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LAB TESTS AND TUMOR MARKERSfPart I Section 2: Site‐Specific Notes

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Lab Test and Tumor Markers in SSFObj iObjective

• To review and understand:To review and understand:• Where and what to look for lab test resultsWh d SI • What does SI mean

• Prefixes and abbreviation• Common Codes in Site‐Specific Factors• Tumor Markers to site or histology specific Tumor Markers to site or histology specific schemas

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R di l b d T M kRecording lab test and Tumor Markers• Guide to registrars how to code lab test Guide to registrars how to code lab test results– Lab test should be coded in the CS SSFs– Tumor markers and laboratory test may vary according to the lab and/or manufacturer

– When ever possible code the clinician’s or pathologist’s interpretations of the lab testI th b f d t ’ i t t ti f – In the absence of a doctor’s interpretation of the test, if the reference range is available use this information to assign the codeg

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R di l b d T M kRecording lab test and Tumor Markers• Only when there is no clinician/pathologist Only when there is no clinician/pathologist interpretation of the lab test and no description of the reference range in the description of the reference range in the medical record should the registrar use background information listed in the tumor background information listed in the tumor marker notes to code the SSF

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R di l b d T M kRecording lab test and Tumor Markers• Refer to the CS Manual for allowable codesRefer to the CS Manual for allowable codes

R f h CS M l f ddi i l di • Refer to the CS Manual for additional coding choices when the test results are not in the M di l R dMedical Record

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Lab Tests & Tumor MarkersLab Tests & Tumor Markers

• What does SI mean?What does SI mean?– French abbreviation for International System for standard units of measure for standard units of measure

– Most SI values are based on kilogram, liter, or standard unit of time (seconds)standard unit of time (seconds)

– A nanogram (ng) is one‐thousandth of a microgram (μg)g (μg)

– A milliliter (ml) is one‐thousandth of a liter

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Lab Tests & Tumor MarkersLab Tests & Tumor Markers

• What does SI mean?– Lab value expressed in μg/L is equivalent to the same value expressed in ng/mlSome lab values such as hormone levels are recorded – Some lab values, such as hormone levels, are recorded in International Units per Liter (IU/L) This is equivalent to mIU/mLh l f d h– The equivalence of mIU to ng varies according to what

is measured• SI Conversion: 1 μg/L = 1 ng/ml. For example, 1 ng of SI Conversion: 1 μg/L 1 ng/ml. For example, 1 ng of

AFP is approximately equal to 1 mIU• Micrograms (μg) per liter may be shown as ug/L

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http://www.nwscc.cc.al.us/nsfdc/tgh/Measurement/NSF%20Measurement_files/image021.jpg

Lab Tests & Tumor MarkersLab Tests & Tumor Markers• Prefixes and abbreviations

– Units of Measure –described and written in various ways in the medical record

– Unit of Measure – dependent on the printer used to report

– Prefix “micron” (one millionth of a unit) –scientific notation by the Greek Letter scientific notation by the Greek Letter mu(μ)

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Abbreviations for units of measurement

Number Prefix WrittenNumber Prefix Written1,000,000 Mega‐ M1000 Kilo‐ k10 Deka‐ da1 (baseline)1/10 Deci‐ d/1/100 Centi‐ c1/1000 Milli‐ mOne millionth Micro m u or mcOne millionth Micro‐ m, u, or mcOne billionth Nano‐ nOne trillionth Pico‐ pOne quadrillionth Femto f

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Abbreviations for units of measurement

Unit Abbrev E lUnit AbbrevGram: grLiter : L l

ExamplesFemtomole : fmol

Liter : L, lUnit : UMeter: M

Microgram: ugrmcgMeter: M

milli‐Equivalent mEqUnit of substance: Mole

gμgr

Millilit L lUnit‐of‐ substance: Mole, mol

Milliliter : mL, ml

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Common Codes in SSFCommon Codes in SSF

Numeric Site‐Specific factor : pCode 000 CEA, Chromogranin, CA‐125,

means a zero value on the test itselfCode 979 (depending on the test) = 97.9Code 980 Means that the true value was higher

(Code 988 Test was not performed (Remember Do not assume test was done

Code 997 Ordered but no report in the MRCode 997 Ordered but no report in the MRCode 999 No information in the MR about the

lab value

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Tumor Markers by Site or histology S ifi S hSpecific Schemas

CA 19‐9 Lab ValueCA 19 9 Lab Value– Appears in Schema: Stomach, Appendix, Ampulla of vater Intraheptatic bile ducts Ampulla of vater, Intraheptatic bile ducts, perihilar bile duct, Distal bile duct, all subsitesof pancreas

• Normal reference range <37 U/mL

• FCDS & CoC Not Required in SSF’s

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CA 19‐9 Lab ValueCA 19 9 Lab Value– Note 1: Carbohydrate Antigen 19‐9 is a tumor marker that has value in the management of marker that has value in the management of certain malignancies.

– Note 2: Record in Units/milliliter the highest Note 2: Record in Units/milliliter the highest CA 19‐9 lab value recorded in the medical record prior to treatment.

• Example: A pretreatment CA 19‐9 of 60 Units/milliliter (U/ml) would be recorded as 600recorded as 600. .

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Lab Value And InterpretationLab Value And Interpretation

CEA (CARCINOEMBRYONIC ANTIGEN)CEA (CARCINOEMBRYONIC ANTIGEN)

Used in schemas: Stomach; Small intestine; Appendix carcinoma;

Normal reference range• Nonsmoker: < 2.5 ng/ml (SI: <

/L) intestine; Appendix carcinoma; Colon; Rectum; Ampulla of Vater; Perihilar bile ducts; Distal bile ducts; Ampulla of Vater

2.5 μg/L) • SI Conversion: 1 μg/L = 1

ng/ml.

Source documents: clinical labreport, sometimes pathology orcytology report; H&P operative

• Smoker: < 5 ng/ml (SI: < 5 μg/L) 1 μg/mL = 1 mg/L

cytology report; H&P, operative report; consultant report;Discharge summary

Ex: Colon/Rectal/Appendix SSF 1 FCDS NOT required CoC “required” CoC required

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CEA (CARCINOEMBRYONIC ANTIGEN)CEA (CARCINOEMBRYONIC ANTIGEN)

• Record both the reported

• CEA Interpretation• Code the corresponding interpretation of

the CEA lab value as stated by the clinician. Use code 000 if

value and the clinician’s interpretation of the highest value prior to treatment.

clinician. Use code 000 ifthere is a statement in the record that If there is no statement that the CEA is positive/elevated,negative/normal or the like, code the interpretation as 999• Code in nanograms per

milliliter (ng/ml) the highest preoperative CEA lab value d t d If lti l

interpretation as 999.• 010 Positive/elevated• 020 Negative/normal• 030 Borderline; undetermined whether

positive or negativedocumented. If multiple CEA tests were performed prior to treatment, record the highest value

• Notes: CEA is not a screening test and is not specific to colorectal cancer. Unlikely to be benign if > 10 ng/ml. Distant metastasis most likely if the highest value. ng/ml. Distant metastasis most likely if >100 ng/ml.

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Lab Value And InterpretationLab Value And InterpretationCHROMOGRANIN A (CGA) SSF 3 digit field implied decimal pointSSF 3 digit field implied decimal pointProtein released by neuroendocrine cells

Appears in Schemas: Pancreas Record the higest CgA value Appears in Schemas: Pancreas (endocrine, all subsites); Neuroendocrine tumors – Stomach; Small intestine; Appendix; Colon; Rectum; Ampulla of Vater

Record the higest CgA value prior to treatment

Normal reference rangeRectum; Ampulla of Vater

Source documents: pathology report (immunohistochemistry stain) or clinical lab report (blood serum)

f g• Path report: Positive/negative• Lab: 6.0 – 40.0 ng/mL Results

vary by laboratory

Other names: Serum chromogranin A, CGA, chromograninChromagranin A is positive moreft f WD NET (C i id) th PD

Ex: NET Ampulla SSF 5 FCDS NOT required CoC “required” often for WD NET (Carcinoid) than PD CoC required

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HPV (HUMAN PAPILLOMA VIRUS) STATUSHPV (HUMAN PAPILLOMA VIRUS) STATUS

• Appears in Schemas: All head and neck sites

• FCDS & CoC Not Required in SSF’shead and neck sites

(carcinoma and melanoma) except major salivary glands and “Other Ph ” A P i

q

• Other names: human papillomavirus, HPV, HPV Pharynx”; Anus; Penis

• Source documents: th l t

papillomavirus, HPV, HPV DNA test, human papillomavirus in situ hybridization, HPV hybrid

pathology report (immunohistochemicalstaining), molecular analysis

y ycapture test; high risk types: hr‐HPV, HRHPV

y

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LDH LDH VALUE LDH UPPER LIMIT OF NORMALLDH, LDH VALUE, LDH UPPER LIMIT OF NORMAL

• Appears in Schemas: Melanoma Skin, Testis, L h O l Ad

• Normal reference range varies widely by laboratory,

ti t d th it f Lymphoma Ocular Adnexa

• Source documents: clinical laboratory report; may be

patient age, and the units of measurement

• Examples of reference range lab llaboratory report; may be

included in a liver or hepatic panel/profile, a

• cardiac panel, or a general metabolic panel of tests

values:• Lab A Total LDH 71 – 207 U/L• Lab B Total LDH 300 – 600 U/L

metabolic panel of tests

• Other names: LD, Lactate dehydrogenase, lactase d h d l d

• Lab C Total LDH 45 – 90 U/L• Lab D Total LDH 150 – 250 U/L

y gdehydrogenase, lactic acid dehydrogenase

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Lab Value And InterpretationLab Value And InterpretationLDH (MelanomaSkin)& Preorchiectomy LDH Interpretation (Testis)

l Sk Melanoma Skin Testis Description000 998 Test not done; test not ordered and

not performed002 000 Within normal limits002 000 Within normal limits004 010 Range 1: less than 1.5 times the upper

limit of normal for that lab; for melanoma only: stated as elevated, NOS

R i h li i 005 020 Range 2: 1.5 to 10 times the upper limit of normal for that lab

006 030 Range 3: more than 10 times the upper limit of normal for that lab

008 997 Test ordered, but results not in chart

See schema for additional code choicesMelanoma skin SSF 4 Required by FCDS & CoCTestis SSF 10 Preorchiectomy LDH Interpretation Required by FCDS & CoC

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LDH (Melanoma Skin) SSF4LDH (Melanoma Skin) SSF4For melanoma, an abnormal value (SSF4 codes 004 006) MUST be documented by at least two 004‐006) MUST be documented by at least two separate tests obtained more than 24 hours

t di t th AJCC C St i apart, according to the AJCC Cancer Staging Manual

Note: LDH may not be done for early stage melanomas. If so, code as 000

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MITOTIC COUNT Appears in Schemas: FCDS & C C R i d

Source documents: FCDS & CoC RequiredGIST Appendix GIST Colon GIST Esophagus GIST P i

pathology report

Other names: Mitotic rate, GIST PeritoneumGIST RectumGIST Small IntestineGIST Stomach M l Ski

mitotic index (a ratio—do not record thismeasurement),

Melanoma Skin mitotic activity

CoC Required FCDS & CoC NOT RequiredNET Ampulla CoC Requ ed

Melanoma ChoroidMelanoma Ciliary Body Melanoma Iris

NET Colon NET Small Intestine NET Stomach NET Rectum Melanoma IrisNET RectumPancreas Head, Pancreas Body Tail, Pancreas Other

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Record the number of cells actively • NET (ampulla, colon, rectum, small intestine stomach): count per 10 dividing as determined by the

Pathologist

The Count will vary according o

intestine, stomach): count per 10 high power fields (HPF*) or2 square millimeters

GIST ( di l h The Count will vary according o the type of tumor

Follow the Instructions in the SSF

• GIST (appendix, colon, esophagus, peritoneum, rectum, small intestine, stomach): count per 50

• HPF* or 5 square millimetersnotes

• Melanoma of skin: count per square millimeter

• Ocular melanoma (choroids, ciliarybody, iris): count per 40 HPF* or 4 square millimeters

• * The usual high power is 40x fmagnification

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• This site‐specific factor is a three digit field This site specific factor is a three digit field with an implied decimal point between the second and third digitssecond and third digits

• For example: Mitotic count is reported as8 i HPF f GIST C l .8 mitoses per 50 HPF for a GIST Colon tumor, record as 008 Mitotic rate is reported as 11 mitoses per 50 HPF for a GIST Colon, record as 110

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ReferenceReference

• Collaborative Stage Data Collection System Collaborative Stage Data Collection System Coding Manual and InstructionsPart I Section 2: Site Specific NotesPart I Section 2: Site‐Specific NotesVERSION 02.00.00INCORPORATING UPDATESTHROUGH JANUARY 1, 2010

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