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LARYNGOSCOPY - ENDOLARYNGEAL EXAM WAS GROSSLY UNREMARKABLE EXCEPT THAT SHE APPEARS TO HAVE A T1A SQUAMOUS CELL CARCINOMA OF THE RIGHT TRUE VOCAL FOLD. IT EXTENDS FROM ALMOST THE ANTERIOR COMMISSURE ALL THE WAY BACK TO THE VOCAL PROCESS AND IS EXOPHYTIC IN NATURE. IT DOES NOT EXTEND INTO THE VENTRICLE OR ONTO THE FALSE VOCAL FOLD. NO SUBGLOTTIC EXTENSION IS SEEN. A. RIGHT POSTERIOR FALSE VOCAL CORD FOLD, BIOPSY:  SQUAMOUS CELL CARCINOMA IN SITU. B. RIGHT POSTERIOR TRUE VOCAL CORD FOLD, BIOPSY:  SQUAMOUS CELL CARCINOMA, SUSPICIOUS FOR INVASION. C. RIGHT MID TRUE VOCAL CORD, BIOPSY:  SQUAMOUS CELL CARCINOMA, SUSPICIOUS FOR INVASION. D. RIGHT ANTERIOR TRUE VOCAL FOLD, BIOPSY:  INVASIVE AND IN SITU SQUAMOUS CELL CARCINOMA, MODERATELY DIFFERENTIATED.

Pathologists rarely diagnose a GIST as a malignant tumor. Per the AJCC, GISTs encompass a continuum in terms of biologic potential, with larger more mitotically active tumors landing on the "histologically sarcomatous" or malignant end of the spectrum. Because the pathologists generally do not categorize these tumors as benign or malignant, the judgement is typically made by the clinician in light of all the clinical and pathologic findings. Unless there are obvious distant metastases, the clinician usually decides whether a GIST is malignant and treats the patient as such.

In the case above, the patient underwent a gastric biopsy on 04/10/2014 that showed GIST. The subsequent resection on 04/12/2014 showed a 4.5 cm GIST, spindle cell type with 6 mitoses/5 square mm. The resection pathology report does not indicate the GIST is malignant, but does identify a large tumor with mitotic activity. After reviewing the evidence in this case, the clinician calls this a malignant GIST on 04/29/2014 and starts the patient on Gleevec.

Although neither the biopsy nor the resection call this a malignant tumor, should the date the GIST was first diagnosed (biopsy on 04/10/2014) be used to code the diagnosis date, since this is the date the tumor (ultimately felt to be malignant) was diagnosed? If the diagnosis date is coded as the date malignant GIST was first mentioned (04/29/2014), this would exclude surgery as treatment for this tumor.

Would this be a histologic diagnosis because the tumor was histologically confirmed to be GIST? Or must this be a clinical diagnosis because the diagnosis of malignancy was only made clinically (by the clinician's review of the clinical and pathologic findings)?

The patient was diagnosed with a carcinoid tumor of the small intestine. The pre-surgical work-up also identified a lung nodule that showed no octreotide uptake, but was indeterminate on biopsy. The imaging differential diagnosis included carcinoid, hamartoma, or a non-calcified granuloma. The patient underwent a resection of the primary small bowel tumor, and the physician noted the lung nodule was of unclear diagnosis. The physician stated a solitary lung metastasis would be atypical, but that lung metastatic involvement could not be ruled out. The physician recommended resection of the lung nodule to ensure that the patient was disease free. The lung wedge resection proved a pulmonary hamartoma.

The rules for coding Surgical Procedure of Other Site are not entirely clear. The definitions for First Course of Therapy in the SEER Manual do state that treatment includes, "Procedures that destroy or modify primary (primary site) or secondary (metastatic) cancer tissue." This would seem to exclude the lung resection as it did not destroy, modify or remove metastatic cancer tissue. However, the instructions for coding Surgical Procedure of Other Site do not address removal of distant sites that are not incidental. The lung resection was not incidental; the physician recommended it to ensure the lung was not involved, but it also disproved metastatic involvement. Should the Surgical Procedure of Other Site field be coded 0 (none) or 4 (non-primary surgical procedure to distant site) in this case?

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.

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?