First Course Treatment--All Sites: The patient has undergone part of the planned first course of treatment when a metastatic deposit is identified. If the patient continues with the planned first course of treatment, should the modalities of treatment given after the metastatic deposit is discovered be included in the coding of the first course of cancer-directed treatment fields?
Yes, those modalities should be counted as part of first course of cancer-directed treatment if the patient continues with the planned first course. For example, if patient has the originally planned type of surgery, radiation, or drug protocol, then code the given treatment as first course.
Caution: It is not a change in the treatment plan if the drugs are changed but the action of the drugs remains the same. This is still first course. However, if the treatment is changed from a chemotherapy drug to a hormonal drug following the discovery of the mets, do not code the hormonal therapy as first course.
Date of Diagnosis/EOD-Extension--Placenta: How do you code these fields for a patient who presents with a vaginal metastatic lesion for a placenta primary? Should EOD-Extension be coded to 60 [Other genital structures NOS: vagina, ovary, broad ligament, fallopian tube] or 85 [metastasis other than lung]? See discussion.
Pt had D&C Feb 5 with features of complete mole. On March 7, pt seen for a mass just inferior to the urethral meatus. At path, vaginal introitus fragments were consistent with choriocarcinoma. At time of March 23 admit for chemo, history is given as large hydatidiform mole evacuated Feb 5. Her beta hCG titers initially fell but approximately one month later hCG titers rose. At that time, she had an obvious vaginal metastatic lesion.
For cases diagnosed 1998 or after: Code the Date of Diagnosis field to March 7, which is the date that the choriocarcinoma was first diagnosed. There was no slide review or clinical statement that the first occurrence was obviously malignant. Therefore, the vaginal mets is not progression and is codeable as extension. Code the EOD-Extension field to 60 [other genital structures, NOS] according to the current EOD scheme for placenta. Even though the mass is discontinuous, it is still included in code 60 per the guidelines of the FIGO system on which the EOD is based.
Surgical Procedure of Other Site--Pancreas: Should an embolization of liver metastasis for a pancreas primary be coded as treatment?
Code "embolization" (or hepatic artery embolization, HAE) to a metastatic site in Surgical procedure of Other Site. Assign code 1 [nonprimary surgical procedure performed].
This procedure was previously coded as other therapy, experimental. Code as surgery as of July 2005.
MP/H Rules/Histology--Breast: What code is used to represent the histology "ductal carcinoma in situ and invasive lobular carcinoma"? See discussion.
Is the histology coded to the combination code of 8522/3 (ductal and lobular) or to the invasive component 8520/3 (lobular)?
For cases diagnosed 2007 or later:
Assuming ductal carcinoma in situ and invasive lobular carcinoma are present in a single tumor, code 8520/3 [Infiltrating lobular carcinoma, NOS].
Using the 2007 MP/H rules for breast, the single tumor invasive and in situ carcinoma module, start and stop at rule H9 and code the invasive histology.
Grade, Differentiation: Do we code to the highest grade even when no grade is given at the time of initial diagnosis, but a grade is obtained on tissue removed after non-surgical treatment has occurred? See discussion.
1. In 2000 a pleural fluid aspirate had no grade. Pt treated with chemo. In 2000 a BSO diagnosed high grade papillary serous adenocarcinoma of the ovary.
2. In 1993 a prostate bx had no grade. Pt treated. In 2001 prostate bx revealed a Gleason's 4+3.
Code the grade at the time of initial diagnosis (if the specimen is from the primary site) or to the grade identified as part of a first course of cancer-directed surgery to the primary site. When different grades are specified for tissue pathologically reviewed from the primary site before and after treatment, code the higher grade. This is true even if the higher grade is obtained while the pt is still undergoing first course of cancer-directed therapy.
1. Code the Grade to 4 [high grade], if the grade information from the BSO specimen represents the grade associated with primary site surgical specimen. Even though the grade was obtained after first course of cancer-directed therapy started, it was obtained during first course of cancer-directed therapy.
2. Code the Grade to 9 [Cell type not determined, not stated or not applicable]. Grade was obtained well after the first course of cancer-directed therapy ended.
Histology (Pre-2007): What code is used to represent the histology adenocarcinoma with "areas of" papillary architecture and "foci of" squamous differentiation? Even though "areas of" and "foci" are non-majority terms, should histology be coded to the combination code of adenocarcinoma with mixed subtypes [8255/3]?
For tumors diagnosed prior to 2007:
Code the Histology field to the majority of the tumor, which is 8140/3 [adenocarcinoma, NOS]. The terms "areas of" and "foci of" should be ignored because they are not terms that reflect the majority of the tumor. Therefore, we cannot use rule A on page 2 of Coding Complex Morphologic Diagnoses because this diagnosis does not represent a complex morphology.
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 (Pre-2007)--Prostate/Prostatic Urethra: What code is used to represent primary site for an "adenocarcinoma with spindle cell differentiation" of the prostatic urethra?
For tumors diagnosed prior to 2007:
Code the Primary Site field to C61.9 [prostate] because the histology is adenocarcinoma.
When a malignancy is identified in the prostatic urethra, look at the histology to determine the primary site. If it is a transitional cell carcinoma, code the Primary Site field to C68.0 [urethra] and if it is an adenocarcinoma, code to C61.9 [prostate].
The EOD scheme is ultimately collapsed into the TNM scheme. The TNM system differentiates between adenocarcinoma of the prostate and transitional cell carcinoma of the urethra. Only adenocarcinoma of the prostate is staged by the prostate scheme. Transitional cell carcinoma of the prostatic urethra is coded to C68.0 [urethra] and staged with that scheme.
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-Extension--Head & Neck: How do you code extension for a supraglottic larynx primary with "pre-epigolottic space" invasion?
For cases diagnosed 1998-2003:
Code the EOD-Extension field to 65 [Pre-epiglottic tissues]. Extension to "pre-epiglottic space" is equivalent to extension to "pre-epiglottic tissue."
First Course of Cancer-Directed Therapy--All Sites: How do we code retinoic acid?
The code for retinoic acid depends upon the primary site and histology of the tumor. Code retinoic acid (also called Vitamin A, tretinoin, ATRA, all-transretinoic acid or Vesanoid) in the Immunotherapy field as 01 [Immuno administered as first course therapy] for acute promyelocytic leukemia. This drug is given to patients as an alternative to chemotherapy.
For all other sites/histologies, code retinoic acid in the Other Cancer-Directed Therapy Field. Use code 2 [Other experimental cancer-directed therapy] or 3 [Double-blind clinical trial, code not yet broken] if the drug is given as part of a protocol. If the drug is not being given as part of a protocol or you don't know whether it is part of a protocol, use code 1 [Other cancer-directed therapy].