Scope of Regional Lymph Node Surgery/CS Reg LN Pos/Exam: How are these fields coded if the operative report does not mention a separate lymph node procedure at the time of the surgery to the primary site? See Discussion.
LUL lobectomy: 1.7 cm apical tumor, diagnosis: moderately well differentiated subpleural squamous cell carcinoma, with involvement of pleural surface. 3 peribronchial LN neg and 2 AP window LNs neg. Stage T2N0.
1. No lymph node dissection or sampling was stated to be done
2. The lobectomy specimen contained the LNs
This answer was provided in the context of CSv1 coding guidelines. The response may not be used after your registry database has been converted to CSv2.
Code the Scope of Regional LN Surgery, Regional Nodes Positive and Regional Nodes Examined fields using the available information on the case. The lymph nodes can be obtained or biopsied during any procedure within the first course of treatment. A separate lymph node surgery is not required to complete these data items.
MP/H Rules/Histology--Brain: How many primaries are reported and what is the histology for a single brain tumor described as a low grade astrocytoma at the time of the initial partial resection and a low grade glioneuronal neoplasm at the time of the subsequent total resection? See Discussion.
On 4/20/07 a partial resection of a brain tumor is interpreted as low grade astrocytoma. Patient has a gross total resection on 8/13/07 with this diagnosis: low grade glioneuronal neoplasm (see comment). Comment: This case has been reviewed at ---. Dr. agrees with our interpretation (low grade glioneuronal neoplasm, possibly a dysembryoplastic neuroepithelial tumor).
For cases diagnosed 2007 or later, this is a single primary. A single tumor is always a single primary.
Assign histology code 9400/3 [Astrocytoma, low grade]. This diagnosis was not revised or amended based on the later surgery. It is possible that the malignant component was entirely removed during the first surgery.
MP/H Rules/Histology--Prostate: If a patient is stated to have prostate "cancer" but a pathology report is not available nor is a specific histology stated in the medical record, can this histology be coded to 8140 [adenocarcinoma] instead of 8000/3 [cancer] because the vast majority of prostate cancers are adenocarcinomas?
For cases diagnosed 2007 and later, the correct histology code is 8000/3 [cancer]. The steps used to arrive at this decision are:
Open the Multiple Primary and Histology Coding Rules Manual. Choose one of the three formats (i.e., flowchart, matrix or text). Go to the Other Sites Histology rules because no specific rules have been developed for prostate primaries.
To determine the histology, start at the SINGLE TUMOR: INVASIVE ONLY module, rule H8. The rules are intended to be reviewed in consecutive order within a module. Code the histology documented by the physician when there is no pathology/cytology specimen or the pathology/cytology report is not available. Code the histology as 8000/3 [cancer] because that is the only available information. In the absence of a pathology report or any other histologic confirmation, code the histology based on the information available.
CS Tumor Size/CS Extension--Prostate: Because prostatectomy results are excluded from the CS Extension field for prostate, is code 95 [No evidence of primary tumor] accurate to reflect bilateral lobe involvement of prostate cancer when it is incidentally found following a radical cystectomy for a bladder primary? Why must tumor size be 000 when the CS Extension code is 95?
This answer was provided in the context of CSv1 coding guidelines. The response may not be used after your registry database has been converted to CSv2.Code prostate CS Extension to 99 [Extension unknown] and code CS Tumor Size according to the information available from the surgery.
CS Extension code 95 [No evidence of primary tumor] should be used only in that rare situation when the only evidence of disease is distant mets or lymph node involvement, no primary tumor found. That is why CS tumor Size must be 000 when CS Extension code 95 is used.
Cell indicator--Lymphoma: If the primary site for a lymphoma is stated to be the lymph nodes but there is no biopsy of a lymph node, can the immunophenotype designation for a lymphoma be coded based on a bone marrow or liver biopsy indicating "diffuse large B-cell lymphoma"?
For cases diagnosed prior to 1/1/2010:
The cell indicator or immunophenotype designation for lymphomas may be coded from pathology reports on tissue from bone marrow or liver when there is no tissue from the primary site. Code information on cell type from any available source.
See the Appendix C of the 2007 SEER manual, Coding Guidelines for Lymphomas, pages C-1055 to C-1056 for more information about coding this field for lymphomas.
For cases diagnosed 1/1/10 and later, refer to the Hematopoietic and Lymphoid Neoplasm Case Reportability and Coding Manual and the Hematopoietic Database (Hematopoietic DB) provided by SEER on its website to research your question. If those resources do not adequately address your issue, submit a new question to SINQ.
MP/H Rules/Multiple Primaries--Breast: How many primaries are abstracted when bilateral breasts contain DCIS? Is a physician statement referring to this situation as one primary ignored? See Discussion.
Patient has microcalcifications both breasts. Has bilateral mastectomy. Path report states Left breast multifocal DCIS predominantly micropapillary. Right breast two foci of DCIS micropapillary.
For cases diagnosed 2007 or later:
There are two primaries in this case.
Using the 2007 MP/H rules for breast, go to the multiple tumors module and start with Rule M4. Stop at rule M7. Tumors on both sides (right and left) are multple primaries.
Always use the 2007 Multiple Primary rules to determine the number of primaries. Do not use the physician statement.
CS Lymph Nodes/CS Mets at Dx--Melanoma: How are these fields coded if a sentinel lymph node biopsy reveals no malignancy but there is an aggregate of melanoma cells in the lumen of a large vein immediately adjacent to the lymph nodes?
This question was answered by the CoC:
Do not count this as regional metastatic disease since there is no evidence it is an established tumor. Stage this as a N0.
Reportability--Melanoma: Is the following reportable? See Discussion.
PATH: Skin, Lt back exc bx: compound nevus with severe cytoarchitectural atypia and regression. Comment: due to overlap of morphology between MM and nevi with severe atypia, and since there's evidence of regression, consideration for re-excision may be considered if clinically indicated.
The final diagnosis, compound nevus with severe atypia, is not reportable. This diagnosis is not listed in ICD-O-3.
Marital Status: Is marital status coded to 2 [married] if the patient is legally married to a same-sex spouse (e.g., patient has a Canadian spouse and in Canada, same-sex marriages are legal)?
Code marital status for same-sex persons based on the legal status. For the case example above, assign code 2 [married].
CS Extension/CS Mets: For primary sites within the peritoneum (abdominalpelvic walls) such as stomach, colon, does the presence of malignant ascites affect the coding of CS Extension or CS Mets?
This answer was provided in the context of CSv1 coding guidelines. The response may not be used after your registry database has been converted to CSv2.
The Collaborative Staging system is governed by site-specific coding rules. Refer to each set of site rules rather than looking for a general answer for all sites in peritoneum. In particular, Ovary and Corpus allow malignant ascites to be coded in CS Extension, but not CS Mets at Dx. For each site, both CS Extension and CS Mets at Dx should be checked for the proper field to code malignant ascites.
An official website of the United States government
Home