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In the WHO Classification of Female Genital Tumors, 5th edition, for the uterine cervix squamous intraepithelial lesions, there is related terminology for high grade squamous intraepithelial lesion HSIL (CIN3) 8077/2 and it is severe squamous dysplasia; squamous cell in situ. However, in the online WHO Classification of Digestive System Tumors, 5th edition, there is no related terminology for esophageal high-grade squamous dysplasia, 8077/2. Can you collect cases of severe dysplasia the same as cases of high grade dysplasia? 

Example Case 1:  2022 mobile tongue tumor biopsy shows squamous cell carcinoma, basaloid non-keratinizing type.

Example Case 2:  2022 base of tongue mass biopsy shows squamous cell carcinoma, basaloid non-keratinizing type, p16 positive.

Table 5, Note 2 (Head and Neck Equivalent Terms and Definitions) instructs us to code non-keratinizing squamous cell carcinoma which is p16 positive to 8085 (Squamous cell carcinoma HPV-positive), ignoring the non-keratinizing subtype. Does p16 or HPV positivity also take priority over multiple subtypes (basaloid non-keratinizing type)?

History provided by the oncologist

Right neck mass since 2019; 04/07/20, initial biopsy p16-negative SCC, delay of treatment due to patient preference, agreed to biopsy of tonsil and work-up August 2022; right tonsil biopsy: p16-positive, G2 SCC, nodal mass at that time >6 cm with extensive extranodal extension, Stage III (cT2, cN3, cM0, p16-positive); based on this history, was staged as a tonsil primary and p16-positive.

Patient details

1. March 2020, CT neck and chest revealed a 0.5 x 2.7 x 2.3 cm low-density necrotic nodal mass at right neck level 2 suspicious for metastatic disease.  There was a slight asymmetric increased size of the right palatine tonsil.  There are a few sub-4 mm pulmonary nodules which are nonspecific.

2.  April 7, 2020, FNA of right neck mass with pathology revealed p16-negative SCC   

3.  April 20, 2020, PET/CT revealed 3 x 2 cm right-sided level 2 node with FDG avidity  

4.  May 5, 2020, flexible laryngoscopy showed no obvious primary lesion   

5.  May 2020, after evaluation by a medical oncology, patient declined any treatment  

6.  June 17, 2022, return visit in medical oncology after PET/CT demonstrates significant progression in the neck; patient definitively declines chemo, but would like surgical opinion.  Now has more rapidly progressive disease with skin breakdown and weeping from malignant lesion right neck.  

7.  June 22, 2022, radiation oncology consultation   

8.  July 15, 2022, tonsil biopsy: Invasive squamous cell carcinoma, moderately differentiated with LVI, p16-positive  

9.  Patient now agreeing to treatment with radiation: Tooth extractions 8/30/2022, radiation planning 9/14/2022  

10.  Patient consulted with cancer specialist who explained surgery is not recommended given level of extranodal extension and risk of seventh cranial nerve paralysis and fistula formation with surgical excision and who recommended chemoradiation

11.  September 9, 2022, patient presented for radiation CT simulation/treatment planning and informs treatment team. Patient declined/refuses concurrent chemotherapy despite recommendations from two cancer institutions.

Patient has a diagnosis of myeloid sarcoma presenting as multiple erythematous papules and nodules on back, chest, right arm & shoulder. Oncologist did not mention any evidence or suspicion of an associated AML diagnosis.

HemeRetic schema EOD Primary Tumor Note 1 states that myeloid sarcoma can be coded as localized (code 100) or systemic (code 700). It is not clear what would qualify as systemic disease for myeloid sarcoma.

Lutathera is a radioconjugate consisting of the tyrosine-containing somatostatin analog Tyr3-octreotate (TATE) conjugated with the bifunctional, macrocyclic chelating agent tetra-azacyclododecanetetra-acetic acid (DOTA) and radiolabeled with the beta-emitting radioisotope lutetium Lu 177 with potential antineoplastic activities.

Acinar predominant adenocarcinoma measures at least 12 mm and involves wedge biopsy margins, while the lepidic predominant adenocarcinoma measures 11 mm and does not involve the margins of that separate specimen. Pathologist also notes, “CT findings of diffuse coarse reticular nodular opacity, these findings may represent pneumonic type adenocarcinoma/diffuse pulmonary involvement or intrapulmonary metastasis.  Both of these scenarios have the corresponding stages of pT4 (if thought to be ipsilateral) or M1a (if thought to also involve the contralateral lobe).”

Patient declined any further treatment and transitioned to hospice before expiring less than 1 month after wedge biopsies.

It is unclear if Rule M6 would apply to these two specimens with different subtypes since this scenario is not specifically addressed in the M rule definitions.

The pathology report states this is a rare entity described in case reports and not incorporated into the WHO classification of tumors. A subsequent endocrinology note stated “papillary tumor, benign by path; tumor was not an adenoma; based on one Mayo study, the recurrence risk is low.”

Patient has a 2021 left parotidectomy showing myoepithelial carcinoma ex-pleomorphic adenoma.  Is this coded to myoepithelial carcinoma (8982/3) or carcinoma ex-pleomorphic adenoma (8941/3)?  It is unclear how to arrive at the correct histology code using the current Solid Tumor Rules.