Report | Question ID | Question | Discussion | Answer | Year |
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20031063 | Date of Diagnosis: When the clinical information on a scan indicates a history of cancer, how do you code the month and/or year of diagnosis given these terms: "early in year," "late in year," "2-3 months ago," "7 months ago," "new diagnosis." See Description. | Case 1. Diagnosed with CLL in late 1996. Assumptions: Code the term "late" in the year to December. Date of diagnosis would be coded to December 1996.
Case 2. Diagnosed with CLL in early 1997. Assumptions: Code the term "early" in the year to January. Date of diagnosis would be coded to January 1997.
Case 3. Admitted July 2000. Per H & P, patient was diagnosed with prostate cancer 2-3 years ago. Assumptions: Select the higher number in the range (in this case 3 years) and subtract 3 years from date of admit to calculate year of diagnosis. Code diagnosis month to the month patient was admitted. Diagnosis date would be coded July 1997.
Case 4. Admitted in October 2001. H&P states that colon cancer was diagnosed 7 months ago. Assumptions: Subtract 7 months from date of admit. Code date of diagnosis to March 2001.
Case 5. Admitted in December 2001. Per H&P, patient has CLL, presumably a new diagnosis. Assumptions: Assume the H&P statement of "new" to be equivalent to "recent" and code date of diagnosis to date patient was admitted. In this case, date of diagnosis would be coded to December 2001.
Case 6. Admitted for radical prostatectomy for prostate cancer in March 2001. H&P states that his PSA was 5 in November 2000 and in January 2001, PSA was 5.3. Biopsies showed adenocarcinoma. Assumptions: Assume the biopsy was done the same month as the January 2001 increased PSA. Date of diagnosis would be coded to January 2001.
Case 7. Outpatient bone scan done December 2001. Clinical history on the scan stated patient has history of prostate cancer. The physician was queried about date of diagnosis. Per the physician response, patient was diagnosed in 2001. Assumptions: Assume the bone scan was part of the initial work-up for prostate cancer and estimate the date of diagnosis to December 2001. |
SEER agrees that these are reasonable assumptions based on the information provided.
Estimate the month and year of diagnosis using the available information. If the information is not sufficient to make an estimation on the month, code the month of diagnosis as "99." Avoid coding "unknown" for the year of diagnosis. |
2003 |
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20031205 | EOD-Pathologic Review of Number of Regional Lymph Nodes Positive and Examined: How are these fields coded when an autopsy report reveals pathologically involved regional lymph nodes but does not state how many nodes were positive nor how many were examined? See Description. | A final autopsy report described widely disseminated adenocarcinoma, probably lung primary. Metastatic tumor in brain, lungs, and in lymph nodes. The Gross description of the autopsy report stated that there were numerous metastases to hilar and mediastinal lymph nodes. The Micro description of the autopsy report did not add any clarification. In the absence of a stated number of lymph nodes, the options for coding number of regional lymph nodes examined are codes 96-98. These codes include descriptions of surgical procedures such as sampling and dissection. How do we code number of regional lymph nodes examined when the pathological examination of lymph nodes was done only at autopsy and not during a surgical procedure? | For cases diagnosed 1998-2003: The rules that apply to the use of pathology reports for EOD coding also apply to autopsy reports. When a cancer diagnosis is made and positive lymph nodes are discovered on autopsy, in the absence of a stated number of lymph nodes, code the number of lymph nodes positive to 97 [Positive nodes but number of positive nodes not specified]. Code the number of lymph nodes examined to 97 [Regional lymph node removal documented as dissection and number of lymph nodes unknown/not stated]. An autopsy is a dissection. |
2003 |
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20031167 | 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. |
2003 |
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20031138 | EOD-Size of Primary Tumor--Testis: Should this field be coded to the gross pathological size when the pathology states "tumor dimension essentially the same as testicle, but is not appropriate in this case because the infiltrate does not form a mass lesion"? See Description. | Gross describes a testicle that measures a 4cm. Path micro states "several large atypical cells...These never form a true mass. Path comment states, "tumor dimension essentially the same as testicle, but is not appropriate in this case because the infiltrate does not form a mass lesion." | For cases diagnosed 1998-2003: Code the tumor size as 999 [Not stated] for the case example above. Keep in mind that tumor size is not used in analysis for certain sites such as testis, stomach, colon & rectum, ovary, prostate, and urinary bladder. Tumor size is important for analysis for certain sites such as lung, bone, breast, and kidney. | 2003 |
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20031175 | First Course Therapy: Are radio immune labeled antibodies, such as Bexxar [Tositum--I-131] coded as immunotherapy, radiotherapy, or experimental therapy? |
Agents such as Bexxar or Zevalin are radioisotopes and coded as radiation. These agents destroy cancer cells with radiation. | 2003 | |
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20031042 | Histology (Pre-2007): How are the following four histologies coded: 1) Adenocarcinoma with focal mucinous adenocarcinoma; 2) Adenocarcinoma with focal areas of bronchioalveolar adenocarcinoma, 3) Mixed infiltrating duct and focal medullary carcinoma, and 4) Mixed infiltrating duct and focal medullary carcinoma? See Description. | 1. How do we code colon: Adenocarcinoma with focal Mucinous adenoca? 8140/3 or 8255/3? 2. A lung lesion with predominant adenoca with focal areas of bronchioalveolar adenoca? 8140/3 or 8255/3? 3. Mixed infiltrating duct carcinoma and medullary ca? 8510/3 or 8255/3? 4. Mixed infil duct ca and focal medulary ca? 8510/3 or 8255/3? |
For tumors diagnosed prior to 2007:
1. 8140/3, Adenocarcinoma. Mucinous has a specific rule (see sinq 20010075): Include the mucinous component only if it is 50% or more of the tumor. "Focal" is not a majority term. 2. 8250/3, Bronchiolo-alveolar adenoca. Code the more specific histology. 3. 8523/3, Infiltrating duct mixed with other types of carcinoma. Combination of infiltrating duct and another type of carcinoma. 4. 8523/3, Infiltrating duct mixed with other types of carcinoma. Combination of infiltrating duct and another type of carcinoma.
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. |
2003 |
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20031146 | 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." | 2003 |
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20031191 | EOD-Clinical Extension--Prostate: How is this field coded when biopsies of the prostatic apex are positive and the physician clinically stages the case as T1c? | For cases diagnosed 1998-2003:
Code clinical extension to 33 [arising in the prostatic apex] when a biopsy of the prostatic apex is positive for malignancy, with no further evidence of involvement. If biopsies of both the apex and another site within the prostate (for example right lobe) are positive and there is no mention that the malignancy arose in the apex, code extension to 34 [extending into the prostatic apex]. |
2003 | |
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20031188 | EOD-Size of Primary Tumor--Breast: How would this field be coded, using the revised and expanded breast code, for a lesion described as "1.3 cm infiltrating ductal carcinoma, associated DCIS?" | For cases diagnosed 1998-2003: Code size of primary tumor as 013. The phrasing suggests that the infiltrating ductal carcinoma measures 1.3 cm. DCIS is also present, but no size mentioned. | 2003 | |
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20031153 | Laterality/Multiple Primaries (Pre-2007)--Ovary: Are ovarian primaries with bilateral involvement always coded to laterality 4 (bilateral)? See Description. | Example: "Right ovary with mass replacing majority of ovarian tissue consistent with serous adenoca. Lt ovary with foci of adenoca." No specific statement of primary. Can we assume that the malignancy originated in the right ovary since it is more extensively involved or should laterality be coded 4 because both ovaries have tumor? | For tumors diagnosed prior to 2007:
If one ovary is listed as the primary site, code laterality to that ovary. The example above is one of those times when you would code to the single ovary. The issue of one or both ovaries being involved is handled in staging.
Abstract the example above as a single primary with code 1 [Right] for laterality.
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. |
2003 |