Tumor Grade

Coding grade Grade has long been a source of confusion…

Coding grade Several issues complicate matters: in situ vs invasive terminology vs numbers special rules for many sites FORDS and SEER manual have different instructions 2) Trying to decide whether to go with terminology or numbers 3) Many sites have their own special rules (breast, prostate, kidney, etc.) 4) CoC and SEER disagree

Changes in coding grade SEER, CDC, and CoC formed a work group to address the problem No new codes; only clarifications and changes to instructions New rules apply to cases diagnosed January 1, 2014 forward

Changes in coding grade Instructions for coding cell indicator in hematopoietic and lymphoid neoplasms (codes 5, 6, 7, 8, 9) have not changed Determine cell indicator using the “Grade of Tumor Rules” in Hematopoietic and Lymphoid Neoplasm Manual

Changes in Coding Grade For solid tumors, grade is a measurement of how closely the tumor cells resemble the tissue from the organ of origin Similarities and differences may be based on pattern (architecture), cytology, nuclear features, or a combination of these Depends upon which grading system is used 1) Well differentiated tumor cells closely resemble the tissue from which they originated Poorly differentiated and undifferentiated tumor cells are disorganized and abnormal; they look very different from the their tissue of origin 3) For example, Gleason grading for prostate uses only pattern; Fuhrman’s for kidney uses only nuclear features; most use a combo

Coding grade Pathologists describe tumor grade using three systems: Two levels of similarity (two-grade system) Three levels of similarity (three-grade system) Four levels of similarity (four-grade system)

Rules for coding solid tumors 1) Code grade based on information prior to neoadjuvant therapy, even if grade is unknown 2) Code grade from the primary tumor only- NOT mets or recurrence; in the rare instance that the tumor extends contiguously to an adjacent site and tissue from the primary site is not available, code grade from the contiguous site Systemic treatment and XRT can alter a tumor’s grade 2) For example, a pancreatic cancer in which the tumor is extending DIRECTLY into the liver, and the liver tumor was bx’d

Rules for coding solid tumor 3) Code the grade (6th digit) for specific histologic terms that imply a grade (i.e., undifferentiated sarcoma 8805/34) 4) For in situ or combined in situ/invasive tumors- if a grade is assigned for an in situ tumor, code it. Do NOT code grade for dysplasia. If there are both in situ and invasive components, code only the grade for the invasive portion, even if it is unknown 3) Full list in manual 4) i.e., high grade dysplasia

Rules for coding solid tumors 5) If more than one grade is given, code the highest grade, even if it is only a focus. Code grade in the following priority order using the first applicable system: Special grade system for the sites listed in #6 Differentiation, using instructions in #7 (2, 3, or 4 grade system) Nuclear grade, using instructions in #7 (2, 3, or 4 grade system) If it isn’t clear whether the grade assigned is differentiation or nuclear, but a 2, 3, or 4 grade system was used, code it using instructions in #7 Terminology Special grade sites- breast, prostate, kidney, etc.

Rules for coding solid tumors 6) Use information from the special grade system first; if no special grade can be coded, go on to #7 Grade information based on CS SSF’s for breast, prostate, heart, mediastinum, peritoneum, retroperitoneum, soft tissue, and kidney parenchyma is used to code grade

Rules for coding solid tumors See the rules for each of these SSF’s for details on how to code grade for these sites:   CS Schema Special grade system Breast Nottingham or Bloom-Richardson (BR) Score/Grade (SSF7) Prostate Gleason's Score on Needle Core Biopsy/Transurethral Resection of Prostate (TURP) (SSF 8) Gleason's Score on Prostatectomy/Autopsy (SSF 10) Heart, Mediastinum Grade for Sarcomas (SSF 1) Peritoneum Retroperitoneum Soft Tissue Kidney Parenchyma Fuhrman Nuclear Grade (SSF 6) DO NOT use SSF’s for sites other than those listed here to code grade (for example, WHO grade for CNS tumors, FIGO for gyn, etc.)

Rules for coding solid tumors 7) Use the two, three, or four grade system information Two grade system   Term Description Grade Code Exception for Breast and Prostate Grade Code 1/2, I/II Low grade 2 1 2/2, II/II High grade 4 3 If the site isn’t one of the ones mentioned in the table in #6, go to rule #7. This is similar to the MPH rules, where you find the rules that fits, then stop. Two grade system is commonly used for TCC of the bladder

Rules for coding solid tumors Three grade system   Term Description Grade Code Exception for Breast and Prostate Grade Code 1/3 Low grade 2 1 2/3 Intermediate grade 3 3/3 High grade 4

Rules for coding solid tumors Four grade system   Term Description Grade Code 1/4 Grade I; Well differentiated 1 2/4 Grade II; Moderately differentiated 2 3/4 Grade III; Poorly differentiated 3 4/4 Grade IV; Undifferentiated 4

Rules for coding solid tumors 8) When coding grade from terminology, use the “description” column or the “grade” column. Breast and prostate use the same grade code with a few noted exceptions. If the grade you have isn’t using a special grading system and is not specified to be a two, three, or four grade system, use terminology to code grade

Rules for coding solid tumors   Description Grade Assign Grade Code Exception for Breast and Prostate Grade Code Differentiated, NOS I 1 Well differentiated Only stated as ‘Grade I’ Fairly well differentiated II 2 Intermediate differentiation Low grade I-II Mid differentiated Moderately differentiated Moderately well differentiated Partially differentiated Partially well differentiated Relatively or generally well differentiated Only stated as ‘Grade II’

Rules for coding solid tumors   Description Grade Assign Grade Code Exception for Breast and Prostate Grade Code Medium grade, intermediate grade II-III 3 2 Moderately poorly differentiated III Moderately undifferentiated Poorly differentiated Relatively poorly differentiated Relatively undifferentiated Slightly differentiated Dedifferentiated Only stated as ‘Grade III’ High grade III-IV 4 Undifferentiated, anaplastic, not differentiated IV Only stated as ‘Grade IV’ Non-high grade 9

Rules for coding solid tumors 9) If no description fits or grade is unknown prior to neoadjuvant therapy, use code 9 (unknown)

Special grade system rules Breast uses Bloom Richardson (BR) or Nottingham Coded in SSF7 Code in priority order BR scores 3-9 BR grade (low, intermediate, high)

Special grade systems rules BR score is expressed as a range, 3-9. Based on three morphologic features: degree of tubule formation/histologic grade, mitotic activity, nuclear pleomorphism/nuclear grade of tumor cells

Special grade system rules If a pathology report uses words such as low, intermediate, or high rather than numbers, use this table to code grade Description CS Code Grade Code Score of 3 030 1 Score of 4 040 Score of 5 050 Score of 6 060 2 Score of 7 070 Score of 8 080 3 Score of 9 090 Low Grade, Bloom-Richardson (BR) grade 1, score not given 110 Medium (Intermediate) Grade, BR grade 2, score not given 120 High Grade, BR grade 3, score not given 130

Special grade system rules If only a grade of 1 through 4 is given with no information on the score, and it is unclear if it is a Nottingham or BR grade, do not use the conversion table. Instead, continue on to #7 in the grading rules If multiple scores are reported, code the highest score

Special grade system rules Kidney uses Fuhrman nuclear grade Parenchyma ONLY- not renal pelvis! Coded in SSF6 Fuhrman nuclear grade is a four-grade system based on nuclear diameter and shape, the prominence of nucleoli, and the presence of chromatin clumping C64.9, never C65.9

Special grade system rules Description CS Code Grade Code Grade 1 010 1 Grade 2 020 2 Grade 3 030 3 Grade 4 040 4 If you code SSF 6 = 030, but code grade = 1, you will get an error message

Special grade system rules Soft tissue sarcoma uses a three-grade system French Federation of Cancer Centers Sarcoma Group (FNCLCC) Coded in SSF1 In some cases (especially for needle bxs), grade may be specified only as “high grade” or “low grade” Numeric grade take precedence over high or low

Special grade system rules Description CS Code Grade Code Specified as Grade 1 [of 3] 010 2 Specified as Grade 2 [of 3] 020 3 Specified as Grade 3 [of 3] 030 4 Grade stated as low grade, NOS 100 Grade stated as high grade, NOS 200

Special grade system rules Prostate uses Gleason grade Coded in SSF8 (bx/TURP) and SSF10 (prostatectomy/autopsy) Gleason grade is based on a 5-component system and generally shows two main histology patterns Prostate –Gleason Grade was a change in 2014 Exclude results from tests performed after neoadjuvant tx

Special grade system rules The primary pattern occupies >50% of the cancer It is usually the first number of the Gleason grade Secondary pattern is indicated by the second number These two numbers are added together to create the score, ranging from 2-10

Special grade system rules If there are two numbers, assume they refer to patterns, and add them together to obtain the score If only one number is given, and it is < 5, and not specified as a score, do not use the information, because it could refer to either a score or a grade If only one number is given, and it is >5, assume that is the score and use it

Special grade system rules Change in prostate grading   Gleason Description SEER score CS Code Grade Code AJCC 7th 2003- 2013 AJCC 6th prior 2003 2 002 1 G1 3 003 4 004 5 005 G2 6 006 7 007 G3 8 008 9 009 10 010 Basically, lower grades (2-4) and higher grades (8-10) have never changed Middle grades have mutated to bring them into line with AJCC 7th Ed Gleason scores of 5 and 6, which used to be 2, is now 1. Gleason 7, which used to translate to grade 3, is now 2.

Special grade system rules Due to coding changes in Gleason Grade 7 in 2014, analysis of prostate grade for cases diagnosed prior to 2014 based solely on the grade field is not recommended Standard setters were trying to balance continuity through time with advances in staging and prognosis As a results, prostate grading over time is a bit of mess

Special grade system rules SSF 8 Code SSF 10 Grade Code 002 003 004 005 006 007 008 009 010 988 998 999 1 2 3 * Conversion table for SSF 8 and SSF10 to grade

Changes in coding grade The new grading instructions can be found at http://seer.cancer.gov/tools/grade/ CoC and SEER has incorporated these instructions in their respective coding manual for 2014 KCR Abstractor’s Manual has been updated

Summary Differentiation correlates with grade: The less differentiated the tumor: the higher the grade and the more aggressive the tumor. The more differentiated the tumor: the lower the grade and the less aggressive the tumor. This sounds backwards, but remember less differentiated actually means it looks less like the cells from the original tissue

Location for Coding Tumor Grade The grade/ differentiation of a tumor is coded in the 6th digit of the morphology code and is only one digit* M- _ _ _ _ /_X In CPDMS.net the grade is separated from the histology so it is not seen in the 6th digit format.

Example Given the following information, provide the Tumor Grade to code in CPDMS.net 3/22/16: Mass of transverse colon: Path states: Invasive colonic adenocarcinoma with ulceration, high grade 4/2. Which code would you record ?

Changes in coding grade Questions?