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Patient was diagnosed on biopsy with lentigo maligna melanoma of the nasal dorsum. The only available documentation of the subsequent surgery is a single pathology report with the nasal dorsum “staged excision (debulking specimen)” and four additional “staged excision” specimens of the same site.

Is it safe to assume this is a Mohs surgery? Would it be safe to assume staged excisions of sites other than skin of face, are also Mohs surgery?

Examples:

Bladder TURB:  Invasive high grade urothelial carcinoma with poorly differentiated (40%), lipoid (5%), and sarcomatoid (55%) components.

Bladder tumor base TURB:  Invasive high grade urothelial carcinoma with poorly differentiated (65%) and sarcomatoid (30%) components.

The Urinary Sites Solid Tumor Rules, histology coding rules, say to code the most specific histology or subtype/variant, regardless of whether it is described as majority, minority, or component.  Poorly differentiated (8020) and sarcomatoid (8122) are both urothelial subtypes, but there is no rule to instruct how to code a tumor/tumors with multiple urothelial subtypes.

A common scenario is a patient has a positive CT of the abdomen/pelvis for liver mass only. Biopsy of the liver mass is positive for cholangiocarcinoma. The physician is also calling the liver tumor the primary site with histology of cholangiocarcinoma. There is no evidence of intrahepatic bile duct (C221) or gallbladder (C240) involvement which are sites specific to this histology. The hematology/oncology consult stages this as Stage IIIA, T3N0M0 intrahepatic cholangiocarcinoma.  Can we code cholangiocarcinoma with site code C220 (liver) or should we assume that C221 (intrahepatic bile ducts) would be a better code to reflect this histology?  

March 2022, left shoulder soft tissue mass excision shows a spindle cell tumor with outside consultation diagnosis of malignant neoplasm with neuroectodermal differentiation and TPR-NTRK1 gene rearrangement. Diagnosis comments indicate the findings most closely resemble the spectrum of kinase-rearranged mesenchymal neoplasms, such as lipofibromatosis-like neural tumor. However, the expression of SOX10 and mature melanocytic markers is unusual, and does not exclude melanocytic differentiation.

Should this be classified as a peripheral neuroectodermal tumor (9364) or as an "NTRK-rearranged spindle cell neoplasm (emerging)" (8990) if there is a NTRK gene rearrangement?

The patient was not synchronously diagnosed with multiple tumors, but three separate tumors with three different histologies were diagnosed at different times and no more specific histology was provided for the NSCLC. The timing rules do not apply to this case (the tumors were not greater than 3 years apart and they were not synchronously/simultaneously diagnosed).

While NSCLC is a NOS histology for both adenocarcinoma and squamous cell carcinoma, it is unclear if Rule M8 should apply because NSCLC is not listed in Table 3 (Table 3 is not an exhaustive list). In some situations, Rule M8 would apply if the tumors were different histologies and one of the histologies was not listed in the Table. Does that logic still apply if one of the tumors is NSCLC? If NSCLC is excluded from Rule M8, is Rule M14 the appropriate M Rule for the 2022 NSCLC diagnosis?

This patient had serosal involvement and the pathologist and managing physician staged this as pT4a disease. This extension seems best captured by EOD Primary Tumor code 500. Additionally, the patient had discontinuous metastatic involvement of the peritoneum, and this was staged by the pathologist and managing physician as pM1b (Intraperitoneal metastasis only, including peritoneal mucinous deposits containing tumor cells). Although this peritoneal involvement was present in the right lower quadrant, it was staged as distant metastatic disease and not as part of the primary tumor category. However, currently EOD Primary Tumor code 600 would seem to apply since the peritoneal tumor was in the right lower quadrant. Code 600 is defined as mucinous tumors with peritoneal involvement confined within right lower quadrant. This EOD Primary Tumor code and the physician’s M category assignment do not align; the physician has staged this as distant metastasis (M category, not the T category). Should the peritoneal metastasis (even limited to the right lower quadrant) be included in the EOD Mets field and not in the EOD Primary Tumor field? In other words, should the peritoneal involvement included in EOD Primary Tumor code 600 be reclassified in EOD Mets code 30 (Intraperitoneal metastasis (peritoneal carcinomatosis) WITH or WITHOUT peritoneal mucinous deposits containing tumor cells)?

The final diagnosis for a left thyroid lobectomy was Papillary thyroid microcarcinoma, further stated to be Histologic Type: Papillary carcinoma, follicular variant, encapsulated/well demarcated, non-invasive. The diagnosis comment states there is a small follicular pattern papillary microcarcinoma.

Is the designation of “non-invasive” for this papillary follicular tumor equivalent to a non-reportable diagnosis of Non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP), 8349/1? Or should this be accessioned as either a reportable in situ (non-invasive) papillary follicular thyroid carcinoma or a papillary microcarcinoma per the diagnosis comment?

Example #1: Cervix loop electrocautery excision procedure (LEEP) pathology: Histologic Type: Squamous cell carcinoma, HPV-associated. Histologic Type Comments: High-risk HPV testing on previous Pap test sample reported as positive for high-risk HPV. The prior Pap diagnosis was HSIL only with molecular results positive for high-risk HPV.

Example #2: Cervix endocervical curettage and biopsy with CIN 3, p16 diffusely positive. Subsequent LEEP with superficially invasive squamous carcinoma (no HPV or p16 testing done). This was followed by an additional cone excision that was negative for residual malignancy and p16 testing was also negative.