up myxofibrosarcoma Not there? Try moving around the prefixes Look up Fibromyxosarcoma Fibromyxosarcoma = 8811/3

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If two or more modifying terms describe the same single tumor and no single code exists, use the higher morphology code (more specific)

Ex. Transitional cell epidermoid carcinoma

(1 tumor)

Epidermoid carcinoma - 8070/3

Transitional cell carcinoma, NOS - 8120/3

Morphology - Multiple Terms (K)

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Rule K does not apply to separate tumors nor to the hematopoetic diseases in general.

For the hematopoetic diseases, code the more specific histology over the higher code.

Example) Diffuse large B-Cell lymphoma (9680/3)

Mantle cell lymphoma (9673/3)

Morphology - Multiple Terms (K)

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Morphology - Multiple Terms (K)

9680/3 – includes NOS term and 27 synonyms (non-specific diagnosis)

9673/3 – does not include NOS and has many fewer synonyms (more specific)

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Exception to rule (K) – errata!

With ICD-O-3, many new subtypes of tumors were added. Some subtypes have lower codes than the NOS term.

Code the subtype of the tumor even if it is lower than the NOS term

Ex) Ductal carcinoma, cribriform type

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Coding Order of Single Tumor

Code histology if only 1 type mentioned Code invasive histology if invasive and insitu Use a mixed code if one exists Use a combination code if one exists Code the more specific term Code the majority of the tumor Code the numerically higher ICD-O-3 code

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Medullary adenocarcinoma

Group Exercise - Morphology

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Medullary adenocarcinoma 8510/3

Acute myelomonocytic leukemia

Group Exercise - Morphology

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Medullary adenocarcinoma 8510/3

Acute myelomonocytic leukemia 9867/3

Malignant neuroastrocytoma

Group Exercise - Morphology

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Medullary adenocarcinoma 8510/3

Acute myelomonocytic leukemia 9867/3

Malignant neuroastrocytoma 9505/3

Seminoma and teratocarcinoma

(1 tumor)

Group Exercise - Morphology

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Medullary adenocarcinoma 8510/3

Acute myelomonocytic leukemia 9867/3

Malignant neuroastrocytoma 9505/3

Seminoma and teratocarcinoma (1 tumor) 9081/3 (higher than 9061/3 and more specific)

Group Exercise - Morphology

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Individual Exercises

Practice Morphology Coding

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A primary cancer is one that originates in a primary site or tissue

Code primary cancer, not extension, recurrence or metastasis

Consult an oncologist for difficult cases

Multiple Neoplasms

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Rules for Multiple Primaries

How to know if we are talking about two or more separate primaries?

Follow rules – In the U.S. registries use the SEER rules for determining multiple primaries.

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Hematopoietic Multiple Primaries

If the physician states that a hematopoietic diagnosis is a new primary, use that information. Otherwise, refer to the 52x52 table.

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Diagnostic Confirmation Microscopic diagnosis preferred

Positive histology, cytology, microscopic NOS

Use Non-microscopic diagnosis only if microscopic does not exist Lab test, direct visualization without mc,

radiology, other clinical diagnosis

Basis of DiagnosisCoding the Diagnosis

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Appendices

1. New ICD-O-3 codes 2. New terms & synonyms (codes were in

ICD-O-2) 3. Terms that changed morphology codes 4. Terms that changed from tumor-like

lesions to neoplasms 5. Deleted terms 6.Terms that changed behavior code

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ICD-O-3 Training Web Site www.training.seer.cancer.gov

ICD-O-3 Training

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Acknowledgements

Many thanks to Professor John Young of the Rollins Schools of Public Health at Emory University who assisted with material for this presentation.

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Time for Exercises!

Now, let’s look at some more exercises and practice coding site and morphology using ICD-O-3

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