# Presentation: 785001

## Renal Pelvis, Ureter, Bladder and Other Urinary

## Equivalent Terms, Definitions,Tables and Illustrations

## Introduction

- Change in groupings
- Previous: Kidney, ureter, renal pelvis
- Bladder, ureter, renal pelvis
- Lower urinary tract
- Lined by transitional epithelium / urothelium

**Notes:**
This is a change in rules.  Previously kidney was grouped with ureter and renal pelvis. Now bladder is grouped with the other organs of the lower urinary tract. All of these organs are lined by transitional urothelium.  Urothelial (transitional cell) carcinoma is common in the bladder, ureter and renal pelvis  but not in the kidney.  Renal cell carcinoma is common in the kidney.  There is a separate set of rules for kidney.

## Urothelium

- Frequent multiple or multifocal tumors
- Field effect: Widespread change in urothelium
- Implantation: Cells washed along in urine

**Notes:**
Tumors of the urothelium are more often multifocal compared to other sites. Experts divide on whether the multifocal tumors are caused by field effect or by implantation.

## Flat Carcinoma In Situ

- Direct spread within the epithelium
- Direct extension
- Field effect
- Implantation

**Notes:**
Flat carcinoma in situ is frequently widespread. It can spread within the epithelium; directly along the mucosa by field effect or implantation. When it spreads by field effect or implantation, the areas of involvement may be discontinuous. Use the multiple primary rules to determine whether there is a single primary or multiple primaries.

## Squamous Cell Carcinoma

**Pure** squamous cell carcinoma has a poor prognosis
- See histology coding rules H5 and H13

**Notes:**
In the United States, transitional cell carcinomas account for more than 90% of all bladder cancers. Squamous cell carcinomas make up 3-8%.  Code the histology to squamous cell carcinoma (8070) only when there are no other histologies present (“pure”).

## Most Invasive - Bladder

- Mucosa
- Lamina propria (some pathologists equate this to submucosa)
- Muscularis mucosae (this layer not always present, may not be mentioned)
- Submucosa
- Muscular layer (muscularis propria, detrusor muscle)
- Serosa, adventitia

**Notes:**
One of the rules says to code the histology of the most invasive tumor. These are the layers of the bladder from the least invasive to the most invasive.

## Most Invasive – Renal Pelvis and Ureter

- Epithelium
- Subepithelial connective tissue, submucosa
- Periureteric fat, peripelvic fat.

**Notes:**
Layers of the renal pelvis and ureter from the least invasive to most invasive.

## Multiple Primary Rules

**Notes:**
Rules used to determine whether the patient has single or multiple primaries.

## Unknown if Single or Multiple Tumors

**Notes:**
Use this module when:

Central registry gets a pathology report of a biopsy followed by a hospital report of a resection. Central registry is not sure if there was a single tumor or multiple tumors

Hospital registry has an H&P documenting a biopsy in the physician’s office. Patient has another biopsy or resection. Registrar cannot confirm whether the patient had a single tumor or multiple tumors.

## M1

- When it is not possible to determine if there is a **single** tumor **or multiple** tumors, opt for a single tumor and abstract as a single** **primary.
***Note:  ***Use this rule only after all information sources have been exhausted.

**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

## Single Tumor

## M2

- A **single tumor** is always a single primary.
***Note: ***The tumor may overlap onto or extend into adjacent/contiguous site or subsite.

**Notes:**
Single tumors are always a single primary no matter how large they become or how many regional sites they may involve.
A single tumor is uncommon in the urinary sites, except in renal pelvis.

## Multiple Tumors

## M3

- When no other urinary sites are involved, tumor(s) in both the **right** **renal pelvis** **and** tumor(s) in the **left renal pelvis** are multiple primaries.
***Note:***  Use this rule and abstract as a multiple primary unless documented to be metastatic.

**Notes:**
Bilateral renal pelvis tumors are multiple primaries.

Abstract as a single primary only when there is a pathology report that says the one side is metastatic from the other or the attending says one side is metastatic. The physician must say one side is metastatic from the other; do NOT assume that the physician means one side is metastatic when they use statements such as “bilateral cancer of the renal pelvis” 

## M4

- When no other urinary sites are involved, tumor(s) in both the **right ureter and** tumor(s) in the **left ureter** are multiple primaries.
***Note:***  Use this rule and abstract as a multiple primary unless documented to be metastatic.

**Notes:**
Bilateral tumors are multiple primaries.

Abstract as a single primary only when there is a pathology report that says the one side is metastatic from the other or the attending says one side is metastatic. The physician must say one side is metastatic from the other; do NOT assume that the physician means one side is metastatic when they use statements such as “bilateral cancer of the ureters”

## M5

- An **invasive** tumor **following** a **non-invasive or** **in situ** tumor more than 60 days after diagnosis is a multiple primary.

**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

## M5 Notes

***Note 1:*** The purpose of this rule is to ensure that the case is counted as an incident (invasive) case when incidence data are analyzed.
***Note 2:*** Abstract as multiple primaries even if the medical record/physician states it is recurrence or progression of disease.

**Notes:**
Note one 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 two: 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. 

## M6

- Bladder tumors with any **combination** of the following histologies: **papillary carcinoma** (8050), **transitional cell carcinoma **(8120-8124), **or** **papillary transitional cell carcinoma** (8130-8131), are a single primary.

**Notes:**
Point out number ranges. Any combination of tumors within these ICD-O-3 ranges of codes are single tumors.

## M7

- Tumors diagnosed **more than three (3) years** apart are multiple primaries.

**Notes:**
SEER DB
Renal pelvis 7,091 cases
Ureter 5,022 cases
	(Renal pelvis and ureter) There are only 2 cases of recurrence in the same site, same histology within a three year period.

# of bladder cases 145,656

## M8

- Urothelial tumors in two or more of the following sites are a single primary (See Table 1)
- Renal pelvis (C659)
- Ureter(C669)
- Bladder (C670-C679)
- Urethra /prostatic urethra (C680)

**Notes:**
This rule takes care of the field effect or implantation, multicentric/multifocal when the tumors occur in neighboring organs.
This rule applies when 2 sites or more than 2 combinations of sites from the urinary system are involved.
Table 1 lists the urothelial tumors.

## M9

- Tumors with ICD-O-3 **histology** codes that are **different** at the first (_**x**_xxx), second (x_**x**_xx) or third (xx_**x**_x) number are multiple primaries.

**Notes:**
The same as the old rule.

## M10

- Tumors in sites with ICD-O-3 **topography** codes with **different** second (C_**x**_xx) and/or third characters (Cx_**x**_x) are multiple primaries.

**Notes:**
A  tumor in the renal pelvis and a separate tumor in any other site are multiple primaries.

## M11

- Tumors that **do not meet any** of the above **criteria** are a single primary.
***Note: ***When an invasive tumor follows an in situ tumor within 60 days, abstract as a single primary.

**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 code is new for most people. The note is intended to reassure the abstractor that they should default to a single primary.

## Histology Rules

## Single Tumor

## H1

- Code the histology documented by the physician when there is **no pathology/cytology specimen** or the **pathology/cytology** report is **not available**.

**Notes:**
Used when there was no pathology or cytology specimen or when the abstractor does not have access to the pathology or cytology report.

## H1 Notes

***Note 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 or MRI scans

**Notes:**
Gives a priority for coding histology.

--If the medical record references a pathology or cytology report. Example: Patient had a biopsy of the prostate prior to arrival that was positive for adenocarcinoma
--Use the physician’s documentation in the medical record giving the histology. Example: H&P with a diagnosis of squamous cell carcinoma of the lung.
--Reference to histologic type in scans.

## H1 Notes

***Note 2:***  Code the specific histology when documented.
***Note 3:  ***Code the histology to 8000 (cancer/malignant neoplasm) or 8010 (carcinoma, NOS)  as stated by the physician when nothing more specific is documented.

**Notes:**
If any of the documentation sources mentions a specific histology, code as documented.

If the only mention is that the patient has “carcinoma” of the renal pelvis, code 8010.

If the only mention is that the patient has cancer of the renal pelvis code 8000.

## H2

- Code the histology from the metastatic site when there is **no pathology/cytology specimen from the primary site**.
***Note:***  Code the behavior /3

**Notes:**
If there is no pathology or cytology specimen from the primary site, code the histology from a biopsy of a metastatic site. Example: Patient has a lung biopsy positive for metastatic transitional cell carcinoma.  CT confirms a large mass in the left ureter.

## H3

- Code **8120** (transitional cell/urothelial carcinoma) (Table 1 - Code 8120) when there is:

**Notes:**
Transitional cell carcinoma is called many names. This rule helps clarify the terminology that equals code 8120.

## H3 Continued

- Pure transitional cell carcinoma or
- Flat (non-papillary) transitional cell carcinoma or
- Transitional cell carcinoma with squamous differentiation or

**Notes:**
Point out bullet three – you do NOT code the differentiation. You only code squamous cell carcinoma of the bladder, ureter, or renal pelvis if it is pure.  Pure squamous cell carcinoma has a worse prognosis.

## H3 Continued

- Transitional carcinoma with glandular differentiation or
- Transitional cell carcinoma with trophoblastic differentiation or
- Nested transitional cell carcinoma or
- Microcystic transitional cell carcinoma

**Notes:**
Again, bullets 1 and 2 use the term differentiation, however you code the transitional cell.

## H4

- Code **8130** (papillary transitional cell carcinoma) (Table 1 - Code 8130) when there is:
-   Papillary carcinoma or
-   Papillary transitional cell carcinoma or
-   Papillary carcinoma and transitional cell carcinoma

**Notes:**
Note bullet 1. Even if the diagnosis is papillary carcinoma, the correct code is papillary transitional cell carcinoma.

## H5

- Code the histology** **when only **one histologic type** is identified.
***Note : ***Only code squamous cell carcinoma (8070) when there are no other histologies present (pure squamous cell carcinoma).

**Notes:**
Code squamous cell carcinoma only when it is “pure.”   Pure squamous cell carcinoma has a worse prognosis.  
The note is a reminder that you never assign code 8070 for just squamous differentiation.

## H6

- Code the invasive histologic type when a single tumor has **invasive and in situ **components.

**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. 

## H7

**Code** **the** most** specific** histologic **term**.
**Examples**
- Cancer/malignant neoplasm, NOS (8000) and a more specific histology or
- Carcinoma, NOS (8010) and a more specific carcinoma or
- Sarcoma, NOS (8800) and a more specific sarcoma (invasive only)

**Notes:**
This is a version of the previous NOS and more specific rule.

## H7 Notes

***Note 1: ***The specific histology for **in situ** tumors may be identified as pattern, architecture, type, subtype, predominantly, with features of, major, or with ____differentiation
***Note 2: ***The specific histology for **invasive **tumors may be identified as type, subtype, predominantly, with features of, major, or with ____differentiation

**Notes:**
Make sure you tell the abstractors that “NOS” is an ICD-O term. The pathology report will not say “adenocarcinoma, NOS” it will simply say adenocarcinoma.

## H8

- Code 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 7 rules

## Multiple Tumors Abstracted as a Single Primary

## H9

- Code the histology documented by the physician when there is **no pathology/cytology specimen **or the **pathology/cytology** report is **not available**.

**Notes:**
Same as H1

## H9 Notes

***Note 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 or MRI scans

## H9 Notes

***Note 2:***  Code the specific histology when documented.
***Note 3:  ***Code the histology to 8000 (cancer/malignant neoplasm) or 8010 (carcinoma, NOS) as stated by the physician when nothing more specific is documented.

## H10

- Code the histology from the metastatic site when there is **no pathology/cytology specimen from the primary site**.
***Note:***  Code the behavior /3

**Notes:**
Same as H2

## H11

- Code **8120** (transitional cell/urothelial carcinoma) (Table 1 – Code 8120) when there is:
- Pure transitional cell carcinoma or
- Flat (non-papillary) transitional cell carcinoma or

**Notes:**
Same as H3

## H11 Continued

- Transitional cell carcinoma with squamous differentiation or
- Transitional cell carcinoma with glandular differentiation or
- Transitional cell carcinoma with trophoblastic differentiation or
- Nested transitional cell carcinoma or
- Microcystic transitional cell carcinoma

## H12

- Code **8130** (papillary transitional cell carcinoma) (Table 1 – Code 8130) when there is:
- Papillary carcinoma or
- Papillary transitional cell carcinoma or
- Papillary carcinoma and transitional cell carcinoma

**Notes:**
Same as H4

## H13

- Code the histology when only **one histologic type** is identified.
***Note: ***Only code squamous cell carcinoma (8070) when there are no other histologies present (pure squamous cell carcinoma).

**Notes:**
Same as H5

## H14

- Code the histology of the **most invasive** tumor.
***Note:*** See the Renal Pelvis, Ureter, Bladder and Other Urinary Equivalent Terms, Definitions, Tables and Illustrations for the definition of most invasive.

**Notes:**
H6 is for single tumors, H14 is for multiple tumors.  

## H14 Continued

- If one tumor is in situ and one is invasive, code the histology from the invasive tumor.
- If both/all histologies are invasive, code the histology of the most invasive tumor.

## H15

- Code the histology with the **numerically higher** ICD-O-3 code.

**Notes:**
Same as H8

## MP/H Task Force