Reportability/Date of diagnosis--Liver: Does the final diagnosis of a scan have higher priority than the findings in the discussion in the body of the report? See Discussion.
A patient with liver cancer becomes transplant eligible when the tumor is 2 cm in size. Frequently, liver tumors will be watched (no biopsy) for months until they meet the 2 cm size criteria. In the meantime, multiple scans will describe the tumor using variations of ambiguous terms that drift in and out of reportablility. One day the tumor is labeled "presumed hepatocellular carcinoma." Weeks later it is back to "worrisome for hepatoma." A single scan will use different terms in different sections of the report.
Example case: Abdominal CT reveals a 1 cm liver lesion. Per the discussion portion of the scan, the lesion is consistent with hepatocellular carcinoma. Per final diagnosis: 1 cm liver lesion, possibly hepatocellular carcinoma. Is this report diagnostic of cancer? Would the date of this report be the date of diagnosis? (Patient did receive a liver transplant for hepatocellular carcinoma months later.)
When a reportable ambiguous term is used in one part of a report or the medical record and a non-reportable ambiguous term is used in another part of the report or the medical record, accept the reportable term and accession the case.
The example above is reportable. "Consistent with" is a reportable ambiguous term. Accept "consistent with" over the non-reportable term "possibly."
The date of this report would be the date of diagnosis if this is the earliest report using reportable terminology.
First course treatment--Prostate: If a patient has a prostatectomy and the margins are positive, then several months later radiation is given because the PSA levels never decreased or have risen, is the radiation coded as first course of treatment or subsequent treatment?
Record the radiation as first course of treatment even though it was delayed for several months.
Radiation is highly effective when there is a small or microscopic amount of tissue left at the margin following prostatectomy. In most regions, radiation therapy is the standard of care for positive margins at prostatectomy.
Surgery of Primary Site--Breast: How is this field coded when a re-excision follows a prior mastectomy?
Code the most extensive surgery in Surgery of Primary Site. This is a cumulative field. Assign the appropriate code including all surgeries of the primary site performed during the first course of treatment.
The correct code for mastectomy followed by re-excision will depend on the extent of the re-excision. For example, if the re-excision removed muscle, code radical mastectomy.
MP/H Rules--Breast: Is inflammatory breast cancer always one primary per lifetime? Or is a subsequent inflammatory breast cancer a second primary if diagnosed more than five years later?
For cases diagnosed 2007 or later, a diagnosis of inflammatory breast cancer more than five years after a previous diagnosis of inflammatory breast cancer is a separate (new) primary. See rule M5 in the Breast Multiple Primary Rules.
Race, ethnicity/Spanish surname or origin: If birthplace is Brazil or Portugal, patient's last name is on the Spanish Surname list, and there is no text to further clarify ethnicity, what is the correct Spanish Ethnicity code: 0 or 7? See Discussion.
See also SINQ 20081075.
Assign code 7 [Spanish surname only] when the last name is on the Spanish Surname list. This includes cases for which the birthplace is Brazil, Portugal or the Philippines and there is no text to further clarify ethnicity.
The instruction to use code 0 [Non-Spanish/Non-Hispanic] in the SEER manual on page 51 (#2) applies when the only information available is the birthplace or a statement of "Portuguese," "Brazilian" or "Filipino."
MP/H Rules: Does the presence of metastases affect the application of the MP/H rules? See Discussion.
Single lung tumors presenting in each lung but the patient also presents with bone mets? Would rule M6 apply? Or do the bone mets represent additional tumors?
For cases diagnosed 2007 or later, the MP/H rules do not apply to metastases. Ignore metastases when applying the rules.
For the case above, use rule M6 and abstract as two primaries (right lung and left lung). The bone mets are ignored.
First course treatment: Is subsequent treatment with R-ICE first course or second course therapy if the patient underwent ABVD x2 cycles and subsequent imaging showed no response to treatment and evidence of progression [new adenopathy] for a lymphoma case? See Discussion.
Patient was initially diagnosed with Hodgkin Lymphoma, Nodular Sclerosing on 3/3/06.
Patient received ABVD x 2 cycles. Had disease reassessed in May, 2006, no response to treatment, showed evidence of progression (new adenopathy). Patient's pathology from 3/06 was sent for consult: Diagnosis was Hodgkin with some overlapping features of B-cell Non Hodgkin Lymphoma. Treated 5/18/06 with R-ICE FOR NHL.
The R-ICE treatment in this case is not part of the first course. Documentation of treatment failure and/or disease progression signifies the end of the first course of treatment.
MP/H Rules--Melanoma: How many primaries are represented if subsequent to a diagnosis of malignant melanoma of skin of left thorax in April 2006, a metastatic melanoma is discovered in the soft tissue of the abdomen and in the skin and subcutaneous tissue of the groin in late 2007? See Discussion.
4/20/06: skin left lateral thorax, excision: Pedunculated malignant melanoma, 0.5 CM in height, Clark's level 3, Breslow depth 0.5 CM, superficial ulceration noted. No host response. Margins clear.
6/19/06: Four sentinel LNs negative. Interferon therapy.
10/30/07: FNA of soft tissue, left lower abdomen: consistent with metastatic melanoma.
12/20/07 A) sentinel lymph node, left groin, biopsy: No morphologic or immunophenotypic findings support for metastatic melanoma (see comment). B) skin and subcutaneous tissue, left groin, excisional biopsy: Metastatic malignant melanoma (see comment). Lymphovascular invasion identified. Margins free of melanoma. Melanoma 1.5 MM from the closest designated deep margin and 5 MM from the designated 6:00 margin. C) skin, left groin/additional inferior margin, excisional biopsy: No significant histopathologic abnormality. No evidence of villus or melanoma or malignancy. Comment: A 0.8 cm metastatic nodular melanoma is present in the adipose tissue. The underlying skin is unremarkable. There is no evidence of ulceration, melanocytic lesion, melanoma in situ, or regression of melanoma. Block A1 is sent for immunohistochemical studies. The immunophenotypic findings provide no support for metastatic melanoma in lymph node. Please see the immunohistochemical study. The primary MD states "Recurrent intransit mets, left groin."
For cases diagnosed 2007 or later, this is a single primary, melanoma of the thorax 4/20/06. The subsequent reports mention metastases, but do not document another primary. Do not count metastatic lesions as new primaries.
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