Question: 20170055

Status


Final

Category


#1:   First course treatment
#2:   Surgery of Primary Site
#3:   Corpus uteri


References


Source 1:   2016 SEER Manual
pgs:  
Notes:   App. C-Corpus Uteri Surgery Codes
Source 2:   Glossary; NCI Definitions of Cancer Terms
pgs:  
Notes:  


Question


First Course of Treatment/Surgery of Primary Site--Corpus uteri:  Do you code total hysterectomy or radical hysterectomy when a specimen indicates the uterus, cervix, ovaries, fallopian tubes, and right and left parametrium were resected, but shows no portion of the vagina.  See Discussion.



Discussion


AFS1-AFS2-frozen section control, endomyometrium; AFS3-frozen section control, subserosal intramural mass; A4-anterior cervix; A5-posterior cervix; A6-anterior cervical endometrial junction; A7-posterior cervical endometrial junction; A8-A10-anterior endomyometrium, including tumor; A11-A13-posterior endomyometrium, including tumor and adjacent mass; A14-random section subserosal mass; A15-left parametrium at margin of resection; A16-right parametrium at margin of resection; A17-A18-left ovary and fallopian tube; A19-A20-right ovary and fallopian tube. The final diagnosis includes Endometrial adenocarcinoma, favor serous carcinoma, with papillary and solid areas. Tumor involves: Cervix present, Right ovary, Left ovary, Right fallopian tube, Left fallopian tube, Right parametrium, Left parametrium.



Answer


Assign code 50 for total hysterectomy.  According to Appendix C Surgery Codes for Corpus Uteri of the 2016 SEER Coding and Staging Manual, total hysterectomy is surgery to remove the entire uterus, including the cervix; whereas, radical hysterectomy includes the vagina.



History




Last Updated


09/01/2017

Date Finalized


11/08/2017