Scope of Regional Lymph Node Surgery/CS Reg LN Pos/Exam: How are these fields coded if the operative report does not mention a separate lymph node procedure at the time of the surgery to the primary site? See Discussion.
LUL lobectomy: 1.7 cm apical tumor, diagnosis: moderately well differentiated subpleural squamous cell carcinoma, with involvement of pleural surface. 3 peribronchial LN neg and 2 AP window LNs neg. Stage T2N0.
1. No lymph node dissection or sampling was stated to be done
2. The lobectomy specimen contained the LNs
This answer was provided in the context of CSv1 coding guidelines. The response may not be used after your registry database has been converted to CSv2.
Code the Scope of Regional LN Surgery, Regional Nodes Positive and Regional Nodes Examined fields using the available information on the case. The lymph nodes can be obtained or biopsied during any procedure within the first course of treatment. A separate lymph node surgery is not required to complete these data items.
Reportability--Hematopoietic, NOS: The Abstracting and Coding Guide for the Hematopoietic Diseases, page 47, states to determine whether the physician is using the term myelodysplasia to describe bone marrow marrow malfunction or a neoplasic syndrome in order to determine reportability. What do we do when there is no information one way or the other?
For cases diagnosed prior to 1/1/2010:Without further information, the term "myelodysplasia" alone is not reportable. If a more definitive diagnosis is made later, the case may become reportable.
For cases diagnosed 1/1/10 and later, refer to the Hematopoietic and Lymphoid Neoplasm Case Reportability and Coding Manual and the Hematopoietic Database (Hematopoietic DB) provided by SEER on its website to research your question. If those resources do not adequately address your issue, submit a new question to SINQ.
Histology--Pancreas: How is a "gastrin and somatostatin producing endocrine neoplasm" coded that has lymph node metastasis?
The best code available for this situation is 8153/3 [Gastrinoma, malignant].
Many pancreatic endocrine tumors produce more than one peptide, such as gastrin and somatostatin in this case. ICD-O-3 does not provide a code for pancreatic endocrine tumors which produce more than one peptide. According to the WHO Classification of Tumours of Endocrine Organs, there is a distinct hormonal syndrome associated with gastrin producing tumors, and not with many of the somatostatin producing tumors. Therefore, our pathologist consultant advises us to code to gastrinoma in this case.
MP/H Rules/Histology--Thyroid: Regarding rule H15, is the mixed code 8340 [Papillary carcinoma, follicular variant] used when there are subtypes of these histologies described, such as a tumor diagnosed with follicular and papillary microcarcinoma or should 8341 [Papillary microcarcinoma] be used?
For cases diagnosed 2007 or later:
For coding purposes, this is a papillary and follicular combination that would be coded to the combination code 8340/3 [Papillary carcinoma, follicular variant].
For thyroid cancer only, the term micropapillary does not refer to a specific histologic type. It means that the papillary portion of the tumor is minimal or occult, usually less than 1 cm. in diameter.
MP/H Rules--Ovary: Rule M7 states bilateral epithelial tumors (8000-8799) are reportable as a single primary. Are bilateral germ cell tumors of the ovary (e.g., dysgerminoma (9060/3)) that occur simultaneously now reported as two primaries?
For cases diagnosed 2007 or later, rule M7 applies to ovarian epithelial tumors with ICD-O-3 histology codes between 8000 and 8799. Rule M7 does not apply to dysgerminoma which is coded to 9060. Go on to the next rule, M8 and abstract as multiple primaries, left and right.
MP/H Rules/Histology--Breast: If the abstractor only has the CAP protocol information from a pathology report and it does not include a "final diagnosis" label, which fields of the protocol are used to determine the histology and whether there is carcinoma in situ present in the specimen?
For cases diagnosed 2007 or later, if the CAP protocol is used in lieu of a final diagnosis, use all of the information in the CAP protocol.
Date of Diagnosis: Can the phrase "suspicious for a primary lung tumor" from a CT be used to code date of diagnosis? See Discussion.
Thorax CT on 4/18/05 states 'enlarged RUL nodular opacity suspicious for a primary lung tumor.' Biopsy confirmation was not done until 8/4/05 because patient declined further work-up until then. Would date of diagnoses be 4/18/05 or 8/4/05?
Code the diagnosis date 08/04/2005 based on the biopsy.
The statement "suspicious for a primary tumor" is not a clinical diagnosis of cancer or malignancy.
Multiple Primaries (Pre-2007)--Breast: How many primaries are to be abstracted when each of multiple breast "re-excisions" performed more than two months apart in 2006 demonstrate intraductal carcinoma and there is no mention of "recurrence"? See Discussion.
Right Breast
06/27/2002 exc bx, DCIS. Margins involved.
09/24/2002 re-exc, several foci of intraductal ca. Margins involved.
10/15/2002 re-exc, microfocus of DCIS
Radiation treatment started 11/18/2002.
Is this 1, possibly 2, or maybe 3 breast primaries because of the 2 month rule and no statement of "recurrence"? Based on SINQ #20000478, this would be at least 2, but possible 3 primaries. Based on SINQ #20021143, this would be 1 primary if the case were diagnosed from 1998-2003. The excisions appear to represent wider excisions of the same tumor.
For cases diagnosed prior to 2013:
For tumors diagnosed prior to 2007, this is one primary, assuming these are wider excisions of the same tumor.
For tumors diagnosed 2007 or later, refer to the MP/H rules. If there are still questions about how this type of tumor should be coded, submit a new question to SINQ and include the difficulties you are encountering in applying the MP/H rules.
MP/H Rules/Histology--Breast: Which report and diagnosis should be used to code the histology if an excisional biopsy that removes the majority of the tumor has a diagnosis of "carcinoma," and the subsequent lumpectomy diagnosis is "microscopic residual disease consistent with infiltrating duct carcinoma"?
For cases diagnosed 2007 or later, code histology for this case to 8010 [carcinoma]. The histology is coded from the pathology report with the most representative specimen (the most tumor tissue) even when the most representative specimen has a less specific histology.
MP/H Rules/Reportability/Diagnostic Confirmation--Colon: Please clarify how to code diagnostic confirmation when there is no mention of a malignant polyp in the pathology report of a familial polyposis case given this statement: "Even if you have only one malignant polyp it is a single primary if there is a diagnosis of FAP. Even if there is no mention of a malignant polyp, if there is a diagnosis of FAP you will use this rule."
For cases diagnosed 2007 or later:
In the very unlikely event of a FAP diagnosis with no malignancy, the case would not be reportable.
When FAP is diagnosed along with a colon malignancy, it is presumed that the malignancy originated in one of the numerous polyps, even if this is not explicitly stated. Use rule M3 for any colon malignancy (in a polyp, frank, or not stated) with a diagnosis of FAP and abstract as a single primary.
An official website of the United States government
Home