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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

Pathology report reads left ovary: noninvasive low grade (micropapillary) serous carcinoma (MPSC), fragmented; right ovarian excrescence and posterior cul-de-sac: noninvasive implants identified; right ovary: noninvasive low grade (micropapillary) serous carcinoma (MPSC), scattered autoimplants (noninvasive); tumor is present on ovarian surface, noninvasive autoimplants

This patient underwent a "partial decortication" per the operative report. While the operative report does not specifically note that this was performed with a partial pleurectomy, it appears the patient had a partial pleurectomy because the largest specimen removed was a "pleural peel" specimen, which included the parietal and visceral pleural surfaces with a small amount of underlying lung tissue. The operative report notes the patient had involvement of both the lung and chest wall. A total resection was not possible due to the extent of the tumor. However, this patient does appear to have undergone at least a partial resection of the pleura/tumor burden. The patient did not simply undergo a pleurodesis to free adhesions. Per the NCI's PDQ, pleurectomy and decortication are performed together. Because the operative report and pathology report only called this procedure a "partial decortication" without specifically mentioning a pleurectomy, would this be coded as a tumor excision (surgery code 20)? Or should we assume the procedure is best coded as a partial pleurectomy and decortication and use code 30 (simple/partial resection)?

The MRI states "Lhermitte-Duclos disease" but does not include "dysplastic gangliocytoma of cerebellum"; is this the same as "Lhermitte-Duclos dysplastic gangliocytoma of cerebellum (C716)"?

Breast biopsy (from hospital A): DCIS, solid, cribriform, comedo type, high nuclear grade

Breast Lumpectomy (from hospital B): DCIS, cribriform type, nuclear grade 1, tumor 2.5cm

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.

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.