EOD-Size of Primary Tumor/First Course Treatment--Breast: How is tumor size coded when preventative tamoxifen treatment precedes breast cancer diagnosis? Can we code the tumor size from the surgical specimen? Is tamoxifen treatment here? See Description.
What is the tumor size in this situation? Patient is on the STAR trial (preventative tamoxifen for women with high risk for breast cancer). Patient develops breast cancer and has surgery.
For cases diagnosed 1998-2003: Code EOD-Size of Primary Tumor from the surgical pathology report.
Do not code this preventative tamoxifen as first course cancer-directed treatment. This tamoxifen was part of a clinical trial intending to delay or prevent beast cancer from developing.
Multiple Primaries/Histology--Hematopoietic, NOS/Lymphoma: How many primaries are represented and what are the histologies for "B-cell lymphoma with immunophenotypic findings consistent with hairy cell leukemia" found on a bone marrow biopsy? See Description.
Pathologist completed AJCC lymphoma staging form indicating this case should be abstracted as a lymphoma.
For cases diagnosed prior to 1/1/2010:Abstract as one primary, 9591/3 [B-cell lymphoma, NOS]. The bone marrow diagnosis indicates that the main/definite diagnosis is B-cell lymphoma, with a lesser indication of hairy cell leukemia. Both of these are mature B-cell neoplasms according to the WHO histological classification.
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.
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: What histology code is used for a patient diagnosed with "myelodysplasia" prior to 2001, if a bone marrow biopsy in 2002 is consistent with myelodysplastic syndrome with refractory anemia with bilineage dysplasia with excess blasts and the final impression is "myelodysplastic syndrome slowly evolving toward acute leukemia?"
Patient was admitted in July 15, 2002. Per the H&P, patient was diagnosed 5 years ago with myelodysplasia. Patient had bone marrow biopsy about 5 years ago and then again on 6-10-02. Patient has become transfusion dependent since mid-March. Bone marrow on 6-10-02 was consistent with myelodysplastic syndrome with refractory anemia with bilineage dysplasia with excessive blasts. Impression: Myelodysplastic syndrome slowly evolving toward acute leukemia. Plan: start chemo. 7-16-02 bone marrow biopsy showed acute myeloid leukemia.
Can we assume that the myelodysplasia diagnosed 5 years ago was refractory anemia and therefore, patient's first reportable diagnosis would be the AML? Or is the 6-10-02 bone marrow biopsy showing refractory anemia to be the first reportable diagnosis because the term "myelodysplasia" is non-specific?
For cases diagnosed prior to 1/1/2010:
Based on the information provided, the diagnosis date is June 2002. The diagnosis is 9895/3, acute myeloid leukemia with multilineage dysplasia (AML with prior myelodysplastic syndrome). According to the SEER table of hematopoietic diseases, refractory anemia and myelodysplastic syndrome followed by AML is one primary.
Prior to 2001, a diagnosis of myelodysplasia was not reportable.
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.
Surgery of Primary Site--Skin: Should this field be coded to 45 [wide excision or reexcision of lesion or minor (local) amputation with margins more than 1 cm, NOS], 46 [with margins between 1 and 2 cm], or 47 [with margins greater than 2 cm] for a skin primary diagnosed in 2003 when margins are stated exactly as 2 cm?
Use code 46 [Wide excision...with margins more than 1 cm and less than 2 cm] when margins are exactly 2 cm.
Hormone Therapy--Hematopoietic, NOS: Is hormonal therapy coded for myelodysplastic syndrome, NOS? See Description.
Patient with myelodysplastic syndrome refused chemotherapy and was treated with high dose steroids. Patient also received Rituxan.
Hormones, such as glucocorticoids and androgens, are generally of little if any benefit to patients with myelodysplastic syndrome, according to the NCI PDQ. Do not code steroids as treatment in the example above.
Surgery of Primary Site--Breast: How is this field coded when a patient has a reduction mammoplasty (for macromastia) and within the pathology specimen there is an incidental finding of carcinoma?
For cases diagnosed 1998-2003: Code this reduction mammoplasty to 20, 21 or 30, depending on whether or not there was a nipple resection. According to our surgical consultant, a reduction mammoplasty is more like a partial mastectomy than a lumpectomy or other breast surgery.
EOD-Size of Primary Tumor: Can the term "filling defect" be used to code tumor size? See Description.
Site: Bladder
CT abd/pelvis: 4 cm filling defect of the bladder encasing jetstream of distal ureter. 2-3 cm lesion may be extension to bladder. KUB: 3-4 cm filling defect within bladder.
Cystoscopy: large bladder tumor with small tumor extending out of the large tumor.
OP Findings: Large tumor on right of bladder extending from bladder neck lateral and posterior
Pathology: TURB: High grade TCC, Grade III with focal lamina propria invasion.
For tumors diagnosed 1998-2003:
Information on size from imaging/radiographic techniques can be used to code size when there is no more specific size information from a pathology or operative report, but it should be taken as low priority, just above a physical exam.
The term "filling defect" from a CT or KUB may be used to code tumor size for bladder in the absence of more reliable size information from path, operative or endoscopic reports.
Surgery of Primary Site--Head & Neck: Is a composite resection performed for an oral cavity primary coded to 40 [Radical excision of tumor, NOS], 41 [Radical excision of tumor only], 42 [Combination of 41 with resection in continuity with mandibles (marginal, segmental, hemi-, or total resection], 43 [Combination of 41 with resection in continuity with maxilla (partial, subtotal, or total resection)]? See discussion.
Example:
Patient underwent composite resection of left soft palate, tonsillar fossa, medial pterygoid and lateral tongue for a primary of the retromolar trigone. There was no mention of an excision of the mandible; however, the procedure included the application of a mandibular reconstruction plate.
Use surgery codes 40-43 for composite resection of an oral cavity primary. In the case example, code Site-Specific surgery as 42 [Combination of 41 WITH resection in continuity with mandible]. Even though excision of mandible was not mentioned, there was mention of a mandibular reconstruction plate. Since the retromolar trigone is ON the mandible, resection of the mandible is likely.