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EOD includes all information available within four months of diagnosis in the absence of disease progression or upon completion of surgery(ies) in first course of treatment, whichever is longer. Since the imaging was within the four-month window, and the nodes could have been positive during surgery but not assessed by the surgeon, use the information from the imaging.

Assign code 600 for EOD Regional Nodes for involvement of the aortocaval and retroperitoneal nodes (para-aortic nodes), size unknown.

Report papillary renal neoplasm with reverse polarity as 8260/3. According to the WHO Classification of Urinary and Male Genital Tumors, 5th edition, this is a distinctive pattern of papillary renal cell carcinoma that has been recently recognized. These tumors have recurrent mutations of KRAS, differing from typical papillary renal cell carcinoma. We recommend that you include with reverse polarity in your histology text to differentiate this entity from others classified in 8260/3.

Determining first course treatment is based on knowing the treatment plan and its course as to whether it was completed as initially planned. Read the medical record, scans, labs, and physician notes. First course of therapy ends when the treatment plan is completed as planned.  Alternatively, first course of therapy ends when there is documented disease progression, recurrence, or treatment failure.  A change to a drug in a different group or a change to a different treatment modality indicates the end of the first course of treatment.  While a physician/clinician statement of progression, additional imaging, or other procedures that assess treatment efficacy, or increase in tumor burden can be used to denote progression, recurrence, or failure, a change to the initial treatment plan is a signal to to the registrar to suspect the end of first course of therapy.  Once the initial treatment plan is changed, everything after the change is subsequent treatment.

In the scenario provided, code FOLFIRINOX as first course of treatment.  Based on the information provided, the Abraxane, Gemzar, and SBRT are second course and everything that followed that is second or subsequent course. The physician noted progressive disease and a new treatment regimen was started -- this is a clear indication of the end of the first course of treatment. The planned treatment course was FOLFINOX and surgery. Once that initial treatment plan is changed, everything after the change is no longer first course of treatment. Use text fields to document the details.

Assign C221 (intrahepatic bile duct) as the primary site for cholangiocarcinoma (8160/3).  Our expert GI pathologist confirms that even when intrahepatic bile ducts are not specifically mentioned, intrahepatic cholangiocarcinoma originates in the intrahepatic bile ducts.

Assign code 0 to each of the three Neoadjuvant Therapy data items in this situation.

We will add an example to the coding instructions for these data items in the next release of the manual.

We consulted an expert genitourinary pathologist who advises that micropapillary serous borderline tumor of the testis is reportable. He states "it is the same neoplasm as in the ovary. It arises from tissue (tunica vaginalis) surrounding the testis so is a paratesticular neoplasm." 

 Please note: not all borderline tumors are reportable and this diagnosis is an exception because it is assigned /2 in ICD-O-3.2. It is reportable for cases diagnosed Jan 1, 2021 and later.

Assign code 8071/3 for keratinizing squamous cell carcinoma.  Codes 8085 and 8086 are only valid for the Head and Neck sites listed in Table 5 beginning with cases diagnosed 01/01/2022 and forward.

Report germ cell neoplasia in situ (9064/2). Assign 999 for EOD Primary Tumor and assign 9 for SS2018.

This particular histology is in the Soft Tissue Abdomen and Thoracic schema where EOD PT 000 and SS2018 0 are not available. This histology will be moved to the Ovary schema after redefining certain schemas and thus making the more accurate choices for EOD and SS2018 available. The schema redefine is planned for 2024 implementation.

Code this multifocal thyroid carcinoma, single primary, as papillary thyroid carcinoma, follicular variant (8340/3) using Solid Tumor Rules, Other Sites, Rule H13 that says to code the most specific histologic term. We consulted with our endocrine specialty pathologist and when there is a mix of papillary and follicular variants, assign 8340.

Non-invasive follicular thyroid neoplasm with papillary-like nuclear features is coded as 8349/1 beginning in 2021.  According to the WHO Classification of Endocrine Organs, 4th edition, it was formerly classified as non-invasive encapsulated follicular variant of PTC (FVPTC) (8343/2) but was reclassified based on extremely low malignant potential.

Beginning with cases diagnosed 1/1/2022, the term "configuration" can be used to code histology for urinary sites only. At the request of the AJCC urinary experts, the instructions were changed to allow configuration to be used to code histology.