Primary Site/Histology (Pre-2007): What are the correct site and histology codes for "tubal serous adenocarcinoma" identified in a fallopian tube? See Description.
The pathology report of a laparoscopic left salpingo-oophorectomy states: 1.5 cm intraluminal mass left fallopian tube: micro: tubal serous adenocarcinoma, poorly differentiated, infiltrates the muscular wall of the fallopian tube; serosa does not appear to be penetrated. The left ovary is negative for malignancy.
For tumors diagnosed prior to 2007:
Code histology as 8441 [serous adenocarcinoma].
The primary site for this case is fallopian tube, not the suggested site code of ovary.
For tumors diagnosed 2007 or later, refer to the MP/H rules. If there are still questions about how this type of tumor should be coded, submit a new question to SINQ and include the difficulties you are encountering in applying the MP/H rules.
EOD-Extension--Kaposi Sarcoma: Is a "markedly enlarged spleen" involvement for cases of Kaposi Sarcoma?
For cases diagnosed 1998-2003: No. Splenomegaly is not synonymous with "extension to" or "involvement of" the spleen in Kaposi's sarcoma. Look for a definite statement of Kaposi's lesion(s) involving the spleen.
Primary Site--Head & Neck: What is the anatomical distinction among tonsillar fossa, tonsillar pillar, and tonsil NOS?
Operative findings describe a right tonsil three times the size of the left tonsil. Tonsil is dissected from the tonsillar fossa. There appeared to be no involvement of tumor below the tonsillar capsule.
The tonsil lies in an indentation called the tonsillar fossa. The tonsillar fossa is bordered on either side by the tonsillar pillars. The tonsillar pillars are part of the supporting structure of the throat opening.
Code C09.9 [Tonsil NOS] as the primary site for the case above.
EOD-Extension--Corpus Uteri: How is this field coded for a stage III A endometrial primary with positive pelvic washings, involvement of the omental serosa, and negative lymph nodes?
For cases diagnosed 1998-2003: Code EOD-extension as 85 [Metastasis]. According to our TNM consultant, Omental metastasis is M1, Stage IVB [EOD 85].
Primary Site/Histology--CLL/SLL: How should these fields be coded when the pathological diagnosis of chronic lymphocytic leukemia/small lymphocytic lymphoma is made on bone marrow biopsy only but scans show lymphadenopathy? See Description.
What histology would we give these two examples?
1. Bone marrow bx: CLL/SLL. CT chest/abdomen: Mediastinal and retroperitoneal adenopathy.
2. Bone marrow bx: CLL/SLL. CT chest/abdomen: Mediastinal and retroperitoneal adenopathy suspicious for lymphoma.
For cases diagnosed prior to 1/1/2010:If a lymph node or other solid tissue is involved initially, code to SLL. For lymphoma, any mention of lymph nodes is indicative of involvement. Involvement does not have to be proven pathologically in order to code to Small Lymphocytic Lymphoma (SLL). Code both of the examples to SLL.
For cases diagnosed 2010 forward, refer to the Hematopoietic and Lymphoid Neoplasm Case Reportability and Coding Manual and the Hematopoietic Database (Hematopoietic DB) provided by SEER on its website to research your question. If those resources do not adequately address your issue, submit a new question to SINQ.
Reportability/Histology--Hematopoietic, NOS: Does the presence of sideroblasts on a bone marrow biopsy confirm a diagnosis of refractory anemia with sideroblasts?
Final path diagnosis of bone marrow biopsy:
I. Hypercellular marrow for age with trilinear hyperplasia.
II. Decreased iron stores with decreased sideroblasts.
Comment: Although the overall picture is not diagnostic of a specific entity, it is most consistent with an early stage myelodysplastic syndrome which would best be considered refractory anemia at this point.
In this case the percentage of sideroblasts is not stated. Would the path diagnosis of "decreased sideroblasts" along with the path comment of "refractory anemia" indicate that this case should be coded to 9982/3 [Refractory anemia with sideroblasts]?
For cases diagnosed prior to 1/1/2010:
For the hematologic diseases, do not accession the case unless there is a definite positive diagnosis. A positive diagnosis, such as "Refractory anemia" must be stated in order to code that diagnosis. Other words associated with the positive diagnosis, such as "sideroblasts" are NOT to be used alone to assume a diagnosis.
Decreased sideroblasts does not make a diagnosis of Refractory anemia with sideroblasts. The sideroblasts for 9982/3 [Refractory anemia with sideroblasts] are characteristic in rings, and are INCREASED to make the diagnosis.
Based on the information provided, this case is not reportable. The final path diagnosis is not a reportable disease. The comment further states that the overall picture is not diagnostic of a specific entity. Therefore, it should not be reported at this point.
For cases diagnosed 2010 forward, refer to the Hematopoietic and Lymphoid Neoplasm Case Reportability and Coding Manual and the Hematopoietic Database (Hematopoietic DB) provided by SEER on its website to research your question. If those resources do not adequately address your issue, submit a new question to SINQ.
EOD/Surgery of Primary Site--Melanoma: If a melanoma primary site is other than skin, vulva, penis, or scrotum should these fields be coded using melanoma schemes? See discussion.
Should a melanoma of the cervix be coded using the melanoma or the cervix schemes for these fields?
For cases diagnosed 1998-2003: Use the EOD and surgery code schemes for cervix uteri. The EOD scheme for melanoma excludes melanoma of the cervix uteri. The surgery code scheme for skin excludes cervix uteri.
First Course Treatment--Thyroid: Is hormone replacement following total thyroidectomy coded as first course treatment for all thyroid cases?
Code Hormone therapy as 01 [Hormone therapy administered as first course therapy] when thyroid replacement therapy is part of the first course of treatment for follicular or papillary thyroid cancer following thyroidectomy.
Thyroid hormone replacement therapy has a treatment effect on differentiated (follicular and papillary) carcinomas of the thyroid. This treatment effect is not seen for most medullary and undifferentiated thyroid cancers.
Grade, Differentiation--Bladder: How is this field coded for a five grade system? See Description.
Example: Invasive, high grade transitional cell carcinoma (Grade 4-5/5)
For this example, code grade as 4 based on the term "High grade." If "high grade" was not stated, the grade would be coded as 9, not determined. There is no SEER translation between the ICD-O grades and a five grade system for bladder. None of the pathololgist experts we querried knew of a five grade system for bladder.
EOD-Size of Primary Tumor--Breast: How do we code this field when there is a difference between the size of the tumor mentioned in the gross (i.e., macroscopic description) and the comment sections of a pathology report? See Description.
Path Macro Summary states size as 1.5 cm. The path comment states "largest area of tumor seen is 1.5 cm. However, 8 of the nearly contiguous sections are involved with an estimated 2.4 cm area of involvement."
For cases diagnosed 1998-2003: Code the size of the largest area of tumor from the path macro summary. For the example provided, code the size as 015 [1.5 cm]. In this case, the additional sections of tumor described in the path comment do not seem to represent pieces of one larger tumor. The 2.4 cm estimated area of involvement was determined by adding together noncontiguous tumor sections. According to the CAP protocol for breast, Note J "When 2 or more distinct invasive tumors are present, each is separately measured...they are not combined into a single larger size."
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