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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.  

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 pathology diagnosis reads: Diagnosis Right Kidney, Laparoscopic Nephrectomy: 

-Renal Cell Neoplasm of Oncocytosis (pT1a, pNX See Comment and Template). 

-Surgical margins free of tumor.

Kidney, right, nephrectomy:

Tumor histologic type: Renal cell neoplasms of oncocytosis (see Note)

Sarcomatoid features (%) Not identified

Tumor size: 4 cm (greatest dimension largest tumor)

Other dimensions: 2.7 x 2.5 cm

Macroscopic extent of tumor: Limited to kidney

Focality: Multifocal

Number of tumors: 11 grossly visible, range 0.2 4 cm

Fuhrman grade: 2 of 4

Microscopic extent of tumor:

Perinephric fat invasion: Not identified

Renal sinus invasion: Not identified

Other: N/A

Renal vein involvement: Not identified

Adrenal gland present: No

Involved by tumor: N/A

Direct invasion or metastasis: N/A

Cancer at resection margin: Not identified

Location(s): N/A

Pathologic findings in nonneoplastic kidney: Multiple collections of oncocytic cells

Hilar lymph nodes present: No

Number of involved/number present: N/A

"Thank you for sending this fascinating case. In reviewing the H&E-stained slides, we recognize that multiple lesions of varying sizes are present within the specimen, some with features of oncocytoma, some with those of chromophobe RCC, and yet others with features of both. The immunohistochemical studies for CK7 performed at your institution serve to highlight this point with "mass #1" showing focal single cell staining typical of oncocytoma and "mass #2" showing a patchy and confluent staining pattern typical of chromophobe RCC. This second mass was also positive with special stain for Hales colloidal iron. As mentioned, the morphology varies somewhat in each tumor, however, every single mass is comprised of cells with eosinophilic (pink to bright red) cytopolasm. Some tumors show more tightly nested or sheet like growth, others are more tubular or microcystic. Another important feature, present on slides of renal cortex are microscopic tumorlets seemingly emanating from eosinophilic tubules. This finding, along with the presence of numerous oncocytic neoplasms is supportive of the above diagnosis. The absence of clinical features to suggest Birt-Hogg-Dube syndrome is noted. Although these tumors are not recognized in the current classification of renal tumors, we regard these neoplasms as being a distinct entity, unrelated to both oncocytoma and chromophobe renal cell carcinoma, and have applied the designation "renal tumor of oncocytosis" to such lesions (Gobbo S, et al. Renal cell neoplasms of oncocytosis have distinct morphologic, immunohistochemical, and cytogenetic profiles. Am J Surg Patholl 34:620-626, 2010). We concur that the expected behavior in these cases is one of indolence."

The language appears similar to the mucinous cystic neoplasm of the pancreas with high grade dysplasia (8470/2), which was clarified to be reportable in 2014.

Should the histology for "Ductal carcinoma with neuroendocrine features" be coded to 8500 (Ductal carcinoma, NOS) or 8574 (Adenocarcinoma with neuroendocrine differentiation)?

This diagnosis is not listed in the ICD-O-3 though it is listed as code 9509/1 for this specific tumor in the 2007 WHO classification of Tumours of Central Nervous System. (See link:  http://link.springer.com/article/10.1007/s00401-007-0243-4/fulltext.html.)

In Appendix C- Breast (SEER Manual 2015) it states under the codes for TOTAL MASTECTOMY (Codes 40-49, 75): For single primaries only, code removal of involved contralateral breast under the data item Surgical Procedure/Other Site (NAACCR Item # 1294). [SEER Note: Example of single primary with removal of involved contralateral breast--Inflammatory carcinoma involving both breasts. Bilateral simple mastectomies. Code Surgery of Primary Site 41 and code Surgical Procedure of Other Site 1.] HOWEVER, underneath that it states code 76 is used for: 76 Bilateral mastectomy for a single tumor involving both breasts, as for bilateral inflammatory carcinoma. So