Classification of human tumors

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Modern medicine has managed to ensure that malignant tumors in humans are survived for five years in 50–58% of cases and 10 years in 38–47%, while the disease "cancer" used to mean a death sentence. Nevertheless, around a third of all people continue to die from a tumor. Advances in tumor treatment rely heavily on the enforcement of guidelines that summarize current knowledge of specific tumors. However, treatment according to guidelines requires an exact classification of the tumor.

The most important classification is the ICD-10 , which is essentially an anatomical division into tumors in different parts of the body. The next most important classification is microscopic precision, histology . This is defined in the ICD-H . Furthermore, the extent of the tumor must be determined prior to therapy, which is expressed according to the TNM scheme. In addition, there are criteria for each tumor entity to determine the degree of malignancy. In the simplest case, this is grading , i.e. the histological impression of malignancy. For some tumors there are special genetic changes that determine malignancy. For breast cancerthis is for example the amplification of Her-2 . There are also special tumor properties that enable the use of certain drugs, so-called target therapies. An example would be the EML4-ALK rearrangement in non-small-cell lung cancer . Not every therapy can be used for every person because the resistance to side effects is different. Since more than half of tumor patients are older, classifications of individual fitness, a so-called age assessment, are required. Sometimes it is only individual organ systems that no longer function well, for example the liver , lungs or kidneys . Here, too, there are classifications that can be found in the guidelines in order to decide whether an effective tumor therapy is likely to be tolerated by the patient.

Classification of human tumors according to the ICD (International Classification of Diseases)

The ICD is an internationally binding, systematic classification of all human diseases. Today the version ICD-10 applies, whereby the ICD-11 is about to be introduced (planned for January 1, 2022). The codes derived from this can be found, for example, on hospital admissions, prescriptions and doctor's letters. These codes are the basis of national and international tumor statistics. They are necessary parameters for calculating the DRG , the hospital billing systems of many countries, including Germany (G-DRG) , Switzerland ( SwissDRG ) and Austria (LKF system) .
In the ICD-10, tumors are mostly classified according to their location. Exceptions are the neoplasms of the lymphatic, hematopoietic and related tissue. The ending .9 denotes an imprecise localization; the exact location can be found within the two-digit group in the systematic directory of the ICD-10-WHO (2019).
The rough classification of neoplasms is as follows:

  • C00-C14: ENT tumors
  • C15-C26: gastrointestinal tumors
  • C30-C39: tumors of the respiratory organs and intrathoracic organs
  • C40-C41: bone tumors , cartilage tumors
  • C43-C44: skin tumors
  • C45-C49: connective tissue tumors
  • C50: breast tumors
  • C51-C58: tumors of the female genital organs
  • C60-C63: tumors of the male genital organs
  • C64-C68: tumors of the urinary organs
  • C69-C72: Tumors of the eye and CNS
  • C73-C75: tumors of the endocrine organs
  • C76-C80: CUP , lymph node and organ metastases
  • C81-C96: Malignant changes in lymphatic and blood-forming tissues
  • C97: tumors in multiple locations
  • D00-D09: In-situ neoplasms
  • D10-D36: Benign neoplasms
  • D37-D48: neoplasms with uncertain or unknown behavior

Notes: The intrathoracic organs include the lungs, windpipe, pleura, heart and the space between the two lungs (mediastinum). CNS is the central nervous system, i.e. the brain, spinal cord, meninges and spinal cord membranes. CUP stands for "Cancer of Unknown Primary", ie tumors whose place of origin is unknown. In situ means new formation without invasion, i.e. H. a still harmless preliminary stage of possibly metastatic tumors.

ENT tumors

Neoplasms of the lip, oral cavity and pharynx ( ENT tumors ) malignant
primary
malignant
secondary
in situ benign Character unsure
or unknown
lip C00.9 C79.8 D00.0 D10.0 D37.0
Tongue base C01 C79.8 D00.0 D10.1 D37.0
Other and unspecified parts of the tongue C02.9 C79.8 D00.0 D10.1 D37.0
Gums C03.9 C79.8 D00.0 D10.3 D37.0
Floor of the mouth C04.9 C79.8 D00.0 D10.2 D37.0
palate C05.9 C79.8 D00.0 D10.3 D37.0
other and unspecified parts of the mouth C06.9 C79.8 D00.0 D10.3 D37.0
Parotid gland C07 C79.8 D00.0 D11.0 D37.0
other and unspecified large salivary glands C08.9 C79.8 D00.0 D11.9 D37.0
Tonsil C09 C79.8 D00.0 D10.- D37.0
Oropharynx ( mesopharynx tumors ) C10.9 C79.8 D00.0 D10.5 D37.0
Nasopharynx ( epipharyngeal tumors ) C11.9 C79.8 D00.0 D10.6 D37.0
Recessus piriformis C12 C79.7 D00.0 D10.7 D37.0
Hypopharynx C13.9 C79.8 D00.0 D10.7 D37.0
other and inaccurately designated locations of the lip, oral cavity and pharynx C14.9 C79.8 D00.0 D10.9 D37.0

Notes:
The throat is called the pharynx. It is divided into 3 levels: epipharynx or nasopharynx, mesopharynx or oropharynx and hypopharynx. The piriform recess is a protrusion between the larynx and throat, in which tumors very often develop.

Digestive organ tumors

Neoplasms of the digestive organs malignant
primary
malignant
secondary
in situ benign Character unsure
or unknown
Esophagus (gullet) C15.9 C78.8 D00.1 D13.0 D37.7
stomach C16.9 C78.8 D00.2 D13.1 D37.1
Small intestine C17.9 C78.4 D01.4 D13.- D37.2
Large intestine C18.9 C78.5 D01.0 D12.- D37.3 / 4
Rectosigmoid, transition (transition from large intestine to rectum) C19 C78.5 D01.1 D12.7 D37.5
Rectum (rectum) C20 C78.5 D01.2 D12.8 D37.5
Anus and anal canal (anus) C21.- C78.5 D01.3 D12.9 D37.7
Liver and intrahepatic bile ducts C22.9 C78.7 D01.5 D13.4 D37.6
Gallbladder C23 C78.8 D01.5 D13.5 D37.6
other and unspecified parts of the biliary tract C24.9 C78.8 D01.5 D13.5 D37.6
Pancreas (pancreas) C25.9 C78.8 D01.7 D13.6 / 7 D37.7
other and imprecisely designated digestive organs C26.9 C78.8 D01.9 D13.9 D37.9

Tumors of the respiratory system

Neoplasms of the respiratory organs and other intrathoracic organs malignant
primary
malignant
secondary
in situ benign Character unsure
or unknown
Nasal cavity and middle ear C30.0 / 1 C78.3 D02.3 D14.0 D38.5
Sinuses C31.9 C78.3 D02.3 D14.0 D38.5
Larynx (larynx) C32.9 C78.3 D02.0 D14.1 D38.0
Trachea (windpipe) C33 C78.3 D02.1 D14.2 D38.1
Bronchi and lungs C34.9 C78.0 D02.2 D14.3 D38.1
Thymus C37 C79.8 D09.3 D15.0 D38.4
Heart, mediastinum and pleura C38.9 C79.8 / C78.1 / 2 - D15.- D48.7 / D38.3 / 2
other and inaccurately designated locations of the respiratory system and other intrathoracic organs C39.9 C78.3 D02.4 D14.4 D38.6

Notes:
The thymus is an immunological organ in the anterior chest in which immune cells mature. The mediastinum is the space between both lungs. The pleura is a layer of cells that lines the lungs and the inner surface of the chest.

Tumors of the female genital organs

Neoplasms of the female genital organs malignant
primary
malignant
secondary
in situ benign Character unsure
or unknown
Vulva (labia) C51.9 C79.8 D07.1 D28.0 D39.7
Vagina (sheath) C52 C79.8 D07.2 D28.1 D39.7
Cervix uteri ( cervix ) C53.9 C79.8 D06.- D26.0 D39.0
Corpus uteri (uterine body) C54.9 C79.8 D07.0 / 3 D26.1 D39.0
Uterus, part unspecified (uterus) C55 C79.8 D07.3 D26.9 D39.0
Ovary (ovary) C56 C79.6 D07.3 D27 D39.1
other and unspecified female genital organs C57.9 C79.8 D07.3 D28.7 / 9 D39.7 / 9
Placenta (placenta) C58 C79.8 D07.3 D26.7 D39.2

Tumors of the male genital organs

Neoplasms of the male genital organs malignant
primary
malignant
secondary
in situ benign Character unsure
or unknown
penis C60.9 C79.8 D07.4 D29.0 D40.7
Prostate (prostate gland) C61 C79.8 D07.5 D29.1 D40.0
Testicles C62.9 C79.8 D07.6 D29.2 D40.1
other and unspecified male genital organs C63.9 C79.8 D07.6 D29.7 / 9 D40.7 / 9

Urinary organ tumors

Neoplasms of the urinary organs malignant
primary
malignant
secondary
in situ benign Character unsure
or unknown
Kidney , excluding renal pelvis C64 C79.0 D09.1 D30.0 D41.0
Renal pelvis C65 C79.0 D09.1 D30.1 D41.1
Ureter (ureter) C66 C79.1 D09.1 D30.2 D41.2
bladder C67.9 C79.1 D09.0 D30.3 D41.4
other and unspecified urinary organs C68.9 C79.1 D09.1 D30.9 D41.9

Malignant changes in lymphatic and blood-forming tissues

  • C81: Hodgkin lymphoma
  • C82: follicular lymphoma
  • C83: non-follicular lymphoma
  • C84: mature T / NK cell lymphomas
  • C85: Other NHL
  • C86: T / NK cell lymphomas
  • C88: Malignant immunoproliferative diseases
  • C90: multiple myeloma
  • C91: lymphatic leukemia
  • C92: myeloid leukemia
  • C93: monocytic leukemia
  • C94: other leukaemias
  • C95: leukemia of unspecified cell type
  • C96: Other malignant neoplasms of the lymphatic / hematopoietic tissue

Notes: Hodgkin lymphomas are special malignant diseases of the lymph nodes. T / NK cells are special white blood cells. Multiple myelomas are made up of abnormal, antibody-producing cells. Leukemia or blood cancer is when the white blood cells are partially malignant. Lymphatic leukemia arises from white blood cells, which are also found in lymph nodes. Myeloid leukemias arise from white blood cells in the bone marrow.

Classification according to ICD-H (histological tumor type)

While the ICD mainly carries out anatomical divisions, the histological fine structure is classified in the ICD-H. On the one hand, the histological tumor type provides information on the origin of the degenerate tumor cells ( e.g. epithelial cells or connective tissue ), on the other hand, it can express the degree of malignancy (e.g. clear-cell endometrial carcinoma ). The code consists of 4 digits, a slash and another digit. The last digit has the following meaning: / 0: benign, benign / 1 questionable dignity, borderline dignity, semimalignant , potentially malignant / 2: carcinoma in situ , intraepithelial neoplasia, non-invasive tumor / 3: malignant primary tumor, malignant / 6: malignant Metastasis , malignant secondary tumor / 9: Malignant, indeterminate whether primary tumor or metastasis

Important main groups are:

801–804: epithelial neoplasms 805–808: squamous epithelial neoplasms 814–838: adenomas and adenocarcinomas 850–854: ductal , lobular and medullary neoplasms 880: soft tissue neoplasms and sarcomas 819–824 neoplasms of the bone and cartilage tissue

TNM classification

The tumor stage, i.e. the local, regional and systemic spread of a tumor, is determined by the TNM classification. T stands for the local tumor spread, N for regional lymph node involvement and M for distant metastases. The criteria for classification are different for each tumor. Which lymph node groups count as regional lymph node metastases or already as distant metastases is also described in the catalogs. The information provides a large number of possible combinations which make an evaluation more difficult. That is why the Union internationale contre le cancer (UICC) has defined a stage for each tumor type, which is indicated by the Roman numerals I to IV. Regardless of the tumor type, I means an early stage, II means a locally advanced stage, which is usually still operable, III means an advanced, inoperable stage, which can often still be treated with radiation therapy. Stage IV usually means an inoperable, metastatic tumor that can only be treated by drug therapy or purely palliative . The tumor stage can be supplemented with a prefix : c means a clinical stage (for example cT3 cN1 M0). In this case, the tumor size and the lymph node involvement were only determined by external examination or image diagnostics and not confirmed histologically by an operation. P means a postoperative stage with established histology (for example pT2 pN0 M0). R means a relapse, i.e. a recurrence of the tumor after primary therapy. For example, a tumor that has had a relapse two years after initial treatment has stage rpT3 rpN1 M0. The tumor stage can also be supplemented with suffixes . These usually define a fine subdivision of the respective stage.

Molecular biological classification

In recent years a number of properties have been researched that are neither clinically nor microscopically recognizable. These molecular biological properties can influence the behavior of the tumor with and without therapy. In the case of many tumors, molecular biological properties determine whether special therapies are used.

Endocrine classification

For the endocrine classification of breast cancer , estrogen and progesterone receptors are of outstanding importance. The introduction of tamoxifen therapy for estrogen receptor positive breast cancer marked a breakthrough in the treatment of primary and metastatic tumors. The receptor content is determined today on tissue samples by immunohistochemistry and is quantified according to the immunoreactive score (IRS) . Androgen receptors are particularly important for the treatment of prostate cancer .

Targets

The English word target means target or target. It marks a paradigm shift in the treatment of tumors. While classic chemotherapy basically damages all cell systems in the same way, target therapy attacks a special tumor property, such as an oncogene . One example is HER2 / neu , an epithelial growth factor that occurs particularly in breast cancer. Tumors that amplify HER2neu grow particularly quickly and malignantly. The drug trastuzumab can block HER2 / neu and, in combination with chemotherapy, improve the patient's chances of recovery. HER2neu can be detected immunohistochemically. The result is given in -, +, ++ and +++. Only triple positive results are used for the therapy decision.

Immunomodulatory classification

The body's own immune defense plays an important role in destroying individual, newly formed tumor cells and delaying tumor spread. Special immune cells , so-called killer cells , are able to destroy other cells. So that the killer cells do not destroy the body's own, healthy cells, there are markings on the cell surface of healthy cells, a kind of friend-foe recognition, so-called checkpoints . Some tumor cells use these markers to avoid attack by killer cells. New anti-tumor drugs, so-called immune checkpoint inhibitors , block this protection against attack by the tumor cells and enable the body's own defense system to fight the tumor. PD-1 and CTLA-4 are currently used therapeutically . For some lung tumors, therapy with a checkpoint inhibitor is equivalent to or superior to chemotherapy. PD-1 inhibitors are particularly effective if there is a large amount of PD-L1 (binding site for PD-1) on the surface of the tumor cells.

Genetic classification

Tumor cells are characterized by the fact that there are massive changes in the cell nucleus. The change can consist in the mutation of individual genes, in the loss of chromosome segments or in the change in the number of chromosomes. In the case of breast cancer, lung cancer , leukemia and lymphoma , an increasing number of mutations must be investigated in order to be able to make an optimal therapy decision. If, for example, chromosome segments are randomly exchanged, a permanent activation of a tyrosine kinase can trigger a permanent growth and division impulse. EML4-ALK results from the inversion of a section of chromosome 2p. This fuses the EML4 gene with the ALK gene and activates it to the maximum. The ALK inhibitor crizotinib can be used to successfully treat non-small-cell lung carcinomas that have this characteristic.

Another example is the Philadelphia chromosome. It is created by a translocation between chromosomes 9 and 22 , which creates a shortened chromosome 22. In acute lymphoblastic leukemia (AML), the determination of the Philadelphia chromosome is carried out regularly. The faulty chromosome fusion creates a BCR-ABL fusion protein. This is a very active tyrosine kinase, which increases cell proliferation and prolongs cell survival. This increases the number of white, leukemic blood cells with this mutation enormously.

A 21-gene Oncotype DX can be performed to determine malignancy in breast cancer . In this test, 21 tumor genes that have been shown to have an influence on the prognosis are determined and a score is calculated from them. Together with clinical data, the prognosis can be determined more precisely than was previously possible.

Patient factors

General performance

The general condition of a tumor patient has a major impact on life expectancy and the ability to carry out aggressive therapies. The most important classifications are the Karnofsky index and the ECOG classification. The need for care can be qualified with the Barthel index .

Organ failure

If the general condition is poor, it is important to identify which organ system is impaired. The New York Heart Association Functional Classification (NYHA) is most commonly used for heart failure . For liver function, organ failure can be quantified according to CHILD-Pugh . For various laboratory values, there is common information about the severity of the deviation. These are often used in guidelines to decide whether to continue or discontinue therapy.

Age Accessment

A significant percentage of cancer patients are of advanced age. Many therapy studies in the past have excluded older patients from participating. Recent studies have shown that very fit older patients can benefit from a therapy, while older patients with a poor general condition survive less with the same therapy. There are now a number of classifications that can be used to quantify the fitness of older patients. The "G-8 Geriatric Screening Tool" uses seven questions and age to assess frailty. The TGUGT (Timed Get Up and Go Test) determines the time it takes a patient to get up from the chair, walk three meters and sit down again without touching the wall. There has not yet been any general agreement on a standard.

disability

Disabilities can make cancer therapies difficult to perform. There is an internationally recognized classification of disabilities that is unfortunately rarely used in clinical practice: The International Classification of Functioning, Disability and Health (ICF).

Web links

Commons : Tumors  - Collection of pictures, videos and audio files

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