MP/H Rules/Histology--Head & Neck: Please clarify rule H3. The first statement is "Do not code terms that do not appear in the histology description". The second statement is "Do not code...unless the words...appear in the final diagnosis"
One of our pathology labs frequently will state "keratinizing squamous cell" in the microscopic description (histologic description), but only state "squamous cell carcinoma" in the final diagnosis. May we code from the histologic description if it's not in the final diagnosis?
Follow rule H3 and code squamous cell carcinoma for these cases unless you can obtain confirmation that these cases should be coded keratinizing squamous cell carcinoma from the lab and/or pathologist. Document this confirmation in your policies and procedures.
The MP/H rules were written with input from leading pathologists in each specialty area. Based on their expert opinion, we instruct registrars to code histology based on the information in the final diagnosis. The microscopic description may contain other terms, but the pathologist lists only the pertinent terms in the final diagnosis.
Primary Site--Skin: Should cutaneous leiomyosarcoma be coded to primary skin of site (C44_) or soft tissue (C49_)?
Code cutanteous leiomyosarcoma to skin. Leiomyosarcoma can originate in the smooth muscle of the dermis. The WHO classification designates this as cutaneous leiomyosarcoma. The major portion of the tumor is in the dermis, although subcutaneous extension is present in some cases.
Reportability--Skin: Is this case not reportable if the intranasal polyp is covered with cutaneous epithelium (essentially skin) or, is it reportable as a primary intranasal basal cell carcinoma? I have found one article regarding primary intranasal basal cells, which are described as being "very rare". But, I am not sure whether, in those cases, cutaneous epithelium was found.
FINAL DIAGNOSIS: (A) Nasal cavity, polyp, excision: Sinonasal inflammatory polyp with overlying cutaneous epithelium showing foci of superficial (noninvasive) basal cell carcinoma
Report this case as a basal cell carcinoma, noninvasive, of the nasal cavity, based on the information provided.
The polyp was removed from the nasal cavity (C300) which is a reportable site for basal cell carcinoma.
Reportability: Is penile intraepithelial neoplasia, differentiated type, reportable? See discussion.
Foreskin circumcision shows: Penile intraepithelial neoplasia, differentiated type (differentiated PeIN). If reportable, how would the histology and behavior be coded? Is this behavior /2?
For cases diagnosed 2018 and later
Differentiated penile intraepithelial neoplasia (differentiated PeIN), is reportable (8071/2).
Please note: Penile intraepithelial neoplasia, grade 3 (PeIN 3) is also reportable to SEER (C600-C609, 8077/2).
MP/H/Histology--Lung: Would you code a lung primary of "non-small cell carcinoma with neuroendocrine differentiation" to non-small cell carcinoma (8046/3) or carcinoma with neuroendocrine differentiation (8574/3)? See discussion.
The pathology report states "Right mediastinal mass: poorly differentiated non-small cell carcinoma with neuroendocrine differentiation." This is the only histologic confirmation of this lung primary that is collected.
Code carcinoma with neuroendocrine differentiation (8574/3). MP/H rule H7 applies: code the higher ICD-O-3 code. There is non-small cell lung carcinoma (8046/3) and a carcinoma, NOS with neuroendocrine differentiation present (8574/3).
Reportability/MP/H Rules: Where can I find documentation on how to accession malignant tumors in transplanted organs? See discussion.
A patient was diagnosed with hepatocellular cancer (HCC) in 2010, and underwent a hepatectomy, and then received a donor liver. In 2014, HCC was discovered in the liver once again. This likely is a new primary, but there are no specific rules to cover this. There are many odd situations involving transplanted organs, many of which pose reportability and multiple primary problems.
Accession the new tumor in the transplanted organ as you would any other new/second primary. As transplants have become more common especially for liver, lung, and kidney, we are seeing more of these types of cases. We are adding instructions to the revised MP/H rules on coding subsequent primaries when they occur in a transplanted organ. We are also looking at adding a data field that will identify cancers/tumors which arose in a transplanted organ. We feel this is important to track for analysis. Until the revised MP/H rules are implemented, we will look at adding general coding instructions to the SEER Program Manual for transplants.
Primary Site--Sarcoma: What is the best primary site code for an undifferentiated sarcoma of the pulmonary artery? See discussion.
Consolidation of the case: The operating hospital stated: SOFT TISSUE: Resection: Procedure: Radical resection Other: Pneumonectomy Tumor Site: Right pulmonary artery - They used code C383 (mediastinum NOS). The consulting hospital stated: Lung, right, pneumonectomy: High grade sarcoma consistent with intimal sarcoma; tumor involves pulmonary artery. They used code C449 (other soft tissue NOS). Would C493 (soft tissue thorax) be correct?
Code the primary site to pulmonary artery, C493. According to the WHO classification of tumors, intimal sarcomas are malignant mesenchymal tumors arising in large blood vessels. They show mostly intraluminal growth with obstruction of the vessel. They may occur in the pulmonary vessels or, less often, in the aorta.
Grade--Breast: Do you take grade from the most representative specimen along with the histology? What is the correct histology/grade combination? See discussion.
Breast biopsy (from hospital A): DCIS, solid, cribriform, comedo type, high nuclear grade
MP/H rules are to code histology based on the specimen with the most tumor tissue. That would be the lumpectomy in this case. The histology is DCIS, cribriform type.
The general rule for grade is to code the highest grade specified within the applicable grading system. For the case information provided, follow instruction #5, nuclear grade: use Coding for Solid Tumors #7: 2-, 3-, or 4- grade system. High nuclear grade (grade code 3 for breast) is higher than nuclear grade 1 (grade code 1).
First course treatment/Hormone Therapy--Lung: How is this field coded when the patient receives Prednisone for a metastatic lung adenocarcinoma? See Discussion.
The SEER*Rx Database, Prednisone Primary Site indicates "Prednisone is used to treat multiple sites and histologies." The Remarks information states, "Prednisone may be coded as treatment (hormonal) for all sites and histologies. It is most often used as part of a drug regimen." While it is clear that Prednisone is coded as hormone therapy when administered as part of a drug regimen like CHOP, how is Prednisone coded when given outside of a drug regimen? Also, how is Prednisone coded for cancer-directed treatment of a metastatic lung primary? The NCI's PDQ does not list hormone therapy as cancer-directed treatment for a Stage IV lung adenocarcinoma.
In our specific case, Prednisone was started just after diagnosis, and before the completion of work-up proving distant metastasis. Often, Prednisone (or another hormone agent) is given as an ancillary treatment for the symptoms associated with the malignancy, and not as cancer-directed treatment.
Do not code Prednisone when it is given for symptoms. In most cases when Prednisone is given by iteself, not as part of a drug regimen, it does not affect the cancer and would not be coded as treatment.