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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.

There is an ICD-O histology code for papillary carcinoma, columnar cell (8344/3) as well as papillary carcinoma, encapsulated (8343/3). Per Rule H13, the terms “with features of” may be used to identify a subtype.

Considering these two subtypes, and knowing there is no specific histology code for this combination, is the first rule that applies H17 (code the numerically higher histology code)?

There is an ICD-O histology code for papillary carcinoma, tall cell (8344/3) as well as papillary carcinoma, oxyphilic cell (8342/3). Per SINQ 20150045, the term oncocytic is synonymous with oxyphilic in this context.

The term “variant” can be used for the Other Sites (non-updated STR sites) primaries when the ICD-O-3.2 (or ICD-O-3 for older cases) includes the term “variant” in the histology name. The MPH General Instructions did not include the term “variant” as a term that can be used to code histology.

History provided by the oncologist

Right neck mass since 2019; 04/07/20, initial biopsy p16-negative SCC, delay of treatment due to patient preference, agreed to biopsy of tonsil and work-up August 2022; right tonsil biopsy: p16-positive, G2 SCC, nodal mass at that time >6 cm with extensive extranodal extension, Stage III (cT2, cN3, cM0, p16-positive); based on this history, was staged as a tonsil primary and p16-positive.

Patient details

1. March 2020, CT neck and chest revealed a 0.5 x 2.7 x 2.3 cm low-density necrotic nodal mass at right neck level 2 suspicious for metastatic disease.  There was a slight asymmetric increased size of the right palatine tonsil.  There are a few sub-4 mm pulmonary nodules which are nonspecific.

2.  April 7, 2020, FNA of right neck mass with pathology revealed p16-negative SCC   

3.  April 20, 2020, PET/CT revealed 3 x 2 cm right-sided level 2 node with FDG avidity  

4.  May 5, 2020, flexible laryngoscopy showed no obvious primary lesion   

5.  May 2020, after evaluation by a medical oncology, patient declined any treatment  

6.  June 17, 2022, return visit in medical oncology after PET/CT demonstrates significant progression in the neck; patient definitively declines chemo, but would like surgical opinion.  Now has more rapidly progressive disease with skin breakdown and weeping from malignant lesion right neck.  

7.  June 22, 2022, radiation oncology consultation   

8.  July 15, 2022, tonsil biopsy: Invasive squamous cell carcinoma, moderately differentiated with LVI, p16-positive  

9.  Patient now agreeing to treatment with radiation: Tooth extractions 8/30/2022, radiation planning 9/14/2022  

10.  Patient consulted with cancer specialist who explained surgery is not recommended given level of extranodal extension and risk of seventh cranial nerve paralysis and fistula formation with surgical excision and who recommended chemoradiation

11.  September 9, 2022, patient presented for radiation CT simulation/treatment planning and informs treatment team. Patient declined/refuses concurrent chemotherapy despite recommendations from two cancer institutions.

11/16/20: Patient diagnosed with endometrial cancer on by MRI of the pelvis; 11.5 cm uterine mass consistent with cancer with no lymphadenopathy.

1/6/21: Patient had a total abdominal hysterectomy/bilateral salpingo-oophorectomy and pelvic lymph node dissection. Operative report stated patient had mildly enlarged bilateral pelvic nodes.

Path report: Endometrioid adenocarcinoma with invasion of the serosa. Five bilateral pelvic nodes were sampled and negative. Originally, staging had patient as node negative.

1/22/21: Patient had post op imaging done that showed metastatic retroperitoneal, aortocaval, and possibly left iliac lymph nodes. Physician changed staging to include the lymph node involvement.

Patient has a diagnosis of myeloid sarcoma presenting as multiple erythematous papules and nodules on back, chest, right arm & shoulder. Oncologist did not mention any evidence or suspicion of an associated AML diagnosis.

HemeRetic schema EOD Primary Tumor Note 1 states that myeloid sarcoma can be coded as localized (code 100) or systemic (code 700). It is not clear what would qualify as systemic disease for myeloid sarcoma.

Acinar predominant adenocarcinoma measures at least 12 mm and involves wedge biopsy margins, while the lepidic predominant adenocarcinoma measures 11 mm and does not involve the margins of that separate specimen. Pathologist also notes, “CT findings of diffuse coarse reticular nodular opacity, these findings may represent pneumonic type adenocarcinoma/diffuse pulmonary involvement or intrapulmonary metastasis.  Both of these scenarios have the corresponding stages of pT4 (if thought to be ipsilateral) or M1a (if thought to also involve the contralateral lobe).”

Patient declined any further treatment and transitioned to hospice before expiring less than 1 month after wedge biopsies.

It is unclear if Rule M6 would apply to these two specimens with different subtypes since this scenario is not specifically addressed in the M rule definitions.