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The article I read (https://www.ncbi.nlm.nih.gov/pubmed/?term=28984674) makes the distinction between mesophrenic adenocarcinoma and mesophrenic-like adenocarcinoma. The authors propose the term mesonephric-like Mullerian adenocarcinoma. So would this be coded as Mullerian adenocarcinoma?

Example: Operative report states, partial simple vulvectomy, anoscopy with normal-appearing clitoris, clitoral prepuce, bilateral labia majora, and labia minora. There is a 1.5 x 1 cm raised, hyperpigmented lesion which appears consistent with VIN 3 on the perineal body, just to the right of midline, and not touching the midline. It goes quite close to the anus but is not touching the anus.

Final diagnosis on resection is, Invasive squamous cell carcinoma arising in a background of high-grade squamous intraepithelial neoplasia (VIN III) with the following features: Location: perineum. Focal invasion arising in setting of 1 cm area of VIN III.

02/18 RUL biopsy: Moderatley differentiated adenocacarcinoma with acinar predominant pattern

04/18 RUL lobectomy: 6.5cm poorly differentiated adenocarcinoma with solid growth pattern and 1.1 cm separate adenocarcinoma with lepidic predominant pattern

Synoptic report:

Procedure: Lobectomy

Specimen Laterality: Right Tumor

Tumor Site: Upper lobe

Histologic Type: Invasive adenocarcinoma, solid predominant

Tumor Size: 6.5 Centimeters (cm)

Tumor Focality: Synchronous primary tumors in same lobe

Lymph Nodes Number of Lymph Nodes Involved: 0

Number of Lymph Nodes Examined: 12

Nodal Stations Examined: 4R: Lower paratracheal; 8R: Para-esophageal (below carina); 10R: Hilar; 7: Subcarinal

Pathologic Stage Classification (pTNM, AJCC 8th Edition)

Primary Tumor (pT): pT3

Regional Lymph Nodes (pN): pN0

The Histology Coding Instructions give priority to the Final Diagnosis over the CAP protocol. However, when pathology reports are formatted using the CAP protocol, the presence of in situ carcinoma is generally only mentioned in the CAP protocol. Can the presence of in situ tumor mentioned only in the CAP protocol be used to apply rule H7 (Single Tumor: Invasive and In Situ Components Module)? Or are the rules in the Single Tumor: Invasive Only module used?

Example: Final diagnosis is invasive ductal carcinoma. CAP protocol mentions,

Example: Lung resection final diagnosis is Lung adenocarcinoma, see Summary Cancer Data, and the Summary Cancer Data (CAP Synoptic Report) states Histologic type: Invasive adenocarcinoma, solid predominant. Other Subtypes Present: 20% acinar and <5% micropapillary components.

Instruction 1B and Note 1 for Coding Multiple Histologies (Lung Histology Rules) indicates type, subtype, component, and predominantly are all terms that may be used to code the most specific histology. In this case, the multiple specific histologies were documented using all of those terms.

Note 2 for instruction 1B states predominantly describes the greatest amount of tumor and when it is used for the listed subtypes of adenocarcinoma, that subtype should be coded. However, Note 2 does not indicate that the other subtypes are ignored when one is identified to be predominant and the others are identified as subtype or component only.

Patient was diagnosed with Stage IV colon cancer (liver metstasiss) and started on Folfox with Avastin. The medical oncologist decided to continue maintenance treatment with Xeloda and Avastin.

Per Colon NCCN Guidelines Version 3.2019, interest in the use of maintenance therapy approach after first-line treatment of unresectable, metastatic colorectal cancer is growing. In general, this approach involves intensive first-line therapy, followed by less intensive therapy until progression in patients with good response to initial treatment.

Colon Therapy

5/1/18 Colonoscopy biopsy: mod diff colon adenoca, MMR proficient, BRAF wild type

5/5/18 Liver biopsy: mets from colon cancer

6/18/18 " 11/20/2018 Med Onc: started 12 cycles Chemo - Folfox (Fluorouracil, leucovorin, Oxaliplatin) with Avastin

11/28/18 CT Pelvis: continued improvement in the liver mets; no residual tumor involving colon; no new mas or adenopathy in the chest, abdomen or pelvis

12/02/18 Med Onc follow up: Pt had tremendous response to chemotherapy and Avastin, cancer is not curable. Is amenable to maintenance therapy with Xeloda and Avastin; also amenable to descending colectomy in the future

1/7/19 Med Onc: starting maintenance treatment Xeloda + Avastin.

Rule PH28 confirms the more specific histologies are ignored if this is truly a low grade B-cell lymphoma (i.e., non-Hodgkin lymphoma, NOS) since both MALT lymphoma and LPL are more specific types of low grade B-cell lymphomas. This leaves only a diagnosis of low grade B-cell lymphoma with plasmacytic differentiation to consider.

SINQ 20130033 states a low grade B-cell lymphoma with plasmacytic differentiation should be coded as 9680/3 (diffuse large B-cell lymphoma (DLBCL)). However, DLBCL is a high grade B-cell lymphoma, not a low grade B-cell lymphoma.

If the pathologist classifies this as a non-specific low grade B-cell lymphoma, and clarifies that this may represent a more specific type of low grade B-cell lymphoma (MALT lymphoma or LPL), should the histology be coded to a high-grade lymphoma (DLBCL) or non-Hodgkin lymphoma, NOS?

Head and Neck Multiple Primary Rule M8 appears to be the first rule that applies to this case and instructs the user to abstract multiple primaries when separate/non-contiguous tumors are on different rows in the appropriate site table (Tables 1-9) in the Equivalent Terms and Definitions. Table 1 (tumors of the nasal cavity) shows Non-keratinizing squamous cell carcinoma and squamous cell carcinoma on different rows making the 2019 case a new primary. Is this correct?

Example 1: Endometrial biopsy final diagnosis is high-grade serous adenocarcinoma. Should we code this endometrial primary with histology 8441 (serous adenocarcinoma) because C54.X topography code is not listed in the applicable 2018 ICD-O-3 codes Histology Update for the new morphology, or should we apply the new histology code 8461 (high-grade serous carcinoma)?

The NAACCR implementation guideline section 2.3 includes an important reminder that: Many of the new codes, terms, and behaviors listed in this update are site-specific and do not apply to all sites. Applicable C codes will be noted next to the term in bold font.

However, this is followed by the more ambiguous instruction for edits that appear to imply the combination with non-listed sites is possible: These site- and histology-specific combinations will not be added to the Impossible combination edit. However, if a site other than the one listed with the morphology code is assigned, the result will be an edit requiring review. This is Interfield Edit 25.