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Report Produced: 03/26/2023 08:45 AM

Report Question ID Question Discussion Answer (Descending)
20100074 Laterality--Melanoma: For a melanoma case, does the term "mid" imply that the tumor is in the midline when the site is the skin of back (trunk)? Yes. When the location is described as mid-back or mid-chest with no indication of left or right, assign laterality code 5 [midline].
20021153 Grade, Differentiation--Breast: Is "histological grade" another way of saying "tubule formation" which would result in the following case having a Bloom-Richardson (BR) score of 7 which would be coded to grade 2? See discussion. Final path diagnosis stated: Invasive ductal ca, histological grade 3/3, nuclear grade 2/3, mitotic index-moderate. Yes. Code the Grade, Differentiation field to 2 [Grade 2] for this case. This case has a BR score of 7 which converts to a grade of 2. This pathologist seems to be describing the three parts of the BR system: tubule formation, mitotic activity and nuclear grade.
20000474 Date of Diagnosis: If a clinician states his current diagnosis of malignancy is based on a CT scan done at an early date that contained a diagnosis of only "neoplasm" or "worrisome for carcinoma" should the date of diagnosis be the date of the scan? Yes. Code the Date of Diagnosis field to the date of the scan. The physician's clinical impression upon reviewing the earlier scan, is that the malignancy was confirmed by the scan. If there is a medical review of a previous scan that indicates the patient had a malignancy at an earlier date, then the earlier date is the date of diagnosis, i.e., the date is back-dated.
20100104 Grade--Heme & Lymphoid Neoplasms: Is the phrase "aberrant T-cell expression" enough to code the grade field to T-cell when the final diagnosis on the pathology report is "AML with aberrant T-cell antigen expression"? Yes. Code grade to 5 [T-cell]. The T cell receptor, or TCR, is a molecule found on the surface of T lymphocytes (or T cells).
20061077 Chemotherapy--Breast: Is chemotherapy administered for inflammatory breast cancer also coded as therapy for an in situ tumor in the contralateral breast? Yes. Because chemotherapy would likely affect both primaries, code it as treatment for both the in situ and the inflammatory breast cancers.
20000272 Grade, Differentiation: Are anaplastic tumors always coded to grade 4, even for anaplastic brain primaries? Yes. Always code the Grade, Differentiation field to for 4 [Grade IV] for "anaplastic" tumors. Anaplastic is synonymous with undifferentiated. Refer to the example in the SEER Program Code Manual, 3rd Ed.
20061119 Reportability--Breast: Is a biopsy proven squamous cell carcinoma of the breast nipple reportable if a subsequent areolar resection shows foreign body granulomatous reaction to suture material and no evidence of residual malignancy in the nipple epidermis? Yes, this case is reportable. The primary site is C500 [nipple]. There was a diagnosis of malignancy on 2/15/06: "Positive for malignancy." Even though no residual malignancy was found in the later specimen, that does not disprove the malignancy diagnosed on 2/15/06.
20020047 Scope of Regional Lymph Node Surgery/Radiation Sequence with Surgery/Date Therapy Initiated: Is the Scope of Regional Lymph Node Surgery field used to code date of first therapy and radiation sequence with surgery? See discussion. Example: There is no primary site surgery and only an aspirate of a lymph node and the date of therapy is based on this procedure. Yes, the Scope of Regional Lymph Node Surgery field is used to code the Date Therapy Initiated field and the Radiation Sequence with Surgery field.
20061133 Terminology, NOS--Melanoma: Is a diagnosis of melanoma "with associated intradermal nevus" coded the same as a melanoma "arising in a nevus"? Yes, melanoma "associated with" a nevus and melanoma "arising in" a nevus are synonymous.
20071018 Reportability: Is a "goblet cell carcinoid" of the appendix reportable? Yes, goblet cell carcinoid of the appendix is reportable. The ICD-O-3 code for goblet cell carcinoid is 8243/3.