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SEER Inquiry System - Report
Produced: 11/24/2024 6:00 AM
Question 20190071
Inquiry Details
References:
2018 SEER Manual. Appendix C, Surgery Codes Rectum
Question:
First course treatment/Surgery of Primary Site--Rectum: Please provide the correct surgery code for a laparoscopic transanal abdominal transanal (TATA) procedure with bilateral salpingo-oophorectomy (BSO) for rectal cancer following neoadjuvant chemotherapy. See Discussion.
Discussion:
IMPRESSION/PLAN: Patient is a previously healthy middle aged woman with a diagnosis of adenocarcinoma of the rectum, clinical stage II (T3N0M0). We will proceed with a neoadjuvant course of radiation and concurrent chemotherapy (5-FU) to maximize local regional control and survival, and hopefully facilitate a sphincter-sparing resection in the future. The primary tumor and the pelvic nodes at risk will receive 4500 cGy delivered over 25 treatments. The primary tumor will subsequently receive an additional 1080 cGy delivered over 5 treatments, for a cumulative dose of 580 cGy.
PATHOLOGY: Adenocarcinoma of the rectum, clinical stage II (T3N0M0). The patient is referred by (dr) for a neoadjuvant course of chemoradiotherapy.
HPI: Patient presented recently with rectal bleeding and a change in bowel habits. Colonoscopy revealed an ulcerated mass located 4.0 cm above the anal verge. A biopsy was positive for invasive well-differentiated adenocarcinoma that arose from a tubular adenoma. A staging work-up demonstrated no evidence of metastatic disease.
Answer:
Code Surgery of Primary Site as 40, Pull through WITH sphincter preservation (colo-anal anastomosis). The TATA procedure is described as transanal abdominal transanal proctosigmoidectomy with coloanal anastomosis.
We are assuming the BSO was not releated to treatment of the rectal cancer. Do not code it. You may document it in a text field.
