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2011 Reporting Requirements and CSv02.03.02
NCCN/ASCO Treatment Guidelines by Stage
FCDS 2011 Educational Webcast Series
September 15, 2011
Steven Peace, CTR
Colon, Rectum, and Appendix
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Presentation Outline
Overview – Tumor Characteristics
Anatomy of Colon/Rectum – Layers
Multiple Primary and Histology Coding Rules Refresher
Collaborative Stage Data Collection System (CSv02.03.02)
2011 FCDS Required C.S. Site Specific Factors
NCCN/ASCO Treatment Guidelines by Stage
Documentation
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Overview – Tumor Characteristics
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Colon/Rectal Cancer – 3rd most common
2011 estimates in the United States
101,340 new colon cancer cases
39,870 new rectal cancer cases
49,380 deaths
2011 estimates in Florida
10,180 new cases
3,370 deaths
Source: American Cancer Society Cancer Facts and Figures 2011
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Colorectal Cancer Histology
Many originate in polyps
95% - 98% adenocarcinoma
Most produce mucin (glandular)
10% or more are mucinous (>50% mucin production)
<1% are signet ring cell (>50% signet rings) - more aggressive
2% - 5% other cancers (GIST, NET, etc.)
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Screening Advancements
Rigid Sigmoidoscopy
Flexible Sigmoidoscopy
Full Colonoscopy
Virtual Colonoscopy
Other Testing
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Large Intestine Anatomy
Image source: SEER Training Modules Colorectal Cancer
Rectosigmoid
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Colonoscopy Measurements
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Anus 0-4
Transverse 82-132
Sigmoid 17-57
Descending
57-82
Rectosigmoid 15-17 Rectum 4-16
Ascending
132-147
Cecum at 150
Distance from anal verge - approximations only.
Source: AJCC Cancer Staging Manual, fifth edition, page 85, 1997.
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Colorectal Wall Anatomy
Image source: Emory Cancer Institute
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Colorectal Wall Anatomy
Image source: SEER Training Modules Colorectal Cancer
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Intraperitoneal Colorectal Subsites
Anterior Anterior
Rectosigmoid
Image source: SEER Training Modules Colorectal Cancer
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Rectosigmoid/Rectum Anatomy
12 Image source: International Foundation for Functional Gastrointestinal Disorders (IFFGD)
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Regional Lymph Nodes
Image source: SEER Training Modules Colorectal Cancer
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Metastatic Sites
Large intestine
Liver
Lung
Seeding of other segments of colon, small intestine, or peritoneum
Mucinous carcinoma of appendix
Peritoneal surfaces
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Multiple Primary Rules
Histology Coding Rules
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Colon
C18.0-C18.9 (excluding appendix)
CSv2 Coding Instructions, CSv02.03.02
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Schema Selection
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http://www.cancerstaging.org/cstage/index.html
Colon (excludes Appendix, GIST, NET) of Colon
Click on Site Specific Schema tab on the left
Select the Colon Schema
All Florida Cases are coded in CSv02.03.02
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CSv02.03.02, Select Correct Schema
31
Check
Version
Check
Schema
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Colon - CS Tumor Size
35
– 998 = Familial/multiple polyposis
– (M-8220/8221)
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Types of Colon Polyps
37 Source: Abeloff et al: Clinical Oncology, third edition, Elsevier Churchill Livingstone, 2004
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Colorectal Wall Anatomy
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Colon - CS Extension
42
– Codes 600-800 are used for contiguous extension from the
site of origin. Discontinuous involvement is coded in CS
Mets at DX.
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Regional Lymph Nodes
Image source: SEER Training Modules Colorectal Cancer
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Rectosigmoid & Rectum
C19.9-C20.9
CSv2 Coding Instructions, CSv02.03.02
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Schema Selection
50
http://www.cancerstaging.org/cstage/index.html
Rectum (escludes GIST and NET of rectum)
Rectosigmoid and Rectum are combined
Click on Site Specific Schema tab on the left
Select the Rectum Schema
All Florida Cases are coded in CSv02.03.02
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Check
Version
Check
Schema
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Rectum - CS Tumor Size
54
– 998 = Familial/multiple polyposis
– (M-8220/8221)
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Rectum - CS Extension
59
– Codes 600-800 are used for contiguous extension from the
site of origin. Discontinuous involvement is coded in CS
Mets at DX.
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Colon and Rectum
Site-Specific Factors
FCDS-Required ONLY SSFs for this Presentation
Schema Number Schema Name FCDS Required CoC Additional
Required
50 Appendix 2, 7, 10, 11 1, 3
53 Colon 2, 7, 9, 10 1, 3, 4, 6, 8
56 Rectum 2, 5, 7, 9, 10 1, 3, 4, 6, 8
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FCDS Required = YES
CoC Required = Yes
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FCDS Required = YES – RECTUM ONLY
CoC Required = No 66
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FCDS Required = YES - NEW
CoC Required = NO
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FCDS Required = YES - NEW
COC Required = YES
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FCDS Required = YES – NEW
COC Required = NO
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SSF10 18q Loss of Heterozygosity
Code Description
010 Test positive for loss of heterozygosity
020 Test negative for loss of heterozygosity
988 Not applicable
997 Test ordered, results not in chart
998 Test not done (test not ordered & not performed)
999 Unknown or no information
Not documented in patient record
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Treatment
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Treatment Non-Invasive Polyp Pedunc
Non-Invasive Polyp Sessile
KRAS Wild Type
T1, N0 T2, N0 T3, N0 T4, N0 N1-2-any T Unresectable M1-any T,N Advanced Disease
NeoAdjv Chemo X X
NeoAdjv XRT X X
NeoAdjv Other
Polypectomy X X
Resection w/nodes X X X X X
Resection liver/lung mets X X X
KRAS Test X X X X X X
MSI Test X X X X X X
LOH Test X X X X X X
FOLFOX6 Chemo X X X X X X
FOLFOX6 Variant
FLOX Chemo X X X X
FLOX Variant
CapeOX Chemo X X X X
CapeOX Variant
Irinotecan (not 1st course)
Capecitabine (KRAS Wild) X consider consider consider consider consider consider Panitumumab (KRAS Wild) X consider consider consider consider consider consider
Bevacizumab consider consider consider
5FU+Leucovorin X X X
BRM 1
BRM 2
XRT Beam 1 consider consider consider consider
XRT Beam 2
XRT Other consider consider consider consider
Other
CLINICAL TRIAL REGIMEN consider consider consider consider
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Non-Invasive Tumors
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Polypectomy – No lymph node assessment
Depending upon type of polyp may require further resection
May not even recommend further resection if pedunculated
No KRAS Test
No MSI Test
No LOH Test
No Chemo
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T1 or T2 (minimally invasive)
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Resection with nodes (negative nodes presumed here)
Full TNM Staging – assess penetration through wall
No KRAS Test
No MSI Test
No LOH Test
No Chemo
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T3 or T4
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Penetration partially or fully through colon wall
T4 lesion may recommend neoadjuvant chemo/XRT
High likelihood of positive nodes
Adjuvant chemo recommended
FOLFOX
5FU Leucovorin
KRAS Test - possible
MSI Test – possible
LOH Test – possible
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Folfox and 5FU/Leucovorin
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Regimen Agent Name NSC # Std Dose Std Unit Delivery Method
Schedule
Folfox
Oxaliplatin 266046 85 mg/m2 IV Day 1
Leucovorin 003590 400 mg/m2 IV Day 1
5-FU 019893 400 mg/m2 Bolus Day 1
1200 mg/m2/day IV Day 2, 3 (continuous infusion)
Roswell-Park (Bolus or infusional 5-FU/leucovorin)
Leucovorin 003590 500 mg/m2 IV over 2 hours, days 1,8, 15, 22, 29, and 36
5-FU 019893 500
mg/m2 Bolus 1 hour after start of leucovorin days 1, 8, 15, 22, 29 and 36
5-FU/LV (LV5FU2)
Leucovorin 003590 400 mg/m2 IV over 2 hours on day 1 followed by 5-FU
5-FU 019893 400 mg/m2 Bolus
400mg/m2 and then 1200 mg/m2/day x 2 days (total 2400mg/m2 over 46-48 hours) continuous infusion 1200
mg/m2/day
Bolus
Weekly
Leucovorin 003590 20 mg/m2 IV over 2 hours on day 1 followed by 5-FU
5-FU 0198930 500 mg/m2
IV
bolus injection 1h after the start of leucovorin
OR
5-FU 0198930 2600 mg/m2
IV
24 hour infusion plus leucovorin
Leucovorin 003590 500 mg/m2 IV
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KRAS Wild Regimens and Other Chemo
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Irinotecan (not FDA approved for 1st line therapy)
Capecitabine (KRAS wild) – T3 and higher
Panitumumab (KRAS wild) – T3 and higher
Bevacizumab – T3 and higher
LOH + - NO 5FU regimens – will be resistant
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KRAS Wild Regimens and Other Chemo
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Cetuximab (KRAS wild-type gene only) ± irinotecan
Cetuximab 714692 400 mg/m2
IV
1st infusion, then 250mg/m2
OR
Cetuximab 714692 500 mg/m2 IV
Every 2 weeks
Irinotecan 616348 300-350 mg/m2
IV
Every 3 weeks
OR
Irinotecan 616348 180 mg/m2 IV
Every 2 weeks
OR
Irinotecan 616348 125 mg/m2
Days 1, 8 and repeat 3 weeks
Cetuximab (KRAS wild-type gene only) Cetuximab 714692 400 mg/m2
IV
1st infusion, then 250mg/m2 IV weekly Panitumumab (KRAS wild-type gene only) Panitumumab XXXXX 6 mg/kg
IV over 60 minutes every 2 weeks
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N1-N2 and higher
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KRAS Test - possible
MSI Test – possible
LOH Test – possible
Chemo depends on above outcomes
FOLFOX
FLOX
CapeOX
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Advanced Disease
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KRAS Test – yes (new agents)
MSI Test – yes (familial/hereditary)
LOH Test – yes (response to 5FU)
Chemo based on results of above
Clinical Trial recommendations
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Irinotecan – not FDA first line drug
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Okay for Advanced Disease
Okay after patient failed some other regimen
Regimens with Irinotecan
Irinotecan alone
Irinotecan + Cetuximab (KRAS wild type)
IROX
FOLFOXIRI
FOLFIRI
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What about neo-adjuvant treatment?
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T4 Colon
T3, T4 Rectum – or any rectum
Chemo alone
Radiation alone
Radiation plus chemo
Intent of neo-adjuvant treatment
Measuring response to treatment
Surgery must take place
What happens after surgery?
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Inquiry & Response System
Submit questions to Inquiry & Response System
Allows tracking for educational purposes
Provides information for all
http://web.facs.org/coc/default.htm
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American Joint Committee on Cancer
Contact Information
Karen A. Pollitt – Manager
email: [email protected]
phone: 312-202-5313
Donna M. Gress, RHIT, CTR – Technical Specialist
email: [email protected]
phone: 312-202-5410
General Inquiries can be directed to [email protected]
Collaborative Stage Data Collection System Web Site
www.cancerstaging.org/cstage