FLORIDA DATA SYSTEM JULY/AUGUST 2004 MONTHLY MEMO

HAPPY FOURTH OF JULY UGI Tract Cancer

Seer Training Website: http://training.seer.cancer.gov/ WHAT’S NEW: ss_module07_ugi/00_ugi_home.html The Following newsletters and INTRODUCTION TO UGI glandular cells must replace cancer of the stomach. reports are currently TRACT CANCER an area of squamous cells, for available from the example as in Barrett Most of stomach are esophagus. , arising in FCDS website: Collectively, cancers of the esophagus, stomach, and small the glandular cells in the • FCDS REGISTER intestine are referred to as is the stomach lining. These VOL. 24 upper most common type of cancer glandular cells normally (UGI) cancers. UGI cancers of the esophagus among produce mucus and digestive • FCDS JUNE 2004 represent the second most African Americans, while enzymes. Other stomach MONTHLY MEMO common site and cause of is more cancers may include squamous death among the digestive common in whites. Cancer of cells cancers, , • 6/24/2004: FCDS system cancers. the esophagus is much more sarcomas, and neuroendocrine CHANGES FOR HOSPI- common in some regions of the tumors. TALS SUBMITTING FULL world. For example, CANCER ABSTRACTS Esophagus Cancer rates in Cancer FOR NAACCR V10.1 (Does not pertain to The American Cancer Society Iran, northern China, India, Pathology Data or estimates that during 2003, and southern Africa are 10 to Cancer of the small intestine, a Radiation Therapy ID approximately 13,900 new 100 times higher than in the rare cancer, is a disease in Data) United States. which cancer cells are found in esophageal cancer cases will be diagnosed in the United the tissues of the small States (10,600 men and intestine. Each year US doctors 3,300 women). This disease is diagnose about 1,200 On the Web: about 3 times more common Stomach cancer (also called malignant small intestine among men than women and gastric cancer) can develop in tumors. This is a small number • FLORIDA STATUTES AND any part of the stomach and relative to the frequency of CONSTITUTION almost 3 times more common http://www.flsenate.gov/ among African Americans than may spread throughout the tumors in other parts of the GI Welcome/index.cfm stomach and to other organs. tract. whites. • THE NATIONAL COMMIT- It may grow along the TEE ON VITAL HEALTH There are two main types of stomach wall into the The majority of cancers of the STATISTICS esophageal cancer: squamous esophagus or small intestine. It small intestine are http://ncvhs.hhs.gov/ also may extend through the adenocarcinomas (50% or cell carcinoma and • CDC'S DIVISION OF adenocarcinoma. The majority stomach wall and spread to more) and commonly start in CANCER PREVENTION of cancers in the upper two nearby lymph nodes and to the duodenum, , and AND CONTROL'S (DCPC) thirds of the esophagus are organs such as the liver, the part of the small intestine http://www.cdc.gov/ cancer/ squamous cell carcinoma in , and colon. Stomach nearest the stomach. These nature. Adenocarcinoma starts cancer also may spread to cancers often grow and • INTERNATIONAL AGENCY in glandular tissue, which distant organs, such as the obstruct the bowel. FOR RESEARCH ON normally does not cover the lungs, the lymph nodes above CANCER the collar bone, and the Leiomyosarcomas, another http://www.iarc.fr/ esophagus. It usually occurs in the lower esophagus, near the ovaries. Each year, about type of small intestine cancer, • SEER TRAINING WEB SITE stomach. Before an 24,000 people in the United http:// (Continued on page 2) training.seer.cancer.gov/ adenocarcinoma can develop, States are diagnosed with JULY/AUGUST 2004 MONTHLY MEMO HAPPY FOURTH OF JULY

Page 2 UGI TRACT CANCER (Cont’d)

(Continued from page 1) ANATOMY occur most often in the . Some 20% of malignant lesions of Esophagus the small intestine are tumors, which occur more frequently in the ileum than in the duodenum or jejunum. It is The esophagus is a muscular tube about ten inches (25 cm.) long uncommon to find malignant as a solitary small extending from the hypopharynx to the stomach. The esophagus intestinal lesion. lies posterior to the trachea and the heart, and passes through the mediastinum and the hiatus, an opening in the diaphragm, in FIVE-YEAR SURVIVAL RATES its descent from the thoracic to the abdominal cavity. The (from the National Cancer Institute's Physician Data Query esophagus has no serosal layer; tissue around the esophagus is system, July 2003) called adventitia.

Esophageal cancer is lethal because the esophagus has no There are two subsite descriptions for the esophagus and they serosa; any tumor extension beyond the esophagus can spread are not equivalent. rapidly. Overall, the five-year survival rate is less than 10% for all stages combined. Subsite Description 1

Esophagus Cervical

Stage 0 Excellent Cervical begins at the lower end of pharynx (level of 6th vertebra or lower border of cricoid cartilage) and extends to the Stage I > 65% thoracic inlet (suprasternal notch); 18 cm from incisors. Stage IIA 30% Thoracic Stage IIB 15% Upper thoracic: from thoracic inlet to level of tracheal Stage III < 10% bifurcation; 18-23 cm.

Stage IV Rare Mid thoracic: from tracheal bifuraction midway to gastroesophageal junction; 24-32 cm.

Stomach Stage 0 > 90% Lower thoracic: from midway between tracheal bifurcation and gastroesophageal junction to GE junction, including abdominal 50 - 70% for distal cancers; 10 - 15% for esophagus; 32-40 cm. Stage I proximal cancers Abdominal > 25% for T1/T2 Node positive cases; < Stage II 25% for T3 cases Considered part of lower thoracic esophagus; 32-40 cm.

Stage III 15% for distal cancers Subsite Description 2 Stage IV < 5% Upper third (10% of esophageal cancers) Middle third (40%) Small Intestine Lower third (50%) Stage 0 not reported The figure below illustrates the correlation between subsite Stage I 60-70% descriptions of the esophagus.

Stage II 45-55% Stage III 15%

Stage IV <10%

Carcinoid < 40%

(Continued on page 3) JULY/AUGUST 2004 MONTHLY MEMO HAPPY FOURTH OF JULY

Page 3 UGI TRACT CANCER (Cont’d)

(Continued from page 2) The figure below shows the anatomy of Anatomy of the Small Intestine the stomach. Stomach

The stomach lies just below the diaphragm in the upper part of the abdominal cavity primarily to the left of the midline under a portion of the liver. The main divisions of the stomach are the following:

Cardia

The cardia is the portion of the stomach surrounding the cardioesophageal junction, or cardiac orifice (the opening of the esophagus into the stomach). Tumors of the cardioesophageal junction are Layers of UGI Organs usually coded to stomach. 1. Body of stomach Layers of Esophageal Wall Fundus 2. Fundus 3. Anterior wall The esophageal wall contains four layers: 4. Greater curvature The fundus is the enlarged portion to the mucosa -- surface epithelium, lamina 5. Lesser curvature • left and above the cardiac orifice. propria, and glands 6. Cardia 9. Pyloric sphincter • submucosa -- connective tissue, blood Body vessels, and glands 10. Pyloric antrum muscularis (middle layer) The body, or corpus, is the central part of 11. Pyloric canal • o upper third, striated muscle the stomach. 12. Angular notch o middle third, striated and 13. Gastric Canal smooth Pyloric antrum 14. Rugal folds o lower third, smooth muscle

The pyloric antrum is the lower or distal Small Intestine • adventitia -- connective tissue that portion above the duodenum. The merges with connective tissue of opening between the stomach and the The small intestine is a tube measuring surrounding structures small intestine is the pylorus, and the very about 2.5 cm in diameter. The complete powerful sphincter which regulates the small intestine is approximately 600 cm

passage of chyme into the duodenum is (20 feet) long and coiled in loops, which called the pyloric sphincter. fill most of the abdominal cavity. It extends from the pyloric sphincter to the The stomach is suspended from the ileocecal valve, where it joins the large abdominal wall by the lesser omentum. intestine and is comprised of three parts: The greater omentum attaches the stomach to the transverse colon, spleen Duodenum-- approximately 25 cm long;

and diaphragm. proximal end of small intestine; joined to stomach by the pyloric sphincter.

The common mesentery suspends the small 1. Mucosa 2. Submucosa intestine. The parietal lies Jejunum-- approximately 200 cm long. 3. Muscularis over the duodenum and other structures, 4. Adventitia such as the abdominal aorta. Because Ileum-- approximately 300 cm long; joins 5. Striated muscle they lie behind the peritoneum, they are the cecum at the ileocecal valve. 6. Striated and smooth called retroperitoneal structures. 7. Smooth muscle Peyer patches-- lymphoid tissue in lamina 8. Laminamuscularis mucosae

propria primarily in distal ileum; primary 9. Esophageal glands site for lymphomas.

Meckel diverticulum--congenital anomaly of the ileum, a diverticulum analogous to the appendix of the cecum; a potential site for . (Continued on page 4) JULY/AUGUST 2004 MONTHLY MEMO HAPPY FOURTH OF JULY

Page 4 UGI TRACT CANCER (Cont’d)

(Continued from page 3) ICD-O CODES FOR UGI TRACT CANCER Thoracic (lower): Layers of Stomach Wall RELATED TERMS AND ADJECTIVES Left gastric, cardial, perigastric, NOS, Layers of the stomach wall, among others, posterior mediastinal, nodes of lesser include serosa, muscularis, submucosa, curvature mucosa. The three layers of smooth muscle esophageal, consist of the outer longitudinal, the Esophagus Stomach esophago- middle circular, and the inner oblique muscles. Construction of these muscles Inferior (right) gastric: Stomach gastric, gastro- helps mix and break the contents into a suspension of nutrients called chyme and Small intestine small bowel, propels it into the duodenum. Greater curvature, greater omental, entero-, duodeno-, gastroduodenal, gastrocolic, jejuno-, ileo- gastroepiploic (right or NOS), gastrohepatic, pyloric (including subpyloric and infrapyloric), Esophagus, upper pancreaticoduodenal stomach and small gastrointestinal intestine (UGI), Splenic: esophagogastrod uodeno- Gastroepiploic (left), pancreaticolienal, peripancreatic, splenic hilar

Superior (left) gastric: ICD-O-3 TERM

1. Serosa Lesser curvature, lesser omental, 2. Tela subserosa gastropancreatic (left), gastric (left), Esophagus 3. Muscularis paracardial, cardial, cardioesophageal 4. Oblique fibers of muscle wall C15.0 Cervical esophagus 5. Circular muscle layer Perigastric, NOS 6. Longitudinal muscle layer C15.1 Thoracic esophagus 7. Submucosa Celiac 8. Lamina muscularis Mucosae 9. Mucosa C15.2 Abdominal esophagus 10. Lamina propria Hepatic

11. Epithelium C15.3 Upper third of 12. Gastric glands Small Intestine esophagus 13. Gastric pits 14. Villous folds Duodenum: 15. Gastric areas (gastric surface) C15.4 Middle third of esophagus Hepatic (pancreaticoduodenal,

infrapyloric, gastroduodenal C15.5 Lower third of REGIONAL LYMPH NODES esophagus Jejunum: Esophagus C15.8 Overlapping lesion of esophagus Superior mesenteric Cervical: C15.9 Esophagus, NOS

Ileum: Superior mediastinal, anterior deep cervical (internal jugular), upper cervical, Stomach periesophageal, supraclavicular, lowest Posterior cecal and ileocolic (for terminal paratracheal (azygos), cervical NOS ileum) C16.0 Cardia, NOS Superior mesenteric C16.1 Fundus of stomach Thoracic (upper and middle): C16.2 Body of stomach

Internal jugular, tracheobronchial, C16.3 Gastric antrum peritracheal, perigastric, carinal, hilar,

posterior mediastinal, periesophageal (Continued on page 6) JULY/AUGUST 2004 MONTHLY MEMO HAPPY FOURTH OF JULY

Page 5

DEADLINES AND REMINDERS

PATH LAB REPORTING Every anatomic pathology laboratory that reads biopsy and surgical resection specimens collected from patient encounters within the state of Florida MUST electronically submit the specified data for every malignant cancer case. Specimens read between July 1, 2003 and December 31, 2003 were due to FCDS on or before June 30, 2004. All 2003 data were due on June 30, 2004.

January 1, 2004 through June 30, 2004 data are due December 31, 2004.

FCDS Q & A SEER INQUIRY SYSTEM: HTTP://SEER.CANCER.GOV/SEERINQUIRY/

References References CS Manual, Part II ;pgs 549-551 (Vers 1.0, Jan 1, 2004) 1. CS Manual, Part I ;pgs 27 (Vers 1.0, Jan. 1, 2004) 2. CS Manual, Part II ;pgs 458 (Vers. 1.0, Jan. 1, 2004) Question CS extension--Bladder: How would extension be coded for a Question bladder case that states: papillary transitional cell carcinoma CS Tumor Size--Breast: When the diagnosis is inflammatory with no invasion into the submucosa or deep muscularis. There is carcinoma of the breast, must the CS tumor size always be 998? focal extension of tumor into bladder diverticula. Answer Answer No. For inflammatory carcinoma, code the size of the tumor in CS Assign extension code 01 [Papillary transitional cell carcinoma tumor size. Use code 998 [diffuse] when the tumor is stated to be stated to be noninvasive]. Extension into bladder diverticula does "diffuse." not change the code. Diverticula are pouches in the mucosa Page 27 in Part I of the CS manual will be corrected to define (mucous membrane). code 998 for breast as only "diffuse." The errata should be distributed in July 2004.

JULY/AUGUST 2004 MONTHLY MEMO HAPPY FOURTH OF JULY

Page 6 UGI TRACT CANCER (Cont’d)

(Continued from page 4) Lymphoma (many morphology codes) Leiomyosarcoma (88903, 88913, 88963; 1% of all gastric Stomach (Cont’d) cancers)

C16.4 Pylorus Small Intestine C16.5 Lesser curvature of stomach, NOS (not classifiable to C16.1 to C16.4) Adenocarcinoma (81403) Lymphoma (many morphology codes) C16.6 Greater curvature of stomach, NOS Leiomyosarcoma (88903, 88913, 88963) (not classifiable to C16.0 to C16.4) (82403, 82413, 82433, 82443) C16.8 Overlapping lesion of stomach Synonyms for in situ carcinoma: (adeno)carcinoma in an C16.9 Stomach, NOS adenomatous polyp with no invasion of stalk, confined to epithelium, noninfiltrating, intraepithelial, involvement up to but not including the basement membrane, noninvasive, no stromal involvement, papillary noninfiltrating Small Intestine C17.0 Duodenum EXTENT OF DISEASE FOR UGI CANCER

C17.1 Jejunum C17.2 Ileum (excludes Ileocecal valve C18.0) COMMON METASTATIC SITES C17.3 Meckel diverticulum (site of ) SPREAD PRMARY SITE/METS C17.8 Overlapping lesion of small intestine LYMPHATIC SPREAD Most common for esophageal and stomach cancers; distant lymph C17.9 Small intestine, NOS nodes include supraclavicular, retropancreatic, hepatoduodenal, MORPHOLOGY AND GRADE aortic, portal, retroperitoneal, mesenteric and inguinal If the diagnostic term in the pathology report is not in the INTRACAVITARY SPREAD From stomach--peritoneal following list, be sure to consult your ICD-O manual. seeding; also submucosal extension into esophagus or Esophagus duodenum; direct extension into liver, transverse colon, pancreas Squamous cell carcinoma (The majority of cancers in the upper or diaphragm two thirds of the esophagus are squamous cell carcinoma in nature. Adenocarcinomas, which also arise in the esophagus, are HEMATOGENOUS SPREAD Esophagus--liver, lung, pleura, more prevalent in the lower third of the esophagus.) kidney; Stomach--liver, lung, peritoneum, Adenocarcinoma (in Barrett esophagus) bone; Small intestine--liver, lung Key words: Barrett esophagus--gastric mucosa (glandular) continuing into esophagus

Stomach EXTENT OF DISEASE EVALUATION (Parentheses enclose the names of the organs for which the Adenocarcinoma (81403; 95% of all gastric cancers; subtypes: diagnostic study is useful.) ulcerative 70%, polypoid 10%, scirrhous/diffusely spreading/ 10%, superficially spreading 5%) DEFINITIONS

Signet ring adenocarcinoma (84903) Key words/involvement: Linitis plastica (81423) -- complete involvement of the stomach; leathery appearance Terms which indicate tumor is present. Common terms are provided, but the list is not all-inclusive. (84906) -- metastatic signet ring carcinoma in the ovaries; most likely from stomach or intestinal primary

(Continued on page 7) JULY/AUGUST 2004 MONTHLY MEMO HAPPY FOURTH OF JULY

Page 7 UGI TRACT CANCER (Cont’d)

(Continued from page 6) N1 Regional lymph node metastases

Other words/no involvement: Lower thoracic esophagus Other terms seen in reports which indicate an abnormality but do not indicate tumor is present. Common terms are provided, M1a Celiac lymph nodes but the list is not all-inclusive. M1b Other distant metastasis

Key information: Upper thoracic esophagus

Information to look for in the report of the study. Key M1a Cervical lymph nodes information helps define the extent of disease. M1b Other distant metastases

DIAGNOSTIC STUDIES Mid-thoracic esophagus

• PHYSICAL EXAM M1a Not applicable • LABORATORY TESTS M1b Non-regional lymph nodes or other distant metastases

IMAGING • SMALL INTESTINE • TUMOR MARKERS • ENDOSCOPIES T1 Lamina propria or submucosa • OPERATIVE REPORT T2 Muscularis propria • PATHOLOGY T3 Subserosa, non-peritonealized perimuscular tissues (mesentery, retroperitoneum) = 2 cm UGI CANCER STAGING T4 Visceral peritoneum, other organs/structures (including mesentery, retroperitoneum) > 2 cm Criteria for TNM Clinical Staging: N1 Regional lymph node metastases Physical examination and history; pathologic examination of biopsy specimen to establish a diagnosis of cancer, endoscopies M1 Distant metastasis and imaging procedures, surgical exploration of primary site. STOMACH Criteria for TNM Pathologic Staging: T1 Lamina propria or submucosa Examination of surgically resected specimen and lymph nodes. T2 Muscularis propria or subserosa T2a – Tumor invades muscularis propria Notes on TNM Staging for Stomach T2b – Tumor invades subserosa T3 Penetrates serosa Tumor that involves the gastrocolic or gastrohepatic ligaments or T4 Adjacent structures penetrates into the greater or lesser omentum without perforating the visceral peritoneum covering these structures is N1 1 - 6 nodes coded T2. Any perforation of the visceral peritoneum covering N2 7 - 15 nodes the gastric ligaments or omentum is classified T3. N3 > 15 nodes

Extension of tumor along the stomach wall into the duodenum or M1 Distant metastases esophagus is classified by the greatest depth of invasion at any of these sites, including the stomach.

Adjacent structures of the stomach are the spleen, transverse TREATMENT colon, liver, diaphragm, pancreas, abdominal wall, adrenal gland, kidney, small intestine, and retroperitoneum. Surgery (Stomach)

BRIEF SUMMARIES OF 6th EDITION CATEGORIES Surgery is the treatment of choice for stomach cancer, as long as adequate margins (5-6 cm) around the tumor can be obtained ESOPHAGUS and regional lymph nodes are removed. Total gastrectomy does not improve survival, compared to subtotal or partial T1 Lamina propria or submucosa gastrectomy. T2 Muscularis propria T3 Adventitia T4 Adjacent structures (Continued on page 8) JULY/AUGUST 2004 MONTHLY MEMO HAPPY FOURTH OF JULY

Page 8 UGI TRACT CANCER (Cont’d)

(Continued from page 7)

Key: X = complete * = partial o = optional • = see note under procedure ------Tissue Removed ------Types of Surgery Stomach Stomach Lymph Other Lesion (Upper) (Lower) Nodes Organs#

Local surgical excision Includes excision of ulcer, other lesions or stomach X tissue with evidence of tumor Polypectomy X Partial/subtotal/hemigastrectomy --upper (proximal) portion * X • Includes sleeve resection of stomach may include part of esophagus Antrectomy X X Partial/subtotal/hemigastrectomy --lower (distal) portion. X X • Includes sleeve resection of stomach may include part of duodenum Gastropylorectomy X X Billroth I X X • includes part of duodenum Billroth II X X • includes duodenum Partial/subtotal/hemigastrectomy, not otherwise specified */° */° ° ° Includes sleeve resection of stomach, resection of portion of stomach, NOS

Total/near total gastrectomy (more than 80%) Includes resection with pouch left for anastomosis, total X X X ° gastrectomy following previous partial resection for other reason Hofmeister-Finsterer operation X X X Gastrectomy, not otherwise specified */X */X X °

Gastrectomy (partial/total/radical) with partial/total */X */X X * removal of other organs

Surgery of regional/distant sites/nodes only */X */X

# May include spleen, momentum, mesentery, or mesocolon

(Continued on page 9) JULY/AUGUST 2004 MONTHLY MEMO HAPPY FOURTH OF JULY

Page 9 UGI TRACT CANCER (Cont’d)

(Continued from page 8) Other Therapies Surgery (Esophagus & Small Intestine) RADIATION THERAPY Operative treatment of esophageal cancer carries up to a 40% mortality rate and 10% five year survival. Surgery is most effective for Radiation therapy is most effective for carcinomas of esophageal cancers in the distal half. Maintaining nutrition is extremely the upper third of the esophagus (cervical portion) and important; however, esophageal feeding tubes, colonic interpositioning, for Stage III and IV cancers. Radiation is also used to and feeding gastrostomies are each accompanied by high morbidity. maintain patency of the lumen and to treat metastases. More recently, there has been research on the benefits Laser surgery can help to maintain an open passageway for nutrition. of radiation combined with 5-FU and Mitomycin C chemotherapy for local control of dysphagia. For carcinoid tumors less than 1 cm in diameter, local resection is the Adenocarcinomas of the esophagus are not as treatment of choice. If the tumor is larger than 1 cm, the resection should radiosensitive as squamous cell carcinomas. include regional lymph nodes from the mesentery. Gastric cancer does not respond readily to radiation Key: X = complete * = partial therapy for cure, although it can be used for palliative o = optional treatment, metastases to bone or brain, or to deter TYPES OF SURGERY = see note under procedure gastric hemorrhage.

SYSTEMIC THERAPY ------Tissue Removed ------DRUGS COMMONLY USED FOR TREATING UPPER Tumor Tumor Lymph Other GASTROINTESTINAL CANCERS Organ destruction only Nodes Organs Chemotherapy for esophageal cancer Cryosurgery * Combinations using CisPlatinum (under clinical evaluation) Cautery, fulguration * Examples (without specimen) Cisplatinum, mitomycin C, bleomycin Cisplatinum plus 5-FU Laser surgery with */X Cisplatinum, vindesine, bleomycin specimen Cisplatinum, methotrexate, bleomycin

Excisional biopsy * Chemotherapy for stomach cancer Polypectomy * Combinations using 5-FU, adriamycin, mitomycin C, Excision of lesion * cisplatin, nitrosoureas (BCNU, CCNU)

Partial/simple surgical X Examples: removal, primary site FAM (5-FU, adriamycin, mitomycin C) no lymph node dissection 5-FU plus methyl CCNU Partial/simple surgical X X 5-FU plus adriamycin removal, primary site EAP (Etoposide, adriamycin, cisplatin) with lymph node FAP (5-FU, adriamycin, cisplatin) dissection FAB (5-FU, adriamycin, carmustine

Debulking procedure X */o o Chemotherapy for cancer of small intestine (so stated) with or without lymph node Streptozotocin plus 5-FU dissection Adriamycin plus 5-FU

Radical surgery, primary X X o Hormones (not shown to be effective for esophagus, site stomach or small bowel cancers) Surgery of regional/ o distant sites/nodes only Biological Response Modifiers (under clinical evaluation) Alpha interferon has been tried for metastatic carcinoid tumor, but the toxicity is significant. (Continued on page 10) JULY/AUGUST 2004 MONTHLY MEMO HAPPY FOURTH OF JULY

Page 10 UGI TRACT CANCER (Cont’d)

(Continued from page 9) Use TX if the primary tumor was excised at another facility and no information about tumor size is available. Keys to Abstracting Do not add together the sizes of pieces of tumor removed at The stomach (all sections) is considered a single organ. The biopsy and at resection. Use the largest size of tumor, even if esophagus (entire length) is considered a single organ. The this is from the biopsy specimen. If no size is stated, record as small intestine is considered three organs: duodenum, jejunum, 999 in the field "Size of Tumor." ileum. For esophageal cancer, disregard extension within the wall Gastric ulcers in patients with achlorhydria are malignant until (intraluminal) to adjacent segments of esophagus and code the proven otherwise. maximum depth of invasion through the esophageal wall or extra-esophageal spread wherever it occurs. Debulking is surgical removal of as much macroscopic tumor as possible in the abdomen. The principle behind debulking is to For stomach cancer, disregard extension within the wall reduce the size of the largest residual tumor to less than 2.0 cm (intraluminal) to esophagus or duodenum and code the in greatest dimension so that the patient's total tumor mass is maximum depth of invasion through the stomach wall or extra- minimal. The effectiveness of postoperative adjuvant radiation gastric spread wherever it occurs. and chemotherapy is increased when the tumor burden is smallest. Also called: tumor reduction surgery, cytoreductive For small bowel cancer, disregard extension within the wall surgery. (intraluminal) to adjacent segments of small intestine and code the maximum depth of invasion or spread beyond small bowel Record circumferential lesion (entire circumference) of the wall wherever it occurs. esophagus as 998 in the field "Size of Tumor." If a partial resection of the stomach is performed for diagnosis Record 998 in "Size of Tumor" field if involvement of stomach and a more complete procedure, such as a Billroth II, is done as is described as 3/4 or more of stomach, diffuse, linitis plastica, cancer-directed surgery, code the more complete surgical or widespread. procedure. The surgical code should indicate the status of the primary organ at the completion of the procedure.

Marie Cranmer, CTR - Sanford Melissa A. Schuster, CTR - Cape Coral Jason D. Strader, CTR - West Palm Beach Daniel P. Vargo, CTR - SW Ranches JULY/AUGUST 2004 MONTHLY MEMO HAPPY FOURTH OF JULY

Page 11 EDUCATION AND TRAINING

PRINCIPLES OF FOR CANCER REGISTRY PROFESSIONALS 2005 CTR EXAM CONTENT http://www.ctrexam.org/ December 6 - 10, 2004 Bolger Center for Leadership Development Potomac, Maryland The content of the 2005 CTR Examinations will be Registration fee: $695.00* drawn in part from the publications of several na- tional standard-setting organizations, including: *The registration fee is reduced for participants who stay at the conference center. • International Classification of Diseases for Principles of Oncology is an intensive five-day training pro- Oncology 3rd Edition (ICD-O-3); gram in cancer registry operations and procedures emphasiz- • Facility Oncology Registry Data Standards ing accurate data collection. The training program includes "FORDS: Revised for 2004"; extensive site-specific, hands-on case abstracting and coding • AJCC Cancer Staging Manual 6th Edition; sessions using both full medical records and abstracts that are representative of the many situations registrars may face. This • CoC Cancer Program Standards 2004 program is endorsed by the National Cancer Registrars Asso- • Collaborative Staging Manual and Coding ciation (NCRA) and the North American Association of Central Instructions, version 1.0. Cancer Registries (NAACCR). NAACCR also serves as the fiscal agent for this program. The Collaborative Staging (CS) will test on the fol- lowing data fields and sites. Class size will be limited to 25 registrants.

CS DATA FIELDS: 1. CS Extension CANCER REGISTRATION & SURVEILLANCE 2. CS Lymph nodes TRAINING PROGRAMS 3. CS Metastasis at Diagnosis

The Fullmer Institute is pleased to announce: Specific CS FIELD SITES: • Principles and Practice of Cancer Registration 1. Breast and Surveillance 2. Lung - November 1-5, 2004 3. Colon Rectal (and more dates in 2005!) 4. Bladder • Advanced Topics in Cancer Registration and 5. Kidney Surveillance 6. Melanoma October 18-20, 2004 7. Ovary May 4-6, 2005 8. Corpus Uteri (Endometrium) August 10-12, 2005 9. Pancreas 10. Thyroid For further information and registration go to: http://www.fullmerinstitute.org Please note that Summary Stage 2000 is no longer tested. Plus, the exam content excludes any clarifica- tions posted in the SEER SINQ and Commission on Cancer's Inquiry and Response system.

The 2005 Handbook for Candidates will be posted here in late 2004. JULY/AUGUST 2004 MONTHLY MEMO HAPPY FOURTH OF JULY

FLORIDA CANCER DATA SYSTEM

PROJECT DIRECTOR: Lora Fleming, MD, PhD Path Radiation 2,500,000 15 0 , 0 0 0 ADMINISTRATIVE DIRECTOR: Jill Mackinnon, CTR

2,000,000 12 0 , 0 0 0 EDITORIAL STAFF: Mark Rudolph, M.S. Mayra Alvarez, RHIT, CTR Melissa K. Williams

1, 50 0 , 0 0 0 90,000 CONTRIBUTORS: Betty Fernandez

1,000,000 60,000

500 ,00 0 30,000

0 0 Aug-03 Nov-03 Feb-04 M ay-04 A ug-04 Oct- Dec- Feb- Apr- Jun- Aug- 200 200 200 200 200 200

66046E

P. O. BOX 016960 (D4-11) MIAMI, FL 33101