Report | Question ID | Question | Discussion | Answer | Year |
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20110147 | Multiple primaries/Histology--Heme & Lymphoid Neoplasms: How is the histology coded when no bone marrow examination is performed but the peripheral blood flow cytometry listed several differential diagnoses and the physician states the diagnosis is small lymphocytic lymphoma? See Discussion. | The peripheral blood flow cytometry results state, "findings consistent with a small mature B-cell neoplasm, differential - marginal zone lymphoma, lymphoplasmacytic lymphoma, and atypical CLL." The physician states the diagnosis is "SLL." No bone marrow examination or CT scan was done to assess whether the patient had lymphadenopathy.
Per Rule PH5, if the diagnosis is B-cell CLL/SLL and peripheral blood is involved, the histology is coded to B-CLL/SLL [9823/3]. Should the primary site and histology be coded to bone marrow [C421] and CLL/SLL [9823/3] per Rule PH5 despite the physician's diagnosis of SLL [9670/3]? |
For cases diagnosed 2010 and forward, access the Hematopoietic Database at http://seer.cancer.gov/seertools/hemelymph.
This is a single primary and the primary site and histology is coded as bone marrow [C421] and CLL/SLL [9823/3]. The code 9670/3 [malignant lymphoma, small B lymphocytes, NOS] used for SLL is now obsolete.
Per the Abstractor Notes section in the Heme DB indicates that SLL is, "usually associated with CLL and coded CLL/SLL 9823/3. Small lymphocytic lymphoma (SLL) is almost identical to CLL. A somewhat arbitrary distinction is drawn between them based on the relative degree of marrow and nodal involvement and the numbers of circulating cells."
Per the Definition section in the Heme DB it states that, "CLL by definition involves blood and bone marrow at time of diagnosis." Check the PRIMARY SITE and MODULE RULE sections that indicate the primary site is C421, Rule PH5. Per this rule, code the primary site bone marrow (C421) and code the histology B-cell chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) [9823/3] when the diagnosis is B-cell chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) AND peripheral blood is involved (the bone marrow may also be involved).
This may appear to contradict the physician's diagnosis, but the 2008 WHO no longer codes CLL and SLL as separate neoplasms, rather one neoplasm, CLL/SLL, which reflects the actual neoplastic process. Those patients with SLL usually manifest CLL during the neoplastic process and those patients with CLL usually manifest SLL during the neoplastic process. WHO recommends coding to CLL/SLL rather than coding two primaries when the other neoplasm manifests.
SEER*Educate provides training on how to use the Heme Manual and DB. If you are unsure how to arrive at the answer in this SINQ question, refer to SEER*Educate to practice coding hematopoietic and lymphoid neoplasms. Review the step-by-step instructions provided for each case scenario to learn how to use the application and manual to arrive at the answer provided. https://educate.fhcrc.org/LandingPage.aspx. |
2011 |
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20130125 | Reportability--Heme & Lymphoid Neoplasms: Is self-healing Langerhans cell histiocytosis (LCH) of the skin reportable? | For cases diagnosed 2010 and forward, access the Hematopoietic Database at http://seer.cancer.gov/seertools/hemelymph.
This is a reportable primary. Langerhans cell histiocytosis (LCH) [9751/3] is a reportable neoplasm.
The term "self-healing" means that the neoplasm regressed without treatment. This is a known phenomenon.
SEER*Educate provides training on how to use the Heme Manual and DB. If you are unsure how to arrive at the answer in this SINQ question, refer to SEER*Educate to practice coding hematopoietic and lymphoid neoplasms. Review the step-by-step instructions provided for each case scenario to learn how to use the application and manual to arrive at the answer provided. https://educate.fhcrc.org/LandingPage.aspx. |
2013 | |
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20130140 | Reportability/Ambiguous terminology--Heme & Lymphoid Neoplasms: Is a peripheral blood sample with an immunophenotype that is "characteristic of B-cell chronic lymphocytic leukemia" reportable? | For cases diagnosed 2010 and forward, access the Hematopoietic Database at http://seer.cancer.gov/seertools/hemelymph.
This is a reportable diagnosis of chronic lymphocytic leukemia [9823/3]. The physician is using the terms "characteristic of" in the same manner as he/she would use the terms "diagnostic of."
This case fits with the usual diagnosis of CLL. The peripheral blood is diagnostic for leukemias. There was a specific leukemia noted, B-cell chronic lymphocytic leukemia. CLL (B-cell is the phenotype) is usually diagnosed incidentally by a peripheral smear because it is asymptomatic. However, we recommend looking for further work-up, such as a bone marrow biopsy.
SEER*Educate provides training on how to use the Heme Manual and DB. If you are unsure how to arrive at the answer in this SINQ question, refer to SEER*Educate to practice coding hematopoietic and lymphoid neoplasms. Review the step-by-step instructions provided for each case scenario to learn how to use the application and manual to arrive at the answer provided. https://educate.fhcrc.org/LandingPage.aspx. |
2013 | |
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20130077 | Reportability--Heme & Lymphoid Neoplasm: What is the histology code if a myeloproliferative disorder is reportable should a physician suspect this diagnosis and treats the patient? See Discussion. | Physician suspects patient has a myeloproliferative disorder and treats her with a phlebotomy and Hydrea. Patient receives Hydrea during an inpatient stay, but does not see the Heme/Onc again. The patient is subsequently only seen by a Palliative Medicine physician who also states she has an underlying myeloproliferative disorder. The patient died while an inpatient. | For cases diagnosed 2010 and forward, access the Hematopoietic Database at http://seer.cancer.gov/seertools/hemelymph.
This is a reportable diagnosis and should be accessioned with the histology coded to 9975/3 [myelodysplastic/myeloproliferative neoplasm, unclassifiable].
The term is a reportable ambiguous term per the Hematopoietic Coding Manual (Case Reportability Instructions, Rule 4). Also, the patient was treated for a myeloproliferative disorder, making this a reportable clinical diagnosis per the SEER Manual (Reportability, Pg 4, Exception 1).
Myeloproliferative disorder is synonymous with myeloproliferative disease. Myeloproliferative disease is listed as an alternate name for myelodysplastic/myeloproliferative neoplasm, unclassifiable.
SEER*Educate provides training on how to use the Heme Manual and DB. If you are unsure how to arrive at the answer in this SINQ question, refer to SEER*Educate to practice coding hematopoietic and lymphoid neoplasms. Review the step-by-step instructions provided for each case scenario to learn how to use the application and manual to arrive at the answer provided. https://educate.fhcrc.org/LandingPage.aspx. |
2013 |
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20130081 | Multiple primaries--Heme & Lymphoid Neoplasms: How many primaries are accessioned when a patient is clinically stated to have Stage III follicular lymphoma following a diagnosis suspicious for B-cell lymphoma and is subsequently diagnosed with large B-cell lymphoma? See Discussion. | 01/27/2012 R neck mass FNA: Suspicious for B-cell non-Hodgkin lymphoma. 02/17/2012 Cervical node bx: In situ involvement by follicular-like B-cells of uncertain significance +CD10. Two other cervical biopsies show infarcted, extensively necrotic lymphoid tissue highly suspicious for B-cell lymphoma.
03/20/2012 Bone marrow: Low grade B-cell lymphoproliferative disorder with plasmacytic differential.
04/18/2012 Medical Oncology treats patient for Stage III follicular lymphoma. 10/16/2012 Cervical LN core bx: CD10+ large B-cell lymphoma.
Should Rule M4 (single primary) and Module 6, Rule PH11 apply to this case? |
For cases diagnosed 2010 and forward, access the Hematopoietic Database at http://seer.cancer.gov/seertools/hemelymph.
This case should be accessioned as two primaries: follicular lymphoma [9690/3] diagnosed 02/17/2012 and diffuse large B-cell lymphoma [9680/3] diagnosed 10/16/2012 per Rule M10. This patient was diagnosed with a chronic neoplasm (follicular lymphoma) followed greater than 21 days later by an acute neoplasm (DLBCL).
The follicular lymphoma was initially diagnosed on 02/17/2012. The cervical node biopsies were "highly suspicious for B-cell lymphoma" [9591/3]. While "suspicious" is a reportable ambiguous term used to accession cases, suspicious cytologies are not SEER reportable and, therefore, the diagnosis date cannot be 01/27/2012. The histology of the first primary would be updated to 9690/3 [follicular lymphoma] based on the Medical Oncology note on 04/18/2012 that confirmed the histology was follicular lymphoma and the patient was being treated for such.
The diagnosis of DLBCL was made 8 months later. Rule M4 cannot apply to this case because the follicular lymphoma and DLBCL were not diagnosed simultaneously. Rule M4 only applies when the two non-Hodgkin lymphomas are diagnosed simultaneously AND in the same location.
SEER*Educate provides training on how to use the Heme Manual and DB. If you are unsure how to arrive at the answer in this SINQ question, refer to SEER*Educate to practice coding hematopoietic and lymphoid neoplasms. Review the step-by-step instructions provided for each case scenario to learn how to use the application and manual to arrive at the answer provided. https://educate.fhcrc.org/LandingPage.aspx. |
2013 |
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20110148 | First course treatment/Multiple primaries--Heme & Lymphoid Neoplasms: How many primaries are to be accessioned and how is treatment coded when follicular lymphoma diagnosed in December 2009 is treated with CHOP and a subsequent December 2010 diagnosis of diffuse large B-cell lymphoma is treated with chemotherapy and a bone marrow transplant? See Discussion. | A follicular lymphoma [9690/3] involving multiple lymph nodes was diagnosed on 12/2/2009. The patient had no bone marrow involvement and was treated with CHOP as first course treatment. In October 2010, the patient was put on maintenance Rituxan but disease progression was noted in November 2010. A biopsy of a mesenteric lymph node in December 2010 showed diffuse large B-cell lymphoma [9680/3]. The patient subsequently had chemotherapy and an autologous bone marrow transplant.
According to the Multiple Primaries Calculator in the Heme DB, the DLBCL is a new primary but the physician calls the diagnosis of DLBCL a transformation from the follicular lymphoma diagnosed in December 2009. |
For cases diagnosed 2010 and forward, access the Hematopoietic Database at http://seer.cancer.gov/seertools/hemelymph.
This case should be accessioned as two primaries: follicular lymphoma [9690/3] and diffuse large B-cell lymphoma [9680/3] per Rule M10. Per Rule M10, abstract as multiple primaries when a neoplasm is originally diagnosed as a chronic neoplasm (follicular lymphoma) AND there is a second diagnosis of an acute neoplasm (diffuse large B-cell lymphoma) more than 21 days after the chronic diagnosis.
Record the CHOP as the first course of treatment for the follicular lymphoma because this was the only treatment given for the chronic neoplasm (follicular lymphoma) prior to the transformation to the acute neoplasm (DLBCL). Record the chemotherapy and bone marrow transplant as first course treatment for the DLBCL.
As noted above, follicular lymphoma does transform to DLBCL. This "transformation" is actually a new disease. Follicular lymphoma is a disease in which the lymph nodes have a prominent follicular pattern; DLBCL is a disease with diffuse proliferation of large lymphoid cells. While it is true that follicular lymphoma will transform to DLBCL, this transformation indicates it becomes a different entity.
The DLBCL is coded as a second primary for several reasons: to determine the incidence of follicular lymphomas transforming to DLBCL; survival time can be calculated for the diagnosis of the more aggressive DLBCL; death will be attributed to the DLBCL (for mortality statistics) and not the follicular lymphoma
SEER*Educate provides training on how to use the Heme Manual and DB. If you are unsure how to arrive at the answer in this SINQ question, refer to SEER*Educate to practice coding hematopoietic and lymphoid neoplasms. Review the step-by-step instructions provided for each case scenario to learn how to use the application and manual to arrive at the answer provided. https://educate.fhcrc.org/LandingPage.aspx. |
2011 |
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20110031 | Multiple primaries--Heme & Lymphoid Neoplasms: How many primaries are accessioned if patient initially diagnosed with granulocytic sarcoma on a vocal cord biopsy is subsequently diagnosed with acute myeloid leukemia more than 21 days later? See Discussion. | The patient has a history of refractory anemia with excess blasts diagnosed in 2008. A vocal cord biopsy performed on 6/2/2010 stated, "in view of a previous history of myelodysplastic syndrome this is indicative of transformation to acute leukemia" and consistent with granulocytic sarcoma. A bone marrow biopsy done on 7/19/2010 stated this was compatible with refractory anemia with excess blasts in transformation.
Granulocytic sarcoma is a solid manifestation of AML. When these diagnoses occur more than 21 days apart, are they separate primaries?
According to the WHO definition, this is acute myeloid leukemia complicating myelodysplasia. Which rule applies for this case? |
For cases diagnosed 2010 and forward, access the Hematopoietic Database at http://seer.cancer.gov/seertools/hemelymph.
This case should be accessioned as two primaries. The first is refractory anemia with excess blasts in 2008, and the second is AML June 2, 2010.
As for the disease occurring in 2010, granulocytic sarcoma does not transform into AML. Per the Abstractor Notes section in the Heme DB under the term "granulocytic sarcoma," it indicates that "Myeloid sarcoma (also known as granulocytic sarcoma) may occur de novo; it may precede or coincide with AML, or represent an acute blastic transformation of myelodysplastic syndromes." This means that when granulocytic/myeloid sarcoma is seen with AML, it represents a solid manifestation of the systemically involved AML. In other words, it is all the same disease process (coded to AML) if it occurs simultaneously.
In this case, when the physician gave a provisional diagnosis of "transformation to acute leukemia" it indicated he saw the solid deposits of myeloid cells on the vocal cord. Per Rule M3, AML and myeloid (granulocytic) sarcoma appearing simultaneously are a single primary coded to AML. When the patient has AML, solid myeloid deposits (myeloid sarcoma) may appear. This is a manifestation of the AML rather than a new primary. Rule PH10 states to code the histology to AML.
Under the Transformation section in the Heme DB for refractory anemia with excess blasts (a chronic neoplasm), it indicates this disease process does transform to acute myeloid leukemia, NOS (an acute neoplasm). In this case, the chronic and acute disease processes were diagnosed at different times. Per Rule M10, abstract as multiple primaries when a neoplasm is originally diagnosed in a chronic (less aggressive) phase AND second diagnosis of a blast or acute phase more than 21 days after the chronic diagnosis.
SEER*Educate provides training on how to use the Heme Manual and DB. If you are unsure how to arrive at the answer in this SINQ question, refer to SEER*Educate to practice coding hematopoietic and lymphoid neoplasms. Review the step-by-step instructions provided for each case scenario to learn how to use the application and manual to arrive at the answer provided. https://educate.fhcrc.org/LandingPage.aspx. |
2011 |
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20120076 | Multiple primaries/Histology--Heme & Lymphoid Neoplasms: How many primaries are accessioned and what histology codes are used for a 2005 diagnosis of nodular histiocytic lymphoma followed by a 2012 diagnosis of B-cell chronic lymphocytic leukemia/small lymphocytic lymphoma? See Discussion. | Per the history and physical, patient was diagnosed in 2005 with nodular histiocytic lymphoma and had chemo at that time. Now the patient presents with enlarged right axillary lymph nodes. A lymph node core biopsy confirmed B-cell small lymphocytic lymphoma/chronic lymphocytic leukemia. Flow cytometry was most consistent with B-cell chronic lymphocytic leukemia. | For cases diagnosed 2010 and forward, access the Hematopoietic Database at http://seer.cancer.gov/seertools/hemelymph.
This case should be accessioned as two primaries per Rule M15. Code the histology for the first primary to 9698/3 [nodular histiocytic lymphoma. Per the Alternate Names section in the Heme DB, this histology is synonymous with follicular lymphoma, grade 3. Code the histology for the second primary to 9823/3 [B-cell chronic lymphocytic leukemia/small lymphocytic lymphoma].
Nodular histiocytic lymphoma does not transform into CLL/SLL (Transformations to), nor does CLL/SLL transform to nodular histiocytic lymphoma (Transformations from). Rule M15 indicates we are to use the Heme DB Multiple Primaries Calculator to determine the number of primaries in this case because none of the rules from 1-14 apply. Per the calculator, the CLL/SLL is a new primary.
SEER*Educate provides training on how to use the Heme Manual and DB. If you are unsure how to arrive at the answer in this SINQ question, refer to SEER*Educate to practice coding hematopoietic and lymphoid neoplasms. Review the step-by-step instructions provided for each case scenario to learn how to use the application and manual to arrive at the answer provided. https://educate.fhcrc.org/LandingPage.aspx. |
2012 |
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20120058 | Multiple primaries--Heme & Lymphoid Neoplasms: How many primaries are to be accessioned when the patient is diagnosed with an acute neoplasm (diffuse large B-cell lymphoma) per a pathology report and is subsequently diagnosed clinically with a chronic neoplasm (chronic lymphocytic leukemia/small lymphocytic lymphoma) less than 21 days later? See Discussion. | The patient was diagnosed with an extranodal DLBCL on a biopsy of the stomach. A bone marrow biopsy performed 16 days later showed no DLBCL, but demonstrated an abnormal CD5-positive B-cell population that was subsequently referred to as CLL/SLL by the physician. The peripheral blood was negative and showed only moderate thrombocytopenia.
Does rule M10 apply in this case? Abstract the acute neoplasm as a single primary (DLBCL) as there was only one pathology specimen (stomach biopsy) proving DLBCL and the bone marrow did not definitively identify CLL/SLL. |
For cases diagnosed 2010 and forward, access the Hematopoietic Database at http://seer.cancer.gov/seertools/hemelymph.
This case should be accessioned as two primaries per Rule M11. Code the histology of one primary to 9680/3 [diffuse large B-cell lymphoma], the acute neoplasm. Code the histology for the second primary to 9823/3 [chronic lymphocytic leukemia/small lymphocytic lymphoma], the chronic neoplasm.
Per Rule M11, abstract as multiple primaries when both a chronic and acute neoplasm are diagnosed simultaneously or less than or equal to 21 days apart AND there is documentation of two pathology specimens, one confirming the chronic neoplasm (bone marrow biopsy) and one confirming the acute neoplasm (stomach biopsy).
SEER*Educate provides training on how to use the Heme Manual and DB. If you are unsure how to arrive at the answer in this SINQ question, refer to SEER*Educate to practice coding hematopoietic and lymphoid neoplasms. Review the step-by-step instructions provided for each case scenario to learn how to use the application and manual to arrive at the answer provided. https://educate.fhcrc.org/LandingPage.aspx. |
2012 |
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20110146 | Multiple primaries--Heme & Lymphoid Neoplasms: How many primaries are to be accessioned when a patient was diagnosed in 2003 with malignant lymphoma, mixed cell type, follicular in the inguinal lymph nodes and was recently diagnosed with follicular lymphoma (by a neck lymph node biopsy) involving the neck and mediastinal lymph nodes? | For cases diagnosed 2010 and forward, access the Hematopoietic Database at http://seer.cancer.gov/seertools/hemelymph.
This case should be accessioned as a single primary: malignant lymphoma, mixed cell type, follicular [9691/3] diagnosed in 2003. The following describes how this determination was made.
This case is one in which the terminology for follicular lymphoma has changed over time. In 2003, follicular lymphoma was classified as small cleaved cell, large cell, or mixed cell (both small cleaved and large cell). Those designations are no longer used. This disease process is currently classified as follicular lymphoma NOS, grade 1, grade 2 or grade 3. The change was simply a change in classification/terminology.
Appendix A, Table A3 (Obsolete Terms as Defined in ICD-O-3, Lymphoid Neoplasm Obsolete Terms) should be used to determine the current term when an obsolete term is known/given. Per the Table, "Mixed cell type follicular lymphoma" is currently known as "Follicular lymphoma, grade 2" and the correct histology code is 9691/3. This is the correct histology for the 2003 primary.
Per Rule M15, the histologies must be check in the Multiple Primaries Calculator to determine the number of primaries. Enter [follicular lymphoma, grade 2 (malignant lymphoma, mixed cell type, follicular)] for Histology Code 1 and [follicular lymphoma, NOS] for Histology Code 2. The result is "Same Primary." As a result, accession a single 2003 diagnosed primary with the histology follicular lymphoma, grade 2 [9691/3] when the patient is subsequently diagnosed with follicular lymphoma, NOS.
SEER*Educate provides training on how to use the Heme Manual and DB. If you are unsure how to arrive at the answer in this SINQ question, refer to SEER*Educate to practice coding hematopoietic and lymphoid neoplasms. Review the step-by-step instructions provided for each case scenario to learn how to use the application and manual to arrive at the answer provided. https://educate.fhcrc.org/LandingPage.aspx. |
2011 |