Melanoma Centers for Disease Control and Prevention PowerPoint Presentation

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National Program of Cancer RegistriesEducation and Training Series How to Collect High Quality Cancer Surveillance Data

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NAACCR Administers NPCR-Education Contract for the Centers for Disease Control and Prevention (CDC) Awarded in _____2001 Contract Number: #200-2001-00044

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Melanoma

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Melanoma Sites include Skin (C44.0-C44.9) Vulva (C51.0-C51.2, C51.8-C51.9) Penis (C60.0-C60.2, C60.8-C60.9) Scrotum (C63.2) Accounts for approximately 4% of newly diagnosed cancers annually

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Anatomy of the Skin

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Skin Covers entire surface of body Consists of three layers Epidermis: thin outer layer Dermis: thick underlying layer Hypodermis: fatty layer

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Epidermis Consists of five sub-layers Basal cell layer Innermost layer of epidermis Contains basal cells Contains melanocytes that produce melanin Melanoma develops when melanocytes undergo malignant transformation Contains Merkel cells

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Epidermis Squamous cell layer Resides above basal layer Called stratum spinosum Contains keratinocytes Contains Langerhans cells Is the thickest part of epidermis

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Epidermis Stratum granulosum Thin granular layer Stratum lucidum Translucent layer Stratum corneum Outermost layer Sloughs off dead keratinocytes

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Sub-layers of Epidermis Image source: Merck Source - Dorland’s Illustrated Medical Dictionary

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Dermis Thickest of the three layers Main functions are: Stores much of the body’s supply of water Supplies nutrients to the epidermis Regulates body temperature

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Dermis Contains specialized cells and structures Blood vessels Lymph vessels Hair follicles Sweat glands Sebaceous glands Nerve endings Collagen

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Dermis Papillary layer Regulates body temperature Supplies epidermis with nutrient-filled blood Reticular layer Provides structure and elasticity Supports components of skin

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Hypodermis Network of fat and collagen Functions as: Shock-absorber for body Insulator Stores fat as energy reserve

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ICD-O-3 Histology Coding Melanoma

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Caution!! Pre-2007 Multiple Primary and Histology Rules used in the following slides are based on 2006 rules.

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Common Melanoma Histology Superficial spreading melanoma (8743/3) 70% of melanoma cases Nodular melanoma (8721/3) 15% of melanoma cases Acral lentiginous melanoma (8744/3) 8% of melanoma cases Lentigo maligna melanoma (8742/3) 5% of melanoma cases

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Histology Coding Rules: Melanoma Rules are a hierarchy Use rules in priority order with rule 1 having highest priority Use the first rule that applies Rules from SEER Program Coding and Staging Manual (PCSM) 2004, pages 86-87

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Histology Coding Rules: Melanoma Single Tumor 1. Code the histology if only one type is mentioned in the pathology report Example: Right arm lesion, superficial spreading melanoma Answer: 8743/3 Superficial spreading melanoma

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Histology Coding Rules: Melanoma 2. Code the invasive histology when both invasive and in situ tumor are present Example: Upper back lesion, lentigo maligna and superficial spreading melanoma Lentigo maligna 8742/2 Superficial spreading melanoma 8743/3 Answer: 8743/3 Superficial spreading melanoma

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Histology Coding Rules: Melanoma 2. (Continued) Exception: If the histology of the invasive component is an ‘NOS’ term (melanoma, NOS), then code the histology using the specific term associated with the in situ component and the invasive behavior.

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Histology Coding Rules: Melanoma 2. (Continued) Example: Chest lesion, melanoma and lentigo maligna Malignant melanoma, NOS 8720/3 Lentigo maligna 8742/2 Answer: 8742/3 Lentigo maligna melanoma

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Histology Coding Rules: Melanoma 3. Use a mixed histology code if one exists Example: Scalp lesion, spindle cell and mixed epitheloid melanoma Answer: 8770/3 Mixed epitheloid and spindle cell melanoma 4. Use a combination histology code if one exists

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Histology Coding Rules: Melanoma 5. Code the more specific term when one of the terms is ‘NOS’ and the other is more specific description of same histology Example: Left thigh lesion, melanoma and desmoplastic melanoma Malignant melanoma, NOS 8720/3 Desmoplastic melanoma 8745/3 Answer: 8745/3 Desmoplastic melanoma, malignant

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Histology Coding Rules: Melanoma 6. Code the majority of the tumor Terms that mean majority of tumor: Predominantly; with features of; major; type (eff. 1/1/99); with….differentiation (eff. 1/1/99); pattern and architecture (if in CAP protocol; eff. 1/1/2003) Terms documented in SEER PCSM 2004, page 85

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Histology Coding Rules: Melanoma 6. (Continued) Example: Chest lesion, superficial spreading melanoma, nodular type Superficial spreading melanoma 8743/3 Nodular melanoma 8721/3 Answer: 8721/3 Nodular melanoma

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Histology Coding Rules: Melanoma 6. (Continued) Terms that DO NOT mean majority of tumor With foci of; focus of/focal; areas of; elements of; component (eff.1/1/99) Terms documented in SEER PCSM 2004, page 85

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Histology Coding Rules: Melanoma 6. (Continued) Example: Right forearm, nodular melanoma with a component of lentigo maligna melanoma Nodular melanoma 8721/3 Lentigo maligna melanoma 8742/3 Answer: 8721/3 Nodular melanoma

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Histology Coding Rules: Melanoma 7. Code the numerically higher ICD-O-3 code Example: Left hip lesion, spindle cell melanoma and nodular melanoma Spindle cell melanoma 8772/3 Nodular melanoma 8721/3 Answer: 8772/3 Spindle cell melanoma

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Histology Coding Rules: Melanoma Multiple Tumors with Different Behaviors in Same Organ Reported as Single Primary Code the histology of the invasive tumor when one lesion is in situ and the other is invasive Example: 2 lesions, left ankle: 1) lentigo maligna 8742/2 2) lentigo maligna melanoma 8742/3 Answer: 8742/3 Lentigo maligna melanoma

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Histology Coding Rules: Melanoma Multiple Tumors in Same Organ Reported as Single Primary 1. Code histology when multiple tumors have the same histology Example: Left lower back, 2 lesions: 1) amelanotic melanoma 8730/3 2) amelanotic melanoma 8730/3 Answer: 8730/3 Amelanotic melanoma

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Histology Coding Rules: Melanoma 5. Code the more specific term when one of the terms is ‘NOS’ and the other is a more specific description of the same histology Example: Right arm, 2 lesions: 1) melanoma, NOS 8720/3 2) balloon cell melanoma 8722/3 Answer: 8722/3 Balloon cell melanoma

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Histology Coding Rules: Melanoma 6. Code all other multiple tumors with different histologies as multiple primaries Example: Left leg, 2 lesions: 1) nodular melanoma 8721/3 2) amelanotic melanoma 8730/3 Answer: 2 primary sites; complete abstract for each one

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Coding Behavior for Melanoma Synonyms for in situ, behavior code 2 Basement membrane of epidermis intact Clark’s level I Intraepithelial Noninvasive

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Coding Grade for Melanoma Histologic grade, differentiation, codes 1 = well differentiated 2 = moderately differentiated 3= poorly differentiated 4= undifferentiated

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Abstracting Melanoma Cases

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Date of Diagnosis: Melanoma Review all sources for first date of diagnosis Physical exams Pathologic confirmation Physicians and nurses notes Consultation reports

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Ambiguous Diagnostic Terms That Constitute a Cancer Diagnosis Apparent(ly) Appears Comparable with Compatible with Consistent with Favors Malignant appearing Most likely Presumed Probable Suspect(ed) Suspicious (for) Typical of

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Ambiguous Diagnostic Terms That Do Not Constitute a Cancer Diagnosis Cannot be ruled out Equivocal Possible Potentially malignant Questionable Rule out Suggests Worrisome

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Determining Primary Site for Melanoma Difference in 4th digit of topography code indicates a different primary site for skin (C44.0 – C44.9) Example: Melanoma of the skin of the lip and of the ear Answer: 2 different sites Skin of lip C44.0 Skin of external ear C44.2

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Determining Primary Site for Melanoma Difference in 4th digit of topography code does not indicate a difference in primary site for Penis (C60.0-C60.2, C60.8-C60.9) Vulva (C51.0-C51.2, C51.8-C51.9) Example: Melanoma, 2 lesions 1) Glans penis C60.1 2) Body of penis C60.2 Answer: C60.9 Penis, NOS

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Laterality for Melanoma Skin sites for which laterality is recorded per FORDS p. 11 and SEER PCSM 2004 p. 79 Skin of eyelid C44.1 Skin of external ear C44.2 Skin of face C44.3 Skin of trunk C44.5 Skin of upper limb and shoulder C44.6 Skin of lower limb and hip C44.7

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Tumor Invasion for Melanoma Clark’s level Measures melanoma invasion by anatomic levels Breslow thickness Measures depth of skin penetration by melanoma

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Melanoma Work-up Physical exam Skin examination Number of nevi Changes in moles and surrounding skin Sensation Consistency Laterality Lymph node examination Size of nodes Number of palpable nodes

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Melanoma Work-up Imaging studies Chest x-ray CT scan of abdomen/pelvis CT scan of bone CT scan of brain CT scan of chest CT scan of liver/spleen

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Melanoma Work-up Biopsy Incisional Shave biopsy, skin punch, wedge excision Excisional biopsy

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The Anatomy of Collaborative Staging:Malignant Melanoma Presentation developed by Collaborative Staging Steering Committee ajcc@facs.org 2005 update

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Malignant Melanoma of Skin Collaborative Staging data items submitted to NPCR CS Extension CS Lymph Nodes CS Mets at Dx

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CS Melanoma Schema for skin, vulva, penis, scrotum Melanoma of visceral sites coded by site-specific schema Do NOT use melanoma of skin schema for Mucous membranes Oral cavity, nasopharynx, vagina, urethra, anal canal Other visceral sites Eye and adnexa

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CS Extension Melanoma: Notes 1. If discrepancy between Clark’s level and pathologic extent, use higher code 2. Code satellite lesions/nodules or in transit mets in CS Lymph Nodes 3. Code ulceration in SSF2. 4. Note 4 deleted August 2004.

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CS Extension Melanoma

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CS Extension Melanoma

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CS Lymph Nodes Melanoma: Notes 1. Code regional nodes and nodes, NOS, only; distant nodes coded in CS Mets at Dx Specific regional LNs listed by primary site Code 10: regional nodes by site Code 12: certain head and neck nodes Regional lymph nodes include ipsilateral or contralateral nodes for head, neck, and trunk; ipsilateral nodes for extremities

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CS Lymph Nodes Melanoma: Notes 2. Satellite lesions/nodules or in-transit metastasis coded in CS Lymph Nodes

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CS Lymph Nodes Melanoma: Notes 3. Clarification (added August 2004) Codes 10-12 Regional nodes involved without nodules or in- transit mets Codes 13-15 Satellites or in-transit mets without regional node involvement Codes 20-22 Both satellites or in-transit mets and regional nodes involved

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Satellite Nodules and In-transit Mets Source: TNM-interactive. Wiley-Liss, 1998 Satellite nodules/lesions (tumor nests or nodules in dermis or subq tissue) In-transit mets (in lymph channels between primary and regional nodes)

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CS Lymph Nodes Melanoma Revised and new codes 13-15 13 Satellite nodules or in-transit mets (distance from primary not stated) WITHOUT nodes or nodes not stated 14 Satellite nodules or in-transit mets < 2 cm from primary, WITHOUT nodes or nodes not stated 15 Satellite nodules or in-transit mets > 2 cm from primary tumor WITHOUT nodes or nodes not stated

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CS Lymph Nodes Melanoma Revised and new codes 17,18, 20, 22 17 Matted nodes listed in code 10 18 Matted nodes listed in code 12 20 Satellite nodules or in-transit mets WITH regional nodes listed in code 10 22 Satellite nodules or in-transit mets WITH regional nodes listed in code 12

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CS Mets at Dx Melanoma 00 No; none 05 Underlying cartilage, bone, skeletal muscle Distant lymph nodes Distant metastasis, NOS Metastasis to skin or subcutaneous tissue beyond regional lymph nodes

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CS Mets at Dx Melanoma 43 Lung 44 Other distant metastases 52 (10) + (42) 53 (10) + (43) 54 (10) + (44) 99 Unknown

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CS Mets at Dx Melanoma 40 Distant mets, NOS 52 Skin or subq mets beyond reg LN Combinations 52 10 + 42 53 10 + 43 54 10 + 44 99 Unknown; not assessed; not documented 44 Brain 43 Lung 44 Liver 10 Distant lymph nodes 44 Bone 05 Underlying cartilage, bone, skeletal muscle Primary site

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Case Study 1: Nodes negative (clinical only) 1 cm lesion on shoulder, cervical and axillary LN neg on PE. Remainder of PE neg. Exc. bx: Clark level II, Breslow 1.33 mm. CS Extension 10 Clark level II CS Lymph nodes 00 Negative on physical exam CS Mets at Dx 00 Exam negative

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Case Study 2: In-transit mets Small (< 1 cm) nodule on calf. Exc. bx: ulcerated nodular melanoma, Clark IV, Breslow 3.42 mm. Small dark nodule on inner thigh 5 cm from primary bx’d: same cell type. Rest of exam negative. CS Extension 30 Clark level IV CS Lymph nodes 15 In-transit mets > 2 cm away; involvement of regional nodes not stated CS Mets at Dx 00 Exam negative

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Case Study 3: Involved lymph nodes 2 cm area of purplish discoloration with raised center on forearm. Axilla negative. Rest of exam WNL. Exc. bx: superficial spreading melanoma, Breslow 2.02 mm. Wide exc. negative; AxLND: 1/8 node pos. CS Extension 99 Unknown extension CS Lymph nodes 10 Axillary LN from arm primary CS Mets at Dx 00 Negative on exam

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Case Study 4: Mets at diagnosis Difficulty breathing. CXR shows multiple metastatic lesions bilaterally. FNA LLL: metastatic melanoma. No apparent moles or skin lesions; no lymphadenopathy. LDH elevated (2 tests). Site: C44.9, Skin, NOS. CS Extension 95 No evidence of primary tumor CS Lymph nodes 00 No lymphadenopathy CS Mets at Dx 43 Lung mets only

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First Course Treatment Melanoma

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First Course Treatment Intended to affect tumor by Modification Control Removal Destruction Includes curative and palliative treatment

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Surgical Procedure of Primary Site Skin surgical procedure of primary site codes used for skin sites (C44.0-C44.9) FORDS Appendix B, page 268 and SEER PCSM 2004 Appendix C, pages C-439 and C-440

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Surgical Procedure of Primary Site ‘All other sites’ surgical procedure of primary site codes for: Vulva (C51.0-C51.2, C51.8-C51.9) Penis (C60.0-C60.2, C60.8-C60.9) Scrotum (C63.2) FORDS Appendix B, page 284 and SEER PCSM 2004 Appendix C, page C-441

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Surgical Procedure of Primary Site: Skin Code 00: None Codes 10 – 14 Local tumor destruction without pathology specimen Photodynamic therapy (PDT), electrocautery, cryosurgery, laser Codes 20 – 27 Local tumor excision with pathology specimen Excisional biopsy alone or in conjunction with laser, cryosurgery, electrocautery, or PDT

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Surgical Procedure of Primary Site: Skin Codes 30 – 36 Biopsy of tumor followed by gross excision of lesion Does not have to be done under the same anesthesia

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Surgical Procedure of Primary Site: Skin Codes 45 – 47 Wide excision or re-excision of lesion or minor (local) amputation with margins more than 1 cm; margins must be microscopically negative Code 60: Major amputation Code 90: Surgery, NOS Code 99: Unknown

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Surgical Procedure of Primary Site: Vulva, Penis, Scrotum Code 30 Simple/partial removal of primary site Partial penectomy Code 40 Total surgical removal of primary site Total vulvectomy

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Surgical Procedure of Primary Site: Vulva, Penis, Scrotum Code 50 Surgery stated to be “debulking” Code 60 Partial or total removal of the primary with with resection in continuity with other organs

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Scope of Regional Lymph Node Surgery: Melanoma Code sentinel lymph node biopsy Biopsy of first regional node to receive lymph drainage from primary skin site Code regional lymph node dissection

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Scope of Regional Lymph Node Surgery Codes

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Surgical Procedure/Other Site Record removal of distant lymph nodes or other tissues beyond the primary site Biopsy of lung lesion with metastatic melanoma Surgical ablation of liver metastasis Biopsy of cervical lymph node for patient with melanoma of right arm

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Surgical Procedure/Other Site Codes

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Other Therapies: Melanoma Regional treatment modality External beam Chemotherapy Melphalan, Interleukin Hormone therapy Tamoxifen Immunotherapy Interferon, Ganglioside vaccine