# Presentation: 442783

## Colon

## Equivalent Terms, Definitions, and Illustrations

- 98% adenocarcinoma
- 10-15% produce enough mucin to be mucinous

**Notes:**
Only 10-15% of adenocarcinomas should be coded mucinous. We have been over-coding mucinous adenocarcinoma. New rules change the coding process.

## Equivalent Terms, Definitions, and Illustrations

- Mixed histologies
- Mucinous/colloid
- Signet ring
- Others are rare

## Equivalent Terms, Definitions, and Illustrations

**Adenocarcinoma with mixed subtypes** **(8255):** Rarely used for colon primaries (see introduction).
**Adenocarcinoma, intestinal type** **(8144)** is a form of stomach cancer.  Do not use this code when the tumor arises in the colon.

**Notes:**
As seen in previous slides – adenocarcinoma with mixed subtypes would be used rarely.

If the pathology says intestinal adenocarcinoma, ignore the prefix intestinal and code to adenocarcinoma.

## Multiple Primary Rules

## Unknown if Single or Multiple Tumors

## Slide 7

| Rule | Site | Histology | Timing | Behavior | Notes/
Examples | Primary |
| --- | --- | --- | --- | --- | --- | --- |
| UNKNOWN IF SINGLE OR MULTIPLE TUMORS |  |  |  |  | Tumor(s) not described as metastasis |  |
| M1 |  |  |  |  | Use this rule only after all information sources have been exhausted. | Single |

**Notes:**
This is a default so everyone will handle the cases in a standardized manner. 

The note is a warning not to default to a single tumor until all sources of information have been exhausted.

Note:  The matrix format has been condensed to fit on the slides.

## Single Tumor

## Slide 9

| Rule |  | Site |  |  |  | Notes/Examples | Primary |
| --- | --- | --- | --- | --- | --- | --- | --- |
| SINGLE TUMOR |  |  |  |  |  | 1. Tumor not described as metastasis
2. Includes combinations of in situ and invasive |  |
| M2 | Single |  |  |  |  | Tumor may overlap onto or extend into adjacent/contiguous site or subsite | Single |

**Notes:**
Single tumors are always a single primary no matter how large they become or how many regional sites they may involve

## Multiple Tumors

## Slide 11

| Rule |  | Histology |  |  | Notes/Examples | Primary |
| --- | --- | --- | --- | --- | --- | --- |
| MULTIPLE TUMORS
Multiple tumors may be a single primary or multiple primaries |  |  |  |  | 1. Tumors not described as metastases
2. Includes combinations of in situ and invasive |  |
| M3 |  | Adenocarcinoma in adenomatous polyposis (familial polyposis) with one or more malignant polyps  |  |  | Tumors may be present in multiple segments of the colon or in a single segment of the colon. | Single |

**Notes:**
Adenocarcinoma in FAP is always a single primary even if it is present in multiple segments of the colon.

## Slide 12

| Rule | Site |  |  |  |  | Primary |
| --- | --- | --- | --- | --- | --- | --- |
| M4 | Sites with topography codes that are different at the second (Cxxx), third (Cxxx) or fourth (C18x) character  |  |  |  |  | Multiple |

**Notes:**
This is the same and the previous rule for colon – Tumors in different segments of the colon are multiple primaries.
A  tumor in the colon and a separate tumor in any other site are multiple primaries.

## Slide 13

| Rule |  |  | Timing |  |  | Primary |
| --- | --- | --- | --- | --- | --- | --- |
| M5 |  |  | Diagnosed more than one (1) year apart |  |  | Multiple |

**Notes:**
Total number of colon cases in SEER database:  248,519
Number of second tumors, same histology, same segment of colon within one year: 61 which is 0.02%

## Slide 14

| Rule |  |  | Timing | Behavior | Notes/Examples | Primary |
| --- | --- | --- | --- | --- | --- | --- |
| M6 |  |  | More than 60 days after diagnosis | An invasive tumor following an in situ tumor | 1:  The purpose of this rule is to ensure that the case is counted as an incident (invasive) case when incidence data are analyzed.
2:  Abstract as multiple primaries even if the medical record/physician states it is recurrence or progression of disease. | Multiple |

**Notes:**
First explain that if an invasive occurs less than 60 days after an in situ you would abstract as a single primary and code the invasive tumor.

This is new for everyone except SEER registries. Explain the rule thoroughly.

Note 1 means that the incidence counts are for invasive cases only with a few exceptions. 

Explain that we do not want survival graphs showing people dying of in situ disease. We also don’t want the survival time affected by the time between an in situ and an invasive tumor

Note 2: IMPORTANT. You may have to explain to your physicians the reason behind the rule. The CoC physicians were all supportive when the rule and rationale were presented to them. 

## Slide 15

| Rule |  | Histology |  |  |  | Primary |
| --- | --- | --- | --- | --- | --- | --- |
| M7 |  | A frank in situ or malignant adenocarcinoma and an in situ or malignant tumor in a polyp |  |  |  | Single |

**Notes:**
This rule has not changed, same as previous rule.

## Slide 16

| Rule |  | Histology |  |  |  | Primary |
| --- | --- | --- | --- | --- | --- | --- |
| M8 |  | Cancer/malignant neoplasm, NOS (8000) and a specific histology; OR
Carcinoma, NOS (8010) and a specific carcinoma; OR
Adenocarcinoma, NOS (8140) and a specific adenocarcinoma; OR
Sarcoma, NOS (8800) and a specific sarcoma |  |  |  | Single |

**Notes:**
Same as previous NOS rule with more specific instructions.

## Slide 17

| Rule |  | Histology |  |  | Notes/Examples | Primary |
| --- | --- | --- | --- | --- | --- | --- |
| M9 |  | Multiple in situ and/or malignant polyps |  |  | Includes all combinations of adenomatous, tubular, villous, and tubulovillous adenomas or polyps. | Single |

**Notes:**
Multiple polyps are a single primary.

## Slide 18

| Rule |  | Histology |  |  |  | Primary |
| --- | --- | --- | --- | --- | --- | --- |
| M10 |  | Histology codes are different at the first (xxxx), second (xxxx), or third (xxxx) number |  |  |  | Multiple |

**Notes:**
This rule has not changed, same as previous rule

## Slide 19

| Rule |  |  |  |  | Notes/Examples | Primary |
| --- | --- | --- | --- | --- | --- | --- |
| M11 | Does not meet any of the above criteria |  |  |  | 1:  When an invasive lesion follows an in situ within 60 days, abstract as a single primary.
2:  All cases covered by Rule M11 are in the same segment of the colon  | Single |

**Notes:**
This is a default rule. We do not have to write multiple rules saying that these conditions are single primaries. If the case did not meet the criteria for any of the previous rules, it is a single primary.

Using a default rule is new for most people. Notes 1 and 2 are intended to reassure the abstractor that they should default to a single primary.

## Histology Rules

## Single Tumor

## Slide 22

| Rule | Pathology/
Cytology |  | 
 | Notes/Examples | Code |
| --- | --- | --- | --- | --- | --- |
| SINGLE TUMOR |  |  |  |  |  |
| H1 | No pathology / cytology specimen or the pathology/ cytology report is not available |  |  | 1:  Priority for using documents to code the histology
 Documentation in the medical record that refers to pathologic or cytologic findings
 Physician’s reference to type of cancer (histology) in the medical record
 CT, PET or MRI scans
2:  Code the specific histology when documented.
3:  Code the histology to 8000 (cancer/malignant neoplasm, NOS) or 8010 (carcinoma, NOS) as stated by the physician when nothing more specific is documented | The histology documented by the physician |

**Notes:**
Used when there is no pathology or cytology specimen or when the abstractor does not have access to the pathology or cytology report.
Note 1 gives the priority for using documents as follows:
--The medical record references a pathology or cytology report. Example: Patient had a polypectomy prior to admission that was positive for tubular adenocarcinoma
--Use the physician’s documentation in the medical record giving the histology. Example: H&P with a diagnosis of adenocarcinoma of the colon.
--Reference to histologic type in scans.
Note 2 says that if any of the documentation sources mention a specific histology, code as documented.
Note 3 says that if the only mention is that the patient has “carcinoma” of the colon, code 8010.  If the only mention is that the patient has cancer of the colon code 8000.
These may seem basic, but remember that the rules are written for beginning registrars, as well as for experienced registrars.

## Slide 23

| Rule | Pathology/
Cytology |  |  | Notes/Examples | Code |
| --- | --- | --- | --- | --- | --- |
| H2 | None from primary site |  |  | Code the behavior /3 | The histology from metastatic site |

**Notes:**
If there is no pathology or cytology specimen from the primary site, code the histology from a biopsy of a metastatic site. Would be rare in colon.

## Slide 24

| Rule |  | Histology |  | Notes/Examples | Code |
| --- | --- | --- | --- | --- | --- |
| H3 |  | Intestinal type adenocarcinoma or adenocarcinoma, intestinal type |  | 1:  Intestinal type adenocarcinoma usually occurs in the stomach.
2:  When a diagnosis of intestinal adenocarcinoma is further described by a specific term such as type, continue to the next rule. | 8140 (Adeno-carcinoma, NOS) |

**Notes:**
When pathology report says intestinal adenocarcinoma, code as adenocarcinoma. Intestinal adenocarcinoma only occurs in the stomach.

## Slide 25

| Rule |  | Histology |  | Notes/ Examples | Code |
| --- | --- | --- | --- | --- | --- |
| H4 |  | Final diagnosis:
 Adenocarcinoma in a polyp 
 Adenocarcinoma and a residual polyp or polyp architecture is recorded in other parts of the pathology report.
 Adenocarcinoma and there is reference to a residual or pre-existing polyp within the medical record or
 Mucinous/colloid or signet ring cell adenocarcinoma in a polyp or
There is documentation that the patient had a polypectomy |  | It is important to know that the adenocar-cinoma originated in a polyp. | 8210 (Adeno-carcinoma arising in polyp), or
8261 (Adeno-carcinoma in a villous adenoma), or
8263 (Adeno-carcinoma in a tubulovillous adenoma) |

**Notes:**
Very important to know that the adenocarcinoma originated in a polyp. Any reference to a polyp trumps everything else.  
Code adenocarcinoma arising in a polyp (8210, 8261, 8263) when there is any evidence that there was a polyp.  Evidence of polyp may come from final diagnosis, microscopic description or gross description – obtaining polyp information is a specific exception to the general histology coding rule about taking info only from the final diagnosis.

## Slide 26

| Rule |  | Histology |  |  | Code |
| --- | --- | --- | --- | --- | --- |
| H5 |  | Final diagnosis is:
Mucinous/colloid (8480) or signet ring cell carcinoma (8490) or
Adenocarcinoma, NOS and microscopic description documents 50% or more of the tumor is mucinous/colloid or
Adenocarcinoma, NOS and microscopic description documents 50% or more of the tumor is signet ring cell carcinoma |  |  | 8480 (Mucinous/colloid adenocarcinoma) or 8490 (Signet ring cell carcinoma) |

**Notes:**
We have been over-coding mucinous adenocarcinoma and signet ring cell carcinoma.
Should only be classified as mucinous if over 50% of the tumor is mucinous.
Should only be classified as signet ring cell if over 50% of the tumor is signet ring cell.
If the final diagnosis says “mucinous” or “signet ring cell,” code it whether or not stated to be 50% or more of the tumor.

## Slide 27

| Rule |  | Histology |  |  | Code |
| --- | --- | --- | --- | --- | --- |
| H6 |  | Final diagnosis is adenocarcinoma and:
Microscopic description states less than  50% of the tumor is mucinous/colloid, or
Microscopic description states less than  50% of the tumor is signet ring cell carcinoma, or
Percentage of Mucinous/colloid or signet ring cell carcinoma is unknown |  |  | 8140 (Adenocarcinoma, NOS) |

**Notes:**
Code adenocarcinoma if less than 50% of the tumor is mucinous or signet ring cell carcinoma.  Code adenocarcinoma when percent of mucin or signet ring cell is not mentioned.
Rule H6 is the counterpoint to rule H5. 

Note: Previously mucinous and signet ring cell were coded if there was any reference to either histology in the microscopic description of the tumor.

## Slide 28

| Rule |  | Histology |  |  | Code |
| --- | --- | --- | --- | --- | --- |
| H7 |  | Combination of mucinous/colloid and signet ring cell carcinoma |  |  | 8255 (Adenocarcinoma with mixed subtypes) |

**Notes:**
Code 8255 (adenocarcinoma with mixed subtypes) when there is both mucinous/colloid and signet ring cell carcinoma. This will be a rare occurrence.

## Slide 29

| Rule |  | Histology |  |  | Code |
| --- | --- | --- | --- | --- | --- |
| H8 |  | Neuroendocrine carcinoma (8246) and carcinoid tumor (8240) |  |  | 8240 (Carcinoid tumor, NOS) |

**Notes:**
Carcinoid tumor is a specific type of neuroendocrine carcinoma. When the pathology report mentions neuroendocrine and carcinoid, code the more specific histology, carcinoid.

## Slide 30

| Rule |  | Histology |  |  | Code |
| --- | --- | --- | --- | --- | --- |
| H9 |  | Adenocarcinoma and carcinoid tumor  |  |  | 8244 (Composite carcinoid) |

**Notes:**
When the final diagnosis on the pathology says adenocarcinoma and carcinoid, code composite carcinoid.

## Slide 31

| Rule |  | Histology |  |  | Code |
| --- | --- | --- | --- | --- | --- |
| H10 |  | Exactly “adenocarcinoid” |  |  | 8245 (Adenocarcinoid) |

**Notes:**
Only assign code 8245 (adenocarcinoid) when the final diagnosis of the pathology report says exactly “adenocarcinoid.”
Rules H9 and H10 give specific guidelines for using codes 8244 and 8245. There have been many questions about how to use these codes.

## Slide 32

| Rule |  | Histology |  |  | Code |
| --- | --- | --- | --- | --- | --- |
| H11 |  | One type |  |  | The histology |

**Notes:**
Used when diagnosis is simply adenocarcinoma (for example).

## Slide 33

| Rule |  |  | Behavior |  | Code |
| --- | --- | --- | --- | --- | --- |
| H12 |  |  | Invasive and in situ |  | The invasive histologic type |

**Notes:**
This is a change from the previous rules. Be sure to emphasize.

The invasive histology is the one that will affect survival and govern treatment. By coding the invasive type, the case will be placed in the correct analysis group.

Even if the in situ portion is more specific, it will not be the histology that impacts survival and treatment

## Slide 34

| Rule |  | Histology |  | Notes/Examples | Code |
| --- | --- | --- | --- | --- | --- |
| H13 |  | Cancer/malignant neoplasm, NOS (8000) and a more specific histology or
Carcinoma, NOS (8010) and a more specific carcinoma or
Adenocarcinoma, NOS (8140) and a more specific adenocarcinoma or
Sarcoma, NOS (8800) and a more specific sarcoma (invasive only) |  | 1.  The specific histology for in situ tumors may be identified as pattern, architecture, type, subtype, predominantly, with features of, major, or with ____differentiation. 
2.  The specific histology for invasive tumors may be identified as type, subtype, predominantly, with features of, major, or with ____differentiation. | The most specific histologic term |

**Notes:**
This is a version of the previous NOS and more specific rule. You have to be careful to code the more specific ONLY when the two terms are directly related.

Note that the terms pattern and architecture are used to identify the most specific in situ histology. They are not used for invasive histologies.

## Slide 35

| Rule |  |  |  |  | Code |
| --- | --- | --- | --- | --- | --- |
| H14 | None of the above conditions are met |  |  |  | The histology with the numerically higher ICD-O-3 code |

**Notes:**
This is a default rule for any cases did not meet the criteria of the first 13 rules

## Multiple Tumors Abstracted as a Single Primary

## Slide 37

| Rule | Pathology/ Cytology |  |  | Notes/Examples | Code |
| --- | --- | --- | --- | --- | --- |
| MULTIPLE TUMORS ABSTRACTED AS A SINGLE PRIMARY
These rules only apply to multiple tumors that are reported as a single primary |  |  |  |  |  |
| H15 | No pathology/cytology specimen or the pathology/cytology report is not available |  |  | 1:  Priority for using documents to code the histology
Documentation in the medical record that refers to pathologic or cytologic findings
Physician’s reference to type of cancer (histology) in the medical record
CT, PET or MRI scans 
2:  Code the specific histology when documented
3:  Code the histology to 8000 (cancer/malignant neoplasm, NOS) or 8010 (carcinoma, NOS) as stated by the physician when nothing more specific is documented | The histology document-ed by the physician |

**Notes:**
Same as H1

## Slide 38

| Rule | Pathology/
Cytology |  |  | Notes/ Examples | Code |
| --- | --- | --- | --- | --- | --- |
| H16 | None from primary site |  |  | Code the behavior /3 | The histology from a metastatic site |

**Notes:**
Same as H2

## Slide 39

| Rule |  | Histology |  |  | Code |
| --- | --- | --- | --- | --- | --- |
| H17 |  | Clinical history says familial polyposis and final diagnosis on pathology report from resection is adenocarcinoma in adenomatous polyps, or
> 100 polyps in resected specimen
Number of polyps is not given but the diagnosis is familial polyposis |  |  | 8220 (Adenocarcinoma in adenomatous polyposis coli) |

**Notes:**
Gives guidelines for when to code adenocarcinoma in adenomatous polyposis coli. 

## Slide 40

| Rule |  | Histology |  |  | Code |
| --- | --- | --- | --- | --- | --- |
| H18 |  | Multiple in situ or malignant polyps are present, at least one of which is tubulovillous |  |  | 8263 (Adenocarcinoma in a tubulovillous adenoma) |

**Notes:**
Tubulovillous polyps have the worst prognosis.
Multiple polyps means they may be different types. If even one is tubulovillous, default code is 8263.

## Slide 41

| Rule |  | Histology |  |  | Code |
| --- | --- | --- | --- | --- | --- |
| H19 |  | <= 100 polyps in resected specimen, or
Multiple polyps and the number of polyps is not given and familial polyposis is not mentioned |  |  | 8221 (adenocarcinoma in multiple adenomatous polyps) |

**Notes:**
Guidelines for assigning code 8221 (adenocarcinoma in multiple adenomatous polyps).

## Slide 42

| Rule |  | Histology |  | Notes/Examples | Code |
| --- | --- | --- | --- | --- | --- |
| H20 |  | Frank adenocarcinoma and a carcinoma in a polyp, or
In situ and invasive tumors
Multiple invasive tumors |  | 1: See the Colon Equivalent Terms, Definitions and Illustrations for the definition of most invasive.
One tumor is in situ and one is invasive, code the histology from the invasive tumor.
Both/all histologies are invasive, code the histology of the most invasive tumor.
2.  If tumors are equally invasive, go to the next rule | The histology of the most invasive tumor |

**Notes:**
H12 is for single tumors, H20 is for multiple tumors. 

## Slide 43

| Rule |  | Histology |  | Notes/ Examples | Code |
| --- | --- | --- | --- | --- | --- |
| H21 |  | Final diagnosis:
Adenocarcinoma and the microscopic description or surgical gross describes polyps or
Adenocarcinoma and there is reference to residual or pre-existing polyps or
Mucinous/colloid or signet ring cell adenocarcinoma in polyps or
There is documentation that the patient had a polypectomy |  | It is important to know that the adeno-carcinoma originated in a polyp. | 8210 (Adenocarcinoma arising in polyp), or
8261 (Adenocarcinoma in a villous adenoma), or
8263 (Adenocarcinoma in a tubulovillous adenocarcinoma) |

**Notes:**
Same as H4

## Slide 44

| Rule |  | Histology |  |  | Code |
| --- | --- | --- | --- | --- | --- |
| H22 |  | One type |  |  | The histology |

**Notes:**
Same as H11

## Slide 45

| Rule |  | Histology |  | Notes/Examples | Code |
| --- | --- | --- | --- | --- | --- |
| H23 |  | Cancer/malignant neoplasm, NOS (8000) and a specific histology or
Carcinoma, NOS (8010) and a specific carcinoma or
Adenocarcinoma, NOS (8140) and a specific adenocarcinoma or
Sarcoma, NOS (8800) and a specific sarcoma (invasive only) |  | 1: The specific histology for in situ tumors may be identified as pattern, architecture, type, subtype, predominantly, with features of, major, or with ____differentiation 
2: The specific histology for invasive tumors may be identified as type, subtype, predominantly, with features of, major, or with ____differentiation. | The more specific histologic term  |

**Notes:**
Same as H13

## Slide 46

| Rule |  |  |  |  | Code |
| --- | --- | --- | --- | --- | --- |
| H24 | None of the above conditions are met |  |  |  | The histology with the numerically higher ICD-O-3 code |

**Notes:**
Same as H14

## MP/H Task Force