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Patient was found to have two tumors in the esophagus. The large tumor was diagnosed as adenocarcinoma with areas of neuroendocrine differentiation (small cell carcinoma). The smaller tumor was diagnosed as small cell carcinoma. If we accept the "areas of" to be part of the diagnosis, rule H16 indicates that histology for the large tumor would be coded 8045 (combined small cell and adenocarcinoma). If we ignore the "areas of," then histology for the large tumor would be coded to 8140 (adenocarcinoma). Either way, when counting primaries, rule M17 would be applied and the two tumors would be classified as separate primaries. However, it seems that the two tumors are probably the same disease process since they both show small cell carcinoma.

Patient was diagnosed with T1 N0 M0 adenocarcinoma with prominent clear cell features [8310/3] in the LUL on 08/05/2010. The patient underwent a lobectomy only.

On 10/09/2012 the patient underwent an iliac bone biopsy showing non-small cell carcinoma with glandular and squamous features [8560/3]. Clinically, the physician is calling this stage IV adenosquamous carcinoma of lung origin involving lymph nodes, spleen and bones. There were no FDG avid pulmonary nodules found. There was no pathologic comparison to the prior lung tumor.

Should the 2012 diagnosis be a new primary because the histology is different from the 2010 diagnosis? Or should this be one primary because there appears to be only metastatic disease with no new primary lung tumor identified in 2012? The choice of one primary seems supported by the fact that the 2012 tumor showed glandular and squamous features, and the 2010 tumor also showed glandular and clear cell (NOS) features. The clear cell could have been a clear cell squamous cell carcinoma. The original tumor was not re-examined.

Patient was diagnosed with Stage IV colon cancer (liver metstasiss) and started on Folfox with Avastin. The medical oncologist decided to continue maintenance treatment with Xeloda and Avastin.

Per Colon NCCN Guidelines Version 3.2019, interest in the use of maintenance therapy approach after first-line treatment of unresectable, metastatic colorectal cancer is growing. In general, this approach involves intensive first-line therapy, followed by less intensive therapy until progression in patients with good response to initial treatment.

Colon Therapy

5/1/18 Colonoscopy biopsy: mod diff colon adenoca, MMR proficient, BRAF wild type

5/5/18 Liver biopsy: mets from colon cancer

6/18/18 " 11/20/2018 Med Onc: started 12 cycles Chemo - Folfox (Fluorouracil, leucovorin, Oxaliplatin) with Avastin

11/28/18 CT Pelvis: continued improvement in the liver mets; no residual tumor involving colon; no new mas or adenopathy in the chest, abdomen or pelvis

12/02/18 Med Onc follow up: Pt had tremendous response to chemotherapy and Avastin, cancer is not curable. Is amenable to maintenance therapy with Xeloda and Avastin; also amenable to descending colectomy in the future

1/7/19 Med Onc: starting maintenance treatment Xeloda + Avastin.

Patient was diagnosed with smoldering myeloma in October 2021 and put on surveillance. In May 2024, the patient became symptomatic and started chemotherapy.

Is the date of diagnosis in 2021, with date of first treatment with chemotherapy in 2024? Or is active surveillance first course and treatment with chemotherapy as second course in 2024?

Patient was diagnosed with Myeloid Sarcoma (granulocytic sarcoma) by chest wall biopsy. This is an extramedullary manifestation of acute leukemia and is not in the bone marrow (bone marrow is negative).

How should primary site be coded? The Heme DB states that almost any part of the body can be involved. It also states to not code primary site to C421. In this case the only involvement is the chest wall [C493]. However, use of the primary site code C493 triggers an edit error questioning this site/histology combination. If the primary site is coded to C421 [bone marrow], there is no edit error. Please explain the site code and rationale.

Patient was diagnosed with low-grade non-Hodgkin lymphoma in 2011, later classified as hairy cell leukemia-variant.

Right cervical node biopsy in 2020 proved HCL-v and a subsequent 2021 right tongue base biopsy showed DLBCL. The tongue base biopsy path includes the comment, patient has history of HCL-v, but the morphology and flow cytology features are different from the patient's previous right cervical node biopsy. This DLBCL likely represents a second de novo lymphoma, but cannot exclude an unusual transformation of the prior HCL-v.

Per Heme Rule M7, abstract a single primary when a more specific histology is diagnosed after an NOS if the Heme DB confirms the same primary. The histology code for HCL-v, 9591/3 is a non-specific code, but it seems like a specific histology. The Heme Calculator does say 9591 and 9680 are the same primary, but we are unsure if that is correct for this case of HCL-v followed by DLBCL.

Patient was diagnosed with lambda myeloma based on the M spike found on serum protein electrophoresis. A bone marrow biopsy was performed, but it was an insufficient sample.

SPEP is not listed in the Hematopoietic Database as a lab test that can be used as a definitive diagnostic method. Since the physician did base the diagnosis on the SPEP result, would it be appropriate to assign code 5 (Positive laboratory test/marker study) since there was no histological confirmation?

Under code 5, the Hematopoietic Manual states: Laboratory tests are listed under Definitive Diagnostic Methods in the Hematopoietic Database.

Patient was diagnosed with invasive lobular carcinoma of the right breast in April 2001. Following modified radical mastectomy in May 2001, the patient was disease free. In December 2008 the patient was diagnosed with a right chest wall mass, invasive poorly differentiated mammary carcinoma with lobular origin. If this is a new primary in 2008, would we code the primary site to breast or chest wall? Please see I&R answers 25924, 22163 and 26155 with similar case scenarios that give two different answers. One response indicates coding this type of scenario as new primary to chest wall and the other two responses indicate this should not be a new primary because the chest wall is a metastatic site. The pathology report does not state that this is metastatic and it is unknown if there is breast tissue left behind at the chest wall.

Patient was diagnosed with invasive ductal carcinoma with mucinous features in February 2021, left breast biopsies at 2:00 (3 cm from nipple) and 3:00 (8 cm from nipple) positions. Intraductal component was absent in those specimens.

Subsequent left breast total mastectomy in March 2021, provided a final diagnosis of multifocal mixed mucinous carcinoma, grade 1, 27 and 8 mm and ductal carcinoma in situ (DCIS), low to intermediate grade, with focal mucinous features. The Staging Summary lists Histologic Type as mixed mucinous carcinomafor both foci of invasive carcinoma. DCIS is also noted as present negative for extensive intraductal component.

There does not appear to be a clear instruction or code for this histology. As a central registry, we are unable to follow-up with the pathologist regarding this diagnosis.

Just to be clear, there are 2 foci of invasive mixed mucinous carcinoma in this case measuring 27 mm and 8 mm. The DCIS component measured 56 mm.

Patient was diagnosed with hemophagocytic lymphohistiocytosis on blood and bone marrow biopsy. This was also referred to in the chart as hemophagocytosis and hemophagocytic syndrome. Hemophagocytic syndrome is listed in the Heme DB as 9724/3. The patient had several rounds of fairly aggressive chemotherapy. Would the correct primary site for histology 9724/3 be C421 [bone marrow], or C779 [lymph nodes, NOS]? See SINQ 20100113.