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20160019 | Reportability--Lung: Is a case of pulmonary metastatic leiomyoma (favored) vs. low grade leiomyosarcoma reportable, and if so, what is the primary site and histology code? See Discussion. |
Patient presents with an abnormal chest x-ray. PET reveals 4.6 cm left lower lobe mass and several additional bilateral nodules measuring up to 1.6 cm. Biopsy was recommended and is positive for metastatic histologically benign smooth muscle neoplasm. ER/PR are positive. Mayo consult on biopsy agrees with histology. The differential diagnosis includes benign metastasizing leiomyoma and low grade leiomyosarcoma. Comment: If these nodules remain small and do not progressively grow would consider this metastasizing leiomyoma. Physicians state bilateral pulmonary metastatic leiomyoma (favored) vs low grade leiomyosarcoma. Tamoxifen was started. Patient has a history of uterine fibroids. Several months later, imaging reveals stable bilateral multi pulmonary nodules and left lower lobe mass but persistent. Surgery was recommended but cancelled due to insurance. |
This case is not reportable based on the information provided. The histologic diagnosis is "metastatic histologically benign smooth muscle neoplasm." The physicians seem to agree with the histologic diagnosis, benign metastasizing leiomyoma (BML). The WHO classification and ICD-O-3 assign 8898/1 to "metastasizing leiomyoma." WHO states "This resembles a typical leiomyoma but it is found in the lungs of women with a history of typical uterine leiomyomas." A recent article states "Because of the hormone-sensitive characteristics of BML, treatments are based on hormonal manipulation along with either surgical or medical oophorectomy." Tamoxifen treatment is in keeping with the BML diagnosis. |
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20160070 | Primary site/MP/H Rules/Histology: What is the appropriate site and histology code for a tumor described as a "Large mass In suprasellar cistern encroaching into sphenoid & ethmoid sinuses", with the pathology described as "INI-1 deficient sinonasal undifferentiated carcinoma"? Of note, this patient has a history of a pituitary adenoma, resected overseas a few months prior to this diagnosis. |
The primary site is unclear. The lesion is intracranial, but this may not be the primary site. In the absence of any additional information, assign C390, 8020/3. According to WHO, sinonasal undifferentiated carcinoma can involve the nasal cavity, maxillary antrum, and/or ethmoid sinus.
SMARCB1 (INI-1) is a tumor-suppressor gene located on chromosome 22q11.2. Tumors that showed loss of expression were SMARCB1-deficient tumors which are characterized by nests, sheets, and cords of cells without any histologic evidence of specific (eg, squamous or glandular) differentiation. |
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20160024 | Reportability--Melanoma: Please explain how a CTR is to interpret the guideline in the MP/H rules (Cutaneous Melanoma): Evolving melanoma (borderline evolving melanoma): Evolving melanoma are tumors of uncertain biologic behavior. Histological changes of borderline evolving melanoma are too subtle for a definitive diagnosis of melanoma in situ. Is this to mean that evolving melanoma in situ is not reportable? Or should we follow the guidelines in SEER Question 20130022 that states the reportability terms for melanoma and melanoma in situ. |
Follow the guidelines in SINQ 20130022 for now. When the MP/H rules are revised, new instructions will be implemented.
See also SINQ 200120078 and 20110069. |
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20160057 | MP/H Rules/Histology--Prostate: What is the histology code for a prostate case whose histology reads “adenoca with mixed ductal and acinar variants? |
Assign 8523/3.
The 2013 revision to ICD-O-3 has a new code for mixed acinar ductal carcinoma; however, this new code will not be implemented in the U.S. until 2018 or later. Page 7 of the Guidelines for ICD-O-3 Update Implementation document released by NAACCR 1/1/2014 instructs us to use 8523/3 in the meantime. |
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20160061 | Reportability/Behavior--Small intestine: Is a carcinoid tumor, described as benign, reportable? See Discussion.
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A segmental resection pathology report states "benign mucosal endocrine proliferation consistent with a 0.3 cm duodenal carcinoid tumor." The diagnosis comment further states, "the separate small endocrine lesion is histologically benign, consistent with a 3 mm carcinoid tumor." This seems to be an example of a description of a microcarcinoid tumor referenced in SINQ 20160011. However, in this new case the pathologist specifically states the tumor is benign.
The WHO definition of microcarcinoid indicates this is a precursor lesion, which seems to indicate it is not malignant. However, SEER's previous answer stated we should report these tumors because the ICD-O-3 definition of carcinoid is 8240/3. Do you think that the mention of the term "benign" in the pathology report is actually related to the size of this lesion? Is the reference to benign mucosal endocrine proliferation referring to the WHO classification (making the case reportable as stated in SINQ 20160011), or is this a situation in which we should apply the Matrix Rule and the case is nonreportable? |
This carcinoid tumor, described as benign, is not reportable. According to our expert pathologist consultant, this case is not reportable because the pathologist uses "benign" to describe the mucosal endocrine proliferation and based on that, the neuroendocrine cell proliferation is hyperplasia/benign - not reportable. |
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20160075 | MP/H Rules/Histology--Breast: What histology code(s) and MP/H rule applies for a breast resection final diagnosis of "undifferentiated sarcoma associated with a malignant phyllodes tumor and a tumor size of approximately 7 x 6.5 x 4 cm"? (The tumor is primarily sarcoma, with the phyllodes tumor measuring 2.8 cm)? See Discussion. |
Patient has a diagnosis of undifferentiated sarcoma with an associated malignant phyllodes tumor in a single mass. Should this be abstracted as two primaries, one for an undifferentiated sarcoma and the other for a malignant phyllodes tumor? Which MP/H rule applies? |
Abstract a single primary. Based on the information provided, this is a single tumor, and therefore a single primary, Rule M3. Code the histology to malignant phyllodes tumor. According to our expert pathologist consultant, "The presence of a phyllodes tumor component identifies the whole thing as such. Stromal overgrowth/sarcoma is the usual identifier of malignancy in a phyllodes tumor. (If there were no phyllodes component we would be left with undifferentiated sarcoma, but that is not the case here. The diagnosis of malignancy in phyllodes tumor may be difficult/problematic when there is no overt stromal/sarcoma overgrowth as in this case.) As an aside, the behaviors of pure sarcoma and a phyllodes tumor such as we have here are similar, but we would lose the primary diagnosis if we just called this sarcoma." |
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20160079 | First course treatment/Chemotherapy: Is metronomic chemotherapy coded as chemotherapy? |
Code metronomic chemotherapy as chemotherapy. Metronomic chemotherapy, also referred to as low-dose metronomic (LDM) chemotherapy, is an emerging cancer treatment approach which administers relatively low doses of traditional chemotherapy drugs over a long period of time and without ‘breaks’ in treatment. By using lower doses this method of treatment minimizes the side effects of traditional chemotherapy. |
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20160039 | First course treatment/Surgery of Primary Site: If a procedure stated to be an "excisional biopsy" doesn't grossly remove the tumor, should Surgery of Primary Site be coded as an excisional biopsy? See Discussion for example. |
Would you code an excisional biopsy as Surgery for the following case?
The patient presented with a large protruding polypoid anal canal mass. The diagnosis of malignancy was made following a procedure referred to by the surgeon as an excisional biopsy. The protruding portion of the anal canal mass was excised, but the deep margin was grossly involved. The PE exam after the "excisional biopsy" found a firm mass, 4 cm in length on DRE. Further work-up with imaging showed gross residual disease extending to adjacent skeletal muscle (external anal sphincter). Although the internal/protruding anal canal portion of the tumor was excised, there was clearly extensive residual tumor. The patient underwent definitive concurrent chemoradiation only; subsequent surgery was not planned or performed. |
Do not record this excisional biopsy as surgery because there was residual macroscopic tumor. See Note 1 under #4 on page 130 in the SEER manual, http://seer.cancer.gov/manuals/2015/SPCSM_2015_maindoc.pdf |
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20160021 | Primary Site--Stomach: How do I code the primary site when the operative report and pathology report state that the tumor site is incisura of the stomach? |
Assign C163. Incisura, incisura angularis, gastric angular notch, angular incisure of stomach all refer to the sharp angular depression in the lesser curvature of the stomach at the junction of the body with the pyloric canal. See Gastric angular notch in #12 on page 76 in the SEER manual, http://seer.cancer.gov/manuals/2015/SPCSM_2015_maindoc.pdf. See also the SEER training website, #12 on the illustration corresponds to the angular notch, http://training.seer.cancer.gov/ugi/anatomy/stomach.html. We will correct the key for this illustration. |
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20160025 | MP/H Rules/Histology: What is the correct histology code for a NUT midline carcinoma? |
Code histology to 8010/3.
NUT carcinoma is identified by the NUTM1 gene rearrangement.
NUT midline carcinomas (NMC) are lethal and morphologically indistinguishable from other poorly diff carcinomas. They are epithelial tumors which can range from undifferentiated carcinomas to carcinomas with prominent squamous differentiation.
A new proposed ICD-O-3 code has been suggested for NUT tumors but it is not yet approved for implementation. Do not use the new code until it is approved for use in the United States.
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