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Procedure: Nephrectomy

Laterality: Left

Tumor type: SOLID VARIANT RENAL CELL CARCINOMA

Nuclear grade: High grade (3/4)

Histologic grade: Poorly differentiated

Pattern of growth: Solid

Tumor size: 5x4.5x4cm

Local invasion: Present

Renal vein invasion: None

Surgical margins: Negative

Non-neoplastic kidney: Unremarkable

Adrenal gland: Not submitted

Lymph nodes: Not present

Pathologic stage: T1b

There are solid sheets of tumor cells without papillary structure. The tumor stains positive for Pax-2, negative for Ecadherin, P63 and CK7, consistent with renal cell carcinoma, solid variant.

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

Examples

8/xx/13 TURBT with path specimen (27): Papillary Urothelial Carcinoma, HG    9/xx/13 Bladder fulgeration w/o path specimen (12)

5/xx/14 Segmental Mastectomy(24): Ductal carcinoma with <1mm marg    6/xx/14 Breast Re-excision (23): Residual ductal carcinoma 1.5mm, marg neg

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?

Foreskin circumcision shows: Penile intraepithelial neoplasia, differentiated type (differentiated PeIN). If reportable, how would the histology and behavior be coded? Is this behavior /2?

The UroVysion website says that standard procedures, e.g., cytology, cystoscopy, take precedence over the UroVysion test. The Quest Diagnostics website says that "A positive result is consistent with a diagnosis of bladder cancer or bladder cancer recurrence, either in the bladder or in another site within the urinary system. A negative result is suggestive of the absence of bladder cancer but does not rule it out." Would we pick up the case if the UroVysion test was positive but the standard procedures were negative or non-diagnostic?

Is the instruction under #4.b. on page 114 of the 2014 SEER Program Coding and Staging Manual incorrect? It says to code Rituxan as chemotherapy.