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The Extent of Disease (EOD) manual states that "Confined to thymus WITH mediastinal or pleural involvement" should be coded as regional by direct extension. I have EOD primary tumor coded as 200 and based on SEER*RSA, this is localized.

ICD-O-3 Rule H states to use the topography code provided when a topographic site is not stated in the diagnosis. This topography code should be ignored if the tumor arose in another site. For the following brain and central nervous system (CNS) examples, should the suggested sub-site codes be assigned based on the histology, or should the primary sites be coded as C719 (posterior fossa or suprasellar brain) since the only information available was a tumor in these non-specific sites?

Example 1: Resection of a posterior fossa tumor proved medulloblastoma, WNT-activated. Although medulloblastoma has a site-associated code in the ICD-O-3 (C716, cerebellum), the only information available is that this was a posterior fossa tumor (C719).

Example 2: Resection of a suprasellar brain tumor proved pineoblastoma. The pathologist labeled this as a brain tumor, suprasellar. Although pineoblastoma has a site-associated code in the ICD-O-3 (C753, pineal gland), the only information available is that this was a suprasellar brain tumor (C719).

Washington State added to birth certificates, which allows people to have their certificates changed to this non-binary gender designation. Gender X is defined as a gender that is not exclusively male or female, including, but not limited to: intersex, agender, amalgagender, androgynous, bigender, demigender, female-to-male, genderfluid, genderqueer, male-to-female, neutrois, nonbinary, pangender, third sex, transgender, transsexual, Two Spirit, and unspecified.

Example: Operative report documents a left breast skin sparing mastectomy and sentinel node biopsy procedure. Pathology report lists left axillary sentinel nodes in specimen A) with 0/2 nodes positive, and left breast mastectomy without axilla in specimen B) yielding an additional 0/2 intramammary nodes positive. Would the Scope of Regional Node Surgery be coded as 2 (SLN biopsy) to capture the intent of the sentinel node procedure only, or 6 (code 2 + 4) to capture the actual type and number of nodes removed?

SEER Coding and Staging Manual includes Scope of Regional Lymph Node Surgery instruction 4.b. which mentions assigning code 4 to intra-organ node removal. Similarly, there is instruction for coding SLN biopsy as code 2 and SLN biopsy with axillary dissection at the same time (code 6) or during separate procedures (code 7). However, it is not clear this combination code is how we should also capture an incidental intra-organ node removal.

The Solid Tumor Rules instruct us not to use differentiation for coding histology unless it is specifically listed in the table. The terminology non-small cell carcinoma with neuroendocrine differentiation is not in lung histology Table 2.

However, SINQ 20150033, prior to Solid Tumor rules, indicates this diagnosis should be coded to 8574 (adenocarcinoma/carcinoma with neuroendocrine differentiation).

This presentation appears to represent distinctly different histologies. However, because the 2018 histology diagnosis is not in the table and the prior SINQ appears to disagree with current instruction, it is not clear how to apply the M rules to this case. The outcome of the histology coding will affect the number of primaries reported in this case.

For example, 9/12/18 left lung upper lobe lobectomy: 1.5 cm, 0.8 cm invasive component, lepidic predominant adenocarcinoma with acinar and lepidic patterns, G2, no visceral pleural invasion, no LVI, 0/14 LNS positive. An additional minimally invasive adenocarcinoma, 1 mm, was seen away from the main tumor. The correct coding of the minimally invasive adenocarcinoma will ultimately determine if we have one tumor (using rule M7) versus two primaries (using rule M6).

IMPRESSION/PLAN: Patient is a previously healthy middle aged woman with a diagnosis of adenocarcinoma of the rectum, clinical stage II (T3N0M0). We will proceed with a neoadjuvant course of radiation and concurrent chemotherapy (5-FU) to maximize local regional control and survival, and hopefully facilitate a sphincter-sparing resection in the future. The primary tumor and the pelvic nodes at risk will receive 4500 cGy delivered over 25 treatments. The primary tumor will subsequently receive an additional 1080 cGy delivered over 5 treatments, for a cumulative dose of 580 cGy.

PATHOLOGY: Adenocarcinoma of the rectum, clinical stage II (T3N0M0). The patient is referred by (dr) for a neoadjuvant course of chemoradiotherapy.

HPI: Patient presented recently with rectal bleeding and a change in bowel habits. Colonoscopy revealed an ulcerated mass located 4.0 cm above the anal verge. A biopsy was positive for invasive well-differentiated adenocarcinoma that arose from a tubular adenoma. A staging work-up demonstrated no evidence of metastatic disease.

Rule PH28 confirms the more specific histologies are ignored if this is truly a low grade B-cell lymphoma (i.e., non-Hodgkin lymphoma, NOS) since both MALT lymphoma and LPL are more specific types of low grade B-cell lymphomas. This leaves only a diagnosis of low grade B-cell lymphoma with plasmacytic differentiation to consider.

SINQ 20130033 states a low grade B-cell lymphoma with plasmacytic differentiation should be coded as 9680/3 (diffuse large B-cell lymphoma (DLBCL)). However, DLBCL is a high grade B-cell lymphoma, not a low grade B-cell lymphoma.

If the pathologist classifies this as a non-specific low grade B-cell lymphoma, and clarifies that this may represent a more specific type of low grade B-cell lymphoma (MALT lymphoma or LPL), should the histology be coded to a high-grade lymphoma (DLBCL) or non-Hodgkin lymphoma, NOS?

Example 1: Operative report states the surgery is a right breast simple mastectomy. There is no lymph node removal documented or attempted; however, a single incidental intramammary node is found in the final pathology results. How should these nodes be captured in the Scope of Regional Lymph Node Surgery field?

CAnswer Forum states to code Scope of Regional Lymph Node Surgery as 0 (No regional lymph nodes removed), see Scope LN surgery, incidental LN found on path, Breast.

However, SEER Program Coding and Staging Manual 2018 instruction states: Code the removal of intra-organ lymph nodes in Scope of Regional Lymph Node Surgery. Example: Local excision of breast cancer. Specimen includes an intra-mammary lymph node. Assign code 4 (1 to 3 regional lymph nodes removed).

The STORE 2018 Manual does not provide instruction for incidental nodes specifically, but does appear to be focused on capturing procedural intent.

Example 2: Patient has bilateral breast primaries. Operative report states the surgery is bilateral simple/skin-sparing mastectomies with bilateral sentinel node biopsies and immediate reconstruction. However, pathology shows that the left breast specimens are labeled: (a) Left breast mastectomy, (b) Left sentinel lymph node biopsy, (c) Additional left lymph nodes biopsy, and (d) Left axillary contents biopsy. The total nodes removed for this case are: 2/2 positive SLN, 0/1 positive intramammary nodes, 1/1 positive additional lymph node, and 3/3 positive axillary contents nodes. How should these nodes be captured in the Scope of Regional Lymph Node Surgery field?