Surgery of Primary Site/Other Cancer-Directed Therapy--Head & Neck (Nasal cavity): Should a small fragment of bone removed during a maxillectomy following a turbinectomy for a nasal turbinate primary be "partial or total removal with other organ" for coding this field? See discussion.
Excision of a turbinate mass and partial turbinectomy revealed melanoma of the rt nasal turbinate. A subsequent rt medial maxillectomy was performed and a small fragment of bone was included in the resection and identified in the pathology report. Would the removed bone be "connective or supportive tissue" only for a Surgery of Primary Site code of 40 or is it another organ for a code of 60?
The piece of bone was likely removed to access the maxillary sinus and would not be a separate organ. Use the "All Other Sites" surgery coding schemes to code this primary. For cases diagnosed 1/1/2003 and after: Code the Surgery of Primary Site field to 40 [Total surgical removal of primary site]. Code the Surgical Procedure of Other Site field to 2 [Non-primary surgical procedure to other regional sites]. The maxillectomy was not performed in continuity to the turbinectomy and should be coded in this field rather than the Surgery of Primary Site field.
Histology (Pre-2007)--Breast: What code is used for histology "tubular carcinoma with lobular carcinoma in situ"?
For tumors diagnosed prior to 2007:
Assign code 8211/3 [Tubular carcinoma]. According to histology rule #2 for a single tumor on page 86 of the 2004 SEER manual, code the invasive histology when both invasive and in situ tumor are present.
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--Head & Neck: What site code is used to represent the following head and neck primary where there is not a clear statement of primary site? See discussion.
6/29/02: PE: 2-3 cm mass in the posterior pharynx that seems to arise from the right side of back of tongue.
6/29/02 CT soft tissue of neck: 3 cm right sided oropharyngeal mass, possibly arising from right tongue mass. There is near occlusion of airway at this level.
7/3/02 Excision of oropharyngeal tumor: Palpated mass could clearly be felt coming off the right lateral tongue in approximately the mid portion of the tongue near the tonsillar base.
Code the Primary Site field to C02.9 [tongue, NOS], based on the information provided.
Primary Site/EOD Fields--Head & Neck: In the absence of an actual resection and a pathologic evaluation of the affected area, would a laryngoscopy or CT scan provide a better assessment of the EOD and the primary site?
For cases diagnosed 1998-2003:
For Primary Site and EOD, CT information has higher priority than laryngoscopy. The CT scan gives a better picture of the involvement of the deeper tissues. A laryngoscopy falls into the "physical exam" category more than the "operative" category. The laryngoscopy report is not an "operative" report like those generated from a surgical procedure.
EOD-Extension--Hematopoietic, NOS: If a solitary plasmacytoma originates in the right tonsil and extends to the left tonsil, vallecula and hypopharynx, is extension still coded to 10 [localized disease, solitary plasmacytoma only]?
For cases diagnosed 1998-2003:
Code the EOD-Extension field to 10 [localized disease, solitary plasmacytoma only] for all cases of solitary plasmacytoma.
Histology (Pre-2007)--Breast: What code is used to represent the histology "infiltrating lobular carcinoma, solid and classical subtypes"?
For tumors diagnosed prior to 2007:
Code the Histology field to 8520 [Lobular carcinoma].
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: The EOD Manual instructs us not to code the size of a cyst. Can we code the size of tumor lesions described as being multicystic, multiloculated, or as a complex mass with cystic areas? See discussion.
Example 1: Large multicystic ovarian mass lesion measuring 10 cm. Sections through the specimen show a multicystic and solid mass with abundant fluid exuding from the cut surfaces (Size of the solid portions is not stated).
Example 2: A brain MRI: 9-cm. complex mass with cystic areas.
For cases diagnosed 1998-2003:
Yes, if the cystic mass is pathologically confirmed to be malignant, code the EOD-Size of Primary Tumor field based on the size of the mass in the absence of a more precise tumor size description. For the examples in the discussion section, code the EOD-Size of Primary Tumor field to: 1) 100 [10 cm]. 2) 090 [9 cm].
As a point of interest, the size of tumor for ovarian and brain primaries is not used in either analysis or as a prognostic indicator for survival. Therefore, spending time separating the cystic and solid portions of the tumor is unnecessary.
CS Extension/CS Lymph Nodes--Breast: How would you interpret the phrase "axillary lymph node tissue, not clearly a lymph node" or the phrase "satellite nodule of invasive tumor, left axillary lymph node or chest wall tissue"? See discussion.
A lumpectomy with axillary lymph node dissection and removal of nodule in anterior axillary line revealed negative lymph nodes. The nodule specimen was labeled "axillary lymph tissue, not clearly a lymph node". The microscopic description for that specimen stated "Fibroadipose tissue. A fragment of a lymph node is incidentally sampled in block 4 and it is free of tumor". The final path dx stated "Satellite nodule of invasive tumor, left axillary lymph node, or chest wall tissue. Comment: If the tissue is considered chest wall this would be a stage IIIB. If it is considered an intramammary satellite nodule, this is a stage I". The clinician repeated what the comment said, and added "If lymph node mets, this is a stage II."
Code the invasive tumor in the axillary area as a regional lymph node metastasis. According to the AJCC, cancerous nodules in the axillary fat adjacent to the breast, without histologic evidence of residual lymph node tissue, are classified as regional lymph node metastases.
EOD-Size of Primary Tumor: 1) Can we add "Imaging studies" to those EOD schemes that currently do not include this on their priority list for coding size? 2) When an EOD scheme already lists specific types of imaging studies, are we limited to only those types of procedures or can any imaging study be used to code size? See discussion.
How do we determine where to add "imaging studies" to the priority listing? Currently the hierarchy differs for primaries that currently include imaging studies on their EOD schemes. For example, on the breast EOD imaging ranks lower than the physical exam while on the thyroid EOD imaging ranks higher than the physical exam.
For cases diagnosed 1998-2003:
1) You may add "Imaging" to the size priority list for all EOD schemes that currently do not include it. Prioritize it just above the physical exam for these sites.
2) You may use the information from any imaging technique to code tumor size, even for those sites such as breast and bladder where specific imaging tests are mentioned.
EOD-Extension/EOD-Lymph Nodes--Rectosigmoid: How do you code these fields for a scan-based clinically staged T3 N1 rectosigmoid primary in a patient who received chemotherapy and radiation prior to a resection that demonstrated invasion only into the muscularis and no positive lymph nodes?
For cases diagnosed 1998-2003:
Use the best information available, in this case, the clinical staging, to code EOD. Code the EOD-Extension field to 40 [Invasion through muscularis propria or muscularis, NOS] and the EOD Lymph Node field to 3 [Regional lymph node(s) NOS] because the case had a clinical stage of T3 N1. EOD is coded using the most extensive clinical or pathologic stage.