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MRA Thought of the Day- Distal Esophagus vs. EGJ

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Elizabeth R. Patena, M.D, Vice President of Cancer Registry on Distal Esophagus | MRA

Elizabeth R. Patena, M.D., CTR Vice President of Cancer Registry

Distal Esophagus vs. EGJ

When do you code the primary site to Distal Esophagus (C15.5) or Esophagogastric Junction (C16.0)?

The arbitrary 10 cm segment encompassing the distal 5 cm of the esophagus and proximal 5 cm of the stomach, with the EGJ in the middle, is an area of contention. Cancers arising in this segment have been variably staged as esophageal or gastric tumors. So how do we know which staging schema to be used?

Esophageal Cancer

Anatomically, the primary site of esophageal cancer is based on the proximal edge of the tumor. ICD-O-3 has compartmentalized esophagus to cervical esophagus (C15.0), thoracic esophagus (C15.1), and abdominal esophagus (C15.2). The thoracic esophagus is further divided into upper third (C15.3), middle third (C15.4), and lower third (C15.5). In a typical esophagectomy, the cervical esophagus is located at 15 to

Anatomic name

Compartment ICD-O-3

ICD-O-3

Name

Typical esophagectomy

Cervical

C15.0

C15.3

Upper (proximal)

15 to <20 cm

Thoracic

C15.1

C15.3

C15.4

C15.5

Upper (proximal)

Middle

Lower (distal)

20 to <25 cm

25 to <30 cm

30 to <40 cm

Abdominal

C15.2

C15.5

C16.0

Lower (distal)

EGJ/cardia

40 to 45 cm

40 t0 45 cm

From the table shown above, the lower distal esophagus and EGJ (cardia) are both at 40-45 cm. This is the area of contention that leaves the registrar at a dilemma when determining which staging schema to use.

Cancers whose epicenter is in the lower thoracic esophagus, EGJ, or within the proximal 5 cm of the stomach that extend into the EGJ or esophagus are stage grouped to the esophagus. All other cancers with an epicenter in the stomach greater than 5 cm distal to the EGJ, or those within 5 cm of the EGJ but not extending into the EGJ or esophagus are stage grouped to the stomach.

This 5 cm boundary measurement is based on the Siewert classification of gastroesophageal cancers, which defines an area 5 cm above and 5 cm below the cardia or esophagogastric junction. To determine whether a cancer in the fundus or body of the stomach should be coded according to the esophagus schema or the stomach schema, it is necessary to identify the midpoint or epicenter of the tumor. If the midpoint is at or above the cardia, the tumor is definitely esophageal. If the midpoint of the tumor is within 5 cm distal to the esophagogastric junction (EGJ) and the lesion extends to or across the EGJ, the case should be coded with the Esophagus-GE Junction schema. If the midpoint of the tumor is within 5 cm distal to the EGJ and the lesion does not extend to the EGJ, the case should be coded with the stomach schema. Any tumor with a midpoint more distal than 5 cm from the GEJ is coded with the stomach schema.

In some cases, the physician’s description of the tumor location does not specify the epicenter or midpoint of the tumor. Information may be obtained from imaging, endoscopy reports, surgery observation, pathology reports, or other statements in the medical record.

CS Site Specific Factor 25, a schema discriminator, has been included in the Collaborative Staging in order to determine which schema should be used for gastric tumors within 5 cm of the EG junction. Select the code that best describes the location and extent of the tumor, and the computer algorithm will bring the correct schema to the screen. If the tumor midpoint is anywhere in the stomach other than cardia, fundus or body, use code 981. If the tumor midpoint is in the cardia itself, use code 982.

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