Histology (Pre-2007)--Lung: Should the histology "Polymorphic Adenocarcinoma" be coded to 8022/33 [Polymorphic Carcinoma] or 8140/33 [Adenocarcinoma, NOS]?
For tumors diagnosed prior to 2007:
The histology code for pleomorphic adenocarcinoma of the lung is 8140 [Adenocarcinoma, NOS]. According to our pathologist consultant, "Given lung as primary site I prefer 8140. This loses the pleomorphic modifier, but going to 8022 loses the adeno- designation which is more important. Pathologists occasionally use pleomorphic carcinoma for lung tumors which otherwise dont show any adeno or squamous differentiation, for which 8022 would be appropriate, but in this case we do have the adeno designation."
For tumors diagnosed 2007 or later, refer to the MP/H rules. If there are still questions about how this type of tumor should be coded, submit a new question to SINQ and include the difficulties you are encountering in applying the MP/H rules.
EOD-Size of Primary Tumor/First Course Treatment--Breast: How is tumor size coded when preventative tamoxifen treatment precedes breast cancer diagnosis? Can we code the tumor size from the surgical specimen? Is tamoxifen treatment here? See Description.
What is the tumor size in this situation? Patient is on the STAR trial (preventative tamoxifen for women with high risk for breast cancer). Patient develops breast cancer and has surgery.
For cases diagnosed 1998-2003: Code EOD-Size of Primary Tumor from the surgical pathology report.
Do not code this preventative tamoxifen as first course cancer-directed treatment. This tamoxifen was part of a clinical trial intending to delay or prevent beast cancer from developing.
Surgery of Primary Site--Skin: Should this field be coded to 45 [wide excision or reexcision of lesion or minor (local) amputation with margins more than 1 cm, NOS], 46 [with margins between 1 and 2 cm], or 47 [with margins greater than 2 cm] for a skin primary diagnosed in 2003 when margins are stated exactly as 2 cm?
Use code 46 [Wide excision...with margins more than 1 cm and less than 2 cm] when margins are exactly 2 cm.
EOD-Lymph Nodes--Head & Neck: If a pre-treatment description of a chain of lymph nodes doesn't meet the criteria for involvement but the post-treatment description of the same chain of lymph nodes does, should those nodes be counted as involved in coding EOD? See Description.
(Primary site = larynx)
9/12/02 CT neck showed right cervical chain adenopathy. After chemotherapy, an 11/18/02 CT soft tissue of neck showed decrease in size by 50% of what was probably necrotic metastatic node to right mandibular angle.
The term "lymphadenopathy" should be ignored when determining involvement of lymph nodes per SEER. In this case, a probable necrotic metastatic node is mentioned in a subsequent CT taken after treatment.
Should lymph node involvement be coded to 9 based on the 9/12/02 CT or coded to 4 because of the mention of a decrease in size of what was probably a metatastic node on the 11/18/03 CT?
For cases diagnosed 1998-2003, code EOD using the best information available. In this example, the post-treatment description of lymph nodes. A post-treatment description of lymph nodes can be used to code lymph node involvement in the absence of disease progression. Pre-operative treatment does not affect lymph node involvement.
Case example: Code lymph nodes as involved (codes 1-4 depending on size and number) based on the later CT report.
Hematologic Transplant and Endocrine Procedures--Brain and CNS: Is stem cell transplant coded as treatment for medulloblastoma? See Description.
The PDQ lists high-dose chemotherapy with autologous bone marrow rescue as treatment for children under three. A case of medulloblastoma that was treated with gross total resection of the tumor, followed by chemotherapy and autologous PBSC (peripheral blood stem cell) transplant.
A stem cell transplant does not fit the definition of "treatment" because it does not affect, control, change, remove or destroy proliferating cancer tissue. However, there is a place to code this procedure. Code stem cell transplant under Hematologic Transplant and Endocrine Procedures. Assign code 20 [Stem cell harvest].
Multiple Primaries (Pre-2007)/Histology (Pre-2007)--Breast: Would the simultaneously occurring histologies of "high grade ductal carcinoma in situ with micro invasion" and "keratinizing squamous cell carcinoma" be coded as two primaries or as a single primary when the pathologist is not clear whether two separate tumor masses exist?
For tumors diagnosed prior to 2007:
Code as two primaries, assuming the tumors are separate and the margins are clear/negative. Code 8071/3 [Invasive squamous cell ca, keratinizing] and 8500/3 [Ductal carcinoma, "microinvasive"].
For tumors diagnosed 2007 or later, refer to the MP/H rules. If there are still questions about how this type of tumor should be coded, submit a new question to SINQ and include the difficulties you are encountering in applying the MP/H rules.
Primary Site: Should we code C80.9 [unknown primary] or code C34.9 [Lung] according to the terminology, "most likely site of origin is lung"? See Description.
We have a case of metastatic keratinizing squamous cell ca. The work-up shows small densities in the lung that may represent inflammatory or chronic changes. No other imaging that shows origin. Physical exam states 2 months of left axillary mass. H/O SCCA of the skin involving chest wall.
Path reads: Metastatic w/d keratinizing SCCA. This lesion almost undoubtedly represents mets. The most likely site of origin is lung followed by esophageal primary or head & neck. The final discharge states, "Metastatic SCCA to Left Axilla".
Code the primary site according to the physicians' opinion, especially the treatment decision. If the physician treats the patient for a lung primary, code primary site as lung. If the primary site cannot be determined, code C80.9.
According to the pathologist, the most likely primary site for the example above is lung. The final discharge diagnosis does not reflect the pathologist's opinion, and does not contradict it either. If there is no conflicting medical opinion, code primary site to C34.9 [lung].
Primary site--Melanoma: Should melanoma of the nipple be coded to C50.0 [Nipple] or C44.5 [Skin of the trunk]?
Code to C44.5 [skin of trunk]. External melanoma is an epidermal malignancy, beginning in melanocytes in the basal layer of the epidermis. C50.0 excludes skin of breast.
Primary Site--Head & Neck: What is the anatomical distinction among tonsillar fossa, tonsillar pillar, and tonsil NOS?
Operative findings describe a right tonsil three times the size of the left tonsil. Tonsil is dissected from the tonsillar fossa. There appeared to be no involvement of tumor below the tonsillar capsule.
The tonsil lies in an indentation called the tonsillar fossa. The tonsillar fossa is bordered on either side by the tonsillar pillars. The tonsillar pillars are part of the supporting structure of the throat opening.
Code C09.9 [Tonsil NOS] as the primary site for the case above.