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The Summary Cancer Data does not seem to describe a more specific histology, but it does describe the tumor histology with the worst outcome and the most extensive tumor. The anaplastic carcinoma grossly extended into skeletal muscle and gave rise to multiple regional lymph node metastases. The more appropriate histology seems to be 8021.

However, current MP/H Rules for a single tumor indicate the histology should be coded to the numerically higher histology code (8260). Coding the histology to 8260 does not account for the more aggressive tumor. Should this histology be 8260 or 8021?

Instruction number 1 under the Coding Multiple Histologies instructions states to code histology when the histology is described as subtype, type or variant. The general rules do indicate we can code the histology identified as type, but when applying the H Rules, it seems an argument could be made for either H1 or H3. H1 applies if you ignore the diagnosis of carcinoma and only code the histologic type: urothelial carcinoma. However, the rules do seem to imply that you take all histologies into account (e.g., code the subtype/variant when there is a not otherwise specified (NOS) and single subtype/variant). Following this logic, Rule H3 seems to be the only rule that fits, and one would code the subtype/variant urothelial carcinoma when the diagnosis is carcinoma NOS, histologic type: urothelial carcinoma.

The problem is that urothelial carcinoma is not a subtype/variant of carcinoma (NOS) per Table 2. The entry for Carcinoma NOS in Table 2 states, Subtypes of carcinoma NOS include adenocarcinoma and all subtypes/variants of adenocarcinoma. To some, urothelial carcinoma is a more specific type of carcinoma; however, urothelial carcinoma is not also listed as a subtype of carcinoma or of adenocarcinoma; only adenocarcinoma is categorized as a subtype of carcinoma. Consistently applying the rules becomes an issue when rules are interpreted in different ways. Should this Table be amended to include urothelial carcinoma as a subtype/variant of carcinoma NOS with the same caveat given to adenocarcinoma in Table 2?

For example, if race is recorded as unknown on the facesheet of a hardcopy medical record or in the race field of an electronic medical record, how should race be coded for the following descriptions found in the history and physical or consultation reports submitted by clinicians?

1) Patient is Czechoslovakian

2) Patient is born in Czechoslovakia

3) Patient is Ethiopian

4) Patient is born in Ethiopia

5) Patient is Japanese

6) Patient is born in Japan

7) Patient is Brazilian

8) Patient is born in Brazil

Would you code these cases any differently if these descriptions were actually used in the race fields in the medical record or on a death certificate?

Case 1 - CT: Mult pulm nodules, bilat pleural effusions; paraaortic, paracaval, celiac lymphadenopathy. Lytic lesions L4&L5.

Bx L3: Met pd adenoca. Based on the histopathologic features and the results of the immunostains, cholangiocarcinoma is regarded as the most likely primary. However, other possible primaries include pancreas, stomach, and (remotely) lung.

Should primary be coded as C26.9, digestive organ, NOS?

Case 2 - CT: Mult liver masses. Liver Bx: Mod diff adenoca. The most likely primary sites include cholangiocarcinoma, stomach and pancreas.

FDx per attending: Met adenocarcinoma to the liver, probably biliary origin.

What primary site code do we use?

Case 3 - Admitting Dx: Unknown primary with mets to lungs, liver and cerebellar area. Liver Bx: Met adenoca. The combination of morphological and immunohistochemical staining favor a colon primary. However other possibilities include cholangiocarcinoma and pancreatic ca.

Should we code site as C18.9 or C26.9?

We have a case of metastatic keratinizing squamous cell ca. The work-up shows small densities in the lung that may represent inflammatory or chronic changes. No other imaging that shows origin. Physical exam states 2 months of left axillary mass. H/O SCCA of the skin involving chest wall.

Path reads: Metastatic w/d keratinizing SCCA. This lesion almost undoubtedly represents mets. The most likely site of origin is lung followed by esophageal primary or head & neck. The final discharge states, "Metastatic SCCA to Left Axilla".

Left mandible resection: Malignant tumor, favor high grade sarcomatoid carcinoma. Please see comment.

Comment: Considering the focal stain with P63 and the consult from Mayo Clinic done on the previous biopsy, the diagnosis of sarcomatoid carcinoma is more likely.

Gross: left mandible resection...sectioning reveals a...mass that has replaced the majority of the mandibular bone and is at the medial, anterior lateral and posterior soft tissue margins and comes to within 2.4 cm of the anterior boney resection margin and 1.9 cm of the smooth articular temporal mandibular joint surface.

The combination of C411 and 8033/3 is impossible (with no override available).

Should it be coded to where the testis was physically at the time of diagnosis (C621), or should it be coded to C620 to reflect the increased risk for developing malignancy in an undescended testis?

A patient had a ruptured esophagus 25 years ago and had a segment of colon removed and transplanted to serve as esophagus. In 2007, the patient was diagnosed with carcinoma in a polyp by endoscopic biopsy of the transplanted 'esophagus'. What is the primary site code? Is this the same site schema to be used for Collaborative staging and surgery coding?