Report | Question ID | Question | Discussion | Answer | Year |
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20210077 | First Course Therapy/Neoadjuvant Treatment: How are Neoadjuvant Therapy--Clinical Response and Neoadjuvant Therapy--Treatment Effect coded when the neoadjuvant therapy was not completed? Does the entire course of neoadjuvant therapy need to be completed before we can code these fields? See Discussion. |
Example: The neoadjuvant therapy was started, the patient progressed, the treatment plan was altered, and a new course of systemic therapy was started; surgery was cancelled. 01/25/21 Bile duct brushing: Malignant cells present, adenocarcinoma 01/26/21 Surgical oncology consult: Currently unresectable; recommend neoadjuvant chemo 02/22/21-3/29/21 Neoadjuvant Gemzar & Abraxane, two cycles, discontinued due to disease progression 04/17/21 Surgical oncology re-eval: CT positive for disease progression, need to change Rx 04/26/21 Second change of treatment due to progression: Irinotecan, Oxaliplatin, and 5FU 07/16/21 Surgical oncology re-eval: Unresectable, advise 4-6 months of chemo followed by radiation |
Assign code 3 (Progressive disease (PD)(per managing/treating physician statement) for Neoadjuvant Treatment--Clinical Response and code 7 (Neoadjuvant therapy completed and planned surgical resection not performed) for Neoadjuvant Treatment--Treatment Effect. These are the best choices under the circumstances. Use text fields to record the details. |
2021 |
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20210031 | Reportability--Brain and CNS: Are lipomas of the spinal column reportable as a benign tumor of the central nervous system (CNS)? This is seen occassionally at our pediatric facility. |
Spinal cord tumors (including lipomas) are reportable when they arise in the spinal dura or nerve root. The tumor must be of the spinal cord itself or within the spinal cord dura. Spinal cord tumors are reportable when they arise in the intradural space. A reportable intradural tumor can be either intramedullary or extramedullary. Extramedullary intradural spinal tumors are reportable. A spinal tumor originating in the extradural space is not reportable. If it is outside the dura, it is not reportable because it would be outside the CNS. They are not reportable when they arise in the peripheral nerves. |
2021 | |
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20210051 | Primary site/Biliary tract--Ampulla of Vater: What is the correct primary site code for intra-ampullary and periampullary adenocarcinoma, C241 (8144/3) or C249? See Discussion. |
Ampulla, biopsy: High grade dysplasia with focal intramucosal carcinoma in a background of ulceration with acute and chronic inflammation. Surgery pathology: Head of pancreas, duodenum, and distal stomach, pancreaticoduodenectomy-Ampulla, Adenocarcinoma, intestinal type, intra-ampullary and peri-ampullary (mixed type). Grade moderately differentiated, 1.5cm. Tumor invades into duodenal submucosa. Lymphovascular Invasion: Foci suspicious for lymphovascular invasion identified. Perineural Invasion: Present. Synoptic report: Tumor Site Intra-ampullary and peri-ampullary (mixed type). Histologic Type Adenocarcinoma, intestinal type. There is not enough information regarding site in radiology reports or operative report. CT-A/P/C:The patient's known ampullary mass is not well visualized on this exam. No significant intrahepatic or extrahepatic biliary ductal dilation is identified. The pancreatic duct is normal caliber. |
Assign C241. Ampulla (C241) includes both periampullary and intra-ampullary. |
2021 |
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20210058 | Multiple Primaries/Histology--Lymphoma: What is the histology code and how many primaries are there based on a gastrohepatic lymph node biopsy that shows: Nodular lymphocyte-predominant Hodgkin lymphoma with T-cell/histiocyte rich diffuse large B-cell lymphoma (DLBCL)-like transformation. If two primaries, what is the diagnosis date for each primary? See Discussion. |
4/28/21 PET: There is extensive widespread/multifocal hypermetabolic uptake within lymph nodes, skeleton, and spleen, compatible with malignancy. Differential diagnosis includes lymphoma and metastatic disease of indeterminate primary, with lymphoma favored. 4/28/21 Right retroperitoneal lymph node, needle core biopsy: Large B-cell lymphoma. See comment. Comment: The differential includes T-cell/histiocyte-rich large B-cell lymphoma and diffuse variant of nodular lymphocyte predominant Hodgkin lymphoma. It is challenging to distinguish these two on the needle core biopsy. An excisional biopsy is recommended for a definite diagnosis if clinically appropriate. ADDENDUM: B-Cell Lymphoma, FISH: negative. No rearrangement of MYC, BCL2 and BCL6 and no fusion of MYC and IGH. 5/14/21 Gastrohepatic lymph node, biopsy: Nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL) with T-cell/histiocyte rich diffuse large B-cell lymphoma-like transformation. Focal in situ follicular neoplasia. 6/3/21 Medical Oncologist: Biopsy confirms that patient has a nodular lymphocytic Hodgkin lymphoma which has transformed into a T-cell rich DLBCL. This variant of Hodgkin disease is a good prognostic histology which generally behaves indolently, like a low grade lymphoma. |
We consulted with our expert hematopathologist who advised this is a single primary, Hodgkin lymphoma (9659/3). The diagnosis from 5/14/2021 states NLPHL. It also states there is T-cell histiocyte rich large B-cell lymphoma-like transformation. The WHO Classification of Hematopoietic and Lymphoid Tissues demonstrates six different patterns to NLPHL, which are: A) 'classical' nodular, B) serpiginous/interconnected nodular, C) nodular with prominent extra-nodular LP cells, D) T-cell-rich nodular, E) diffuse with a T-cell-rich background, and F) diffuse, B-cell-rich pattern. In this case, they are describing a NLPHL type E (diffuse with a T-cell rich background). The term used is "T-cell histiocyte rich large B-cell lymphoma-LIKE transformation. "Like" as used here means that it is like a transformation; if it was NLPHL transforming to T-cell histiocyte rich large B-cell lymphoma, it would not have the word "like" in the diagnosis. This is a variant of NLPHL and not an actual transformation to another lymphoma. Even though NLPHL can transform to T-cell histiocyte rich large B-cell lymphoma, it is not the case here since the word "like" appears in the diagnosis. We will update the histology in the Hematopoietic and Lymphoid Neoplasm Database to include these additional patterns. |
2021 |
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20210068 | Mets at Diagnosis Fields/Primary Site--Lymph Nodes: How are the Mets at Diagnosis fields coded when the metastatic adenocarcinoma involves only one lymph node area and the primary site is unknown? See Discussion. |
In 2018, patient has lymph node metastasis confined to left retroperitoneal area; core biopsy was done which showed metastatic adenocarcinoma, unknown primary site. There are no other sites of disease found. Should I code Mets at Diagnosis--Distant Lymph Node(s) as 1, and the others such as bone and lung as 0? |
In a situation like this with one area of metastatic involvement and an unknown primary, if there is no further information, we advise that the metastasis are "regional" until/unless proven otherwise. With this in mind, code the Mets at Diagnosis fields as 0, including the Mets at Diagnosis--Distant Lymph Node(s). This case should continue to be worked up to identify the primary site. If a primary site is identified later, update the abstract accordingly. In the meantime, use text fields to describe the situation. |
2021 |
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20210004 | Solid Tumor Rules (2018)/Histology--Colon: What is the histology for a 2020 pathology report final diagnosis showing invasive adenocarcinoma, poorly differentiated with signet ring cell features and signet-ring cell carcinoma in the synoptic report? See Discussion. |
Since the synoptic report and final diagnosis are equal in priority, and the Solid Tumor Rules tell us to code the more specific histology, would this be coded to signet ring cell adenocarcinoma, 8490/3, even though the pathologist used features in the final diagnosis? There is no histology adenocarcinoma with signet ring cell features on the CAP Protocol, so the pathologist may check off the next closest histology " signet ring cell carcinoma " which would not be truly representative of the actual histology. Final Diagnosis: Proximal colon, segmental resection: Invasive adenocarcinoma, poorly differentiated, with signet ring cell features. Synoptic Report A: Colon and Rectum - Resection Specimen Procedure: Right hemicolectomy, Tumor Site: Right (ascending) colon, Histologic Type: Signet-ring cell carcinoma, Histologic Grade: G3: Poorly differentiated. |
Code histology to 8490/3 per H6. The December 2020 Solid Tumor Update includes addition of the following instructions to the "Priority Order for Using Documentation to Code Histology" section. Which document to use when there is conflicting information between the final diagnosis, synoptic report, or CAP protocol: When there are discrepancies between the final diagnosis and synoptic report, use the document that provides the more specific histology. This will likely be found in the synoptic report. The CAP Protocol should be used only when a final diagnosis or synoptic report are not available. Definitions for CAP Protocol, final diagnosis, and synoptic report can be found in the Definitions section. |
2021 |
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20210055 | Tumor Size--Pathologic/EOD 2018: How is Tumor Size--Pathologic coded when Extent of Disease (EOD) Primary Tumor is 800 (No evidence of primary tumor) and there has been no surgery to the primary site? See Discussion. |
The SEER Manual states to assign Tumor Size--Pathological code 000 when EOD Primary Tumor is coded to 800 (No evidence of primary tumor) for any schema. However, the definition of Tumor Size--Pathologic states that it records the size of a solid primary tumor that has been resected. If the primary site has not been resected (does not meet the pathologic staging criteria), then it seems that Tumor Size Pathologic should be 999 when EOD Primary Tumor is coded as 800. |
Assign code 999 for Tumor Size--Pathologic when there is no surgery of the primary site. Code 999 includes "No excisional biopsy or tumor resection done." |
2021 |
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20210044 | Diagnostic Confirmation--Heme & Lymphoid Neoplasms--Plasma Cell Myeloma: Can serum protein electrophoresis (SPEP) be used as a definitive diagnostic method in the absence of a bone marrow biopsy? Is it appropriate to assign code 5 (Positive laboratory test/marker study) if there is no histological confirmation? See Discussion. |
Patient was diagnosed with lambda myeloma based on the M spike found on serum protein electrophoresis. A bone marrow biopsy was performed, but it was an insufficient sample. SPEP is not listed in the Hematopoietic Database as a lab test that can be used as a definitive diagnostic method. Since the physician did base the diagnosis on the SPEP result, would it be appropriate to assign code 5 (Positive laboratory test/marker study) since there was no histological confirmation? Under code 5, the Hematopoietic Manual states: Laboratory tests are listed under Definitive Diagnostic Methods in the Hematopoietic Database. |
Assign code 5 in Diagnostic Confirmation. We consulted with an expert hematopathologist who stated that SPEP would qualify for a diagnostic confirmation code of 5. He also stated that normally a SPEP is followed by a bone marrow biopsy. SPEP has been added to the Definitive Diagnostic Methods for plasma cell myeloma (9732/3). |
2021 |
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20210006 | Behavior/Summary Stage 2018--Colon: What is the correct behavior and Summary Stage for a case of intramucosal adenocarcinoma arising in tubular adenoma? AJCC states this is Tis, though SEER Summary Stagie states this is Localized (code 1). The histology is 8140/2 (adenocarcinoma in situ), but the SEER Summary Stage is Locallized. |
Intramucosal carcinoma of the colon is assigned behavior code of /3. Intramucosal is not the same as in situ in terms of behavior. Behavior and staging are separate concepts, although there is some overlap. Use the instructions for coding behavior to code this field. Do not use stage to determine behavior in this case. For purposes of Summary Stage, intramucosal carcinoma is a localized lesion; however, for purposes of AJCC staging, assign Tis for the stage. |
2021 | |
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20210040 | Solid Tumor Rules (2018, 2021)/Histology--Breast: How is histology coded for a diagnosis ofmixed mucinous carcinoma? See Discussion. |
Patient was diagnosed with invasive ductal carcinoma with mucinous features in February 2021, left breast biopsies at 2:00 (3 cm from nipple) and 3:00 (8 cm from nipple) positions. Intraductal component was absent in those specimens. Subsequent left breast total mastectomy in March 2021, provided a final diagnosis of multifocal mixed mucinous carcinoma, grade 1, 27 and 8 mm and ductal carcinoma in situ (DCIS), low to intermediate grade, with focal mucinous features. The Staging Summary lists Histologic Type as mixed mucinous carcinomafor both foci of invasive carcinoma. DCIS is also noted as present negative for extensive intraductal component. There does not appear to be a clear instruction or code for this histology. As a central registry, we are unable to follow-up with the pathologist regarding this diagnosis. Just to be clear, there are 2 foci of invasive mixed mucinous carcinoma in this case measuring 27 mm and 8 mm. The DCIS component measured 56 mm. |
If the DCIS is separate from the mucinous, apply the breast M rules and abstract TWO primaries per M14. Since all we know of the “mixed mucinous” is there is mucinous present, code 8480/3. |
2021 |