Multiple Primary and Histology Rules 101

1. Multiple Primary and Histology Rules 101 Introductory Workshop May 23, 2006 Pamela Moats, RHIT CTR NCRA-SEER HISTOLOGY LIASION

2. Overview The problem with current rules Overview of changes Format of new rules When and how to use the rules Why site-specific rules are necessary

3. What�s the Problem? 25 year old rules Site-specific exceptions Difficult to train Could not flowchart ICD-O-3 New terms and new codes Non standard usage of nomenclature The registrars did not understand the combination codes that were added to ICD-O-3 When should we use combo codes VERSUS coding multiple tumors? New histologic descriptors were added to ICD-O-3 that did not fall into their own numeric range of codes (Example: non-small cell carcinoma [8046] has the first three digits identical to the small cell carcinomas). Pathologists do not use terms in the same way, so it is difficult for the registrar to select the correct code. The registrars did not understand the combination codes that were added to ICD-O-3 When should we use combo codes VERSUS coding multiple tumors? New histologic descriptors were added to ICD-O-3 that did not fall into their own numeric range of codes (Example: non-small cell carcinoma [8046] has the first three digits identical to the small cell carcinomas). Pathologists do not use terms in the same way, so it is difficult for the registrar to select the correct code.

4. What�s the Problem? Changes in clinical practice Technology advances More histology characteristics descriptors Electron microscopy to immunohistochemistry There have been vast changes in clinical practice in the last 25 years. The advent of sophisticated imagery such as the MRI and CT scan allow physicians to do FNA of a node or primary site rather than doing an invasive procedure. The registrar has more information. Advances in pathology, cytology, and tumor markers have enabled physicians to record more specific histology descriptions. It has also increased the number of cases in which multiple histology descriptors are applied to a single case. Most registrars find it difficult to maneuver through the �sea of words� and choose the appropriate histology code. There have been vast changes in clinical practice in the last 25 years. The advent of sophisticated imagery such as the MRI and CT scan allow physicians to do FNA of a node or primary site rather than doing an invasive procedure. The registrar has more information. Advances in pathology, cytology, and tumor markers have enabled physicians to record more specific histology descriptions. It has also increased the number of cases in which multiple histology descriptors are applied to a single case. Most registrars find it difficult to maneuver through the �sea of words� and choose the appropriate histology code.

5. Purpose of New Rules Clarify rules Prioritize sequence of rules Explain, define terms Promote consistency in coding Same answer from registrar to registrar Preserve integrity of incidence count Improve quality of data overall

6. Major Changes Multiple Primaries Time frame 2 months 1 year or 3 years Histology Take information only from the FINAL diagnosis and not the microscopic description Rules for use of complex/combination codes

7. Primary Sites Lung Colon Breast Kidney Renal pelvis, ureter, and bladder Head and neck Melanoma Brain These sites were chosen using the quality control principles of addressing those sites that comprise the majority of the data base (quantity) and those sites with the greater number of coding errors (high risk). If you look at the right-hand column; breast, colon, and lung along with prostate make up over 50% of our database. If we can make an improvement in the multiple primary and histology coding for that percentage of the database, it is a significant improvement. So, why is prostate missing? As all of you know, there is no problem with determining multiple primaries for prostate (one for a lifetime) or with coding the histology (adenocarcinoma). Now look on the left-hand side of the slide. All of these sites have a �high risk for errors.� The urinary sites are known for problems with field defect that make it difficult to determine the number of primaries. Head and neck sites are so close together that it is difficult to assess where the tumor originated. It is frequently unclear if there is a contiguous tumor or discontinuous. Melanoma has long been a problem with whether to use laterality to determine multiple primaries. Brain tumor histologies have often lead people to code a new tumor (glioblastoma multiforme) when the tumor is actually a recurrence of a previous glial tumor. Breast is also a problem with the in situ histologies and the invasive histologies. All of these things are addressed in the site-specific coding modules. These sites were chosen using the quality control principles of addressing those sites that comprise the majority of the data base (quantity) and those sites with the greater number of coding errors (high risk). If you look at the right-hand column; breast, colon, and lung along with prostate make up over 50% of our database. If we can make an improvement in the multiple primary and histology coding for that percentage of the database, it is a significant improvement. So, why is prostate missing? As all of you know, there is no problem with determining multiple primaries for prostate (one for a lifetime) or with coding the histology (adenocarcinoma). Now look on the left-hand side of the slide. All of these sites have a �high risk for errors.� The urinary sites are known for problems with field defect that make it difficult to determine the number of primaries. Head and neck sites are so close together that it is difficult to assess where the tumor originated. It is frequently unclear if there is a contiguous tumor or discontinuous. Melanoma has long been a problem with whether to use laterality to determine multiple primaries. Brain tumor histologies have often lead people to code a new tumor (glioblastoma multiforme) when the tumor is actually a recurrence of a previous glial tumor. Breast is also a problem with the in situ histologies and the invasive histologies. All of these things are addressed in the site-specific coding modules.

8. How often do new rules apply? Varies by site Multiple Primaries: <10% > 90% of cases are single primaries Histology: 15-25% 75-85% of cases are basic NOS terms adenocarcinoma, ductal carcinoma, etc.

9. Content of Rules Documents General Instructions Site-Specific Rules Equivalent Terms and Definitions Multiple Primary Rules--three formats Notes and examples Histology Rules--three formats Notes and examples General rules Same content and formats as site-specific rules

10. General Terms and Definitions Read and know! Use for all cases with the exception of hematopoietic primaries (leukemia and lymphoma) Use only for multiple primary and histology rules Not for casefinding

11. General Terms and Definitions Bilateral Clinical Diagnosis Contiguous tumor Contralateral Different histology Different (multiple) primaries Focal Foci Focus

12. General Terms and Definitionscontinued Focal-Foci-Focus Focal: limited to one specific area May be microscopic or macroscopic NOT a synonym of (microscopic) focus Foci: plural form of focus Focus: group of cells that can only be seen through a microscope Focal: Limited to one specific area. A focal cancer is limited to one specific area or organ (may be microscopic or macroscopic). Foci: Plural of focus. Focus: A term used by pathologists to describe a group of cells that can be seen only by a microscope. The cells are noticeably different from the surrounding tissue either by their appearance, chemical stain, or other testing. Emphasize the word FOCAL. It means limited to a certain area. It is not a synonym of focus (a microscopic focus). For example, the word �focal� could be used to describe a lesion that is focal (limited to) to the organ of origin. Emphasize the difference between the descriptions of foci and focus and the previous description of focal. Focal: Limited to one specific area. A focal cancer is limited to one specific area or organ (may be microscopic or macroscopic). Foci: Plural of focus. Focus: A term used by pathologists to describe a group of cells that can be seen only by a microscope. The cells are noticeably different from the surrounding tissue either by their appearance, chemical stain, or other testing. Emphasize the word FOCAL. It means limited to a certain area. It is not a synonym of focus (a microscopic focus). For example, the word �focal� could be used to describe a lesion that is focal (limited to) to the organ of origin. Emphasize the difference between the descriptions of foci and focus and the previous description of focal.

13. General Terms and Definitionscontinued Most representative specimen The pathologic specimen from the surgical procedure that removed the most tumor tissue. Might be excisional biopsy rather than -ectomy specimen

14. General Terms and Definitionscontinued Recurrence 1. A new or another occurrence, incidence, episode, or report of the disease in a more general sense � a new occurrence of cancer. 2. The reappearance of disease that was thought to be cured or inactive (in remission). Recurrent cancer starts from cancer cells that were not removed or destroyed by the original therapy.

15. General Terms and Definitionscontinued Recurrence continued Do not use a physician�s statement to decide whether the patient has a recurrence of a previous cancer or a new primary. Use the multiple primary rules as written unless a pathologist compares the present tumor to the �original� tumor and states that this tumor is a recurrence of the previous primary.

16. In Addition� Read the site-specific Equivalent Terms and Definitions before using the site-specific multiple primary rules.

17. How to Use the Rules Read equivalent terms and definitions Choose a format of new rules to use Text Matrix Flowchart

18. Text Multiple Primaries example M2. A single independent non-metastatic tumor is always a single primary. * Note: The tumor may overlap onto or extend into adjacent/contiguous site or subsite. Histology example H4. Code the invasive histologic type when a single tumor has invasive and in situ components.

19. Matrix

20. Flowchart--multiple primaries example

23. Learning Styles Text Flowchart Matrix

24. Warning! Don�t try to use all three rules formats! Don�t combine new rules with old rules!

25. Using the Rules Notes and examples are included with some of the rules to highlight key points or to add clarity to the rules. They are not exclusive. They do not replace the rules.

26. Using the Rules Use multiple primary rules first Three independent modules Unknown number of tumors Single or multiple in primary site Single tumor (primary site) Multiple tumors (primary site) Ask �how many tumors does this case have?�

27. Independent Modules Start with rules in appropriate module. Do not use rules from any other module.

28. Rules are Hierarchical Within each section Use the first rule that applies and STOP.

29. Histology Coding Rules Two independent modules Single Tumor (one primary site) Multiple Tumors abstracted as a single primary site Rules are hierarchical within each module.

30. Multiple Pathology Reports Code from the pathology report from the most representative specimen examined from the final diagnosis

31. Pathology Reports Note 1: A revised/amended diagnosis replaces the original final diagnosis. Code the histology from the revised/amended diagnosis. Note 2: The new rules limit the information to the final diagnosis. The old rules allowed coding from information in the microscopic description.

32. If No Pathology Cytology report Documentation in the medical record that references pathology or cytology

33. Ambiguous Terms-No Longer Utilized Apparent(ly) Appears Comparable with Compatible with Consistent with Favor(s) Most likely Presumed Probable Suspect(ed) Suspicious (for) Typical (of) Cases will be flagged after 1/1/07 that use ambiguous termsCases will be flagged after 1/1/07 that use ambiguous terms

34. No �Negative� Lists If it isn�t listed, don�t code it. No �Do not use ambiguous terms� list No �Terms that do not represent the majority of the tumor� list

35. When? The rules are effective for cases diagnosed January 1, 2007 and after. Do not use these rules to abstract cases diagnosed prior to January 1, 2007.

36. Important! The 2007 multiple primary rules replace all previous multiple primary rules.

37. Why Site-Specific Rules? General rules cannot address site-specific issues Histologies Disease process for that site Valid mixed and combination histology codes For each site, there are prevalent histologies. By using site-specific modules, we are able to identify those histologies and provide specific coding instructions which makes it easier for the registrar to assign a histology code. There are site-specific disease manifestations such as field defect in urinary tract cancers and familial adenomatous polyposis in colon cancer that that make it difficult for the registrar to determine multiple primaries and to code histology. Those disease manifestations are addressed in the site-specific modules. The mixed and combination histology codes have caused a lot of confusion. The site-specific codes have tables that show which codes are valid for that particular site and also specifies the terms that must be present in the pathology report in order to use the combination or mixed code.For each site, there are prevalent histologies. By using site-specific modules, we are able to identify those histologies and provide specific coding instructions which makes it easier for the registrar to assign a histology code. There are site-specific disease manifestations such as field defect in urinary tract cancers and familial adenomatous polyposis in colon cancer that that make it difficult for the registrar to determine multiple primaries and to code histology. Those disease manifestations are addressed in the site-specific modules. The mixed and combination histology codes have caused a lot of confusion. The site-specific codes have tables that show which codes are valid for that particular site and also specifies the terms that must be present in the pathology report in order to use the combination or mixed code.

38. Colon Multiple tumors/polyps Contiguous/overlapping sites Time between diagnoses NOS versus specific histology Mucinous adenocarcinoma Neuroendocrine carcinoma Signet ring cell adenocarcinoma Undifferentiated carcinoma Adenocarcinoma with mixed subtypes

39. Head and Neck What is the primary site? Complex anatomy Laterality Paired site Upper/lower Field effect Multiple tumors Contiguous/overlapping sites What is the primary site? This can be difficult to determine with Head and Neck cases due to: Complex anatomy � lots of structures within head and neck which are located in close proximity to each other Laterality � some anatomy has laterality (left and right cheek mucosa) Paired site �paired site or organ (tonsil, parotid) is different than laterality Upper/lower � gum and gingiva has not been addressed in prior rules Field effect Multiple tumors Contiguous/overlapping sites And physician statements that seem contrary to endoscopy, surgery, or pathology reports. Each report is provided from a slightly different perspective and the primary site may be called something different depending on the perspective. What is the primary site? This can be difficult to determine with Head and Neck cases due to: Complex anatomy � lots of structures within head and neck which are located in close proximity to each other Laterality � some anatomy has laterality (left and right cheek mucosa) Paired site �paired site or organ (tonsil, parotid) is different than laterality Upper/lower � gum and gingiva has not been addressed in prior rules Field effect Multiple tumors Contiguous/overlapping sites And physician statements that seem contrary to endoscopy, surgery, or pathology reports. Each report is provided from a slightly different perspective and the primary site may be called something different depending on the perspective.

40. Head and Neck Site Group � new concept Multiple reports Multiple biopsies Biopsy versus resection Multiple resections In situ and invasive Time between diagnoses Histology Group � new concept Site Group � new concept � certain sites within the head and neck area will be grouped together for purposes of the new rules Multiple reports cause a lot of confusion when abstracting and/or consolidating Multiple biopsies Biopsy versus resection Multiple resections In situ and invasive � alone or in combination can add confusion Time between diagnoses � 3 years between diagnoses Histology Group � new concept � squamous cell carcinoma versus non-squamous and multiple subgroups of squamous cell carcinoma are included in this tableSite Group � new concept � certain sites within the head and neck area will be grouped together for purposes of the new rules Multiple reports cause a lot of confusion when abstracting and/or consolidating Multiple biopsies Biopsy versus resection Multiple resections In situ and invasive � alone or in combination can add confusion Time between diagnoses � 3 years between diagnoses Histology Group � new concept � squamous cell carcinoma versus non-squamous and multiple subgroups of squamous cell carcinoma are included in this table

41. Lung Laterality Multiple tumors Tumors with/without biopsy Multiple reports Contiguous/overlapping sites Time between diagnoses

42. Lung (continued) Multiple tumors in same lung but only one biopsied Rules default to abstracting case as a single primary with metastatic disease when only one tumor is biopsied. Three or more tumors in one or both lungs are usually a single lung primary with metastatic disease.

43. Lung (continued) NOS versus specific histology Histology codes the same at 3 digit level Small cell (8041-8045) / non-small cell (8046) Bronchoalveolar (8250-8254) / mixed (8255) Histology Group � new concept � Chart I Mixed histologies � Table I

44. Melanoma ICD-O-3 topography codes Laterality-related issues Right/left/midline Front/back Upper/lower Precancerous lesions Atypical melanocytic hyperplasia Melanocytic intraepithelial neoplasia Evolving melanoma ICD-O-3 topography codes do not provide sufficient detail to specify the many subsites for skin melanoma Laterality-related issues Right/left/midline � all will be treated as different laterality for Multiple Primary Rules Front/back � will be addressed in Multiple Primary Rules Upper/lower � will be addressed in Multiple Primary Rules Precancerous lesions � source of great confusion � new definitions will help a lot � none of these are reportable malignancies (not reportable to SEER/CoC/NPCR) Atypical melanocytic hyperplasia Melanocytic intraepithelial neoplasia Evolving melanoma ICD-O-3 topography codes do not provide sufficient detail to specify the many subsites for skin melanoma Laterality-related issues Right/left/midline � all will be treated as different laterality for Multiple Primary Rules Front/back � will be addressed in Multiple Primary Rules Upper/lower � will be addressed in Multiple Primary Rules Precancerous lesions � source of great confusion � new definitions will help a lot � none of these are reportable malignancies (not reportable to SEER/CoC/NPCR) Atypical melanocytic hyperplasia Melanocytic intraepithelial neoplasia Evolving melanoma

45. Melanoma In situ melanoma In situ and invasive melanoma Time between diagnoses Regressing melanoma �Recurrence� Effect on incidence counts and rates Histology coding is pretty simple In situ melanoma � when do certain terms refer to in situ melanoma? In situ and invasive melanoma � how are combinations of behavior abstracted and coded Time between diagnoses � 1 year in the same primary site Regressing melanoma � some have been missed in the past �Recurrence� � not such a big issue for melanoma, but addressed here also Effect on incidence counts and rates � very tricky with melanoma so we don�t artificially create an epidemic of melanoma when we compare pre-2007 melanoma rates to 2007 forward rates � we are taking precautions to provide guidance for data analysis and reporting to prevent this from causing reporting problems Histology coding is pretty simpleIn situ melanoma � when do certain terms refer to in situ melanoma? In situ and invasive melanoma � how are combinations of behavior abstracted and coded Time between diagnoses � 1 year in the same primary site Regressing melanoma � some have been missed in the past �Recurrence� � not such a big issue for melanoma, but addressed here also Effect on incidence counts and rates � very tricky with melanoma so we don�t artificially create an epidemic of melanoma when we compare pre-2007 melanoma rates to 2007 forward rates � we are taking precautions to provide guidance for data analysis and reporting to prevent this from causing reporting problems Histology coding is pretty simple

46. Breast TOO MANY TERMS In situ subtypes Invasive subtypes In situ and invasive together �Recurrence� NOS versus specific histology Combination histologies TOO MANY TERMS � we have had many new and expanded terms added and many reports include multiple terms to describe a single or multiple tumors. This is very confusing to registrars In situ subtypes � some ductal subtypes are specific to in situ tumors and we have been incorrectly assigning malignant behavior to some of them as well as incorrectly coding to the more specific term even if it describes only the in situ component of a tumor Invasive subtypes � same issue as above In situ and invasive together � specific instructions on how and what to code when both in situ and invasive tumors co-exist or are combined within a single tumor. �Recurrence� � big issue that we have been working closely with the CoC Breast Site Team to ensure that we have developed clear and reasonably consensus definitions and instructions for coding breast recurrence versus new primary cancers of the breast Combination histologies � ductal and lobular, etc. What about combinations of ductal subtypes, etc. TOO MANY TERMS � we have had many new and expanded terms added and many reports include multiple terms to describe a single or multiple tumors. This is very confusing to registrars In situ subtypes � some ductal subtypes are specific to in situ tumors and we have been incorrectly assigning malignant behavior to some of them as well as incorrectly coding to the more specific term even if it describes only the in situ component of a tumor Invasive subtypes � same issue as above In situ and invasive together � specific instructions on how and what to code when both in situ and invasive tumors co-exist or are combined within a single tumor. �Recurrence� � big issue that we have been working closely with the CoC Breast Site Team to ensure that we have developed clear and reasonably consensus definitions and instructions for coding breast recurrence versus new primary cancers of the breast Combination histologies � ductal and lobular, etc. What about combinations of ductal subtypes, etc.

47. Breast Paget disease Lobular and ductal carcinoma Inflammatory carcinoma Paget disease � with or without invasive ductal or other malignancy of breast Lobular and ductal -- treated as a single primary even if in different tumors within breast Inflammatory carcinoma � even though this is primarily a staging issue � we will be providing some direction for coding histology for these cases. Paget disease � with or without invasive ductal or other malignancy of breast Lobular and ductal -- treated as a single primary even if in different tumors within breast Inflammatory carcinoma � even though this is primarily a staging issue � we will be providing some direction for coding histology for these cases.

48. Kidney Similar to lung Laterality Easy to understand Renal pelvis clearly part of lower urinary tract Histology coding is pretty simple NOS versus specific histology Similar to lung � very straightforward rules that will be easy to use and understand Laterality Easy to understand Renal pelvis clearly part of lower urinary tract � this is new and very clearly spelled out. The kidney produces glandular carcinomas (adenocarcinoma and renal cell carcinoma). The rest of the urinary system, beginning at the renal pelvis produces transitional and squamous cell malignancies � this is in direct relation to the types of cells that line the lower urinary tract from the renal pelvis to the ureters and eventually to bladder. Histology coding is pretty simple Similar to lung � very straightforward rules that will be easy to use and understand Laterality Easy to understand Renal pelvis clearly part of lower urinary tract � this is new and very clearly spelled out. The kidney produces glandular carcinomas (adenocarcinoma and renal cell carcinoma). The rest of the urinary system, beginning at the renal pelvis produces transitional and squamous cell malignancies � this is in direct relation to the types of cells that line the lower urinary tract from the renal pelvis to the ureters and eventually to bladder. Histology coding is pretty simple

49. Renal Pelvis, Ureter, Bladder Laterality Field effect or implantation Multiple tumors Transitional epithelium / urothelium Papillary CA of low malignant potential Papillary carcinoma - grade I/III Papilloma Laterality � only for renal pelvis and ureter of course Field effect or implantation � this is a special issue for lower urinary tract tumors. If a tumor starts in the renal pelvis and through the urine flow eventually deposits or implants lower down in the urinary tract (bladder for example) � are these the same primary or different primaries. This will be covered in these rules. Multiple tumors Transitional epithelium / urothelium � use of current nomenclature � urothelium not transitional epithelium Papillary CA of low malignant potential � is this reportable or not? This is a big issue right now that we are trying to finalize clear and complete instruction for guiding registrars to report or not report these tumors. Papillary carcinoma of low malignant potential is an increasingly applied term that includes both papilloma and papillary carcinoma, grade I/III. Historically we have reported the papillary carcinoma, grade I/III tumors � but as pathologists increasingly use the term low malignant potential to describe these tumors, it takes them off our reportable list � they are not even in situ based on this term�we will provide clear instruction on how to proceed with these tumors for cases diagnosed 1/1/07 and after. Papillary carcinoma - grade I/III Papilloma Laterality � only for renal pelvis and ureter of course Field effect or implantation � this is a special issue for lower urinary tract tumors. If a tumor starts in the renal pelvis and through the urine flow eventually deposits or implants lower down in the urinary tract (bladder for example) � are these the same primary or different primaries. This will be covered in these rules. Multiple tumors Transitional epithelium / urothelium � use of current nomenclature � urothelium not transitional epithelium Papillary CA of low malignant potential � is this reportable or not? This is a big issue right now that we are trying to finalize clear and complete instruction for guiding registrars to report or not report these tumors. Papillary carcinoma of low malignant potential is an increasingly applied term that includes both papilloma and papillary carcinoma, grade I/III. Historically we have reported the papillary carcinoma, grade I/III tumors � but as pathologists increasingly use the term low malignant potential to describe these tumors, it takes them off our reportable list � they are not even in situ based on this term�we will provide clear instruction on how to proceed with these tumors for cases diagnosed 1/1/07 and after. Papillary carcinoma - grade I/III Papilloma

50. Renal Pelvis, Ureter, Bladder Papillary versus flat tumor In situ versus non-invasive In-situ and invasive Non-invasive and invasive Time interval between diagnoses Papillary versus flat tumor � clear definitions and instruction how to code In situ versus non-invasive � clarify TNM TA versus T0 as related to multiple primary and histology coding In-situ and invasive Non-invasive and invasive Time interval between diagnoses Papillary versus flat tumor � clear definitions and instruction how to code In situ versus non-invasive � clarify TNM TA versus T0 as related to multiple primary and histology coding In-situ and invasive Non-invasive and invasive Time interval between diagnoses

51. Brain and Central Nervous System What is the primary site? Complex anatomy Site Group � new concept Time between diagnoses Benign/borderline/malignant What is the primary site? � similar to complexities of head and neck in many ways Complex anatomy Site Group � new concept � this is very similar to the benign/borderline brain and CNS site group concept and presentation. Time between diagnoses Benign/borderline/malignant � we are trying to incorporate all brain tumors into one single set of rules as best we can given the complexities of reporting these highly specific and complex tumors What is the primary site? � similar to complexities of head and neck in many ways Complex anatomy Site Group � new concept � this is very similar to the benign/borderline brain and CNS site group concept and presentation. Time between diagnoses Benign/borderline/malignant � we are trying to incorporate all brain tumors into one single set of rules as best we can given the complexities of reporting these highly specific and complex tumors

52. Brain and Central Nervous System TOO MANY TERMS Progression of disease � histologic type Histology Group � new concept Mixed histology TOO MANY TERMS Progression of disease � histologic type � this is particularly important for glial tumors that have different histologic descriptions as the disease progresses to eventual glioblastoma multiforme. Earlier stages of disease may be called astrocytoma, ependymoma, etc. but they are all glial tumors and rather than report these cases as new primaries or create confusion over which histology to assign, the new rules will provide clarity and direction to the registrar on how to code these cases Histology Group � new concept � really exciting histology table for these tumors Mixed histology � several types of mixed tumors of the brain will be included here TOO MANY TERMS Progression of disease � histologic type � this is particularly important for glial tumors that have different histologic descriptions as the disease progresses to eventual glioblastoma multiforme. Earlier stages of disease may be called astrocytoma, ependymoma, etc. but they are all glial tumors and rather than report these cases as new primaries or create confusion over which histology to assign, the new rules will provide clarity and direction to the registrar on how to code these cases Histology Group � new concept � really exciting histology table for these tumors Mixed histology � several types of mixed tumors of the brain will be included here

53. Highlights of General Rules

54. General Rules Similar to site-specific rules Address remaining combination and mixed histology issues Cover all malignant solid tumors without site-specific rules Exclude hematopoietic Exclude Kaposi sarcoma Exclude benign

55. General Rules Multiple primary and histology Three formats Text, flowchart, matrix Independent modules Unknown Number of Tumors (MP only) Single Tumor (primary site) Multiple Tumors (primary site)

56. General Multiple Primary Rules A single tumor is a single primary Prostate � single primary Kaposi sarcoma � single primary Retinoblastoma � single primary Ovary � bilateral at diagnosis � single primary Thyroid � papillary and follicular at diagnosis � single primary There are a few site-specific rules at the very beginning of the general multiple primary rules � they are very specific and very simple, so these sites do not require a full set of site-specific rules just for a single simple rule. A single tumor is a single primary Prostate � single primary Kaposi sarcoma � single primary Retinoblastoma � single primary Ovary � bilateral at diagnosis � single primary Thyroid � papillary and follicular at diagnosis � single primary There are a few site-specific rules at the very beginning of the general multiple primary rules � they are very specific and very simple, so these sites do not require a full set of site-specific rules just for a single simple rule. A single tumor is a single primary Prostate � single primary Kaposi sarcoma � single primary Retinoblastoma � single primary Ovary � bilateral at diagnosis � single primary Thyroid � papillary and follicular at diagnosis � single primary

57. General Histology Rules In situ tumor only Invasive and in situ tumor Invasive tumor only NOS and specific histology Combination histology codes table The histology rules will include specific rules for the situation when In situ tumor only Invasive and in situ tumor Invasive tumor only They will also provide clear rules for what to do when registrars the use of NOS and specific histology And finally, a complete combination histology codes table will be included for reference and to replace the complex morphology document that registrars have relied on so heavily since it was written. It is now out-of-date and the new rules will replace this outdated document. Combination histology codes table The histology rules will include specific rules for the situation when In situ tumor only Invasive and in situ tumor Invasive tumor only They will also provide clear rules for what to do when registrars the use of NOS and specific histology And finally, a complete combination histology codes table will be included for reference and to replace the complex morphology document that registrars have relied on so heavily since it was written. It is now out-of-date and the new rules will replace this outdated document. Combination histology codes table

58. Project Timeline February 2006 � New Rules Field Trial September 2006 � Train the Trainers II January 1, 2007 � Implementation The 2007 rules will replace all previous rules

59. Further Education 2006-2007 Additional training materials published on web Webcasts State meetings NCRA meetings