First course treatment/Immunotherapy--Heme & Lymphoid Neoplasms: Is donor leukocyte infusion for treatment of hematopoietic neoplasms coded as a bone marrow transplant per the Hematopoetic Manual or as immunotherapy per SEER Inquiry System (SINQ) 20110048? See Discussion.
In the Hematopoetic Manual, page 22, it is states: "The use of donor leukocyte infusions for treatment of hematopoietic neoplasms, specifically leukemias, is increasing. Abstract as bone marrow transplant when a reportable hematopoietic neoplasm is treated with donor leukocyte infusion, even if it is not listed in the treatment section of the Heme db for the specific neoplasm." Question 20110048 in the SEER Inquiry, it is stated "Donor lymphocyte infusion (DLI) is coded as immunotherapy." Donor lymphocyte infusion and donor leukocyte infusions are the same procedure. Please clarify discrepancy as coding is needed for a case treated with donor lymphocytic infusion.
Code donor lymphocyte infusion as immunotherapy. SINQ 20110048 is correct. The Hematopoietic Manual will be corrected during the next update.
First course treatment/Other therapy: How is Sirolimus (Rapamycin) to be coded when given with known chemotherapy agents in a clinical trial? See discussion.
The SEER*Rx Database lists Sirolimus as an ancillary agent under the Category section, but as an mTOR inhibitor under the Subcategory. The Remarks section indicates Sirolimus (AKA Rapamycin) is an immunosuppressant, but is also a type of serine/threonine kinase inhibitor. Other types of kinase inhibitors (including Temsirolimus) are types of Chemotherapy. Although the Coding section states this drug should not be coded, Primary Sites (NSCLC and glioblastoma) are listed for this drug.
The SEER*Rx Database page for this drug is confusing. Please address the following.
1) Should Sirolimus not be coded when it is being given as a kinase inhibitor or an immunosuppressant?
2) If Sirolimus is ever treatment, should it be coded only for the primary sites listed?
3) If Sirolimus is given as part of a non-blind clinical trial for another site other than NSCLC or glioblastoma, should the Other Therapy field be coded to 2 [experimental - other treatment]?
Sirolimus is used to treat GVHD (graft versus host disease) and is not coded as treatment. Even though the sub-category is mTOR inhibitor it does not automatically mean it is a chemotherapeutic agent. Sirolimus affects cells differently than Temsirolimus. The chemical compounds differ between these drugs. In order to code rapamycin, the drug given must be stated to be either the analog or ester compound. The SEER*RX database has been corrected and NSCLC/glioblastoma are no longer listed for sirolimus.
We researched clinical trials and found several that include sirolimus with other chemotherapy drugs for patients who either have received or will be receiving bone marrow transplants for hematologic diseases. In this case it is not coded. There are a few trials that are looking at sirolimus as a treatment for bladder, prostate, nerve sheath tumors, MDS, and AML. For these cases it would be coded in Other (code 2).
Behavior--Prostate: What is the correct behavior of intraductal carcinoma from a prostate biopsy with a Gleason score 4+4=8. While highly aggressive, but not suggestive of invasion, coding behavior as /2 seems inappropriate.
WHO classifies intraductal carcinoma of the prostate 8500/2. According to WHO, "the hallmark of intraductal carcinoma of the prostate is a proliferation of prostate carcinoma cells that is within and may significantly expand the native prostatic ducts and acini, with the basal cell layer at least partially preserved." Further, differentiation between intraductal carcinoma and infiltrating high-grade carcinoma of the prostate may require basal cell stains. Under Prognosis, WHO states: " intraductal carcinoma of the prostate on prostate biopsies is often associated with high-grade cancer (with a mean Gleason score of 8) ."
So while it may seem counter-intuitive, assign behavior code /2 when the diagnosis is intraductal carcinoma of the prostate.
MP/H Rules/Histology--Breast: Which is the correct histology code to use and which MP/H rule applies in the case of a single lumpectomy specimen that demonstrates two separate tumors with the following histologies.
1) Invasive lobular carcinoma
2) Invasive ductal carcinoma with tubular features
See discussion.
Does ductal carcinoma with tubular features qualify for Breast MP/H Rule H28? Or, is it more appropriate to strictly follow Table 2 (not a type of ductal tumor) and apply Rule H29, thus losing the lobular component?
Abstract a single primary using Rule M13. Assign 8523/3 using rule H29. The code for invasive ductal carcinoma with tubular features (8523/3) is higher than the code for invasive lobular carcinoma (8520/3). H28 does not apply because 8523/3 is not included as a type of duct carcinoma on Table 2.
MP/H Rules/Histology--Bladder: Can the histology for a high grade urothelial carcinoma described as having "extensive sarcomatoid dedifferentiation" be coded to sarcomatoid transitional cell carcinoma (8122/3)?
Example; TURBT, Final Diagnosis - Urothelial carcinoma, high grade. Type/grade comment: Extensive sarcomatoid dedifferentiation is present (40-50% of tumor volume).
Code high grade urothelial carcinoma described as having "extensive sarcomatoid dedifferentiation" to sarcomatoid transitional cell carcinoma (8122/3).
Reportability/MP/H Rules/Histology--Ovary: What is the histology code for an ovarian tumor described as a mucinous borderline tumor, intestinal type?
Mucinous borderline tumor, intestinal type, of the ovary is not reportable. The behavior is /1. There is no applicable histology code for this histology when it ocurs in the ovary.
MP/H Rules/Multiple primaries--Melanoma: How many melanoma primaries should be abstracted if, during the workup for a metastatic melanoma of an unknown cutaneous site, an in situ melanoma is also discovered? See Discussion.
Patient has diagnosis of melanoma with spindle cell features found in a right lower lobectomy specimen. Chart notes indicate this is metastatic from a cutaneous primary of unknown site. Further work up includes a biopsy of the tip of the nose, which is diagnostic for in situ melanoma. Should this be abstracted as two separate primaries, one for an invasive melanoma of unknown primary site and the other for an in situ melanoma of the skin on the tip of the nose? Which MP/H Rule would apply?
Yes, abstract this as two separate primaries, an invasive melanoma of unknown primary site and an in situ melanoma of the skin on the tip of the nose. Rule M3 applies.
Grade/Sarcoma--Breast: Is the correct grade for high grade angiosarcoma of the breast a code 3 or 4? The breast usually uses a three grade system but sarcoma is not a typical histologic type of the breast.
Assign grade code 4 using the sarcoma table. Nottingham or Bloom-Richardson (BR) Score/Grade does not apply to angiosarcomas. This is a good question and points out needed clarification of the grade rules.
Reportability--Carcinoid: Is a diagnosis of carcinoid heart disease, based solely on clinical information and no pathology, reportable?
Carcinoid heart disease is not reportable but this diagnosis indicates that the patient likely has a carcinoid tumor which may be reportable. Obtain further information.
MP/H Rules/Histology--Breast: What histology code and MP/H Rule applies to the Histologic Type of "invasive ductal carcinoma with metaplastic stroma" for a single breast tumor? See Discussion.
The patient had a partial mastectomy with final diagnosis of invasive ductal carcinoma with metaplastic stroma. Knowing that metaplastic breast carcinoma has a worse prognosis than other types of breast cancer, is metaplastic stroma a synonym for metaplastic carcinoma when used in this context?
Code to metaplastic carcinoma, 8575/3. According to our expert pathologist consultant, "The term 'metaplastic stroma' implies that at least a portion of the carcinoma has undergone a 'metaplastic' change from epithelial in appearance to 'stromal' in appearance. I assume this is what CAP means by 'Invasive mammary carcinoma with matrix production,' which the WHO equates to metaplastic carcinoma."
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