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Patient has a perihilar bile duct primary with a microscopic focus of invasive moderately differentiated adenocarcinoma arising in a large papilloma. The MP/H Rules do not address adenocarcinomas arising in a papilloma, only adenocarcinomas arising in an adenoma (or polyp). Should the histology be coded as 8140 for the invasive adenocarcinoma component? Or should the matrix principle be applied and the histology coded as a malignant glandular papilloma (8260/3)?

Patient presents with an abnormal chest x-ray. PET reveals 4.6 cm left lower lobe mass and several additional bilateral nodules measuring up to 1.6 cm. Biopsy was recommended and is positive for metastatic histologically benign smooth muscle neoplasm. ER/PR are positive. Mayo consult on biopsy agrees with histology. The differential diagnosis includes benign metastasizing leiomyoma and low grade leiomyosarcoma. Comment: If these nodules remain small and do not progressively grow would consider this metastasizing leiomyoma. Physicians state bilateral pulmonary metastatic leiomyoma (favored) vs low grade leiomyosarcoma. Tamoxifen was started. Patient has a history of uterine fibroids. Several months later, imaging reveals stable bilateral multi pulmonary nodules and left lower lobe mass but persistent. Surgery was recommended but cancelled due to insurance.

The patient underwent a polypectomy. The endoscopy report noted the "single piece polypectomy" only partially removed the polyp/mass as the remainder of the mass was more fixed to the wall. The margins were not noted on the pathology report, but were presumably positive given the endoscopy report and the subsequent low anterior resection (LAR) that proved macroscopic residual tumor. Should the date of the polypectomy be recorded in Date of First Surgical Procedure field? Or would the date of the subsequent LAR be recorded since macroscopic residual tumor was present following polypectomy?

8/1/15 CT Exam showed enlarged prostate and left seminal vesicle with multiple enlarged pelvic LNs. Findings: suspicious for prostate cancer with invasion of seminal vesicle. Bone scan findings: positive bone mets in multiple sites. PSA 169.0 (elevated). Patient was started on casodex 8/12/15. A prostate biopsy was performed on 9/16/15 to confirm diagnosis, adenocarcinoma Gleason 4+5. Patient's treatment continued with radiation to bone.

We are seeing many I-125 seed implants for breast cancer. Many of my associates are coding them as brachytherapy. I think they are the newest of the localization technique like wire localization but with greater accuracy. Most are done the same day as the surgery so brachytherapy does not make sense. Which is correct?

Does ductal carcinoma with tubular features qualify for Breast MP/H Rule H28? Or, is it more appropriate to strictly follow Table 2 (not a type of ductal tumor) and apply Rule H29, thus losing the lobular component?

The SEER*Rx Database lists Sirolimus as an ancillary agent under the Category section, but as an mTOR inhibitor under the Subcategory. The Remarks section indicates Sirolimus (AKA Rapamycin) is an immunosuppressant, but is also a type of serine/threonine kinase inhibitor. Other types of kinase inhibitors (including Temsirolimus) are types of Chemotherapy. Although the Coding section states this drug should not be coded, Primary Sites (NSCLC and glioblastoma) are listed for this drug.

The SEER*Rx Database page for this drug is confusing. Please address the following.

1) Should Sirolimus not be coded when it is being given as a kinase inhibitor or an immunosuppressant?

2) If Sirolimus is ever treatment, should it be coded only for the primary sites listed?

3) If Sirolimus is given as part of a non-blind clinical trial for another site other than NSCLC or glioblastoma, should the Other Therapy field be coded to 2 [experimental - other treatment]?