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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.

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.

The note explains: The International Society for the Study of Vulvovaginal Disease (ISSVD) in 2004 revised its classification of VIN by eliminating VIN 1 and combining VIN 2 and VIN 3 into a single category (see table below). Classification of VIN (usual type) ISSVD [International Society for the Study of Vulvovaginal Disease]1986 classification 2004 classification VIN 1 VIN2 VIN3 VIN Note: VIN 2 and VIN 3 combined into single [non-graded] category, VIN Reference: Scurry J and Wilkinson EJ.  Review of terminology of precursors of vulvar squamous cell carcinoma. Journal of lower genital tract disease, 2006; 10(3):  161-169

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?

Should it be coded to where the testis was physically at the time of diagnosis (C621), or should it be coded to C620 to reflect the increased risk for developing malignancy in an undescended testis?