Reportability--Heme & Lymphoid Neoplasms: Is the diagnosis of large granular lymphocyte syndrome or large granular lymphocyte disorder a reportable synonym for T-cell large granular lymphocytic leukemia? See Discussion.
The physician consult in this case further specifies that the large granular lymphocyte disorder represents an autoimmune disease of autoimmune T-cell mediated mechanism. Is this a reportable diagnosis?
Report large granular lymphocyte disorder (9831/3). Alternate names for T-cell large granular lymphocytic leukemia (9831/3) listed in the Hematopoietic and Lymphoid Neoplasms Database include but are not limited to Chronic large granular lymphocyte lymphoproliferative disorder, large granular lymphocytosis, NOS, and T-cell large granular lymphocytosis.
Surgery of Primary Site--Breast: Would you code a unilateral breast simple mastectomy with tissue expanders and AlloDerm or an acellular dermal matrix as Code 45, Reconstruction with Implant, or Code 46, Reconstruction with Combined Tissue and Implant? See Discussion.
Since acellular dermal matrix/AlloDerm comes from human tissue donors with cells removed and sterilized to promote regenesis and decrease rejection, is Alloderm coded as "Tissue' as it also "provides an additional layer of tissue between the skin and the implant?
Assign code 43 for a simple mastectomy with tissue expanders and acellular dermal matrix/AlloDerm. The tissue expander indicates preparation for reconstruction. The acellular dermal matrix/AlloDerm is not coded because, while they often accompany an implant procedure, they are not the principle element of reconstructive procedures. The principle elements would be tissue from the patient and/or prosthetics (e.g., gel implants).
MP/H Rules/Histology--Brain and CNS: What is the code for an embryonal tumor with multilayered rosettes. WHO shows the code as 9478/3, but this code is not available for use in the United States.
Assign ICD-O-3 code 9392/3 until code 9478/3 is implemented in 2018. Per our expert neuropathologist, embryonal tumor with multilayered rosettes was previously called ependymoblastoma.
MP/H Rules/Histology--Fallopian Tube: What is the histology code of serous tubal intraepithelial (in situ) carcinoma (STIC), bilateral fallopian tubes?
Assign 8441/2. This is based on the WHO classification for female reproductive system tumors.
Multiple Primaries/Histology Rules/Multiple primaries--Kidney, renal pelvis: Are tumors diagnosed more than three years apart multiple primaries according to Rule M7 in a case with metastasis? See Discussion.
5/27/02 Transurethral resection of bladder tumor (TURBT)--papillary transitional cell carcinoma, +lamina propria, no muscle invasion. All urine cytologies in 2011 and 2012 (only follow up received) show no malignancy. 3/11/15 Lung fine needle aspirate--poorly differentiated carcinoma consistent with urothelial carcinoma. 4/30/15 Renal pelvis biopsy--low grade papillary urothelial carcinoma, no lamina propria invasion, no muscularis propria invasion.
Rule M7 applies. Abstract the bladder diagnosis and the renal pelvis diagnosis as separate primaries.
The lung diagnosis is metastatic. The MP/H rules do not apply to metastatic tumors.
Reportability/Histology--Skin: Is 'skin, left temporal scalp, low grade adnexal carcinoma, probable sweat gland origin' reportable as 8400/3, skin of temple?
Assign 8390/3 for adnexal carcinoma of skin. 8390/3 is reportable, including 8390/3 of skin.
Reportability/Histology--Testis: Is neoplasm consistent with carcinoid type of monodermal teratoma reportable as a teratoma, NOS, and if yes, what is the histology code?
Carcinoid type of monodermal teratoma or well differentiated neuroendocrine tumor (carcinoid), monodermal teratoma of the testis is reportable. Assign 8240/3 according to the WHO classification for this neoplasm.
Histology--Heme & Lymphoid Neoplasms: How should histology be coded for final bone marrow diagnosis of myelodysplastic syndrome with excess blasts? See Discussion.
This terminology is not specifically included in either alternate names list for myelodysplastic syndrome, NOS (9989/3) or refractory anemia with excess blasts (9983/3).
Example: Bone Marrow Biopsy, Final Diagnosis: Consistent with involvement by myelodysplastic syndrome with excess blasts-2 (MDS EB-2).
Assign code 9983/3 refractory anemia with excess blasts. Refractory anemia is a type of myelodyplastic syndrome. We will add this to the Heme & Lymphoid database during the next update.
Reportability/Histology--Brain and CNS: Is epidermoid tumor of the cerebellopontine angle (CPA) and trigeminal vesicle nerve reportable, and if so, what is the correct histology code? See discussion.
Patient presented to hospital ED and had brain MRI that revealed 3.2 cm space occupying lesion in region of the left CPA and trigeminal vesicle nerve compatible with epidermoid tumor.
Epidermoid tumor of the brain is not reportable. There is no ICD-O-3 code for epidermoid tumor or epidermoid cyst. This type of tumor is often referred to as a cyst because it has a thin wall that secretes a soft material into the center.
MP/H Rules/Multiple primaries--Breast: Can we accession two breast primaries when imaging is "suspicious for malignancy" on both breasts but only one biopsy is taken and is histologically confirmed, and assume bilateral complete response to neoadjuvant chemotherapy with bilateral mastectomies negative for residual cancer? See Discussion.
The patient is diagnosed by bilateral mammograms suspicious for malignancy in both breasts. A biopsy is done on one breast and is positive. The physician states that he will not biopsy the contralateral breast, as the patient has consented to bilateral mastectomy. The patient receives neoadjuvant chemo, follow by bilateral mastectomies. Both breasts are negative for residual cancer, stated as a complete response. Based on "suspicious for malignancy" can we accession two primaries and assume bilateral complete response?
Accession two breast primaries, one right and one left, rule M7. "Suspicious" is reportable ambiguous terminology.
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