Surgery of primary site--Lung: Should microwave ablation be coded as treatment for lung cancer, and if so, how should it be coded?
Code microwave tumor ablation as surgery. For lung, assign code 15.
This question was discussed by the technical advisory group – a small group of representatives from each standard setter which meets periodically. The group agreed on this consensus answer.
Systemic/Surgery Sequence: Does the Systemic/Surgery Sequence field apply to only the first surgery performed (Date of First Surgical Procedure) or does it apply to the most definitive surgery (Date Most Definitive Surgery) as well? See Discussion.
Example: Bladder primary with transurethral resection of the bladder tumor (TURBT) on 2/17/2017 (Date of First Surgical Proc) followed by a second TURBT on 3/24/2017 (Date Most Definitive Surgery) with mitomycin C instilled on the second, most definitive TURB procedure.
There is an edit failure (IFX166) when Systemic/Surgery Sequence is coded 5 (intra-operative systemic) and Systemic Date does not match Date of First Surgical Procedure. How should we capture the intra-operative systemic treatment during the second, most definitive TURB? Is the correct Surgery/Systemic Sequence code 3 (systemic after surgery) for this case because (intra-operative) chemo was technically given after the first surgery?
Assign code 3 to Systemic/Surgery Sequence and document the intraoperative treatment in the text field. Surgery is defined as a Surgical Procedure to the Primary Site (codes 10-90), Scope of RLN Surgery (codes 1-7), or Surgical Procedure of Other Site (codes 1-5) in the 2018 SEER Manual. In this case, the treatment was after the first surgical procedure.
Systemic/Surgery Sequence: The note associated with code 4 in Systemic Treatment/Surgery Sequence in the 2018 SEER Manual says: Code 4 is intended for situations with at least two episodes or courses of systemic therapy. Does this mean two different types of systemic therapy before and after surgery? See Discussion.
For example, chemotherapy and immunotherapy administered first, followed by surgery, then immunotherapy and hormone therapy after surgery. Or is code 4 used for two administrations of chemotherapy before surgery and two more courses after surgery?
Assign code 4 for the example you describe. Code 4 also applies to cases with one course of chemotherapy before surgery and another course after surgery.
Terminology/EOD-Extension--Prostate: How does SEER define the prostatic "apex"? See discussion.
Some pathologists define the prostatic apex as including the bottom third of the prostate whereas others regard only the bottom-most portion of the gland to be the apex.
SEER defines the apex as being the bottom-most portion of the gland. Apex means "narrowest part," which in the prostate would be the bottom-most portion of the gland.
Terms of involvement--Lung: Is "intense uptake" described on a PET scan an indication of involvement? See Description.
We are seeing increasing use of PET scans as diagnostic tools for cancer. PET scans use different terminology than the ambiguous terms listed in the EOD manual. Could we please have guidelines for interpreting PET scans?
Example: Patient with right lung cancer. PET scan showed intense uptake in the mediastinum and in the hilum. Can we code "intense uptake" as involvement of mediastinal and hilar lymph nodes?
Do not interpret "intense uptake" as involvement. Look for a statement of involvement or other terminology, such as "highly suspicious," "strongly suspicious for" malignancy, involvement, etc.
Tumor Size--Clinical--Breast: Does information from any type of biopsy take precedence over an imaging report? See Discussion.
For example, a patient has a 2.6 cm breast tumor on MRI; a core biopsy measuring 0.7 cm is positive for infiltrating duct carcinoma. Rule #1 states "Use the largest measurement of the primary tumor from physical exam, imaging, or other diagnostic procedures before any form of treatment." However, Rule #9 seems to imply that size from an "incisional biopsy" takes precedence over imaging, even though it is known to be less than the entire tumor in size.
We do not recommend using the size from a core biopsy for clinical tumor size. A core biopsy does not necessarily obtain enough tissue to know the actual tumor size. Since there is imaging for this patient, it is preferable to record clinical tumor size from the imaging report in this case.
The instructions will be clarified in the next revision of the SEER manual.
Tumor Size--Clinical/EOD 2018--Prostate: How is Tumor Size--Clinical coded when there is an incidental finding of prostate cancer on prostatectomy for another reason? See Discussion.
SEER*RSA states EOD Primary Tumor should be coded to 800 for an incidental finding of prostate cancer on prostatectomy for other reasons.
The SEER Manual states to assign code 000 for Tumor Size--Clinical when EOD Primary Tumor is coded to 800; however, the definition for Tumor Size--Clinical indicates clinical classification is composed only of diagnostic workup prior to treatment.
If there is no clinical workup for an incidental finding of prostate cancer, code 000 does not seem appropriate (does not meet criteria for clinical classification). Code 999 seems more appropriate for incidental findings during surgery for other reasons. The SEER Manual does not provide this exception in the current instruction.
Assign code 000 for Tumor Size--Clinical when EOD Primary Tumor is coded 800 (No evidence of primary tumor). Code 000 indicates no tumor was found since there was no clinical workup to identify this incidentally found cancer. This is a special instruction for cases coded 800 in EOD Primary Tumor. Text fields can be used to record details.
Tumor Size--Esophagus: Can information from the endoscopy procedure that implies a size of 3 cm for Tumor Size--Clinical be used for Esophagus? See Discussion.
1-28-2018 CT Scan: 2.4 cm mass
2-15-2018 Endoscopy: Mass was present 22 to 25 cm. Biopsies were taken with cold forceps for histology; biopsy positive.
For the case you describe, we would record the clinical tumor size stated on the CT report.
The priority order for clinical tumor size is as follows.
1. Biopsy or operative (surgical exploration) report
2. Imaging
3. Physical exam
We do not recommend coding tumor size based on an inferred tumor size from a description such as "Mass was present 22 to 25 cm." Look for an actual measurement of the mass, or a stated tumor size. Use text fields to record details.
Tumor Size--Pathologic--Anus: In 2019, the pathology report of an anal canal squamous cell carcinoma stated the tumor size is 2.5 cm from proximal to distal (3.5 cm in circumference). Is the pathologic tumor size tumor size 025 or 035?
Based on the information provided, code the tumor size as 035. We asked an expert pathologist to review this question and she said to use the larger measurement. She also said "the pathologist usually cuts the anus and rectum open like a tube; the “circumference” would be measured flat."
Tumor Size--Pathologic/EOD 2018: How is Tumor Size--Pathologic coded when Extent of Disease (EOD) Primary Tumor is 800 (No evidence of primary tumor) and there has been no surgery to the primary site? See Discussion.
The SEER Manual states to assign Tumor Size--Pathological code 000 when EOD Primary Tumor is coded to 800 (No evidence of primary tumor) for any schema. However, the definition of Tumor Size--Pathologic states that it records the size of a solid primary tumor that has been resected.
If the primary site has not been resected (does not meet the pathologic staging criteria), then it seems that Tumor Size Pathologic should be 999 when EOD Primary Tumor is coded as 800.
Assign code 999 for Tumor Size--Pathologic when there is no surgery of the primary site. Code 999 includes "No excisional biopsy or tumor resection done."
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