Primary Site--Breast: Is there a hierarchy for coding subsite for breast cases when there is conflicting information in the physical exam, mammogram, operative and pathology reports as to the exact location of the primary? See discussion.
Example: Two mammograms were performed. One report indicates the lesion is at 12:00 and the other indicates it is in the upper central quadrant. However, the pathology report from the modified radical mastectomy specimen indicates the mass is in the UIQ.
According to one of our physicians, when a pathologist has a mastectomy specimen with attached axillary contents, the location of the lesion (subsite) is very accurate.
Code the Primary Site field to C50.2 [upper inner quadrant]. In general, the priority for using information is pathologic, operative, and clinical findings. The pathology report would take precedence in this case.
The 2004 SEER Program Code manual will include the following instructions for determining breast subsite.
Priority Order for Coding Subsites
Use the information from reports in the following priority order to code a subsite when the medical record contains conflicting information:
1 Pathology report
2 Operative report
3 Physical examination
4 Mammogram, ultrasound
If the pathology proves invasive tumor in one subsite and insitu tumor in all other involved subsites, code to the subsite involved with invasive tumor.
Primary Site--Breast: What subsite code should be used for a diagnosis of "inflammatory carcinoma"?
Code the Primary Site field to C50.9 [Breast, NOS] for a breast primary presenting with inflammatory cancer unless there is a palpable mass within the breast. If there is a palpable mass, code the primary site to the position of the mass.
Primary Site--Breast: What subsite is to be coded for a case of invasive Paget disease of the nipple with an infiltrating ductal carcinoma of the lower inner quadrant?
Code C50.9 [Breast, NOS]. Code the last digit of the primary site to '9' for single primaries when multiple tumors arise in different subsites of the same anatomic site and the point of origin cannot be determined. Nipple [C50.0] and LIQ [C50.3] fit this rule. This is a single primary per MP/H Breast Rule M9.
Primary site--CLL/SLL: How is the primary site coded and what rule applies when no bone marrow biopsy is performed on a patient diagnosed with chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) which was based on the results of an axillary biopsy, positive peripheral blood and a CT scan showing multiple lymph nodes involved above and below the diaphragm? See Discussion
The physician staged this as Stage 0 CLL/SLL. Should the primary site be coded to lymph nodes if the MD stated this was leukemia?
Code the primary site to C421 [bone marrow] per Rule PH5. Code the primary site to the bone marrow when the peripheral blood is involved, even if no bone marrow biopsy is performed.
According to the notes for Rule PH5, CLL always has peripheral blood involvement (PH5 Note 1). CLL/SLL may also have involvement of lymph node regions in later stages (PH5, Note 2). For this patient a bone marrow biopsy was not performed but he had extensive lymph node and peripheral blood involvement. Therefore, the primary site is coded to C421. In addition, the physician's documentation specifies this patient has Stage 0 disease which indicates this disease process is being classified as leukemia (CLL).
SEER*Educate provides training on how to use the Heme Manual and DB. If you are unsure how to arrive at the answer in this SINQ question, refer to SEER*Educate to practice coding hematopoietic and lymphoid neoplasms. Review the step-by-step instructions provided for each case scenario to learn how to use the application and manual to arrive at the answer provided. https://educate.fhcrc.org/LandingPage.aspx.
Primary site--Colon: How do you determine the correct subsite when there is conflicting information in different reports? Are there priority rules for coding subsite for sites other than Head and Neck? See Discussion.
The path report for a hemicolectomy says, " Specimen: left colon..." and the microscopic says, "...received in formalin designated left colon..." The Operative procedure report says, "Postoperative diagnosis - splenic flexure tumor." The text of this report says, "Mobilizing the splenic flexure mass was incredibly difficult..." and then goes on to describe exactly how and where it was resected. The discharge summary says adenosquamous carcinoma of the splenic flexure. SINQ20051010 says to use the pathology report first, but this was written before the new MP/H rules.
Use the operative report information to code primary site in this case. It is more accurate.
The operative report is usually a better source of location information compared to the pathology report. The pathologist can only reiterate the location as it was reported to him/her.
The 2007 SEER manual states "Unless otherwise instructed, use all available information to code the site," page 69.
Primary Site--Esophagus: What is the difference between C15.5 [Lower third of esophagus] and C15.2 [Abdominal esophagus]?
These descriptions represent the use of two different ways the esophagus can be divided anatomically. The two different systems used are illustrated in the SEER Self Instruction Manual for Tumor Registrars: Book 4. Assign the primary site code that describes the location of the tumor in the same way the tumor's location is described in the medical record.
Primary Site--Head & Neck (Middle ear): How do you code site for a skull based tumor consistent with a low grade papillary adenocarcinoma of "endolymphatic sac origin"?
Code Primary Site to C30.1 [Middle ear]. The endolymphatic sac is part of the inner ear labyrinth located with in the petrous portion of the temporal bone.
Primary Site--Head & Neck: How is this field coded for a tongue primary described as "located on the lateral" or "left oral" tongue? See Discussion.
Case 1. Patient with squamous cell carcinoma, left oral tongue.
Case 2. Squamous cell carcinoma, left lateral tongue.
Case 3. Patient status post biopsy of lesion on tongue. Exam: healing left lateral tongue incision with sutures in place in underside of tongue.
Code Primary Site for cases 1 and 2 above to C023 [Anterior 2/3 of tongue, NOS]. Code lateral tongue without mention of dorsal or ventral surface to C023 [Anterior 2/3 of tongue, NOS].
Code Primary Site for case 3 to C022 [Ventral surface of tongue]. The underside of the tongue is specified as the site of the biopsy in case 3.
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