Report | Question ID | Question | Discussion | Answer | Year |
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20150013 | Surgery of Primary Site: What is the most extensive, invasive or definitive surgical procedure when the second surgical procedure performed has a lower surgery code? See discussion.
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Examples
8/xx/13 TURBT with path specimen (27): Papillary Urothelial Carcinoma, HG 9/xx/13 Bladder fulgeration w/o path specimen (12)
5/xx/14 Segmental Mastectomy(24): Ductal carcinoma with <1mm marg 6/xx/14 Breast Re-excision (23): Residual ductal carcinoma 1.5mm, marg neg |
The code in Surgical Procedure of Primary Site should correspond to the most invasive, extensive, or definitive surgery when the patient has multiple surgical procedures of the primary site even if there is no residual tumor found in the pathologic specimen from the more extensive surgery. The timing of the procedures does not affect the code choice.
Assign code 27 for the first example. Assign code 24 for the second example. |
2015 |
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20150019 | Reportability/Histology--Pancreas: Is well-differentiated neuroendocrine tumor (M8240/3) as stated on a pathology report reportable or can the clinical information be used as an adjunct to the path report, which further states the specific type of neuroendocrine tumor is an Insulinoma, therefore, NOT reportable (M8151/0)? See discussion. |
The diagnosis date is 2/24/14. The pathology report of the pancreas shows: Well-differentiated neuroendocrine tumor (NET), low grade (WHO G1 of 3). Addendum: Ki-67 confirms low grade of pancreatic endocrine tumor (less than 2% Ki-67/MIB-1 index). Chromogranin confirms the endocrine nature of the tumor. The Pre and Post Op Diagnosis is pancreatic neuroendocrine tumor consistent with insulinoma. AJCC Stage as noted on path report: pT1, pNX, pM.
The physician states: The patient has a well-documented insulinoma. Biochemistries confirmed the disease and it is localized in the tail of the pancreas.
The issue with NETs is that pathology report reflects what is seen or what is quantified under the microscope; often, there is a specimen without the accompanying medical history and clinical signs. Many of these NETs are specified on the basis of the hormone, as usually measured in the blood, that is overproduced, something not seen microscopically. All of the islet cell tumors are NETs. The insulinoma in the example above is a well-differentiated NET that is causing insulin to be over-produced. Thus, the diagnoses are not discordant; insulinoma is a more specific NET. |
When the pathology diagnosis is a neuroendocrine tumor (/3) and the clinical diagnosis is an insulinoma (/0), report the case. Although ICD-O-3 classifies insulinoma as /0, the most recent WHO classification lists it as /3. The pathologist and physicians for this case are likely guided by the WHO classification and as a result, would view both the NET diagnosis and the insulinoma diagnosis as malignant. You could report this case as 8240/3 or 8151/3. |
2015 |
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20150055 | Multiple primaries--Heme & Lymphoid Neoplasms: Is this 2 primaries? In 2011, a patient had a spinal mass biopsied positive for DLBCL and follicular lymphoma. The heme rules make this one primary coded as DLBCL. Patient had 2 rounds of chemo, but in 2014, he had a recurrent tumor in the same location. The 2014 biopsy was follicular lymphoma. Is this a new primary -- conversion of acute to chronic after treatment? Or is it the same, since FL was diagnosed in the original specimen? |
Rule M13 applies, abstract as two primaries. Since both DLBCL and FL were present in 2011, rule M2 does not fit -- not a single histology. Rule M13 reflects the situation in this case much better: an acute neoplasm which was treated and a chronic neoplasm diagnosed later. |
2015 | |
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20150031 | MP/H Rules/Multiple primaries--Colon: This is an unusual case of multifocal colon cancer. The case is staged pT4b,N1b. Per our MP rules, this will be 4 separate primaries. Would this be an exception to the rules; if not now, possibly in future versions of the MP rules for colon cancer? See discussion. |
The path report reads: COMMENT: There is multifocal involvement throughout both bowel segments which combined represent a subtotal colectomy procedure. There are at least 11 tumors, all of which are histologically similar. Given the unusual gross appearance, a representative portion of the largest mass (hepatic flexure) was forwarded to _____ for flow cytometric evaluation. There is chronic active colitis in the background suggestive of idiopathic inflammatory bowel disease, specifically ulcerative colitis. However, no dysplasia is seen in multiple random sections of grossly benign large bowel. ADDENDUM from expert gastroenterologist: The carcinomas are poorly differentiated without specific histologic features but are consistent with colon primaries. These findings are consistent with an MLH1-deficient carcinoma. Given the background chronic active colitis consistent with ulcerative colitis, this likely represents colitis-associated neoplasia which can be associated with multifocality. |
This unusual case of multifocal colon cancer is not an exception to the MP/H rules currently.
The current WHO classification for colon tumors mentions ulcerative colitis (UC) associated colorectal cancers and states they are often multiple. This will be discussed for the next version of the MP/H rules. |
2015 |
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20150034 | MP/H/Histology/neuroendocrine : How should the following histologies with neuroendocrine differentiation be coded?
1. Bladder - Invasive urothelial carcinoma with neuroendocrine differentiation
2. Nasopharnyx - Undifferentiated nonkeratinizing nasopharyngeal carcinoma with neuroendocrine differentiation
3. Ductal carcinoma in situ (with neuroendocrine features) cribriform and solid patterns
See discussion. |
We are starting to see more specific histologies with neuroendocrine differentiation. How are we to deal with these histologies and will this be addressed in the revised MP/H rules? |
The term neuroendocrine is often included with other histologies and usually means that neuroendocrine cells are present but not neuroendocrine tumor.
1. If the neuroendocrine cells are stated to be either small cell or large cell, code that histology; however, neuroendocrine, NOS mixed with urothelial does not have an applicable mixed code. Code histology to 8120.
2. Code histology to squamous cell carcinoma, nonkeratinizing, NOS (8072/3). The neuroendocrine component is not specified as either small cell or large cell.
3. Code to 8523/2 per MP/H Rule H6 as intraductal mixed with other types of carcinoma present.
Note that while neuroendocrine differentiation can be identified, it seems to have no prognostic implications. We have consulted with our site specific Subject Matter Experts on how best to capture neuroendocrine, NOS when combined with other histologies. These instructions will be included in the revision of the MP/H rules including the wording of MP/H breast rule H6. |
2015 |
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20150040 | Surgery of Primary Site--Pleura: How is this field coded if the patient underwent an exploratory thoracotomy with partial decortication that excised some, but not all, of the pleural mesothelioma tumors? See Discussion. |
This patient underwent a "partial decortication" per the operative report. While the operative report does not specifically note that this was performed with a partial pleurectomy, it appears the patient had a partial pleurectomy because the largest specimen removed was a "pleural peel" specimen, which included the parietal and visceral pleural surfaces with a small amount of underlying lung tissue. The operative report notes the patient had involvement of both the lung and chest wall. A total resection was not possible due to the extent of the tumor. However, this patient does appear to have undergone at least a partial resection of the pleura/tumor burden. The patient did not simply undergo a pleurodesis to free adhesions. Per the NCI's PDQ, pleurectomy and decortication are performed together. Because the operative report and pathology report only called this procedure a "partial decortication" without specifically mentioning a pleurectomy, would this be coded as a tumor excision (surgery code 20)? Or should we assume the procedure is best coded as a partial pleurectomy and decortication and use code 30 (simple/partial resection)? |
Read the operative report and the pathology report and assign the surgery code that best represents the extent of the surgery. In this case, code 30 seems most appropriate. Do not assign the surgery code based only on the name of the procedure; use all information available to chose the most representative code. |
2015 |
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20150041 | MP/H Rules/Multiple primaries--Breast: Does rule M10 apply in this situation?
L breast biopsy = INVASIVE DUCTAL CARCINOMA
L breast simple mastectomy = 2.0 cm INVASIVE DUCTAL CARCINOMA with an incidental finding of separate 1.0 cm INVASIVE LOBULAR CARCINOMA; pathologist specifically states the tumors are morphologically different. The tumors are both pure Ductal/pure Lobular. |
Yes, Breast rule M10 applies. This case is a single primary.
Follow the MP/H rules even though the "pathologist specifically states the tumors are morphologically different" so that situations like this are reported consistenty accross cancer registries, regions, and states for consistent national reporting. |
2015 | |
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20150026 | First course treatment--Breast: When Lupron is given as cancer-directed treatment for metastatic breast cancer, should it be coded as Hormone Therapy or Other Therapy? See Discussion. |
Per the SEER*Rx Database, Lupron is coded as Other Therapy for breast cancer until such time that it receives FDA approval. However, SINQ 20021042 states Lupron should be coded as Hormone Therapy when given as cancer-directed therapy. These two sources contradict each other.
Information regarding hormone therapy for breast cancer in both the SEER*Rx Database and the National Cancer Institute's Cancer Topics website (http://www.cancer.gov/types/breast/breast-hormone-therapy-fact-sheet) seem to indicate that the SINQ answer is the correct choice. The NCI Cancer Topics website states that Lupron acts to block ovarian function and is an example of an ovarian suppression drug that has been approved by the FDA. The SEER*Rx Database Remarks section states that a combination of letrozole and leuprolide (Lupron) "is considered standard treatment for metastatic breast cancer and is sometimes used for treatment of early stage breast cancer." But the Remarks go on to state that Lupron should be coded as Other Therapy until it receives FDA approval.
It is unclear how to code Lupron for breast cancers when the NCI website indicates that it is standard treatment while the SEER*Rx Database states both that it is and that it is not standard treatment. |
Code Lupron given for breast cancer in the "Other" treatment field using code 6 (other-unproven). Lupron is still not an approved hormone treatment for breast cancer and should not be coded in the hormone field.
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2015 |
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20150020 | Reportability/Primary site--Skin: Is a basal cell carcinoma of the lip "ever" reportable and if so, what would need to be documented or seen? See discussion. |
There is a 1988 case that hit the SEER edits for other reasons but not because of that site/histo combination (C000 and 8090/3); however, there is no text. Per a Dataminer query, there are 42 cases in the state database with C000-C009 and 8090. On review, a few did have a mention of the word "upper lip/mucosa" in the PE text or OP findings (not path because a lot of these are removed in the MD office and we don't see the path report). Other times, there is no mention but the abstractor used the C00 codes instead of C44 so the cases get through. SINQ #20031110 addresses this in relation to C000, Lip, NOS but we want to know if this answer meant you would never report a basal carcinoma lip case period (even if there is a mention of mucosa or any mention of mucosa in the path report). Are there any exceptions? It seems if you would never report a basal lip carcinoma, then SEER would block those cases from being reported/submitted and the wording would be stronger in the SEER manual. Right now the reportability only addresses if someone codes C44 but if someone decides to use C00 codes then it is allowed. Under Primary Site, there is even a listing under 12 for "absence of any additional information" and lists "Colored / lipstick portion of upper lip" as code C000. |
BCC of lip C00_ is rare and requires a statement that the tumor is on the vermilion border (rather than skin) to be coded C00_ and to be reported. Our expert pathologist consultant refers to an article in the Am Acad Dermatol 2004; 50(3): 384-387. |
2015 |
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20150044 | Reportability--Ovary: Is micropapillary serous carcinoma (MPSC) of the ovary reportable? What are the differences between “noninvasive" and “low malignant potential?" See discussion. |
Pathology report reads left ovary: noninvasive low grade (micropapillary) serous carcinoma (MPSC), fragmented; right ovarian excrescence and posterior cul-de-sac: noninvasive implants identified; right ovary: noninvasive low grade (micropapillary) serous carcinoma (MPSC), scattered autoimplants (noninvasive); tumor is present on ovarian surface, noninvasive autoimplants |
Noninvasive low grade (micropapillary) serous carcinoma (MPSC) of the ovary is reportable. Assign code 8460/2, applying the ICD-O-3 matrix concept to this noninvasive carcinoma. Noninvasive can be used as a synonym for in situ, ICD-O-3 behavior code /2. See page 66 in the softcover ICD-O-3. Low malignant potential (LMP) means that the neoplasm is not malignant, but has some chance of behaving in a malignant fashion. LMP can be used as a synonym for ICD-O-3 behavior code /1, see page 66. |
2015 |