SEER Study Guide

Social History

Spanish speaking male. Patient’s birthplace is Mexico. Marital status is divorced. Primary payer at diagnosis: Insurance, NOS.

Physical Exam

01/16/2014 – HPI: Pt admitted from ER w/ back and hip pain over last 2 months and painless hematuria. IMP: Gross hematuria concerning for neoplasm. Plan: CT IVP and TURBT/cytoscopy.

02/07/2014 – cc: Pt w/ metastatic TCC of bladder w/ bony mets, here to establish oncologic care. IMP: Aggressive TCC of bladder w/ bony mets, mets iliac and retroperitoneal adenopathy and partially resected bladder mass. Plan: Discussed chemo, would mainly be palliative, would like to improve symptom management before starting while patient thinks about this option.

03/26/2014 – Received notification from Hospice that patient died today.

Scans

01/16/2014 – CT IVP: Fungating soft tissue w/in bladder completely obstructing Rt ureteral orifice. Extensive retroperitoneal adenopathy highly suspicious for mets.

01/16/2014 – CT Lumbar Spine: Innumerable sclerotic lesions concerning for mets. These involve nearly all vertebral bodies, sacrum, bilat femurs and pelvic bones.

01/16/2014 – CT Abd/Pelvis: Moderate Rt hydroureteronephrosis to level of bladder. 3 mm calculus in bladder and hemorrhage c/w passed stone. Abnl soft tissue thickening of posterior bladder wall, suspicious for neoplasm. Areas of bony sclerosis and inguinal adenopathy, concerning for mets. Attending Comment: Very high suspicion for malignancy given bladder wall thickening, adenopathy, sclerotic bone lesions. There is also bilat iliac and retroperitoneal adenopathy.

01/17/2014 – Bone Scan: Diffuse osseous mets.

Operative Reports

02/01/2014 – TURBT: Large fungating mass at bladder neck, appeared to involve both bladder and prostatic tissue on both sides. An extremely large amount of tumor was removed.

Treatment Plan

02/19/2014 – Pt opted for Hospice.

01/18/2014 – Path Report #1

Clinical Diagnosis/History:

History of worsening back pain and painless hematuria with radiographic findings concerning for malignancy.

Cytologic Impression:

Urine (voided):  Malignant cells present.  Histologic evaluation is required for definitive diagnosis.  See comment.

Diagnosis Comment:

60 mls grossly hemorrhagic fluid is received from which two Papanicolaou-stained concentrated smears are made.  Smears contain numerous cytologically malignant cells scattered singly and in cohesive clusters characterized by enlarged size with increased nuclear to cytoplasmic ratios, hyperchromatic nuclei with coarse chromatin, irregular nuclear contours, and anisonucleosis.  There are features of squamous differentiation with keratinized squamous cells and keratin debris.  The findings are positive for malignancy, suggest poorly differentiated carcinoma.  Although urothelial carcinoma with squamous differentiation is favored, there is insufficient material available for cell block preparation and marker studies.  Please note that cytology alone cannot distinguish in situ from invasive carcinoma.  Histologic evaluation is required for definitive diagnosis and tumor subclassification.

02/01/2014 – Path Report #2

Clinical Diagnosis/History:

History of bladder mass, painless hematuria.

Procedure:  Transurethral biopsy.

Per electronic medical record: 25 pack year history of smoking, previously employed as a painter and light construction worker.

Final Diagnosis:

  1. A) Bladder, transurethral resection of tumor:

High-grade urothelial carcinoma with focal squamous differentiation and multifocal necrosis.

Invasion into muscularis propria.

No definite lymphovascular invasion is identified, see comment.

Diagnosis Comment:

Immunohistochemical staining for CD31 highlights abundant vasculature around tumor nests, but fails to confirm true vascular invasion.

Immunohistochemistry Studies:

Specimen: A3

Population: Carcinoma cells

CD31 CD31 [JC/70A]  Diffuse interstitial and vascular reactivity

Intensity:  Strong

Gross Description:

Specimen A:  Received in formalin labeled “bladder mass” are numerous pieces of tan, brown, and hemorrhagic tissue weighing in aggregate 32 g and measuring in aggregate 10 x 7 x 0.5 cm.  Approximately 1/2 the tissue is submitted in cassettes A1-A5.

Data Item :

Diagnosis Date

Correct Answer :

01/16/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the 01/16/2014 CT IVP scan stating “suspicious for mets”.

Ambiguous terminology may be used to accession a case when the ambiguous terminology is considered reportable. “Suspicious” is a reportable ambiguous term.

[2014 SEER Manual, Date of Diagnosis.]

Data Item :

Primary Site

Correct Answer :

C675

Rationale:

The TURBT operative report indicates there is a large mass at the bladder neck. Per the SEER coding guidelines, the priority for coding primary site is from the operative report (TURBT). Apply code C675 (bladder neck).

[2014 SEER Manual, Primary Site; 2014 SEER Manual, Appendix C, Bladder, Coding Guidelines.]

Data Item :

Laterality

Rationale:

Code 0 (not a paired site) when the primary site is not considered a paired site per SEER.

[2014 SEER Manual, Laterality.]

Data Item :

Histology

Correct Answer :

8120

Rationale:

The MP/H Rules (general rules) state the priority for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. In this case, the patient had a TURBT (transurethral resection of bladder tumor) with pathology showing high-grade urothelial carcinoma with focal squamous differentiation.

Per the MP/H Rules, Urinary, apply rule H5 and code the histology to transitional cell carcinoma when that is the only histology present. The term “focal” is not used to code a more specific histology, so the focal squamous differentiation can be ignored. Code the histology as 8120 (transitional cell carcinoma).

[2007 Multiple Primary and Histology Coding Rules]

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology report, this is a malignant (invasive) tumor. Code the behavior as /3 (malignant) when the primary tumor, or any portion of the primary tumor, is invasive.

[2014 SEER Manual, Behavior Code.]

Data Item :

Grade

Correct Answer :

4

Rationale:

Code the highest grade given from the primary tumor prior to neoadjuvant treatment. In this case, the TURBT pathology report identified high-grade urothelial carcinoma. Per the instructions for coding grade for transitional cell carcinoma of the bladder, the terminologies high grade TCC and low grade TCC are coded in the two-grade system. Per the two-grade system conversion table, high grade urothelial carcinoma of the bladder is coded as SEER code 4.

Data Item :

Clin T

Correct Answer :

4A

Rationale:

The 01/16/2014 CT scan showed abnormal soft tissue thickening of the bladder wall that was suspicious for malignancy. There is no documentation whether the bladder mass was palpable, mobile, or fixed. The 02/01/2014 TURBT operative report identified a large, fungating mass at the bladder neck that involved both the bladder and prostatic tissue.

The patient did not have a complete resection of the tumor per the operative report and 02/07/2014 physical exam note. While there was no removal of involved prostatic tissue, it was involved clinically by TURBT visualization. Imaging evidence of extravesical (prostatic) invasion can be used to assign the clinical T category. Apply code 4A (T4a, tumor invades prostatic stroma).

[AJCC Cancer Staging Manual, 7th Edition]

Data Item :

Clin N

Correct Answer :

2

Rationale:

The 01/16/2014 CT Abd/Pelvis showed bilateral iliac and retroperitoneal adenopathy. The 02/07/2014 physical exam note indicates the physician diagnosed the patient with metastatic iliac and retroperitoneal adenopathy. While retroperitoneal nodes are considered distant nodes, iliac nodes are regional for the bladder. Because the patient has bilateral iliac adenopathy, it can be assumed the patient has multiple regional nodes involved. Apply code 2 (N2, multiple regional lymph node metastasis in the true pelvis (iliac nodes)).

[AJCC Cancer Staging Manual, 7th Edition]

Data Item :

Clin M

Correct Answer :

1

Rationale:

The patient has clinical evidence of distant metastatic disease. The 01/17/2014 bone scan showed diffuse osseous metastases. The 01/16/2014 CT scan showed retroperitoneal adenopathy. Retroperitoneal nodes are distant lymph nodes for a bladder primary. The 02/07/2014 physical exam note indicates the patient has bony metastases as well as metastatic retroperitoneal adenopathy. Apply code 1 (M1, distant metastasis).

[AJCC Cancer Staging Manual, 7th Edition]

Data Item :

Path Stg Grp

Correct Answer :

BLANK

Rationale:

There was no surgical resection of the primary site (cystectomy) and/or regional lymph nodes. Surgery was not planned. Apply code BLANK.

Note: Click here to open “TNM_Document.pdf” which describes general rules for developing preferred answers in SEER*Educate.

[AJCC Cancer Staging Manual, 7th Edition]

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Note: Click here to open “TNM_Document.pdf” which describes general rules for developing preferred answers in SEER*Educate.

[AJCC Cancer Staging Manual, 7th Edition]

Data Item :

SS 2000

Correct Answer :

7

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has distant stage disease as the patient was clinically diagnosed with bone and distant (retroperitoneal) lymph node metastases. The primary tumor was considered regional by direct extension to the prostate on imaging. The patient also had clinical evidence of regional (iliac) lymph node involvement. The presence of bone and distant retroperitoneal lymph node metastases is always coded as distant stage disease, regardless of the tumor involvement or whether regional lymph nodes were involved. Apply code 7 (Distant site(s)/lymph node(s) involved).

[2014 SEER Manual, SEER Summary Stage 2000.; SEER Summary Staging Manual 2000.]

Social History

Alaska native male lives with his wife. Born in Alaska. Primary payer at dx is Insurance, NOS.

Physical Exam

05/13/2014 – HPI: 57 yo male who first noticed gross hematuria approximately 1 year ago. He did not seek medical attention until approximately 01/2014. PTA 01/10/2014, TUR found large bladder tumor c/w invasive urothelial carcinoma. Started PTA neoadjuvant chemotherapy on 01/30/2014with 4 cycles of gemcitabine and cisplatin. Last cycle ended on 04/22/2014. Radiology: PTA CT scan 01/23/2014 with residual bladder mass, original read did not notice any adenopathy, but on my review, there appears to be an ~ 2 cm enlarged LN along Rt external iliac. IMP: Muscle invasive bladder cancer, status post 4 cycles of neoadjuvant gemcitabine and cisplatin. Plan: After discussion of treatment, the patient wishes to undergo cystectomy. Tentative operative date: 06/06/2014

Scans

06/03/2014 – CT Abd/Pelvis: Decreased urinary bladder wall thickening. Decreased size of metastatic left external iliac LN, previously measured 2.3 x 1.6 cm. FIND: Not suspicious for osseous mets.

Operative Reports

06/05/2014 – Radical cystectomy, radical retropubic prostatectomy, bilat extended pelvic LN dissection, ileal neobladder formation, omental flap: Matted portion of nodes along common iliac vein and artery.

Chemo Text

01/30/2014 – PTA chemo: 4 cycles of Gemcitabine and Cisplatin.

01/10/2014 – Path Report #1

Clinical Diagnosis/History:

Slide review.

Final Diagnosis:

Outside Laboratory (01/10/2014)

Urinary bladder, transurethral resection:

High-grade urothelial carcinoma with micropapillary features, invading muscularis propria.

Lymphovascular invasion:  Present.

Materials Received:

Specimen A:  Urinary Bladder Transurethral Resection

06/05/2014 – Path Report #2

Clinical Diagnosis/History:

188.9.  Bladder CA.  Per electronic medical record:  History of high-grade urothelial carcinoma with micropapillary features with biopsy proven invasion into muscularis propria and lymphovascular invasion, status post neoadjuvant chemotherapy.

Final Diagnosis:

  1. A) Left pelvic lymph nodes, dissection: Positive for carcinoma, present in 1 of 4 lymph nodes, approximately 3.0 cm in greatest dimension (1/4).
  1. B) Left common iliac lymph nodes, dissection: Positive for carcinoma, present in 1 of 1 lymph node, 0.6 cm in greatest dimension (1/1).
  1. C) Right external iliac lymph nodes, dissection: 3 lymph nodes, negative for carcinoma (0/3).
  1. D) Right pelvic lymph nodes, dissection: Fibroadipose tissue, no lymph nodes, no carcinoma identified.
  1. E) Right obturator lymph nodes, dissection: Positive for carcinoma, present in 1 of 2 lymph nodes, 0.8 cm in greatest dimension (1/2).
  1. F) Right common iliac lymph nodes, dissection: 1 lymph node, negative for carcinoma (0/1).

G-I)  Margins, left ureteral, right ureteral and urethral, excisions:  No high grade dysplasia or carcinoma identified.

  1. J) Bladder and prostate, cystoprostatectomy:

Focal urothelial atypia consistent with high grade intraepithelial neoplasia/carcinoma in situ; no residual invasive carcinoma identified.  (See comment)

Edema, fibrosis, hemosiderin deposition and focal foreign body type giant cell reaction in lamina propria, suggestive of previous therapy effect.

Prostatic parenchyma, no carcinoma identified.

  1. K) Perirectals, excision: Fibroadipose and fibrovascular tissue with nerve trunks, no carcinoma identified.

L,M)  Final left ureteral and  final right ureteral margins, excision:  Segment of ureter, no high grade dysplasia or carcinoma identified.

Comment:

The scarred area in the bladder is submitted entirely for histologic evaluation and no residual carcinoma is identified.  Metastatic foci show focal micropapillary features.

Intraoperative Consultation:

GFS)  Left ureteral margin:   Negative for carcinoma.

HFS) Right ureteral margin:  Negative for carcinoma.

IFS)   Urethral margin:          Negative for carcinoma.

Gross Description:

Specimen A:  Received in formalin labeled “left pelvic lymph nodes” is a 6.0 x 3.0 x 2.0 cm yellow fatty portion of tissue.  Within this tissue are four possible tan-yellow/red lymph nodes that range from 1.1 to 5.0 cm in length.  The lymph nodes are entirely submitted as follows:  A1 – one bisected node; A2 – one serially sectioned node; A3 – one serially sectioned node; A4-A6 – one serially sectioned lymph node.

Specimen B:  Received in formalin labeled “left common iliac lymph nodes” is a 2.0 x 1.0 x 0.5 cm focally firm, gray-red lymph node which is serially sectioned and entirely submitted in cassette B1.

Specimen C:  Received in formalin labeled “right external iliac lymph nodes” is a 4.5 x 2.5 x 1.1 cm yellow, fatty portion of tissue.  Within this tissue are three tan lymph nodes which range from 1.1 to 2.0 cm in greatest dimension.  The lymph nodes are entirely submitted as follows:  C1 – one serially sectioned lymph node; C2 – one inked bisected node and one whole node.

Specimen D:  Received in formalin labeled “right pelvic lymph nodes” is a 3.0 x 2.0 x 0.6 cm yellow, fatty portion of tissue.  There is no grossly obvious lymph node tissue identified.  The specimen is sectioned and entirely submitted in cassette D1.

Specimen E:  Received in formalin labeled “right obturator lymph nodes” is a 5.0 x 3.0 x 1.5 cm yellow-red, fatty portion of tissue.  Within this tissue are two tan lymph nodes measuring 1.0 and 4.0 cm in greatest dimension.  The smaller lymph node is bisected and entirely submitted in cassette E1, and the larger lymph node is serially sectioned and entirely submitted in cassettes E2-E4.

Specimen F:  Received in formalin labeled “right common iliac lymph nodes” is a 1.5 x 0.7 x 0.5 cm yellow-red lymph node which is bisected and entirely submitted in cassette F1.

Specimen G:  Received fresh in a container for frozen labeled “left ureteral margin” is a 0.4 cm in diameter and 0.2 cm in length tan, rubbery, tubular portion of tissue which is entirely submitted for frozen.  The frozen section residue is submitted in block GFS1.

Specimen H:  Received fresh in a container for frozen labeled “right ureteral margin” is a 0.4 cm in diameter and 0.2 cm in length rubbery, tubular, tan portion of tissue which is entirely submitted for frozen.  The frozen section residue is submitted in block HFS1.

Specimen I:  Received fresh in a container for frozen labeled “urethral margin” is a 0.8 x 0.5 x 0.2 cm tan, rubbery portion of tissue which is entirely submitted for frozen.  The frozen section residue is submitted in block IFS1.

Specimen J:  Received fresh labeled “bladder/prostate” is a 7.5 x 6.5 x 4.5 cm bladder with an attached 4.5 x 4.3 x 4.0 cm prostate.  The attached peritoneal reflection is tan-pink, smooth and shiny, with no obvious lesions or masses. It is opened with a Y-shaped incision through the prostatic urethra and the anterior face of the bladder to reveal tan-pink trabeculated bladder mucosa.  Located in the posterior right aspect of the bladder is a 1.0 x 0.5 cm scarred retracted area.  The scarred retracted area encompasses the right ureteral orifice.  No other masses or lesions are identified.  The prostate is serially-sectioned revealing yellow-white uniform rubbery cut surfaces with no discrete masses or lesions identified.  The perivesicular fibroadipose tissue is serially-sectioned revealing yellow lobulated fibrofatty cut surfaces.  The specimen is inked as follows:  anterior left blue, anterior right black, posterior left orange, and posterior right green.  Representative sections are submitted labeled as follows:  J1 – ureteral and urethral margins, J2-J4 – representative cross-sections of prostate, J5 – right ureteral orifice and random section trigone, J6-J10 – entirety of scarred area, including left ureteral orifice, J11 – random sections of dome/anterior wall, J12 – random sections left posterior wall, J13 – one candidate lymph node.

Specimen K:  Received in formalin labeled “perirectal mass” is a 4.0 x 2.2 x 1.8 cm focally firm, pale yellow portion of tissue and a separate soft, yellow, fatty portion of tissue.  The fatty portion of tissue measures 3.0 x 2.2 x 1.0 cm.  There are no lymph nodes identified grossly.  The firm portion of tissue has an attached linear staple line along one edge.  The specimen is inked and the staples are removed.  The cut surfaces have a focally firm, nodular, gray-white to yellow-red appearance.  The firm portion of tissue is entirely submitted in cassettes K1-K3.  A representative section of the loose, yellow fatty tissue is submitted in K4.

Specimen L:  Received in formalin labeled “final left ureteral margin” is a rubbery, tan-pink, tubular portion of tissue consistent with a segment of ureter measuring 0.7 cm in length and 0.4 cm in outside diameter.  The lumen is grossly patent.  There is an attached surgical clip at the midpoint of the ureter.  The specimen is inked, trisected, and entirely submitted in cassette L1.

Specimen M:  Received in formalin labeled “final right ureteral margin” is a segment of ureter measuring 0.7 cm in length and 0.5 cm in outside diameter.  The ureter has a patent lumen.  There is a surgical clip at the midpoint of the ureter.  The specimen is inked, trisected, and entirely submitted in cassette M1.

Data Item :

Diagnosis Date

Correct Answer :

01/10/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the PTA 01/10/2014 TURB (transurethral resection of bladder) showing high grade urothelial carcinoma with micropapillary features.

Data Item :

Primary Site

Correct Answer :

C679

Rationale:

The physical exam states that the 01/10/2014 TURB found a large bladder tumor, with no mention of subsite. The review of the TURB pathology did not mention a subsite. The cystoprostatectomy operative report and pathology report also do not mention a specific subsite of where the tumor arose. There was mention of a “scarred retracted area” in the posterior right aspect of the bladder, but there is no statement of there being a mass at this location or that this was the location of the primary tumor. Per the SEER coding guidelines, the priority for coding primary site is from the operative report, TURB and the cystoprostatectomy. No bladder subsite was stated. Apply code C679 (bladder, NOS).

[2014 SEER Manual, Primary Site]

Data Item :

Laterality

Correct Answer :

0

Rationale:

Code 0 (not a paired site) when the primary site is not considered a paired site per SEER.

Data Item :

Histology

Correct Answer :

8131

Rationale:

The MP/H Rules (general rules) state the priority for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. In this case, the patient had a TURB (transurethral resection of bladder) with pathology showing high-grade urothelial carcinoma with micropapillary features. The cystoprostatectomy showed carcinoma in situ with no residual invasive carcinoma. The most representative specimen would be the TURB specimen, taken prior to neoadjuvant treatment.

Per the MP/H Rules, Urinary, apply rule H7 and code the most specific histology term, urothelial carcinoma with micropapillary features. See Table 1- Urothelial Tumors to determine specific histology term. Code the histology as 8131 (micropapillary urothelial carcinoma).

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology report, this is a malignant (invasive) tumor. Code the behavior as /3 (malignant) when the primary tumor, or any portion of the primary tumor, is invasive.

Data Item :

Grade

Correct Answer :

4

Rationale:

Code the highest grade given from the primary tumor prior to neoadjuvant treatment. In this case, the TURB (prior to neoadjuvant treatment) pathology report identified high-grade urothelial carcinoma. Per the instructions for coding grade for transitional cell carcinoma of the bladder, the terminologies high grade TCC and low grade TCC are coded in the two-grade system. Per the two-grade system conversion table, high grade urothelial carcinoma of the bladder is coded as SEER code 4.

Data Item :

Clin T

Correct Answer :

2

Rationale:

The PTA 01/10/2014 TURBT showed a large bladder tumor consistent with invasive carcinoma. The PTA pathology report proved invasive urothelial carcinoma with micropapillary features that invaded the muscularis propria. The PTA CT scan on 01/23/2014 (following TURBT) showed residual bladder tumor, but no further documentation of extension.

The patient started neoadjuvant chemotherapy and the 06/03/2014 CT scan following treatment showed decreased urinary bladder wall thickening. Per the AJCC, bladder wall thickening suggests T3 disease, but there was no documented evidence the bladder mass invaded perivesical tissue.

Because there was no documentation to support the presence of T3 disease prior to treatment, T3 disease cannot be coded. Clinically, the greatest documented extent was the PTA TURBT findings of muscularis propria invasion. A TURBT is considered a clinical staging procedure for the bladder. Apply code 2 (T2, tumor invades muscularis propria).

Data Item :

Clin N

Correct Answer :

1

Rationale:

The PTA 01/23/2014 CT scan was reviewed by the physician at this facility and showed an enlarged right external iliac lymph node. A repeat CT scan was performed on 06/03/2014 after neoadjuvant chemotherapy. Although this should be excluded from clinical staging because it was performed after definitive treatment began, the follow-up scan refers back to the pre-treatment scan indicating a decrease in size of a metastatic external iliac node.

The follow-up CT scan confirmed the PTA clinical findings of regional lymph node metastasis. Although not explicitly documented, it appears this patient was being treated with neoadjuvant treatment for known metastatic disease. The patient has at least one involved regional node. Apply code 1 (N1, single regional lymph node metastasis in the true pelvis (external iliac node)).

Data Item :

Clin M

Correct Answer :

0

Rationale:

Per the AJCC Cancer Staging Manual, general instructions, a case with no symptoms or signs of metastasis is classified as clinically M0.

The PTA 01/23/2014 CT scan made no mention of distant metastatic disease. There were no symptoms or findings the physician felt clinically suspicious for metastasis. Apply code 0 (M0, no distant metastasis).

Data Item :

Clin Stg Grp

Correct Answer :

4

Rationale:

Per the urinary bladder staging form, when the clinical TNM is cT2 cN1 cM0, apply code 4 (Stage IV).

For bladder primaries, any lymph node involvement, with or without distant metastatic disease, is considered Stage IV disease.

Data Item :

Clin Desc

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

IS

Rationale:

The 06/05/2014 post-neoadjuvant treatment radical cystectomy pathology report showed no residual invasive carcinoma. The bladder showed focal carcinoma in situ only. Although the previous TURBT showed invasive urothelial carcinoma with micropapillary features, post-neoadjuvant treatment pathologic staging (ypT staging) is based on the radical or partial cystectomy findings after treatment only.

This classification is used to demonstrate the response to treatment, and also to help determine whether further adjuvant treatment is needed. The cystectomy pathologically proved in situ disease only following neoadjuvant treatment. Apply code IS (Tis, carcinoma in situ: “flat tumor”).

Data Item :

Path N

Correct Answer :

3

Rationale:

The 06/05/2014 post-neoadjuvant treatment radical cystectomy included resection of multiple primary (pelvic, external iliac, obturator) and secondary (common iliac) regional lymph nodes. The pathology report showed metastatic carcinoma in one left pelvic, one right obturator and one common iliac node. The rest of the resected nodes were negative. The patient had multiple nodes in the true pelvis, plus a common iliac node involved. Apply code 3 (N3, lymph node metastasis to the common iliac lymph nodes).

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic examination of distant metastasis. This patient had a clinical assessment only, clinically M0. Apply code BLANK.

Data Item :

Path Stg Grp

Correct Answer :

4

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, for cases with known pT and pN categories, use the clinical M category to complete the pathologic stage group.

Per the urinary bladder staging form, when the TNM is ypTis ypN3 cM0, apply code 4 (Stage IV).

This patient has post-neoadjuvant pathologic (yp) Stage IV disease with ypTis and ypN3 disease. For bladder primaries, any lymph node involvement, with or without distant metastatic disease, is considered Stage IV disease.

Data Item :

Path Desc

Correct Answer :

4

Rationale:

The patient received neoadjuvant chemotherapy (systemic) treatment with Gemcitabine and Cisplatin on 01/30/2014 and surgery was performed on 06/05/2014. Apply code 4 (Y-Classification during or after initial multimodality therapy–pathologic staging only).

Data Item :

SS 2000

Correct Answer :

7

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has distant stage disease as there was pathologic evidence of metastasis to the regional common iliac nodes following neoadjuvant treatment. Prior to neoadjuvant treatment, the tumor was clinically localized and only regional external iliac node involvement was noted. Post-neoadjuvant treatment resection showed no residual invasive disease, but pathologic evidence of common iliac nodal involvement. Although the common iliac nodes are considered regional nodes for a bladder primary per the AJCC, they derive a distant SEER Summary Stage. There were no distant metastases. Apply code 7 (Distant, distant lymph node(s) involved).

Social History

Retired African-American female with four adult children. Divorced, born in New York City. Insurance: Medicare and Medicaid.

Physical Exam

07/18/2014 – cc: 71 y/o w/ abnormal left mammogram. HPI: Abnormal mammogram of the left breast done PTA on 03/29/2014. This was followed by PTA needle bxs on 04/08/2014 and 04/17/2014 both of which revealed an atypical intraductal papillary lesion, bordering on DCIS. Pt also underwent PTA bilateral breast MRI on 04/22/2014, with the right breast negative, but the left breast was found to have a clumped non-mass-like enhancement measuring 7 x 1.8 x 1.4 cm. Several prominent left axillary nodes also found, measuring up to 15 mm. PE: LN’s: Palpable, mobile, normal-appearing left axillary node. Breast: No erythema or peau d’orange or any skin retraction, tethering or dimpling. No evidence of eczematoid change or crusting or discharge. No discrete masses palpable on either breast. IMP: Lt breast atypical indtraductal papillary lesions. Plan: Excisional bx.

08/06/2014 – IMP: Left breast intermediate grade DCIS, status post excisional biopsy, with persistently positive margins. Plan: Clearly needs additional surgery, with radiation possible depending on type of surgery.

08/23/2014 – Patient has decided to go forward with mastectomy. Radiation will not be needed.

Operative Reports

07/22/2014 – Left breast mammographic wire localized excisional biopsy times 2: 3 o’clock posterior and anterior biopsy. No gross palpable lesions in either specimen. Total extent excised measured approximately 7 cm.

09/09/2014 – Left skin-sparing mastectomy, left axillary sentinel lymph node dissection: No gross mass lesions within breast, and both sentinel lymph nodes grossly normal on inspection and palpation intraoperatively.

04/08/2014 – Path Report #1

Clinical Diagnosis/History:

Slide review.

Final Diagnosis:

  1. A) Outside Hospital (04/08/2014)

Left breast, calcifications and adjacent tissue, core needle biopsy:  Atypical intraductal papillary lesion, bordering on ductal carcinoma in situ, with associated microcalcifications.  No invasive carcinoma identified.

  1. B) Outside Hospital (04/17/2014)

Left breast, calcifications and adjacent tissue, core needle biopsy:  Atypical intraductal papillary lesion, bordering on ductal carcinoma in situ, with associated microcalcifications.  No invasive carcinoma identified

Materials Received:

Specimen A:  L Breast Stereotactic Core Bx

Specimen B:  L Breast Stereotactic Guided Bx

07/22/2014 – Path Report #2

Clinical Diagnosis/History:

Per electronic medical record:  History of left breast mammogram calcifications with biopsy demonstrating atypical intraductal papillary lesions, suspicious for DCIS, separated by approximately 5.0 cm.

Final Diagnosis:

  1. A) Left breast, 3:00 anterior, excisional biopsy: Papillary ductal carcinoma in situ with the following:
  2. Extent: Spanning 2.2 cm.
  3. Nuclear grade: Intermediate.
  4. Margins: DCIS present at anterior, posterior, medial, lateral and superior margins; present <0.1 cm from inferior margin.
  5. Calcifications present in association with papillary lesion.
  6. Estrogen receptor positive (Allred score 8 of 8).
  7. No invasive carcinoma identified.
  8. Biopsy site changes.
  1. B) Left breast, 3:00 posterior, excisional biopsy:
  2. Usual ductal hyperplasia.
  3. No atypical hyperplasia, in situ or invasive carcinoma identified.
  4. Biopsy site changes.

Comment:

  1. A) The left breast anterior biopsy demonstrates a spectrum of papillary neoplasia with features ranging from intraductal papilloma to papillary atypical ductal hyperplasia to papillary ductal carcinoma in situ. Immunohistochemical stains for myoepithelial cells confirm a non-invasive process, and demonstrate absence of myoepithelial cells within the majority of the intraductal papillary proliferation, consistent with in situ papillary carcinoma.

Gross Description:

Specimen A:  Received labeled “left breast 3:00 anterior biopsy” is a 3.2 g lumpectomy specimen measuring 2.2 SI x 2.0 ML x 1.3 AP cm.  The specimen has been previously inked per protocol by the surgeon with anterior green, inferior blue, lateral orange, medial yellow, posterior black, superior red.  It is serially sectioned from superior to inferior into five slices, with the first and last slice measuring 0.7 cm and the remaining slices averaging 0.4 cm in thickness.  A possible biopsy site is identified and no definite lesions.  Total formalin fixation time:  26 hours. The entire specimen is submitted:

A1 – superior margin

A2-A4 – slices 2-4, respectively

A5 – inferior margin

Specimen B:  Received labeled “left breast 3:00 posterior biopsy” is a 4.9 g lumpectomy specimen measuring 3.9 ML x 2.4 SI x 1.5 AP cm.  The specimen has been previously inked per protocol by the surgeon with anterior green, inferior blue, lateral orange, medial yellow, posterior black, superior red.  It is serially sectioned from medial to lateral into six slices, with the first and last slice measuring 1.0 cm and the remaining slices averaging 0.4 cm in thickness.  No distinct lesions are identified. Total formalin fixation time:  26 hours. The entire specimen is submitted as follows:

B1 – slice 1, lateral margin

B2 – slice 2

B3 – slice 3

B4 – slice 4

B5 – slice 5

B6 – slice 6, lateral margin

IHC Studies:

Specimen A2:  Population: Cells of interest

P63  P 63, (BC4A4)                     Positive, see comment    Controls appropriately positive

CALPONIN  Calponin [3(16)]    Positive, see comment    Controls appropriately positive

ER   Estrogen Receptor [SP1]     95% positive cells           Intensity: Strong

IHC Interpretation:

Variable loss of myoepithelial cells within papillary proliferations. Preserved myoepithelial staining around ducts.

IHC Report:

ER/PR and HER2 immunohistochemical analyses are performed in accordance with CAP/ASCO guidelines [Hammond et al, Wolf et al]. Department of Pathology protocols dictate that breast cancer containing tissue will be fixed in neutral buffered formalin for a minimum of 6 hours to a maximum of 48 hours for HER2 and 72 hours for ER/PR, unless otherwise noted in this report. ER and PR stains are interpreted using a modified H-score system (Allred) based on the proportion of cells staining and intensity of staining, with >1% of cells with weak staining intensity (Allred score 3 of 8) is the clinically validated threshold for a positive result [Harvey et al]. HER2 interpretative criteria recommended by CAP/ASCO are used with modification [Grimm et al], where 3+ staining (intense, uniform, homogeneous circumferential membrane staining in >30% of tumor cells) is required for a positive (“high over-expression”) result.  Cases with 2+ (equivocal) HER2 staining or those that fail our inclusion criteria for IHC testing will be tested for gene amplification using a validated fluorescent in-situ hybridization (FISH) technique.  These assays have not been validated on decalcified tissues.  Results should be interpreted with caution given the likelihood of false negativity on decalcified specimens.

References:

Grimm EE, et al. Am J Clin Pathol (2010) 14; 284-92. Hammond ME, et al. J Clin Oncol (2010) 28; 2784-95. Harvey et al. J Clin Oncol (1999) 17; 1474-81. Wolff AC, et al. Arch Pathol Lab Med (2007) 131; 18-43.

Specimen A2:  Population: Cells of interest

Fixation time QA    Fixation time QA on predictive markers       Meets Requirements  Controls appropriately positive

09/09/2014 – Path Report #3

Clinical Diagnosis/History:

233.0 DCIS, left breast mastectomy, DIEP sentinel node biopsy.  Per electronic medical record:  Papillary ductal carcinoma in situ.  Imaging demonstrated segmental amorphous calcifications in the 3:00 position spanning approximately 6.5 cm corresponding to segmental non-mass enhancement by MRI.

Final Diagnosis:

  1. A) Left breast, mastectomy: Papillary ductal carcinoma in situ with the following:
  2. Nuclear grade: Intermediate.
  3. Size/extent: Two foci, 2.3 cm and 1.3 cm in the lower outer quadrant.
  4. Margins: Papillary DCIS is present 0.2 cm from inferior superficial margin in the lower outer quadrant and free of other margins by >0.5 cm.
  5. Previously reported to be estrogen receptor positive (Allred score 8; Path Report #2)
  6. Calcifications present in association with DCIS.
  7. Surgical site changes.
  8. No invasive carcinoma identified.

B, C)  Left axillary sentinel nodes #1 and #2 as designated, excisions:  3 lymph nodes negative for carcinoma by H&E-stain (1 lymph node in part B and 2 in part C).

  1. D) Left breast, lower outer quadrant, superficial margin, excision:
  2. Fat necrosis and foreign body giant cell reaction.
  3. No atypical hyperplasia, in situ or invasive carcinoma identified.
  4. E) Left breast skin, excision: Skin with no neoplasm identified.

Gross Description:

Specimen A:  Received fresh labeled “left breast” is a 346 g skin-sparing mastectomy specimen measuring 16 (ML) x 14.5 (SI) x 3 (AP) cm with 5.5 cm diameter portion of pigmented skin including a 1.5 cm diameter everted nipple.  The specimen is inked as follows:  superior superficial = orange, inferior superficial = blue, posterior = black and serially sectioned from medial to lateral to reveal a 2.5 x 2.0 x 1.6 cm firm, white region with ill-defined borders and associated biopsy site and clip, which is located in approximately the 3-4:00 position 2.5 cm from the nipple and present 2.0 cm from the nearest blue inked margin, 4.0 cm from the nearest black-inked black margin, 4.2 cm from the nearest orange-inked margin.  A second 2.2 x 1.5 x 1.0 cm somewhat firm, cystic region is also present in the lower outer quadrant, located 1.7 cm inferior to the lateral-most aspect of the above-mentioned lesion, and present 0.1 cm from the nearest blue-inked margin, 1.5 cm from the nearest black-inked margin, and distant from the orange-inked margin.  The remainder of the specimen demonstrates approximately 60% yellow, lobulated fatty tissue and 40% white more fibrous tissue.  No other masses or lesions are identified.  Representative sections, including the entire firm white mass with associated biopsy site are submitted.  Total formalin fixation time:  23 hours.

A1 – nipple

A2-A9 – entire lesion, medial to lateral (A6, A7 = composite, A8, A9 = composite)

A10 – second lesion, irregular fibrous region lower outer quadrant

A11 – upper outer quadrant

A12 – upper inner quadrant

A13 – lower inner quadrant

A14-15 tissue between lesion #1 and #2, composite

Specimen B:  Received in formalin labeled “left axillary sentinel node #1” is a 2.5 x 1.6 x 1.0 cm tan lymph node which shows focal injected blue dye staining.  The lymph node is serially sectioned and entirely submitted in cassettes B1 and B2.

Specimen C:  Received in formalin labeled “left axillary sentinel node #2” are two tan lymph nodes measuring 1.0 x 0.7 x 0.5 cm and 1.8 x 1.0 x 0.7 cm.  The smaller lymph node is bisected and submitted in cassette C1, and the larger lymph node is trisected and entirely submitted in cassette C2.

Specimen D:  Received in formalin labeled “left breast lower outer quadrant” is a 1 g breast excision measuring 2.5 x 1.9 x 0.5 cm with one surface previously inked green per protocol by the surgeon.  The specimen is serially sectioned and entirely submitted in two cassettes.

Specimen E:  Received in formalin labeled “left breast skin” are two strips of dark brown skin measuring 3.2 cm in length and 21 cm in length.  The smaller skin measures 0.5 cm in diameter, and the larger skin measures 0.8 cm in diameter.  No gross lesions are noted.  Representative sections from each are submitted in cassette E1

Data Item :

Diagnosis Date

Correct Answer :

07/22/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the 07/22/2014 excisional biopsy.

The patient did have a PTA 04/08/2014 biopsy showing an atypical intraductal papillary lesion, bordering on ductal carcinoma in situ. However, “bordering on” is not an ambiguous term indicating malignancy. No reportable diagnosis was made on the PTA biopsies or PTA scans.

Data Item :

Primary Site

Correct Answer :

C505

Rationale:

The mastectomy pathology report indicates that there are two tumors located in the lower outer quadrant. The excisional biopsy indicates tumor was taken from the 3:00 position, but the gross description on the mastectomy report shows the excisional biopsy site was at the 3:00-4:00 position. The biopsied tumor was in the lower outer quadrant. The mastectomy pathology report has priority over the biopsy pathology as the entire breast was removed with a clear statement of the primary tumor location. The 2014 SEER Manual (Appendix C, Breast) indicates that when multifocal tumors are all within one quadrant, the specific quadrant should be coded. Apply code C505 (lower outer quadrant).

Data Item :

Laterality

Correct Answer :

2

Rationale:

Code 2 (left) when the primary site is a paired site and the primary tumor originated on the left.

Data Item :

Histology

Correct Answer :

8503

Rationale:

The MP/H Rules (general rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. The patient underwent both an excisional biopsy and a mastectomy. The mastectomy is the most representative specimen, as it removed the most tumor tissue, and it showed papillary ductal carcinoma in situ. Per the MP/H Rules, Breast, apply rule H23 and code the histology when only one histologic type is identified. Code the histology as 8503 (Papillary ductal carcinoma).

Data Item :

Behavior

Correct Answer :

2

Rationale:

Per the pathology report, this is an in situ tumor. Code the behavior as /2 (in situ) when the primary tumor is non-invasive.

Data Item :

Grade

Correct Answer :

2

Rationale:

Code the highest grade given from the primary tumor prior to neoadjuvant treatment. Both the excisional biopsy and the mastectomy state the tumor is intermediate nuclear grade. There are special grade system rules for the breast (Bloom-Richardson or Nottingham score/grade). However, no Bloom-Richardson grade is given. Continue on to the next grade rule. Apply Coding for Solid Tumors, Rule 7b. Use the nuclear grade and the three-grade system conversion table to determine the correct grade code. Apply code 2 (intermediate grade, exception for breast grade code).

Data Item :

Clin T

Correct Answer :

BLANK

Rationale:

The rule for documenting carcinoma in situ is listed on page 12, Table 1.8 in the AJCC Cancer Staging Manual: “Carcinoma in situ, stage pTis cN0 cM0 as both clinical and pathologic stage 0.”

The CAnswer Forum, AJCC TNM Staging Forum, “Chapter 32, page 353?” Thread, provides further clarification. Clinical and pathologic stage group 0 is reflected in the cancer registry data fields as follows:

CLINICAL              T (blank)              N0          M0         Stage 0

PATHOLOGIC     Tis           N (blank)             M (blank)            Stage 0

Data Item :

Clin N

Correct Answer :

0

Rationale:

The 04/22/2014 MRI found several prominent left axillary nodes measuring up to 15 mm, but there is no statement of nodal involvement. The 07/18/2014 physical exam noted palpable, mobile, normal-appearing left axillary nodes. Because the patient was diagnosed with carcinoma in situ, the nodes are considered clinically negative. By definition, in situ carcinoma cells cannot metastasize. Apply code 0 (N0, no regional lymph node metastases).

Data Item :

Clin M

Correct Answer :

0

Rationale:

Per the AJCC Cancer Staging Manual, general instructions, a case with no symptoms or signs of metastasis is classified as clinically M0.

Because the patient was diagnosed with carcinoma in situ, the patient is considered clinically free of distant metastasis. By definition, in situ carcinoma cannot metastasize. Apply code 0 (M0, no clinical or radiographic evidence of distant metastases).

Data Item :

Clin Stg Grp

Correct Answer :

0

Rationale:

Per the AJCC Cancer Staging Manual general instructions, carcinoma in situ should be reported as both clinical and pathologic Stage Group 0. Apply code 0 (Stage Group 0).

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0 (None).

Data Item :

Path T

Correct Answer :

IS

Rationale:

The 07/22/2014 excisional biopsy and the 09/09/2014 mastectomy both showed papillary ductal carcinoma in situ only. Apply code IS (Tis, carcinoma in situ).

Data Item :

Path N

Correct Answer :

0

Rationale:

Per Table 1.6, N Classification Rules, a pathologic N value cannot be assigned in the absence of a surgical resection. Although Table 1.6 also states a biopsy confirming the highest N may be used, it is used only in appropriate circumstances where the pathologic staging criteria for the site has been met.

The 09/09/2014 mastectomy included resection of three sentinel lymph nodes. The nodes were pathologically negative. Although in situ carcinomas by definition cannot metastasize, this patient also had sentinel lymph nodes removed that pathologically confirmed this. Apply code 0 (N0, no regional lymph node metastasis identified histologically).

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither M0 nor MX are valid categories and they may not be assigned.

Assessment of metastases to group a patient by pathologic TNM grouping may be either clinical (cM0, cM1) or pathologic (pM1). This patient had a clinical assessment only, clinically M0. There was no pathologic examination of distant metastasis. Apply code BLANK (Not recorded).

Data Item :

Path Stg Grp

Correct Answer :

0

Rationale:

Per the AJCC Cancer Staging Manual general instructions, carcinoma in situ should be reported as pathologic Stage Group 0. Apply code 0 (Stage Group 0).

Data Item :

Path Desc

Correct Answer :

3

Rationale:

The 07/22/2014 left breast excisional biopsy showed a single 2.2 cm tumor. The 09/09/2014 mastectomy pathology report showed two separate tumors in the lower outer quadrant measuring 2.3 and 1.3 cm. Although the excisional biopsy margins were positive, three measured tumors were removed, one by excisional biopsy and two by mastectomy. Apply code 3 (M-Multiple primary tumors in a single site).

Data Item :

SS 2000

Correct Answer :

0

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has in situ disease involving the left breast only. The patient has no regional lymph node or distant metastases as in situ disease, by definition, cannot metastasize. Apply code 0 (In situ).

Social History

Divorced caucasian woman with no children. Lives alone. Born in Nebraska. Insurance: Blue Cross

Physical Exam

03/12/2014 – cc: 47 y/o woman w/ left breast cancer. HPI: Pt noted a mass on self-breast exam on UOQ of left breast in late January 2014. Her outside MD found a left breast superficial nodule measuring ~ 5 mm in the UOQ. She underwent PTA diagnostic imaging on 02/04/2014, which revealed no abnormalities, only pt’s retropectoral silicone implants. A diagnostic targeted left ultrasound of that region did demonstrate a 6 x 3 x 6 mm mass adjacent to the implant capsule. She underwent a PTA needle bx on 02/05/2014 which demonstrated an invasive ductal carcinoma. PE: LN’s: No cervical, supraclavicular, or axillary adenopathy palpable bilaterally. Breasts: No erythema, peau d’orange or skin retraction. Left breast has a palpable implant as well as a 6 mm nodule at 3 o’clock, mobile, and does not appear to be fixed. IMP: c T1a -T2 N0 ductal ca left breast. Plan: Surgery. Candidate for endocrine tx, depending on surgery results may want to order gene recurrence score assay to make decision about chemo, discussed rads.

Scans

03/11/2014 – Interpretation of outside breast imaging from 2/4/2014 (mammo); 2/5/2014 (lt breast bx post clip mammo); 2/12/2014 (breast MRI); 2/13/2014 (Lt axillary US): Rt breast: benign. Lt breast: Biopsy proven malignancy at 3:00 in left breast, 4 cm from the nipple, measuring up to 6 mm and not seen on breast MRI. Findings consistent with known malignancy. Prominent axillary LN.

03/13/2014 – Breast Lt U/S: Prominent axillary LN measuring up to 15 mm. Findings demonstrate a suspicious abnormality.

Operative Reports

03/27/2014 – Bilateral skin-sparing mastectomies, Lt axillary sentinel node dissection: all 6 L axillary SLNs neg for CA.

03/27/2014 – Immediate reconstruction, bilateral breasts using 400 ml Moderate Plus profile silicone implants, AlloDerm sling of inerior pole, 6 x 16 cm sheet used bilterally, Bilateral free-nipple graft (procedure only).

Hormonal Text

04/18/2014 – Started Tamoxifen.

Stage

04/05/2014 – Per MD note: p T1c N0 M0.

02/05/2014 – Path Report #1

Clinical Diagnosis/History:

Slide review.

Final Diagnosis:

Outside Hospital (02/05/2014)

Left breast, core needle biopsy:  Invasive ductal carcinoma with the following features:

Nottingham grade 1 of 3 derived as follows: poor tubule formation (3), low nuclear grade (1), low mitotic activity (1).

Involving two tissue cores with a maximum contiguous length of 0.3 cm in this sample.

Associated in situ component is not identified.

Microcalcifications are not identified.

Angiolymphatic invasion is not identified.

Prognostic/predictive markers (performed at referring institution and reviewed at this facility:

  1. Positive for estrogen and progesterone receptor expression (Allred score 4+2 = 6 of 8 and 3+2 = 5 of 8, respectively).
  2. Negative for HER2/neu overexpression by immunohistochemical technique (0+).

Diagnosis Comment:

By additional immunohistochemistry performed at the referring institution and reviewed at this facility, there is no immunoreactivity for p63 and smooth muscle myosin around nests of neoplastic cells, supporting the histologic impression of invasive carcinoma.

03/22/2014 – Path Report #2

Clinical Diagnosis/History:

Left lymph node biopsy.

Final Diagnosis:

  1. A) Lymph node, left axillary, needle core biopsy: Lymph node fragment negative for carcinoma.

Gross Description:

  1. A) Received in formalin labeled “left axilla lymph node” are approximately six gray-tan to yellow cores of fibroadipose tissue ranging from 0.2 x 0.1 cm to 1.1 x 0.1 cm. The specimen is wrapped, inked yellow, and entirely submitted in cassette A1.  Total fixation time:  66 hours.

03/27/2014 – Path Report #3

Clinical Diagnosis/History:

Left breast cancer.

Final Diagnosis:

  1. I) Left breast, mastectomy (306 grams): Invasive ductal carcinoma, 1.7 cm in greatest dimension and extending to within 0.1 cm of the posterior margin; see Summary Data.

B-G)  Sentinel lymph nodes, #1-#6, excisions: 6 lymph nodes with no carcinoma identified (one in each of parts B-G).

  1. A) Right breast, mastectomy (220 grams): Breast with axillary suture granulomas; no atypical hyperplasia, in situ or invasive carcinoma identified.
  1. H) “Old breast implants” removal: Breast prostheses (gross exam only).

Summary Cancer Data:

Left breast

Invasive carcinoma with the following features:

Histologic type: Invasive ductal carcinoma, NOS (85003)

Size (largest focus): 1.7cm

Comment about size determination: Measured grossly.

Focality of invasive carcinoma: Single contiguous focus

Nottingham Grade: Grade I: 3-5 points

Tubule Formation: 2  points (10 – 75%)

Nuclear Pleomorphism: 2 points (moderate)

Mitotic Activity: 1 point

Ancillary Studies

Source: Outside pathology lab (slides reviewed)

Estrogen receptor: Positive (Allred score = 6 of 8)

Progesterone receptor: Positive (Allred score = 5 of 8) c-erb-B2 (HER2/neu) by IHC: Negative for HER2/neu overexpression by IHC

HER2/neu by FISH: Not performed/reported

Skin status: Cannot assess (skin not present)

Nipple status: Cannot assess (nipple not present)

Skeletal muscle status: Skeletal muscle not present

Ductal carcinoma in-situ (DCIS): Present (85002)

Nuclear grade of DCIS: Intermediate

Necrosis associated with DCIS: Not identified

Distance spanned by DCIS: 0.1cm

DCIS qualifies as “extensive intraductal component”: No

Lobular carcinoma in-situ (LCIS): Absent

Changes consistent with previous biopsy site: Present

Final surgical resection margins (including separately submitted margins):

Invasive carcinoma margins:

Invasive carcinoma is <0.1 cm from the posterior margin and 1 cm or greater from all other margins.

DCIS Margins: DCIS is 0.3 cm from the posterior margin and 1 cm or greater from other margins.

Lymph node involvement

Sentinel nodes: Sentinel nodes with carcinoma 0    / Total sentinel nodes 6

Non-sentinel nodes: Non-sentinel nodes with carcinoma: 0    / Total non-sentinel nodes: 0

Total number of nodes with macrometastases: 0

Total number of nodes with micrometastases: 0

Total number of nodes with isolated tumor cells: 0

Minimum pathologic stage (AJCC, 7th ed., 2010)

Primary tumor [pT]: pT1c: Tumor > 1.0 cm and <= 2.0 cm – greatest dimension

Regional nodes [pN]: pN0: No regional lymph node metastasis histologically

(ITCs may be present)

N stage modifier: (sn): Only sentinel node(s) evaluated.

Distant metastasis [pM]: Not applicable or no pathologic information

Gross Description:

Specimen A:  Received fresh in a container labeled “right breast” is a 220 g, 21 (SI)x 14 (ML) x 2.5 (AP) cm right skin sparing simple mastectomy with a short suture attached to the superior edge of the breast and a long suture attached to the lateral side of the breast.  The breast margins are tan-yellow and shaggy and the deep fascia is freely moveable over the breast.  The margins of resection are inked as follows:  lateral side orange anteriorly, medial side anterior blue, entire posterior margin black.  The apparent nipple location is marked green.  The breast is serially sectioned from inferior to superior and approximately 60% of the cut surfaces consist of yellow, lobulated adipose tissue, the remaining composed of white, fibrous, focally dense breast tissue.  No masses are identified.  At the lateral edge of the breast, two lymph node candidates are identified measuring 0.5 and 1.5 cm in greatest dimension.  Representative sections are submitted labeled:  A1, A2 – random superior outer quadrant; A3, A4 – random inferior outer quadrant; A5, A6 – random superior inner quadrant; A7, A8 – random inferior inner quadrant; A9 – breast tissue beneath possible nipple site; A10 – 2 axillary lymph node candidates.

Specimen B:  Received fresh in a container for frozen labeled “left axillary sentinel lymph node #1” is a 2.0 x 1.0 x 0.5 cm blue-stained lymph node.  The specimen is bisected and a cytological touch preparation is prepared.  The lymph node is entirely submitted in cassette B1.

Specimen C:  Received fresh in a container for frozen labeled “left axillary sentinel lymph node #2” is a 2.0 x 1.0 x 0.5 cm blue-stained lymph node candidate.  The specimen is bisected and a cytological touch preparation is prepared.  The lymph node is entirely submitted in cassette C1.

Specimen D:  Received fresh in a container for frozen labeled “left axillary sentinel lymph node #3” is a 1.0 x 1.0 x 0.4 cm blue-stained lymph node.  The specimen is bisected and a cytological touch preparation is prepared.  The lymph node is entirely submitted in cassette D1.

Specimen E:  Received fresh in a container for frozen labeled “left axillary sentinel lymph node #4” is a 1.0 x 1.0 x 0.4 cm blue-stained lymph node.  The specimen is bisected and a cytological touch preparation is prepared.  The lymph node is entirely submitted in cassette E1.

Specimen F:  Received fresh in a container for frozen labeled “left axillary sentinel lymph node #5” is a 1.0 x 1.0 x 0.2 cm blue-stained lymph node candidate.  A cytological touch preparation is prepared.  The lymph node is entirely submitted in cassette F1.

Specimen G:  Received fresh in a container for frozen labeled “left axillary sentinel lymph node #6” is a 0.4 cm tan rubbery blue-stained lymph node candidate.  The specimen is bisected and a cytological touch preparation is prepared.  The lymph node is entirely submitted in cassette G1.

Specimen H:  Received fresh in a container labeled “old breast implants” are two translucent discoid breast implants with an average weight of 116 g and average measurements of 12.0 x 12.0 x 2.0 cm.  The implants are intact and no soft tissue is received.  The implants are labeled, respectively, “Style 10, Lot 1695892 Allergan 210 cc” and “Style 10, Lot 1548561 Allergan 210 cc.”

Specimen I:  Received fresh in a container labeled “left breast” is a 306 g, 22 (ML) x 17 (SI) x 2 (AP) cm left skin sparing simple mastectomy.  The breast margins are tan-yellow and shaggy and the deep fascia is freely moveable over the breast.  There is a short suture attached to the superior side of the breast and a long suture attached to the lateral edge of the breast.  The margins of resection are inked as follows:  superior anterior orange, inferior anterior blue, posterior black, possible nipple site green.  The breast is serially sectioned from medial to lateral and between the superior outer and inferior outer quadrants of the breast in the 3:00 position approximately 3.8 cm from the possible nipple site is a 1.7 x 1.0 x 1.0 cm firm mass located 0.3 cm from the blue-inked anterior margin, 0.2 cm from the black-inked deep margin.  The deep fascia is freely moveable over the mass.  The mass is sectioned further and there is a centrally inserted metallic spring-like clip.  No additional masses are identified.  Representative sections are submitted labeled:  I1 – normal breast tissue lateral side of mass; I2 – lateral extent of mass adjacent to site of clip; I3 – medial extent of mass; I4 – normal breast tissue medial side of mass; I5 – random superior outer quadrant adjacent to mass; I6 – random inferior outer quadrant adjacent to mass; I7 – random superior inner quadrant; I8 – random inferior inner quadrant; I9 – breast tissue beneath site of possible green-inked nipple location.

Frozen Section Diagnosis:

B-G)  Touch prep, lymph node:  Negative for carcinoma.

Data Item :

Diagnosis Date

Correct Answer :

02/05/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the PTA 02/05/2014 left breast core biopsy.

Data Item :

Primary Site

Correct Answer :

C508

Rationale:

The 03/12/2014 physical examination documents an UOQ (upper outer quadrant) mass identified on self-exam and by outside physician. The physical exam on that visit identified a nodule at 3 o’clock. The 03/11/2014 interpretation of outside breast imaging describes a nodule or biopsy proven malignancy at 3:00 in the left breast. The PTA 02/05/2014 biopsy pathology report does not mention a subsite. The 03/27/2014 mastectomy pathology report does not mention a subsite in the final diagnosis, but the gross description of the left breast identifies a mass in the 3:00 position.

Per 2014 SEER Manual, Appendix C, Breast, the pathology report has priority for coding a subsite when there is conflicting information. Apply code C508 (overlapping lesion of breast).

Data Item :

Laterality

Correct Answer :

2

Rationale:

Code 2 (left) when the primary site is a paired site and the primary tumor originated on the left.

Data Item :

Histology

Correct Answer :

8500

Rationale:

The MP/H Rules (General Rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. The patient underwent a bilateral mastectomy. The mastectomy is the most representative specimen, as it removed the most tumor tissue, and it showed ductal carcinoma, NOS. Per the MP/H Rules, Breast, apply rule H14 and code the histology when only one histologic type is identified. Code the histology as 8500 (ductal carcinoma, NOS).

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the core biopsy pathology report and the mastectomy pathology report, this is a malignant tumor. Code the behavior as /3 when the primary tumor, or any portion of the primary tumor, is invasive.

Data Item :

Grade

Correct Answer :

1

Rationale:

Code the highest grade given from the primary tumor prior to neoadjuvant treatment. Both the core biopsy and the mastectomy state the tumor is Nottingham grade 1. Both pathology reports also provide scores for the morphologic features used to determine Bloom-Richardson (BR): degree of tubule formation, mitotic activity, and nuclear grade. These three scores added together provide the BR score. The BR score is 5 on both pathology reports. There are special grade system rules for the breast (Bloom-Richardson or Nottingham score/grade). Use the Nottingham or Bloom-Richardson (BR) table to determine the correct grade code. Apply code 1 (Score of 5).

Data Item :

Clin T

Correct Answer :

1B

Rationale:

The patient noted a mass, and the physician palpated a left breast mass measuring about 5 mm. The PTA left breast ultrasound showed a 6 mm mass that was biopsy proven to be invasive ductal carcinoma. The physician clinically staged this as cT1a – T2, but this is inconsistent with the given information in this case. The range in T values may reflect uncertainty in size because the mass was adjacent to a silicone implant in the breast. The best clinical size appears to be 6 mm; therefore, apply code 1B (T1b, tumor greater than 5 mm but less than or equal to 10 mm in greatest dimension).

Data Item :

Clin N

Correct Answer :

0

Rationale:

The 03/12/2014 physical exam indicated no cervical, supraclavicular, or axillary adenopathy palpable bilaterally. The physician clinically staged this patient as N0 per the 03/12/2014 physical exam note. The subsequent left axillary ultrasound and axillary lymph node biopsy were negative for metastatic carcinoma, confirming the physician’s clinical assessment that the lymph nodes were negative. A pathologic examination (lymph node core biopsy in this case) of a single node in the absence of pathologic evaluation of the primary site is considered a clinical staging procedure. Apply code 0 (N0, no regional lymph node metastases).

Data Item :

Clin M

Correct Answer :

0

Rationale:

Per the AJCC Cancer Staging Manual, general instructions, a case with no symptoms or signs of metastasis is classified as clinically M0.

The limited PTA imaging made no mention of suspicious findings. The physical exam was negative. There were no symptoms or findings the physician felt clinically suspicious for metastasis. Apply code 0 (M0, no clinical or radiographic evidence of distant metastases).

Data Item :

Clin Stg Grp

Correct Answer :

1A

Rationale:

Per the breast staging form, when the clinical TNM is cT1b cN0 cM0, apply code 1A (Stage IA).

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0 (None).

Data Item :

Path T

Correct Answer :

1C

Rationale:

The 03/27/2014 mastectomy showed a single invasive ductal carcinoma tumor measuring 1.7 cm (17 mm) that was localized to the breast tissue with negative margins. The physician pathologically staged this tumor as T1c per the 04/05/2014 Stage note. Apply code 1C (T1c, tumor greater than 10 mm but less than or equal to 20 mm in greatest dimension).

Data Item :

Path N

Correct Answer :

0

Rationale:

The 03/27/2014 mastectomy included resection of six sentinel lymph nodes. The nodes were pathologically negative. No immunohistochemistry stains or isolated tumor cells appear to have been performed on the sentinel nodes per the pathology report. The physician pathologically staged this as N0 per the 04/05/2014 Stage note. Apply code 0 (N0, no regional lymph node metastasis identified histologically).

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic examination of distant metastasis. Apply code BLANK (Not recorded).

Data Item :

Path Stg Grp

Correct Answer :

1A

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, for cases with known pT and pN categories, use the clinical M category to complete the pathologic stage group.

Per the breast staging form, when the pathologic TNM is pT1c pN0 cM0, apply code 1A (Stage IA).

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0 (None).

Data Item :

SS 2000

Correct Answer :

1

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has local stage disease as there was pathologic evidence of a single invasive ductal carcinoma tumor confined to the left breast tissue only. The patient has no regional lymph node or distant metastases. Apply code 1 (Localized only).

Social History

Married female here with her oldest child. Born in Alaska. Pt mixed Alaskan Native/Caucasian. Primary payer is medicare with supplement, NOS.

Physical Exam

03/05/2014 – cc: 58 y/o woman with endometrial adenocarcinoma here to discuss tx options. HPI: On 02/19/2014 pt woke up in the middle of the night w/ vaginal bleeding heavier than menses and went to outside ER. U/S revealed soft tissue mass w/in endometrial cavity, 5 x 3 x 2 cm, suspicious for neoplasia. Had PTA D&C and ECC on 02/21/2014 that showed endometrial adenocarcinoma, FIGO grade 3 (poorly differentiated), with histologic evidence of smooth muscle invasion. Endocervical tissue with fragments of endometrial adenocarcinoma. PE: Pelvic: External genitalia normal. Vagina and cervix normal. No active or purulent discharge from cervix. Adnexa nonpalpable. Plan: TAH/BSO.

Scans

03/04/2014 – CT Chest/Abd/Pelvis: heterogenous uterus larger than expected for age c/w hx of endometrial cancer. Multiple retroperitoneal, pelvic and inguinal prominent LN’s, indeterminate by size criteria. At least 3 indeterminate pulmonary nodules.

Operative Reports

03/07/2014 – Robotic-assisted laparoscopic hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic and periaortic lymph node dissection: On entering the abdomen, normal-appearing structures, normal liver and diaphragm. No suspicious findings in the pelvis. No evidence of disease outside the pelvis. Depth of invasion appears to be less than 50%. No suspicious LN’s.

Treatment Plan

03/15/2014 – Recommended 6 cycles taxol/carboplatin chemo and vaginal brachytherapy.

02/21/2014 – Path Report #1

Clinical Diagnosis/History:

Post-menopausal bleeding. Slide review.

Final Diagnosis:

Outside Hospital (02/21/2014)

Endometrium, curettage (part A): Endometrioid adenocarcinoma, FIGO grade 3 of 3; see comment.

Endocervix, curettage (part B): Fragments of endometrioid adenocarcinoma admixed with strips of benign endocervical mucosa.

Diagnosis Comment:

Sections of the endometrial curettage specimen include possible invasion of smooth muscle bundles by carcinoma, suggestive of myometrial invasion.

03/07/2014 – Path Report #2

Clinical Diagnosis/History:

Endometrial cancer.  Per electronic medical record:  Endometrial adenocarcinoma, FIGO grade 3 (endometrial cavity mass measuring 5 x 3 x 2 cm in size).

Final Diagnosis:

  1. A) Uterus, bilateral fallopian tubes and ovaries, hysterectomy, bilateral salpingo-oophorectomy:
  2. Endometrioid adenocarcinoma, FIGO grade 3 of 3, with secretory features. See summary cancer data.
  3. Adenomyosis and multiple leiomyomata (largest 1.8 cm).
  4. Cervix with no evidence of neoplasia.
  5. Left and right ovaries with no evidence of neoplasia.
  6. Left and right fallopian tubes with no evidence of neoplasia.
  7. See comment.

B-D)  Lymph nodes, right pelvic, left pelvic, peri-aortic, dissections:  Multiple lymph nodes with no neoplasm identified, including 5 right pelvic, 9 left pelvic, and 5 periaortic lymph nodes.

IHC Interpretation:

Pancytokeratin and Pax8 immunostains support the final diagnosis of a carcinoma of mullerian origin.

Frozen Section Diagnosis:

Specimen A:  Gross endometrial tumor less than half of thickness of myometrium.

Gross Description:

Specimen A:  Received fresh labeled “uterus, cervix, bilateral tubes and ovaries, gross-depth of invasion” is a 92 g (post-fixation), 10 x 4.5 x 3.0 cm uterus, a 3.5 x 2 x 1 cm right ovary, a 8 x 0.5 x 0.5 cm right fallopian tube, a 3 x 1.5 x 0.8 cm left ovary, and a 7 x 0.5 x 0.5 cm left fallopian tube.  The uterine serosa is tan-pink, smooth, and glistening.  The ectocervix is tan-white, smooth, and glistening; there is a patent 0.5 cm cervical os.  The margins of resection are marked as follows:  anterior = blue and posterior = black.  On the right anterior surgical margin, there is a 1.8 x 1.5 x 0.5 cm tan-white, ovoid nodule.  The uterus and cervix are bivalved, and the endocervical canal and cervical cut surfaces are unremarkable.  Filling the endometrial cavity, attached to both anterior and posterior walls, is a 3 x 2 x 0.5 cm tan-white, exophytic, soft, friable lesion which occupies approximately 90% of the endometrial lining.  The lesion is focally approaching the anterior lower uterine segment.  The uterus is serially sectioned, and the lesion extends into the anterior and posterior myometrium and comes to within 0.5 cm from the anterior serosal surface and 1.5 cm from the posterior serosal surface.  The depth of invasion in the anterior and posterior myometrium is 1 cm and 0.5 cm, respectively.  The uninvolved myometrium is tan-pink and rubbery and measures up to 2.5 cm in thickness.  The serosa of the right ovary is tan-white, smooth, and glistening.  The right ovary is sectioned and has tan, rubbery cut surfaces with normal internal architecture.  No lesion is identified.  The serosal surface of the right fallopian tube is tan-pink, smooth, and glistening.  The right fallopian tube is serially cross-sectioned, and there are tan-pink, rubbery cut surfaces with a patent 0.2 cm lumen.  No lesion is identified.  The serosa of the left ovary is tan-white, smooth, and glistening.  The left ovary is sectioned and has tan, rubbery cut surfaces with normal internal architecture.  No lesion is identified.  The serosal surface of the left fallopian tube is tan-pink, smooth and glistening.  The left fallopian tube is serially cross-sectioned, and there are tan-pink, rubbery cut surfaces with a patent 0.2 cm lumen.  No lesion is identified.  Representative sections are submitted as follows:  A1-A2 – posterior cervix and lower uterine segment; A3-A4 – full thickness sections of anterior endomyometrium with deepest invasion;  A5-A6 – full thickness sections of posterior endomyometrium with deepest invasion; A7 – another full thickness section of posterior endomyometrium with the deepest invasion; A8 – anterior lower uterine segment grossly involved by the lesion; A9 – anterior cervix and ovoid nodule; A10 – left ovary; A11 – left fallopian tube; A12 – right ovary; A13 – right fallopian tube.

Specimen B:  Received in formalin labeled “right pelvic lymph nodes” are two yellow, lobulated fragments of adipose tissue measuring 6.0 x 5.5 x 1.0 cm in aggregate dimension.  Six individual lymph node candidates are identified on cut surfaces ranging in size from 0.1 cm to 3.6 cm.  The larger lymph nodes are sectioned and have tan, indurated cut surfaces.  However, no masses are appreciated.  Representative sections are submitted labeled:  B1 – 2 individual lymph node candidates; B2 – 2 bisected lymph nodes, one marked blue; B3 – 1 bisected lymph node; B4, B5 – one bisected lymph node.

Specimen C:  Received in formalin labeled “left pelvic lymph nodes” are a few yellow, lobulated fragments of adipose tissue measuring 6.0 x 4.5 x 1.5 cm in aggregate dimension.  Numerous lymph node candidates are identified on cut surfaces ranging in size from 0.5 cm to 3.0 cm.  Representative sections are submitted labeled:  C1 – 1 bisected lymph node; C2 – 1 bisected lymph node; C3 – 1 bisected lymph node; C4 – 1 bisected lymph node; C5 – 1 bisected lymph node; C6 – 1 bisected lymph node; C7 – 3 individual lymph node candidates.

Specimen D:  Received in formalin labeled “peri aortic lymph nodes” is a 4.5 x 1.5 x 1.0 cm yellow, lobulated portion of fibrofatty tissue, sectioned to reveal four lymph node candidates ranging in size from 1.0 to 1.5 cm.  Lymph node candidates are entirely submitted in cassette D1.

Summary Cancer Data:

Specimen type: Hysterectomy

Other organs present: Right ovary

Left ovary

Right fallopian tube

Left fallopian tube

Specimen integrity: Intact hysterectomy specimen

Chemotherapy and/or radiation therapy prior to surgery: Unknown/History not provided

Characteristics and Extent of Neoplasm

Histologic type: Endometrioid adenocarcinoma, secretory variant (83823)

Histologic grade:

FIGO G3: More than 50% nonsquamous solid growth OR 6-50% solid with high nuclear grade

Tumor size: Greatest diameter: 3cm

Tumor size comment:

Although the tumor is close to the endocervix, we see no convincing evidence of extension into the endocervix (slide A2).

Tumor site (epicenter): Endometrium of fundus (C54.1)

Myometrial invasion: Depth of invasion: 1cm    / Myometrial thickness: 1.4cm

Comment about myometrial invasion:

Myometrium measures up to 2.5 cm in thickness; however, the deepest invasion of 1 cm is found in the section of myometrium that has a thickness of 1.4 cm (slide A4)

Lower uterine segment: Carcinoma involves LUS mucosa only

Cervix and endocervix: Negative for carcinoma

Extra-uterine involvement: No extra-uterine involvement

Venous/lymphatic (large/small vessel) invasion: Indeterminate

Lymph Node Status

Pelvic node summary: Nodes with carcinoma: 0    / Total nodes examined: 14

Para-aortic node summary: Nodes with carcinoma 0    / Total nodes examined 5

Minimum Pathologic Stage (AJCC, 7th ed., 2010)

Primary tumor (pT): pT1b: Tumor invades one-half or more of the myometrium

Regional lymph nodes (pN): pN0: No regional lymph node metastasis

Minimum FIGO Stage

FIGO Stage (2010): IB: Tumor invades one-half or more of myometrium

Diagnosis Comment:

  1. A) Although at the time of surgery, the tumor appeared to invade less than 50% of myometrial wall thickness, the gross examination of the fixed specimen, confirmed by microscopy, shows invasion that is greater than 50% of myometrial wall thickness.

Immunohistochemistry Studies:

Specimen A6:  Population: Carcinoma cells

Pax8 Pax8                                                      Positive, uniformly Controls appropriately positive

AE1/AE3 Pan-Cytokeratin Cocktail             Positive, uniformly Controls appropriately positive

ER Estrogen Receptor [SP1]                         Positive, uniformly

Amendment Reason:

This case was amended to correct the type of carcinoma in the final diagnosis and template from clear cell adenocarcinoma to endometrioid carcinoma with secretory features, to correct the template to suspicious for lymphatic vascular space invasion, to add estrogen receptor immunohistochemical data and to add a second paragraph to the comment below.

Amentment Comment:

This case is challenging because the neoplastic cells have a clear cytoplasm.  However they do not have the high nuclear grade that is characteristic of “clear cell” carcinoma of the endometrium.  Nor do the tumor cells express intense estrogen receptor immunoreactivity (clear cell carcinomas of endometrium typically do not express intense ER).

Data Item :

Diagnosis Date

Correct Answer :

02/21/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the PTA 02/21/2014 endometrial curettage. The physical exam notes the patient underwent an ultrasound on 02/19/2014 that showed a soft tissue mass in the endometrial cavity that was suspicious for neoplasia. Neoplasia alone is not a reportable term; it is not equivalent to malignancy.

Data Item :

Primary Site

Correct Answer :

C541

Rationale:

The PTA curettage, CT scan, and surgical resection showed the primary tumor was in the endometrium. Apply code C541 (endometrium).

Data Item :

Laterality

Correct Answer :

0

Rationale:

Code 0 (not a paired site) when the primary site is not considered a paired site per SEER.

Data Item :

Histology

Correct Answer :

8382

Rationale:

The MP/H Rules (general rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. In this case, the patient underwent both an endometrial curettage and a hysterectomy. The hysterectomy pathology report is the most representative specimen, and the final diagnosis was endometrioid adenocarcinoma with secretory features. The summary cancer data further specified the histologic type as endometrioid adenocarcinoma, secretory variant.

Endometrioid adenocarcinoma, secretory variant is a specific histologic type. Per the MP/H Rules, Other Sites, apply rule H11 and code the histology when only one histologic type is identified. Code the histology as 8382 (endometrioid adenocarcinoma, secretory variant).

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology reports, this is a malignant tumor. Code the behavior as /3 (malignant) when the primary tumor, or any portion of the primary tumor, is invasive.

Data Item :

Grade

Correct Answer :

3

Rationale:

Code the highest grade given from the primary tumor prior to neoadjuvant treatment using the solid tumor coding rules. The FIGO grade is not used to code the grade field; this is collected in a SSF if applicable. Both the PTA endometrial curettage review of slides and the hysterectomy pathology showed a FIGO grade 3 adenocarcinoma. The physical exam note on 03/05/2014 states the PTA curettage showed poorly differentiated endometrial adenocarcinoma.

Code the grade of the primary tumor documented in the medical record as the available pathology reports only indicated a FIGO grade. Use the four-grade system conversion table to convert poorly differentiated to the appropriate code. Apply grade code 3.

Data Item :

Clin T

Correct Answer :

1

Rationale:

The PTA ultrasound showed a 5 cm mass in the endometrial cavity. The PTA 02/21/2014 D&C showed evidence of smooth muscle bundle (myometrial) invasion, while the endocervical curettage (ECC) showed adenocarcinoma admixed with strips of benign endocervical mucosa. It is unclear if the endocervix was actually involved pathologically. The cervix was negative on physical exam.

The 03/04/2014 CT scan showed no evidence of involvement beyond the corpus uteri. The tumor is clinically at least T1 with invasion of the myometrium. There was no definitive cervical (T2) involvement clinically identified, and the T1 category cannot be further subclassified as T1a or T1b. The depth of myometrial invasion was not determined clinically. Per the AJCC, when there is uncertainty in assigning a T category, default to the lower of the two categories in the uncertain range. Apply code 1 (T1, tumor confined to corpus uteri).

Data Item :

Clin N

Correct Answer :

0

Rationale:

The 03/04/2014 CT scan identified multiple prominent lymph nodes (retroperitoneal, pelvic and inguinal), but noted they were indeterminate by size. There is no definitive statement these nodes are involved. The regional nodes are presumed to be clinically negative. Imaging and physical exam were performed and there was no mention of any involved or clinically suspicious regional nodes. Apply code 0 (N0, no regional lymph node metastasis).

Data Item :

Clin M

Correct Answer :

0

Rationale:

Per the AJCC Cancer Staging Manual, general instructions, a case with no symptoms or signs of metastasis is classified as clinically M0.

The 03/04/2014 CT scan identified indeterminate pulmonary nodules only. The physical exam was negative for any suspicious findings, and there was no definitive statement of metastasis. There were no symptoms or findings the physician felt clinically suspicious for metastasis. Apply code 0 (M0, no distant metastasis).

Data Item :

Clin Stg Grp

Correct Answer :

1

Rationale:

Per the corpus uteri carcinoma staging form, when the clinical TNM is cT1 cN0 cM0, apply code 1 (Stage I).

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

1B

Rationale:

The 03/07/2014 hysterectomy pathology report showed endometrioid adenocarcinoma invading 1 cm into a 1.4 cm thick myometrium. There was no involvement of the cervix or evidence of extra-uterine involvement. Apply code 1B (T1b, tumor invades one half or more of the myometrium).

Data Item :

Path N

Correct Answer :

0

Rationale:

The 03/07/2014 hysterectomy included resection of multiple regional lymph nodes (pelvic and periaortic). The pathology report showed the resected nodes were negative for metastatic carcinoma. Apply code 0 (N0, no regional lymph node metastasis).

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic examination of distant metastasis. Apply code BLANK.

Data Item :

Path Stg Grp

Correct Answer :

1B

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, for cases with known pT and pN categories, use the clinical M category to complete the pathologic stage group.

Per the corpus uteri staging form, when the pathologic TNM is pT1b pN0 cM0, apply code 1B (Stage IB).

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Data Item :

SS 2000

Correct Answer :

1

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has local stage disease as there was pathologic evidence of invasion of the myometrium only. The primary tumor involved one half or more of the myometrium per the hysterectomy pathology report. The patient has no regional lymph node or distant metastases. Apply code 1 (Localized only).

Social History

Divorced Caucasian woman w/ two children. Born in Texas. Has private insurance: Managed care.

Physical Exam

03/21/2014 – cc: 48 y/o w/ atypical endometrial hyperplasia. HPI: Pt recently presented to gynecologist in February of 2014 w/ worsening heavy vaginal bleeding, w/ new abdominal and pelvic cramping with bloating. PTA endometrial bx on 02/25/2014 showed low-grade endometrial neoplasm w/ features of at least complex atypical hyperplasia. There’s concern that there’s underlying cancer. PE: Pelvic: Normal external genitalia and normal-appearing cervix. Mobile uterus. IMP: Suspicious for an endometrioid neoplasm. Plan: Surgery scheduled for next week.

Operative Reports

03/25/2014 – Robotic assisted laparoscopic total hysterectomy, bilateral salpingo-oophorectomy: Some mild adhesions of the omentum to the right lower quadrant of the ileocecal junction to the right adnexa, and adhesions of intestines to the left ovary (not unexpected given that she had a hx of prior open appendectomy and left ovarian cystectomy). No evidence of mets disease on intra-abdominal exploration. Intraoperatively, uterus had a small tumor in lower uterine segment that was less than 2 cm. No obvious myometrial invasion.

Treatment Plan

03/28/2014 – No further treatment planned for this localized endometrial carcinoma.

02/25/2014 – Path Report #1

Clinical Diagnosis/History:

Slide review.

Final Diagnosis:

Outside Laboratory (02/25/2014)

Endometrium, biopsy:  Low-grade endometrioid neoplasm with features of at least complex atypical hyperplasia.

03/25/2014 – Path Report #2

Clinical Diagnosis/History:

Obese patient with irregular vaginal bleeding, biopsy showing low-grade endometrioid neoplasm with features of complex atypical hyperplasia.  Per electronic medical record:  Endometrium with low-grade endometrioid neoplasm with features of at least complex atypical hyperplasia.

Final Diagnosis:

  1. A) Uterus, bilateral ovaries and fallopian tubes, hysterectomy, bilateral salpingo-oophorectomy:

Low-grade endometrioid neoplasm with features of at least complex atypical hyperplasia (involving much of endometrium) to focal low grade endometrioid carcinoma with no myometrial invasion and no lymphatic -vascular space invasion (Figo Stage IA).

Cervix with no evidence of neoplasia.

Myometrium with no diagnostic alterations.

Right and left ovaries with no evidence of neoplasia.

Right and left fallopian tubes with no evidence of neoplasia.

Diagnosis Comment:

Most cases of HNPCC are associated with mutations in, or abnormal expression of DNA mismatch repair enzymes.  More than 95% of the time, the abnormalities are in MLH1 or MSH2 although MSH6 and pMS2 may also be affected (1).  Immunohistochemistry detects approximately 86% of MLH1 disorders and 92% of MSH2 disorders (2).  Most cases of HNPCC exhibit microsatellite instability (MSI) length alterations in simple, repetitive microsatellite sequences due to failure of mismatch repair during DNA replication.  Approximately 93-94% of HNPCC tumors with MSI have abnormal IHC expression of MLH1 or MSH2 (2,3).  Colorectal carcinomas without MSI virtually never have IHC abnormalities (1,3).  Both IHC and MSI are screening tests with false-positive and false-negative results (2,4,5) and the diagnosis of HNPCC must be made in conjunction with family history and other genetic or molecular tests.

(1)  Ruszkiewsicz A, et al.  Correlation of mismatch repair genes immunohistochemistry and microsatellite instability status in HNPCC-associated tumours.  Pathology (2002) 34:541-547.

(2)  Hendriks Y, et al.  Conventional and tissue microarray immunohistochemical expression analysis of mismatch repair in hereditary colorectal tumors.  Am J Pathol (2003) 162:469-477.

(3)  Lanza, et al.  Immunohistochemical pattern of MLH1/MSH2 expression is related to clinical and pathological features in colorectal adenocarcinomas with microsatellite instability.  Mod Pathol (2002) 15:741-749.

(4)  Salahshor S, et al.  Microsatellite instability and hMLH1 and hMSH2 expression analysis in familial and sporadic colorectal cancer.  Lab Invest (2001) 81:535-541.

(5)  Reyes AM, et al.  Comparison of selection strategies for genetic testing of patients with hereditary nonpolyposis colorectal carcinoma: effectiveness and cost-effectiveness.  Cancer (2002) 95:1848-1856.

Gross Description:

Specimen A:  Received fresh labeled “uterus, cervix, tube and ovary” is a 172 g, 13 x 6.8 x 3.5 cm uterus, 3 x 2 x 1 cm right ovary, 6 x 0.5 x 0.5 cm right fallopian tube, 3.5 x 3 x 1.5 cm left ovary, and 6 x 0.5 x 0.5 cm left fallopian tube.  The uterine serosa is tan-pink, smooth, and glistening.  The ectocervix is tan-white, smooth, and glistening; there is a patent 1.2 cm cervical os.  The margins of resection are marked with black ink.  The uterus and cervix are bivalved, and the endocervical canal and cervical cut surfaces are unremarkable.  Filling the endometrial cavity, attached to both anterior and posterior walls, is a 4 x 3.5 cm exophytic, soft, friable lesion which occupies 90% of the endometrial lining.  The lesion does not appear to involve the lower uterine segment.  The uterus is serially sectioned, and the lesion does not extend into the anterior or posterior myometrium.  The uninvolved myometrium is tan-pink and rubbery, and it measures up to 3 cm in thickness.  The serosa of the right ovary is tan-white, smooth, and glistening.  The right ovary is sectioned and has tan, rubbery cut surfaces with normal internal architecture.  No masses or lesions are identified.  The serosal surface of the right fallopian tube is tan-pink, smooth, and glistening.  The right fallopian tube is serially sectioned, and there are tan-pink, rubbery cut surfaces with a patent 0.2 cm lumen.  No masses are identified.  The serosa of the left ovary is tan-white, smooth, and glistening.  The left ovary is sectioned and has tan, rubbery cut surfaces with normal internal architecture.  No masses or lesions are identified.  The serosal surface of the left fallopian tube is tan-pink, smooth, and glistening.  The left fallopian tube is serially cross-sectioned, and there are tan-pink, rubbery cut surfaces with a patent 0.2 cm lumen.  No masses are identified.  Representative sections are submitted as follows:  A1FS – frozen section thawed and resubmitted; A2-A3 – anterior cervix and lower uterine segment; A4-A5 – composite section of full-thickness anterior endomyometrium; A6-A7 – anterior endometrium; A8-A9 – posterior cervix and lower uterine segment; A10, A11 – composite section of full-thickness posterior endomyometrium; A12-A13 – posterior endometrium; A14 – left ovary; A15 – left fallopian tube; A16 – right ovary; A17 – right fallopian tube.

Immunohistochemistry Studies:

Specimen A6:  Population:  Neoplastic cells

MLH1 MLH1 [G168-728]   No loss of expression

MSH2 MSH2 [G219-1129]  No loss of expression

MSH6 MSH6 (BC/44)          No loss of expression

PMS2 PMS2                         No loss of expression

IHC Interpretation:

No loss of mismatch repair protein expression.

Frozen Section Diagnosis:

Specimen A:  Endometrioid lesion without gross myometrial invasion.  No tubal or ovarian neoplasm.

Specimen AFS:  Complex atypical hyperplasia; no invasive carcinoma in representative section of thickest area.

Addendum Reason:

Reporting of immunohistochemistry for mismatch repair proteins performed at the request of physician.

Addendum – Final Diagnosis:

Specimen A:  Uterus, bilateral ovaries and fallopian tubes, hysterectomy, bilateral salpingo-oophorectomy:  Low-grade endometrioid neoplasm without loss of the mismatch repair proteins MSH2, MSH6, MLH1, and PMS2.  See comment.

03/25/2014 – Path Report #3

Clinical Diagnosis/History:

Obese patient with irregular vaginal bleeding and biopsy showing low-grade endometrioid neoplasm.

Diagnosis Comment:

55 mls slightly hemorrhagic fluid is received from which two Papanicolaou-stained concentrated smears are made.  Smears contain mesothelial cells with wash artifact in a bloody background.  Negative for malignancy.  Please also refer to the concurrent surgical case for more information.

Cytologic Impression:

Peritoneal wash:  Negative for malignancy.  See comment.

Data Item :

Diagnosis Date

Correct Answer :

03/25/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the 03/25/2014 total hysterectomy. The physical exam and PTA endometrial biopsy note the patient has an endometrial neoplasm with features of at least complex atypical hyperplasia. There was concern that the patient has underlying cancer. Atypical hyperplasia, endometrial neoplasm or concerning for cancer are not reportable terms and are not equivalent to malignancy.

Data Item :

Primary Site

Correct Answer :

C541

Rationale:

The total hysterectomy pathology report showed the primary tumor was in the endometrium. Apply code C541 (endometrium).

Data Item :

Laterality

Correct Answer :

0

Rationale:

Code 0 (not a paired site) when the primary site is not considered a paired site per SEER.

Data Item :

Histology

Correct Answer :

8380

Rationale:

The MP/H Rules (general rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. In this case the patient underwent an endometrial biopsy that was non-reportable and a total hysterectomy. The hysterectomy pathology report is the only and most representative specimen that identified malignancy, and the final diagnosis was endometrioid carcinoma.

Endometrioid carcinoma is a specific histologic type. Per the MP/H Rules, Other Sites, apply rule H11 and code the histology when only one histologic type is identified. Code the histology as 8380 (endometrioid carcinoma).

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology report, this is a malignant tumor. Code the behavior as /3 (malignant) when the primary tumor, or any portion of the primary tumor, is invasive.

Data Item :

Grade

Correct Answer :

2

Rationale:

Code the highest grade given from the primary tumor prior to neoadjuvant treatment. The total hysterectomy pathology report final diagnosis showed focal low grade endometrioid carcinoma. Use the grade conversion tables in the SEER Manual when there are no special grade systems for solid tumors that apply. Per the terminology conversion table, low grade is coded as grade code 2.

Data Item :

Clin T

Correct Answer :

X

Rationale:

The patient’s endometrial tumor cannot be assigned a clinical T category. The PTA 02/25/2014 endometrial biopsy showed at least complex atypical hyperplasia, but no definitive evidence of malignancy. The 03/21/2014 physical exam notes that, despite the negative biopsy, there is still concern for underlying cancer. Although the PTA biopsy was negative for malignancy, the physical exam was concerning. The subsequent surgery appears to have been done due to concern for cancer. Specific physical exam and clinical findings attributable to the primary tumor were not noted. The tumor cannot be clinically assessed. Though there was clinical concern for malignancy, the primary tumor was only evaluated pathologically. Apply code X (TX, primary tumor cannot be assessed).

Data Item :

Clin N

Correct Answer :

X

Rationale:

The regional nodes cannot be assigned a clinical N category. The patient underwent a PTA endometrial biopsy, but there is no indication any imaging was performed PTA or at this facility. There is no mention of regional lymph nodes on the physical exam note.

The minimal PTA and physical exam findings documented do not allow for clinical staging of the regional nodes. There is no indication whether suspicious nodes were clinically identified. Apply code X (NX, regional lymph nodes cannot be assessed).

Data Item :

Clin M

Correct Answer :

0

Rationale:

Per the AJCC Cancer Staging Manual, general instructions, a case with no symptoms or signs of metastasis is classified as clinically M0.

The physical exam was negative for any suspicious findings. There were no symptoms or findings the physician felt clinically suspicious for metastasis. Apply code 0 (M0, no distant metastasis).

Data Item :

Clin Stg Grp

Correct Answer :

99

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, a clinical Stage Group cannot be assigned when the T or N categories are assigned an X value. One exception: any combination of TX or NX with M1 is classified as Stage IV.

When the TNM is cTX cNX cM0, apply code 99 (Unknown).

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

1A

Rationale:

The 03/25/2014 hysterectomy pathology report showed focal low grade endometrioid carcinoma with no myometrial invasion (the carcinoma was limited to the endometrium). There was no involvement of the cervix or evidence of extra-uterine involvement. Apply code 1A (T1a, tumor limited to endometrium or invades less than one half of the myometrium).

Data Item :

Path N

Correct Answer :

X

Rationale:

Per Table 1.6, N Classification Rules, a pathologic N value cannot be assigned in the absence of a surgical resection. Although Table 1.6 also states a biopsy confirming the highest N may be used, it is used only in appropriate circumstances where the pathologic staging criteria for the site has been met.

The patient did not undergo a lymph node resection during the TAH/BSO. In order to assign the pN0 category, histologic examination of regional nodes is required. The regional lymph nodes cannot be assessed pathologically. The surgical observation of nodes at the time of resection, without pathologic examination, is not recorded in the pathologic stage. Apply code X (NX, regional lymph nodes cannot be assessed).

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic examination of distant metastasis. Apply code BLANK.

Data Item :

Path Stg Grp

Correct Answer :

99

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, a pathologic Stage Group cannot be assigned when the T or N categories are assigned an X value. One exception: any combination of TX or NX with pM1 is classified as Stage IV.

When the pathologic TNM is pT1a pNX cM0, apply code 99 (Unknown).

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Data Item :

SS 2000

Correct Answer :

1

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has local stage disease as there was pathologic evidence of tumor confined to the endometrium only. The primary tumor did not involve the myometrium per the hysterectomy pathology report. The patient has no regional lymph node or distant metastases. Apply code 1 (Localized only).

Social History

30 y/o single Filipino woman, was born in the Philippines and moved here in 2003. Primary payer at dx is Medicaid.

Physical Exam

05/28/2014 – HPI: Pt being seen 8 days after being discharged from hospital for perforated diverticulitis or underlying malig with abscess. Initially presented to ER for LLQ pain. Left AMA. Plan: Surg admit tomorrow.

08/29/2014 – Pt s/p total proctocolectomy with end ileostomy for rectosigmoid adenocarcinoma. Post-op CT on 08/08/2014 w/ new large enhancing pelvic mass associated w/ retroperitoneal and pelvic LAD, susp for aggressive tumor recurrence. Mass bx positive for carcinoma. Pt not deemed further surgical candidate and started on palliative chemo. Pt now s/p cycle 1 of FOLFIRI after rapid recurrence in pelvis. Re-image after 4 cycles to assess radiologic response.

Scans

05/18/2014 – CT Abd/Pelvis: Extensive mural thickening of sigmoid colon w/ adjacent extensive pelvic inflammation, susp for diverticulitis, with focus of pneumatosis sugg of perforation. Omentum herniating between rectus muscles, likely related to previous laparotomy incision. Adnexa not well visualized. Findings: Liver, lungs WNL. No osseous lesions. Likely reactive mesenteric and retroperitoneal LN’s.

05/28/2014 – CT Abd/Pelvis: Development of two abscesses w/in RLQ adjacent to sigmoid colon. Diff dx includes GI lymphoma, adenocarcinoma, Crohn’s, trauma and possibly diverticulitis. Enlarged retroperitoneal LNs, non-specific, either reactive or possibly related to an underlying malignancy.

06/04/2014 – CT Chest: No pulmonary mets. No LAD.

Labs

06/04/2014 – CEA: <0.7 ng/mL (0-5 ng/ml normal)

Operative Reports

05/30/2014 – Rigid sigmoidoscopy, bx rectal mass, diagnostic laparoscopy, washout abd abscess, intra-op US: Ulcerated appearing mass at 18 cm, bx’d. Mild amount ascites in colic gutters and over liver. No carcinomatosis. No liver masses. No addl abdominal masses. Matted bowel in pelvis w/ adhesions in LLQ w/ known abscess. Appendix normal.

07/02/2014 – Total proctocolectomy with end ileostomy, endometrial bx. Findings: Perforated rectosigmoid adenocarcinoma. No carcinomatosis or mets disease to liver on visual inspection. Large adherent mass w/ noted tumor, abscess, colon, uterus and fallopian tubes attached. Performed subtotal colectomy w/ distal margin just distal to peritoneal reflection. Removed tumor and abscess mass by peeling it off uterus. Tumor noted along the border of uterus, confirmed by frozen section of uterine fundus tissue. Due to evidence of tumor involvement of uterus, GYN intraoperative consult performed.

08/09/2014 – Complex pelvic mass bx.

Treatment Plan

06/19/2014 – IMP: Primary tumor in high rectum/distal sigmoid. Significant adhesions throughout entire area due to perforation of carcinoma. Plan sigmoid resection and primary anastomosis or subtotal colectomy with ileorectal anastomosis. Will likely need chemotherapy postoperatively.

07/25/2014 – Onc Note: T4b N0 M0, Stage IIC w/ tumor left on uterus due to desire to preserve fertility. Pt s/p subtotal colectomy (R1 resection) w/ positive margins. Recommend beginning FOLFOX 6 weeks from surgery.

Chemo Text

08/20/2014 – Started FOLFIRI.

05/30/2014 – Path Report #1

********** This Is An Addendum Report **********

Revision #1 (See end of report for new text): Additional Studies

Clinical Diagnosis/History:

Status post perforated diverticulitis

Final Diagnosis:

  1. A) Rectum, biopsy: Fragments of colonic mucosa with poorly-differentiated, non-small cell carcinoma that involves muscularis propria; see comment.

Comment:

Histologically this carcinoma is characterized by sheets and aggregates of tumor cells.

Gross Description:

Specimen A:  Received in formalin labeled “rectosigmoid biopsy” are four tan-pink tissue fragments measuring 0.5 to 0.2 cm in greatest dimension.  They are wrapped and entirely submitted in one cassette.

Addendum Issued To Report Results Of Immunohistochemical Stains For Microsatellite Instability Markers:

At the request of physician, immunohistochemical stains for microsatellite instability markers are performed with the following results:

IHC Studies:

Specimen A1:  Population: Neoplastic cells

CK 5 Cytokeratin 5 (EP1601Y)            Negative                 Controls appropriately positive

AE1/AE3   Pan-Cytokeratin Cocktail   Positive, uniformly Controls appropriately positive

S100 S-100 [DR96+BC96]                   Negative                  Controls appropriately positive

IHC Studies:

Specimen  A1:  Population:      Neoplastic cells

MLH1 MLH1 [G168-728]        Negative  Controls appropriately positive

MSH2 MSH2 [G219-1129]       Positive, variably  Controls appropriately positive

MSH6 MSH6 (BC/44)               Positive, variably  Controls appropriately positive

PMS2 PMS2                              Negative  Controls appropriately positive

IHC Interpretation:

Pankeratin positivity is characteristic of carcinoma.  Lack of keratin 5 expression argues against a squamous cell carcinoma and against a urothelial carcinoma.  Lack of S100 expression argues against a melanoma.

IHC Interpretation:

Loss of mismatch proteins MLH1 (with secondary loss of PMS2), consistent with sporadic microsatellite instability colorectal carcinoma due to methylation of MLH1 or Lynch syndrome due to germline mutation of MLH1.  MLH1 and PMS2 exist as heterodimers, with MLH1 dominant.  With loss of MLH1 there is also loss of PMS2, which is not due to a mutation in the PMS2 gene.  Most cases of loss of MLH1 (90%) are due to somatic inactivation of MLH1 due to promoter hypermethylation of the gene (sporadic MSI carcinoma) but about 10% are due to germline mutation of the MLH1 gene (Lynch Syndrome).  To distinguish, additional tests may be performed.  These tests include germline sequencing and testing for V600E mutation of BRAF (which is almost always present in cases of sporadic MSI carcinoma with MLH1 hypermethylation, and is almost always absent in Lynch Syndrome-associated carcinoma).

05/30/2014 – Path Report #2

Clinical Diagnosis/History:

Pelvic abscess.

Cytologic Impression:

Peritoneal fluid:  No cytologically malignant cells are identified.  See comment.

Comment:

10 mls hemorrhagic fluid is received from which two Papanicolaou-stained concentrated smears and one cellblock with hematoxylin and eosin-stained slide are made.  Slides contain mesothelial cells with wash artifact in a background of red and white blood cell components.  No cytologically malignant cell subpopulation is identified.  Please also refer to the concurrent surgical pathology case for more information.

Specimen Source:

Specimen A:  Peritoneal Fluid

Specimen Description:

10 ml hemorrhagic fluid in specimen tube

Cytopreparation:

Smears, 1 cell block

07/02/2014 – Path Report #3

********** This Is An Amended Report **********

Revision #1 (See end of report for new text): Additional Studies

Revision #2 (See end of report for new text): Additional Studies

Clinical Diagnosis/History:

Not provided.

Final Diagnosis:

  1. A) Colon, ascending, transverse, and descending, resection:

Colon (46.5 cm) with focal moderately active serositis and no evidence of carcinoma.

B, C, F)  Designated “tumor biopsy #1 and #2,” “pelvic tumor,” biopsies:

Poorly differentiated carcinoma with extensive necrosis.

  1. D) Endometrium, biopsy:

Shedding endometrium with no evidence of neoplasia.

  1. E) Sigmoid colon and rectum, resection:

Poorly differentiated carcinoma, see summary data below. Portion of adherent ovary. See comment.

  1. G) Designated “abscess cavity,” biopsies:

Poorly differentiated carcinoma with extensive necrosis and fibrinopurulent exudate involving a portion of bowel.

Comment:

The invasive carcinoma seen in this specimen has prominent tumor infiltrating lymphocytes and the histology of medullary carcinoma.  These two histologic features can be seen in microsatellite unstable carcinomas and in carcinomas arising in the setting of HNPCC.  Immunohistochemical stains for mismatch repair proteins were performed on the previous biopsy specimen and showed loss of expression of both MLH1 and PMS2, suggesting a defect in this pathway.  While patients with sporadic carcinomas can have microsatellite unstable tumors, loss of expression of two proteins, as well as the patients age, are concerning for a germline mutation associated with HNPCC.  The diagnosis of HNPCC must be made in conjunction with family history and other genetic/molecular testing.  BRAF testing will be preformed and reported in an addendum.

Summary Cancer Data:

Specimen and Tumor Location

Specimen type: Rectal/rectosigmoid colon (low anterior resection)

Specimen length:    38.5cm

Tumor site:    Rectosigmoid (C19.9)

Intactness of mesorectum:     Incomplete

Characteristics and Extent of Neoplasm

Histologic type:    Medullary carcinoma (85103)

Histologic grade:   Poorly differentiated

Tumor size:    Greatest diameter: 13.5cm

Tumor perforation (macroscopic):   Present

Microscopic tumor extent:     Tumor is adherent to other organs or structures

Adherent structure/organ:     Uterus and ovary

Tumor deposits:     Indeterminate

Lymphatic [small vessel] Invasion  (L): Not identified

Venous [large vessel] Invasion (V):     Not identified

Perineural invasion:     Absent

Final Surgical Resection Margins

Grossly positive margin(s):   None

Microscopically positive margin(s):     None

Lymph Node Status

Node summary:  Nodes with carcinoma: 0    / Total nodes examined: 24

Minimum Pathologic Stage (AJCC, 7th ed., 2010)

Primary tumor (pT): pT4b: Tumor directly invades or is adherent to other organs or structures

Regional lymph nodes (pN):    pN0: No regional lymph node metastasis

Other Findings

Tumor-Infiltrating Lymphocytes per high-power field:   11

Peri-tumoral lymphocytic response: Marked (>=3 aggregates/section) or Crohn-like reaction

Gross Description:

Specimen A:  Received fresh labeled “ascending transverse and descending colon” is a 46.5 cm in length colon including cecum dilated up to 9 cm and a 5.1 cm in length appendix.  There is a moderate amount of attached epiploic fat.  There is a small amount of omentum.  The serosal surface appears to have a few adhesions near the area of the descending colon.  The majority of the serosal surface appears smooth and glistening.  The cecum appears discolored to a red-tan to purple.  The ileocecal valve margin staple line is removed.  The underlying surface is inked blue.  The bowel is opened and a moderate amount of fecal material is present.  The mucosa is rinsed.  The mucosa appears red-tan and focally hemorrhagic.  The area near the cecum has green-stained portion.  The appendiceal orifice is unremarkable.  The mucosa is carefully examined for lesions and none are identified.  The mucosa appears mostly flattened with fine foldings.  Cassette index:

A1 – small bowel margin, en face

A2 – distal margin

A3-A6 – random large bowel

Specimen B:  Received fresh labeled “tumor biopsy #1” are two pieces of tan-red tissue fragments measuring 2.8 x 1 x 0.5 cm and 1.8 x 0.8 x 0.5 cm.  As per the surgeon, these were cut from the surface of the uterus.  A portion is submitted for frozen section.  Cassette index:

BFS – frozen section residue

B2 – remaining tissue

Specimen C:  Received fresh labeled “tumor biopsy #2” are three pieces of tan-pink tissue measuring 1.5 x 1 x 1 cm, 1.8 x 1 x 0.8 cm, 2.5 x 1.3 x 1.0 cm.  A portion is submitted for frozen section.  Cassette index:

CFS – frozen section residue

C2 – remaining tissue

Specimen D:  Received in formalin labeled “uterine contents” are multiple fragments of tan-red mucoid tissue measuring 2.5 x 1.5 x 0.5 cm in aggregate.  They are wrapped and entirely submitted in cassette D1.

Specimen E:  Received fresh labeled “sigmoid colon and rectum” is a 38.5 x 11.5 x 8 cm portion of bowel with a large, necrotic, exophytic, white-tan tumor.  It is located 2 cm from the distal margin of resection.  The specimen is largely disrupted.  The tumor appears to erode significantly through the bowel wall.  The tumor measures 13.5 x 11 x 8 cm.  The proximal margin is 10.5 cm away from the tumor.  This margin is taken en face. There is portion of colonic mucosa that is present and has normal foldings.  It has moderate amount of hemorrhagic material within.  After the margins are taken, the tumor is cross sectioned.  The exophytic portion of the tumor is noted by the surgeon to be adherent to the uterus.  After cross sectioning, the tumor appears to be pushing the bowel lumen, causing stenosis.  One portion of the bowel lumen is 2 cm in diameter.  No retroperitoneal margin is identified due to the distortion of the specimen and perforation by the tumor.  Cassette index:

E1 – representative sections of distal margin

E2 – tumor to proximal margin

E3 – perpendicular sections through distal margin

E4 – additional tumor to distal margin

E5- E7 – tumor

E8 – tumor to bowel

E9 – bowel to tumor

E10 – tissue near adherent loop

E11 – tumor and fat

E12-E19 – representative lymph node candidates

Specimen F:  Received in formalin labeled “pelvic tumor” are multiple fragments of tan-pink and rubbery tissue.  Some areas appear necrotic.  There is a moderate amount of hemorrhage.  They measure 4.5 x 4 x 1 cm in aggregate dimensions.  The non-necrotic portions are submitted in cassette F1.

Specimen G:  Received in formalin labeled “abscess cavity” are multiple fragments of tan-pink, hemorrhagic, firm, rubbery tissue measuring 4.5 x 4 x 2 cm.  Representative portions are submitted in cassette G1.

IHC Interpretation:

The neoplastic cells are of epithelial origin without neuroendocrine differentiation.

Intraoperative Consultation:

BFS)  Positive for malignancy.

CFS)  Malignant cells present with extensive necrosis.  )

E Gross)  Closest distal margin about 2 cm.

IHC Studies:

Specimen E2:  Population: Neoplastic cells

AE1/AE3   Pan-Cytokeratin Cocktail      ]      Positive, uniformly Controls appropriately positive

CKIT CKIT (C-19)/ CD117 [polyclonal]        Negative                 Controls appropriately positive

Specimen E8:  Population: Cells of interest

SYNAPTO   Synaptophysin [SY38]                Negative                 Controls  appropriately positive

Addendum Reason:

This addendum is to report results of BRAF mutational analysis.

BRAF Results: NEGATIVE for V600E mutation

Specimen E8:

BRAF Interpretation:  The tissue sample tested is negative for the T to A mutation in codon 600 (V600E mutation) of the BRAF gene.  In patients with microsatellite unstable (MSI) cancer, absence of this mutation would be consistent with possible Lynch Syndrome.

Amendment Reason:

This amendment is issued to report results of KRAS mutational analysis.

KRAS Results: Positive for mutation in codon 12 or 13.

Specimen:  E8

KRAS Interpretation:  The tissue sample tested is positive for a mutation in codon 12 or 13 of the KRAS gene.  In patients with metastatic colon cancer, mutations in these condons are associated with lack of response to therapeutic antibodies against the EGF receptor.

08/09/2014 – Path Report #4

Clinical Diagnosis/History:

History of HNPCC.  Now with abdominal mass.  Requested special advanced testing (from electronic order):  r/o HNPCC

Final Diagnosis:

  1. A) Abdominal mass, biopsy: Poorly-differentiated carcinoma, histologically identical to previously diagnosed carcinoma.

Gross Description:

Specimen A:  Received in formalin labeled “A – pelvic soft tissue mass” are multiple irregular fragments of white soft tissue measuring in aggregate 2 x 0.2 x 0.2 cm.  The entire specimen is submitted for microscopic examination.  Summary of sections:

A1 – soft tissue

Data Item :

Diagnosis Date

Correct Answer :

05/30/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the 05/30/2014 sigmoidoscopy with biopsy. The abdominal and pelvic CT scans gave no reportable diagnosis of malignancy.

Data Item :

Primary Site

Correct Answer :

C199

Rationale:

Per the 07/02/2014 operative report and the resection pathology report, the primary tumor was located in the rectosigmoid. Although there was a clinical description of a rectal mass during the sigmoidoscopy, the lower margin of the tumor was at 18 cm and the operative findings indicated this tumor was not in the rectum. A tumor is classified as rectal if the lower margin is less than 16 cm from the anal verge. Apply code C199 (rectosigmoid).

Data Item :

Laterality

Correct Answer :

0

Rationale:

Code 0 (not a paired site) when the primary site is not considered a paired site per SEER.

Data Item :

Histology

Correct Answer :

8510

Rationale:

The MP/H Rules (general rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. This patient underwent a biopsy of the mass followed by a total proctocolectomy. The resection pathology report was the most representative specimen, and the final diagnosis was poorly differentiated carcinoma. The summary cancer data indicated the histologic type was medullary carcinoma. The summary cancer data can be used to code the histology when it provides a more specific histologic type.

Per the MP/H Rules, Other Sites, apply rule H13 and code the most specific histologic term when the diagnosis is carcinoma, NOS and a more specific carcinoma. Code the histology as 8510 (medullary carcinoma).

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology reports, this is a malignant tumor. Code the behavior as /3 (malignant) when the primary tumor, or any portion of the primary tumor, is invasive.

Data Item :

Grade

Correct Answer :

3

Rationale:

Code the highest grade given from the primary tumor, prior to neoadjuvant treatment, when multiple grades are given. Both the biopsy and resection showed poorly differentiated carcinoma. Use the grade conversion tables in the SEER Manual when there are no special grade systems for solid tumors that apply. Per the terminology conversion table, poorly differentiated is coded as grade code 3.

Data Item :

Clin T

Correct Answer :

X

Rationale:

The patient’s rectosigmoid tumor cannot be assigned a clinical T category. The 05/18/2014 and 05/28/2014 CT scans showed mural thickening of the colon with adjacent inflammation and subsequent development of abscess surrounding the sigmoid colon. The scans were suggestive of perforation. The 05/30/2014 sigmoidoscopy with diagnostic laparoscopy identified matted bowel in the pelvis with adhesions in the LLQ with known abscess.

The biopsy proved carcinoma invaded the muscularis propria, but the laparoscopy and imaging indicate the possibility that the tumor extended further. It is unclear clinically whether the perforation and/or adhesions were actually due to tumor involvement or to inflammation/abscess involvement. Per the CAnswer Forum, perforation alone is not sufficient to assign the T category. The 06/19/2014 treatment plan note states there are adhesions throughout the area due to perforation of carcinoma, but at laparoscopy, this was identified as matted bowel and adhesions due to abscess. The extent of the primary tumor was not identified by clinical means. Apply code X (TX, primary tumor cannot be assessed).

Data Item :

Clin N

Correct Answer :

0

Rationale:

The 05/18/2014 CT scan identified likely reactive mesenteric and retroperitoneal lymph nodes. The 05/28/2014 CT scan identified enlarged retroperitoneal lymph nodes that were non-specific, either reactive or possibly related to an underlying malignancy. The 05/30/2014 laparoscopy showed no carcinomatosis and made no mention of clinically suspicious regional lymph nodes.

There was no definitive imaging or laparoscopic evidence of lymph node involvement. There was no definitive statement from the physician or other indication in the record that the “enlarged” nodes actually were considered involved. Apply code 0 (N0, no regional lymph node metastasis).

Data Item :

Clin M

Correct Answer :

0

Rationale:

Per AJCC Cancer Staging Manual, general instructions, a case with no symptoms or signs of metastasis is classified as clinically M0.

The CT scans on 05/18/2014, 05/28/2014, and 06/04/2014 all showed no evidence of distant metastatic disease, and the 05/30/2014 laparoscopy showed no carcinomatosis, liver masses or abdominal masses. There were no symptoms or findings the physician felt clinically suspicious for distant metastasis at diagnosis. Apply code 0 (M0, no distant metastasis).

Data Item :

Clin Stg Grp

Correct Answer :

99

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, a clinical Stage Group cannot be assigned when the T or N categories are assigned an X value. One exception: any combination of TX or NX with M1 is classified as Stage IV.

Colorectal primaries are often staged following pathologic examination of a resected specimen. When the TNM is cTX cN0 cM0, apply code 99 (Unknown).

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

4B

Rationale:

Total proctocolectomy was performed on 07/02/2014. Pathologic staging includes pathologic examination of the resected specimen in addition to surgical observations. The pathology report identified medullary carcinoma in the rectosigmoid colon that was adherent to the uterus and ovary. The operative report indicated there was evidence of tumor involvement of the uterus, but the uterus was not resected in an effort to preserve the patient’s fertility.

The greatest pathologic extent of disease was the adherent tumor on the uterus and ovary and direct invasion of the uterus. The oncologist pathologically staged this as T4b per the 07/25/2014 oncology note. Apply code 4B (T4b, tumor directly invades or is adherent to other organs or structures).

Data Item :

Path N

Correct Answer :

0

Rationale:

The 07/02/2014 proctocolectomy included resection of multiple regional lymph nodes, NOS. The nodes were pathologically negative. Apply code 0 (N0, no regional lymph node metastasis).

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic examination of distant metastasis. This patient had a clinical assessment only, clinically M0. Apply code BLANK.

Data Item :

Path Stg Grp

Correct Answer :

2C

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, for cases with known pT and pN categories, use the clinical M category to complete the pathologic stage group.

Per the colon and rectum staging form, when the pathologic TNM is pT4b pN0 cM0, apply code 2C (Stage IIC).

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Data Item :

SS 2000

Correct Answer :

7

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has distant stage disease as the primary tumor pathologically showed involvement of the uterus. The operative report confirmed uterine involvement at surgery. Direct tumor extension to the uterus is considered distant by direct extension. There were no regional lymph nodes or distant metastases. Apply code 7 (Distant, distant site(s) involved by extension).

Social History

65 y/o married Black/White man. Born in Louisiana. Primary payer at dx is private insurance, managed care.

Physical Exam

08/10/2014 – ED Note: Bloody stool and 25-pound weight loss over the last month. DRE w/ large rectal mass. Plan: Urgent bx/scope by GI service.

Scans

08/10/2014 – CT Abd/Pelvis: Large presacral mass infiltrates rectal wall w/ associated irregular rectal wall thickening, inseparable from bladder and prostate, multiple enlarged mesenteric and iliac LNs. Appearance c/w a malignant tumor, likely of rectal origin. Mild Rt hydroureteronephrosis due to compression of ureteropelvic junction by the mass. Indeterminate lucent focus in iliac bone. No evidence of peritoneal or liver mets, lung bases clear. FINDINGS: 10.1 x 9.4 cm mass involving rectal wall, bladder, prostate, and seminal vesicles. Pelvic mesentery and iliac lymphadenopathy.

08/30/2014 – MRI Pelvis: Large necrotic mass w/ obliteration of mesorectal fascia, gross invasion of the prostate and bladder, posterior extension of tumor into presacral space and bilateral obturator internus muscles. Involvement of ischiorectal fat and upper portions of bilateral sphincters. Gross invasion of upper sphincters. Enlarged common iliac and external iliac LNs present bilaterally. IMP: Low rectal cancer.

08/30/2014 – CT Chest: Five indeterminate 2 mm pulmonary nodules. Three additional foci ground glass opacity in RUL, may represent inflammation, but appearance is indistinguishable from adenoca in situ. FU in 3 months.

Scopes

08/15/2014 – Colonoscopy w/ biopsies: Large rectal mass, suspect this is rectal cancer. CT scan demonstrated large pre-sacral mass that involves rectal wall as well as urinary bladder, prostate and seminal vesicles. Based on CT scan, this appears to be a T4 lesion and at least N1. There is also a 1.1 cm left external iliac enlarged LN, most likely represents mets. Plan: Refer to oncology, will likely require chemo as well as radiation.

Treatment Plan

08/22/2014 – Plan neoadjuvant chemo/rad. After completion in 2-3 months, plan surg. Will probably need total pelvic exenteration. After surg, pt will receive further chemo.

Chemo Text

09/10/2014 – Started FOLFOXIRI.

08/15/2014 – Path Report #1

********** This Is A Revised Or Corrected Report ***********

**** Please See End Of Report For Detail Of Corrections ****

********** This Is An Addendum Report **********

Revision #1 (See end of report for new text): IHC/IF Results

Clinical Diagnosis/History:

Rectal mass on CT.  Endoscopic findings:  Rectal mass.  Questions to pathologist:  Rule out adenoma/cancer

Final Diagnosis:

A,B)  Rectum, mass #1, #2, biopsies:  Invasive adenocarcinoma, well-differentiated.  A HEABS stain highlights the architectural changes.

Gross Description:

Specimen A:  Received in neutral buffered formalin and labeled with the patient’s name is a specimen designated “rectal mass # 1,” comprising 6 pieces of tan white tissue measuring 0.2 cm to 0.9 cm.  Submitted in total in 1 cassette.

Specimen B:  Received in neutral buffered formalin and labeled with the patient’s name is a specimen designated “rectal mass # 2,” comprising 5 pieces of tan white tissue measuring 0.5 cm to 0.8 cm.  Submitted in total in 1 cassette.

IHC Studies:

Specimen B1:  Population: Carcinoma cells

MLH1 MLH1 [G168-728]          No loss of expression

MSH2 MSH2 [G219-1129]         No loss of expression

MSH6 MSH6 (BC/44)                 No loss of expression

PMS2 PMS2                                No loss of expression

Addendum Reason:

An addendum is issued to report the results of additional immunohistochemical studies.  The final diagnosis is unchanged.

Addendum:

  1. B) Rectum, mass #2, biopsy: Invasive adenocarcinoma with no loss of expression of mismatch repair gene products (MLH1, MSH2, MSH6, or PMS2), by immunohistochemical technique.

Data Item :

Diagnosis Date

Correct Answer :

08/10/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the 08/10/2014 CT scan that showed a large presacral mass that was consistent with a malignant tumor.

Ambiguous terminology may be used to accession a case when the ambiguous terminology is considered reportable. “Consistent with” is a reportable ambiguous term. The clinical diagnosis of malignancy was subsequently confirmed by biopsy.

Data Item :

Primary Site

Correct Answer :

C209

Rationale:

The 08/10/2014 CT scan identified a presacral mass with infiltration and associated rectal wall thickening. The CT scan did not definitively identify the mass as a rectal mass, but did state it was likely of rectal origin. The 08/30/2014 MRI showed an extensive low rectal cancer and the 08/15/2014 colonoscopy identified a large rectal mass that was suspicious for rectal cancer. The primary tumor was in the rectum per the imaging and colonoscopy findings. Apply code C209 (rectum).

Data Item :

Laterality

Correct Answer :

0

Rationale:

Code 0 (not a paired site) when the primary site is not considered a paired site per SEER.

Data Item :

Histology

Correct Answer :

8140

Rationale:

The MP/H Rules (general rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. This patient underwent a biopsy of the rectal mass only. The biopsy pathology report was the most representative specimen, and it showed adenocarcinoma.

Per the MP/H Rules, Other Sites, apply rule H11 and code the histology when only one histologic type is identified. Code the histology as 8140 (adenocarcinoma, NOS).

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology report, this is a malignant tumor. Code the behavior as /3 (malignant) when the primary tumor, or any portion of the primary tumor, is invasive.

Data Item :

Grade

Correct Answer :

1

Rationale:

Code the highest grade given from the primary tumor prior to neoadjuvant treatment. The rectal mass biopsy pathology report showed well differentiated adenocarcinoma. Use the grade conversion tables in the SEER Manual when there are no special grade systems for solid tumors that apply. Per the terminology conversion table, well differentiated is coded as grade code 1.

Data Item :

Clin T

Correct Answer :

4B

Rationale:

The 08/10/2014 CT scan showed a large presacral mass involving the rectal wall, bladder, prostate and seminal vesicles. The 08/30/2014 MRI showed a large necrotic mass that obliterated the mesorectal fascia and invaded the prostate, bladder, presacral space, obturator internus muscles, ischiorectal fat and bilateral sphincters.

The 08/15/2014 colonoscopy with biopsy identified a large rectal mass that, based on the CT scan, appears to be a T4 lesion. The biopsy confirmed adenocarcinoma in the rectal mass. There was clinical imaging evidence of direct invasion into multiple organs (at least the bladder, prostate, and seminal vesicles). Apply code 4B (T4b, tumor directly invades or is adherent to other organs or structures).

Data Item :

Clin N

Correct Answer :

1

Rationale:

The 08/10/2014 CT scan identified multiple enlarged mesenteric and iliac lymph nodes. The 08/30/2014 MRI identified enlarged common iliac and external iliac lymph nodes bilaterally; however, common and external iliac nodes are not regional nodes for a rectal primary.

The 08/15/2014 colonoscopy report indicates the physician staged this as at least N1 disease based on the CT scan. The only regional nodes mentioned on the CT scan were mesenteric (NOS) nodes. Because there is no documentation regarding the specific number of regional nodes involved, a more specific N category cannot be determined. Apply code 1 (N1, metastasis in 1-3 regional lymph nodes).

Data Item :

Clin M

Correct Answer :

1A

Rationale:

The 08/10/2014 CT scan and 08/30/2014 MRI showed iliac adenopathy (enlarged common and external iliac nodes). Neither scan definitively called these metastases, but also showed no evidence of other distant metastases. The 08/15/2014 colonoscopy report states there was a 1.1 cm left external iliac enlarged lymph node that most likely represents metastasis.

External iliac nodes are considered distant lymph nodes for a rectal primary. There was no other definitive evidence of distant metastasis in other organs or sites. Involvement of a single metastatic site (including distant nodes) is considered M1a disease. Apply code 1A (M1a, metastasis confined to one organ or site).

Note: It is unclear whether the enlarged common iliac is actually involved in this case. If the enlarged common iliac node was involved, this would be considered M1b disease.  However, the colonoscopy report states the physician reviewed the CT scan (most likely the 08/10/2014 CT scan) at the time of the colonoscopy and only indicated the enlarged left external iliac node most likely represented metastasis. The physician reviewed the imaging and still didn’t provide any clarification whether this “enlarged” common iliac node is truly involved. M1a is felt to be the most defensible M category based on the physician’s assessment.

Data Item :

Clin Stg Grp

Correct Answer :

4A

Rationale:

Per colon and rectum staging form, when the TNM is cT4b cN1 cM1a, apply code 4A (Stage IVA).

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

BLANK

Rationale:

Per Table 1.5, T classification rules, a pathologic T value cannot be assigned in the absence of a surgical resection. Although Table 1.5 also states a biopsy confirming the highest T may be used, it is used only in appropriate circumstances where the pathologic staging criteria for the site has been met.

There was no resection of the primary tumor. Surgery was planned following neoadjuvant chemotherapy and radiation, but has not been performed. The primary tumor was not eligible for pathologic staging. Apply code BLANK.

Data Item :

Path N

Correct Answer :

BLANK

Rationale:

Per Table 1.6, N Classification Rules, a pathologic N value cannot be assigned in the absence of a surgical resection. Although Table 1.6 also states a biopsy confirming the highest N may be used, it is used only in appropriate circumstances where the pathologic staging criteria for the site has been met.

The patient did not undergo a lymph node resection. Surgery was planned following neoadjuvant chemotherapy and radiation, but has not been performed. There was no removal of regional lymph nodes; therefore, the lymph nodes were not eligible for pathologic staging. Apply code BLANK.

Note: Click here to open “TNM_Document.pdf” which describes general rules for developing preferred answers in SEER*Educate.

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic assessment of distant metastasis. Apply code BLANK.

Data Item :

Path Stg Grp

Correct Answer :

BLANK

Rationale:

There was no surgical resection of the primary tumor and/or regional lymph nodes. Surgery was planned following neoadjuvant treatment, but has not been performed yet. Apply code BLANK.

Note: Click here to open “TNM_Document.pdf” which describes general rules for developing preferred answers in SEER*Educate.

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Note: Click here to open “TNM_Document.pdf” which describes general rules for developing preferred answers in SEER*Educate.

Data Item :

SS 2000

Correct Answer :

7

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has distant stage disease as the patient was clinically diagnosed with distant (external iliac) lymph node metastases. The primary tumor was considered distant by direct extension to the presacral space and ischiorectal fat on imaging. The patient also had clinical evidence of regional mesenteric lymph node metastases. The presence of distant external iliac lymph node metastases is always coded as distant stage disease, regardless of the tumor involvement or whether regional lymph nodes were involved. Apply code 7 (Distant lymph node(s) involved).

Social History

Ethiopian male, 64 y/o, born in NY. Pt is married w/3 adult children, currently retired. Insurance: Medicaid administered through HMO.

Physical Exam

02/06/2014 – cc: Pt referred for evaluation of Rt oral cavity mass. HPI: Presented to dentist approximately 2 months ago and found to have fleshiness around the gingiva of tooth #31. He reportedly had the area cauterized and treated w/ laser. Lesion was persistent during follow-up and PTA biopsy was taken on 01/29/2014, which was c/w moderately differentiated SCC. PE: Pt denies dysphagia, or changes to voice. HEENT: Nose, normal. Oral cavity and oropharynx demonstrates a fleshy erythematous mass along the buccal and lingual surface of tooth #30 and 31. Mass does not involve the tongue or floor of mouth. Neck: Normal, no masses or lymphadenopathy. PTA CT from January reviewed, which does not demonstrate any significant bony erosion along tooth #30 and 31. IMP: At least T2 N0 SCC of the right oral cavity. Outside scan is limited, repeat CT of the head and neck to rule out any neck disease. Surg discussed, pt is ready to move forward.

Scans

02/14/2014 – CT Head/Neck: Mild asymmetric soft tissue thickening along the buccal mucosa adjacent to teeth number 30 and 31, w/ mild stranding of adjacent fat likely consistent w/ pt’s known SCC. No evidence of any met lymphadenopathy in the neck. Small area of nodular consolidation in the Lt lung apex may be secondary to aspiration/infection.

05/29/2014 – CT Head: New enhancing soft tissue in the Rt submandibular region suspicious for disease recurrence. No cervical lymphadenopathy.

Operative Reports

02/19/2014 – Rt modified neck dissection, Rt marginal mandibulectomy, composite resection including bone, FOM and ventral tongue: Exophytic tumor on the buccal aspect of teeth numbers 29 to 31. There did not appear to be any invasion into the marrow space or the inferior alveolar nerve. Small LNs in levels 1 and 2 of Rt neck. Postop Dx: T2 SCC of the Rt gingivial mucosa, lateral floor of mouth.

Treatment Plan

02/28/2014 – Tumor Board Note: Given that margins were negative and there were no cervical LNs, we will continue to observe the patient clinically.

Stage

02/28/2014 – Tumor Board: T2 N0 M0 stage II SCC of the mandibular alveolus.

02/19/2014 – Path Report #1

Clinical Diagnosis/History:

Floor of mouth cancer.

Final Diagnosis:

  1. A) Right submandibular gland, excision: Salivary gland with no diagnostic abnormalities.

B, C)  Lymph nodes, right level I and right levels II and III, respectively, neck dissection: 17 lymph nodes negative for carcinoma as follows: 6 level I nodes, 7 level II nodes and 4 level III nodes.

  1. D) Mandible, right composite resection: Squamous cell carcinoma with the following features:
  2. Well-differentiated.
  3. Size: 2.5 cm.
  4. Carcinoma does not invade mandible but does erode the cortex of a tooth socket.
  5. Margins: Carcinoma is focally present at black-inked (medial) soft tissue margin near skeletal muscle, 0.2 cm from blue-inked (lateral) soft tissue margin, 0.2 cm from anterior soft tissue margin.  Mandibular bone margins are negative for carcinoma.
  6. Perineural invasion is not identified.
  7. Minimum pathologic stage pT2 NX (AJCC 7th Edition 2010).

E-I)  Margins, sites as designated, biopsies: Negative for carcinoma.

Gross Description:

Specimen A:  Received in a container of formalin labeled “right submandibular gland” is a 3.5 x 2.7 x 1.5 cm tan, lobulated salivary gland.  There are unremarkable cut surfaces.  Representative sections are submitted in cassette A1.

Specimen B:  Received in a container of formalin labeled “right level I neck dissection” are multiple tan, focally hemorrhagic, rubbery portions of tissue measuring 3.0 x 2.5 x 1 cm in aggregate dimension.  A few lymph node candidates are identified on cut surfaces ranging in size from 0.5 cm to 1.3 cm.  Representative sections are submitted labeled:  B1 – four individual lymph node candidates; B2 – two bisected lymph nodes, one marked blue.

Specimen C:  Received in a container of formalin labeled “right neck dissection, levels II and III” is a 7.0 x 4.5 x 1 cm yellow, lobulated, indurated portion of fibrofatty tissue.  There is a single suture attached to the level II end of the specimen and a double suture attached to level III end of the specimen.  The tissue is arbitrarily divided into levels II and III, and there are fatty cut surfaces admixed with numerous lymph node candidates ranging in size from 0.2 cm to 1.4 cm.  Representative sections are submitted labeled:  C1-C3 – level II nodes designated:  C1 – one blue-inked individual lymph node candidate, and one bisected lymph node candidate; C2 – four individual lymph node candidates; C3 – two bisected lymph nodes, one marked blue; C4 – one bisected lymph node, level III; C5 – five individual lymph node candidates, level III.

Specimen D:  Received in formalin labeled “right composite resection, single stitch anterior buccal, double stitch posterior lingual” is a 4.5 AP x 2.2 ML x 2.5 cm SI portion of right mandible with two gold teeth measuring 1.2 x 0.9 and 1 x 1 cm.  On the lateral aspect of the specimen is a 2.5 x 1.5 x 1.5 cm tumor mass invading into buccal mucosa in between two teeth and possibly invading into the bone.  The tumor is grossly 0.1 cm from the blue- inked lateral margin and 0.6 cm from the green-inked posterior soft tissue margin, 0.8 cm from anterior orange-inked margin, and 1.5 cm from the black-inked medial margin.  Representative sections are submitted as follows:  D1 – perpendicular section of the black-inked medial margin; D2 – perpendicular section of the orange-inked anterior margin; D3 – perpendicular section of the green-inked posterior soft tissue margin; D4-D5 – tumor closest to the blue- inked lateral margin; D6 – en face anterior bone margin; D7-D8 – cross sections of mandible; D9 – en face posterior bone margin.  The remaining tissue will be decalcified and submitted later, including en face bone margin (green ink posterior, orange ink anterior, and red ink inferior).

Specimen E:  Received fresh for frozen section labeled “anterior margin” is a 0.7 x 0.3 x 0.1 cm tan-red soft tissue inked black and entirely submitted for frozen section together with parts F and G and then thawed and submitted in cassettes E1/F1/G1FS.

Specimen F:  Received fresh for frozen section labeled “lateral margin” is a 0.6 x 0.2 x 0.1 cm soft tissue, inked blue and submitted together with specimens E and G then thawed and submitted in E1/F1/G1FS.

Specimen G:  Received fresh for frozen section labeled “posterior margin” is a 1 x 0.4 x 0.2 cm soft tissue, inked green and frozen together with parts E and F then thawed and submitted in cassette E1/F1/G1FS.

Specimen H:  Received fresh for frozen section labeled “medial margin” is a 0.6 x 0.2 x 0.1 cm soft tissue inked black and submitted together with part I then thawed and submitted in cassette H1/I1FS.

Specimen I:  Received fresh for frozen section labeled “deep margin” is a 0.6 x 0.3 x 0.2 cm soft tissue, inked blue and submitted together with part H then thawed and submitted in cassette H1/I1FS.

Frozen Section Diagnosis:

EFS, FFS, GFS, HFS, IFS:  No carcinoma

Data Item :

Diagnosis Date

Correct Answer :

01/29/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the PTA 01/29/2014 biopsy noted in the physical exam.

Data Item :

Primary Site

Correct Answer :

C031

Rationale:

The MP/H Rules, Coding Primary Site instructions, state the Tumor Board’s primary site assignment has priority over an operative report or pathology report when the primary site is indeterminate or unclear. The Tumor Board staging note indicates the tumor was located in the mandibular alveolus. The operative report also notes this tumor was on the right gingivial mucosa, lateral floor of mouth. Code the primary site based on the Tumor Board’s assessment. Apply code C031 (Mandibular gingiva).

Data Item :

Laterality

Correct Answer :

0

Rationale:

Code 0 (not a paired site) when the primary site is not considered a paired site per SEER.

Data Item :

Histology

Correct Answer :

8070

Rationale:

The MP/H Rules (general rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. The patient underwent a PTA biopsy and a mandibulectomy with neck dissection. The resection specimen was the most representative specimen, and it showed well-differentiated squamous cell carcinoma of the gingival mucosa. Per MP/H Rules, Head and Neck, apply rule H3 and code the histology when only one histologic type is identified. Code the histology as 8070 (squamous cell carcinoma).

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology report, this is a malignant tumor. Code the behavior as /3 (malignant) when the primary tumor, or any portion of the primary tumor, is invasive.

Data Item :

Grade

Correct Answer :

2

Rationale:

Code the highest grade given from the primary tumor. The PTA biopsy of the lesion on 01/29/2014 showed moderately differentiated squamous cell carcinoma. The surgical resection pathology final diagnosis showed well differentiated squamous cell carcinoma.

Use the grade conversion tables in the SEER Manual when there are no special grade systems for solid tumors that apply. Per the terminology conversion table, moderately differentiated is coded as grade code 2.

Data Item :

Clin T

Correct Answer :

2

Rationale:

The PTA 01/29/2014 gingival mass (lower gum) biopsy was positive for squamous cell carcinoma. The gingival mass did not involve the tongue or floor of mouth on physical exam. The PTA CT scan from January 2014 showed no evidence of bony erosion. There was no statement of the clinical tumor size on imaging or physical exam, but the physician clinically staged this as “at least T2” disease.

The physician’s T category assignment is the only indication of the clinical tumor size and can be used when no other documentation is given. This tumor must clinically be greater than 2 cm in size. Apply code 2 (T2, tumor more than 2 cm but not more than 4 cm in greatest dimension).

Data Item :

Clin N

Correct Answer :

0

Rationale:

The 02/06/2014 physical exam found no masses or lymphadenopathy. The 02/14/2014 CT scan also showed no evidence of any metastatic lymphadenopathy in the neck. The physician clinically staged this as N0 disease per the 02/06/2014 physical exam note. Based on the physical exam and imaging findings, this is clinically N0. Apply code 0 (N0, no regional lymph node metastasis).

Data Item :

Clin M

Correct Answer :

0

Rationale:

Per the AJCC Cancer Staging Manual, general instructions, a case with no symptoms or signs of metastasis is classified as clinically M0.

The 02/14/2014 CT scan noted a small area of nodular consolidation in the left lung apex, possibly secondary to aspiration or infection. The limited imaging was otherwise negative and did not specifically mention distant metastasis. There were no symptoms or findings the physician felt clinically suspicious for metastasis. Apply code 0 (M0, no distant metastasis).

Data Item :

Clin Stg Grp

Correct Answer :

2

Rationale:

Per the lip and oral cavity staging form, when the clinical TNM is cT2 cN0 cM0, apply code 2 (Stage II).

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

2

Rationale:

The 02/19/2014 composite resection pathology report showed a 2.5 cm squamous cell carcinoma invading into the cortical bone, but not through the cortical bone into the trabecular bone (mandible). The tumor is limited to the cortex of the alveolar bone (the bone lining the tooth socket). The margins were negative and no further extension was identified microscopically or by surgical observation.

Per the AJCC Cancer Staging Manual, superficial erosion of the cortex of bone (or tooth socket) by a gingival primary is not sufficient to classify a tumor as T4a. Apply code 2 (T2, tumor more than 2 cm but not more than 4 cm in greatest dimension).

Data Item :

Path N

Correct Answer :

0

Rationale:

The 02/19/2014 composite resection included resection of multiple regional lymph nodes (levels I-III cervical nodes). The pathology report showed the resected nodes were negative for metastatic carcinoma. Apply code 0 (N0, no regional lymph node metastasis).

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic examination of distant metastasis. Apply code BLANK.

Data Item :

Path Stg Grp

Correct Answer :

2

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, for cases with known pT and pN categories, use the clinical M category to complete the pathologic stage group.

Per the lip and oral cavity staging form, when the pathologic TNM is pT2 pN0 cM0, apply code 2 (Stage II).

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Data Item :

SS 2000

Correct Answer :

2

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has regional stage disease as the primary tumor pathologically involved the cortical bone of the mandible. The tumor eroded the cortical bone, but did not extend into the trabecular bone of the mandible. Any involvement of the mandible (cortical or trabecular) is considered regional by direct extension when determining the Summary Stage. There were no regional lymph nodes or distant metastases. Apply code 2 (Regional, direct extension only).

Social History

Filipino male, 80 y/o, single. BP: CA. Has insurance.

Physical Exam

01/29/2014 – HPI: Pt w/ a history of lung adenoca. Has been doing relatively well with FU PTA CT/PET 11/99/2013 demonstrating increased uptake in the floor of mouth. Underwent PTA FOM biopsy 01/04/2014 which was positive for moderately to poorly differentiated squamous cell carcinoma. PE: HEENT: Nasal exam normal. Exam of oral cavity demonstrates a nodularity at the floor of mouth and there appears to be induration to the submental region. It starts w/ in the middle and extends towards the Lt side. There is mild tethering of the ventral surface of the tongue. The mass is abutting the lingual cortex of the mandible (no size). LNs: No palpable lymphadenopathy in the Rt neck nor Lt neck. IMP: An anterior and Lt floor of mouth SCC that appears to be involving a portion of the ventral tongue and abutting of the mandible. Does not appear to be destruction of the mandible but there is involvement of a portion of the floor of mouth musculature. PLAN: Recommend FOM resection for complete clearance and subsequent reconstruction.

Scans

11/99/2013 – PTA CT: Lt side floor of mouth mass that is abutting the mandibular cortex on the Lt side. There does not appear to be destruction on the cortex. It does involve a portion of the deep musculature of the floor of mouth. No lymphadenopathy identified. Increased uptake in floor of mouth and no cervical lymphadenopathy uptake.

Operative Reports

02/25/2014 – Composite resection of ventral tongue and anterior floor of mouth carcinoma. Neck dissection, levels IA, right level IB through III. Findings: A submucosal nodule was present in FOM abutting the anterior mandible and extending into the ventral tongue. No penetration of the periosteum or bone.

Treatment Plan

03/19/2014 – No further therapy with the exception of cancer surveillance is anticipated.

02/25/2014 – Path Report #1

Clinical Diagnosis/History:

Cancer, floor of mouth.

Final Diagnosis:

  1. A) Right submandibular gland, excision: Salivary gland; no neoplasm identified.

B, C, K)  Lymph nodes, as designated, excisions: 6 lymph nodes negative for metastatic carcinoma (0/6), including 1 right level 2, 3 right level 2 and 3, and 2 right peri-facial lymph nodes.

  1. D) Tissue designated “right level 1a,” excision: Fibroadipose tissue and skeletal muscle; no neoplasm identified.
  1. E) Ventral tongue floor of mouth, composite resection: Invasive squamous cell carcinoma, moderately to poorly differentiated, with the following features:
  2. 2.0 cm in maximum dimension.
  3. Carcinoma focally touches the left lateral and posterior margins and is 0.2 cm from the deep margin. It is at least 0.5 cm from right lateral margin.  See comment.
  4. Perineural invasion present.
  5. No angiolymphatic invasion identified.
  6. Minimum pathologic stage: pT1N0MX.

F, J)  Margins, as designated, excisions: Squamous mucosa and skeletal muscle; no neoplasm identified.

G-I)  Margins, as designated, excisions: Skeletal muscle and fibrovascular tissue; no neoplasm identified.

Diagnosis Comment:

Definitive evaluation of the anterior margin was complicated by intraoperative sampling of tissue.

Gross Description:

Specimen A:  Received in formalin labeled “right submandibular gland” are three nodules of fibrovascular tissue measuring 1.0 cm, 1.0 cm, and 2.5 x 1.5 x 1.0 cm.  Cut sections show multilobulated, tan-white, fibrous tissue interspersed amongst yellow adipose tissue.  No discrete masses are appreciated and no foci of hemorrhage or necrosis are appreciated.  Representative sections are submitted in cassettes A1 and A2.

Specimen B:  Received in formalin labeled “right level 2” is a nodule of fibroadipose tissue measuring 2 x 1 x 0.5 cm.  The adipose tissue is dissected away to reveal a single 0.8 cm lymph node candidate that is bisected.  The specimen is submitted in its entirety in a single cassette designated B1.

Specimen C:  Received in formalin labeled “right level 2 and 3” is an irregular portion of fibroadipose tissue measuring 8 x 1.5 x 1.0 cm.  The fat and fibroconnective tissue are dissected to reveal several lymph node candidates measuring 0.3 to 0.9 cm.  The 4 lymph node candidates are entirely submitted in a single cassette designated C1.

Specimen D:  Received in formalin labeled “right level 1a” is an irregular fragment of tan fibrovascular tissue measuring 1.5 x 1.2 x 0.2 cm.  No definitive lymph node candidate is identified.  The specimen is submitted entirely in a single cassette designated D1.

Specimen E:  Received in formalin designated “composite resection of ventral tongue floor of mouth” is an irregular nodule of tan-white and brown soft tissue measuring 3.5 (ML) x 2.0 (AP) x 2.0 (SI) cm.  There is a double short stitch marking the anterior aspect of the specimen and a single long stitch marking the right lateral floor of mouth margin.  There are two additional double-loop sutures in the superior aspect of the specimen designating areas where the surgeon took tissue for research purposes prior to receipt of the specimen by Pathology.  The specimen is inked as follows: anterior blue, right lateral orange, posterior green, left lateral yellow, deep black.  The mucosal surface is tan-pink in color with a central subepithelial nodule that has been incised previously.  The specimen is serially sectioned from medial to lateral to reveal a subepithelial tan-white nodule measuring 1.7 (AP) x 1.0 (SI) x 2.0 (ML) cm.  No areas of hemorrhage or necrosis are appreciated with the mass.  There is a thin rim of skeletal muscle beneath the pushing border of the mass.  It appears to approach to 0.1 cm from the anterior mucosal aspect of the specimen and to within 0.2 to 0.3 cm from the deep aspect of the specimen.  It is at least 0.7 cm from the left lateral aspect of the specimen and no more than 0.1 cm from the right lateral aspect of the specimen.  It is focally 0.1 cm from the posterior inked margin.  The specimen is entirely submitted as follows:  E1-E2 – entire right lateral margin perpendicularly sectioned; E3-E6 – serial sections from right lateral to left lateral; E7 – entire left lateral margin perpendicularly sectioned.

Specimen F:  Received fresh from the Operating Room for intraoperative consultation labeled “right floor of mouth” is a 1.0 x 0.3 x 0.2 cm portion of tan tissue that is inked in black and entirely submitted for frozen section evaluation, then thawed and submitted in cassette F1J1FS.

Specimen G:  Received fresh from the Operating Room for intraoperative consultation labeled “central deep margin” is a 1.5 x 0.7 x 0.2 cm portion of red soft tissue that is inked red and entirely submitted for frozen section evaluation, then thawed and submitted in cassette G1H1I1FS.

Specimen H:  Received fresh from the Operating Room for intraoperative consultation labeled “left deep margin” is a 0.7 x 0.9 x 0.1 cm portion of red soft tissue that is inked black and entirely submitted for frozen section evaluation, then thawed and submitted in cassette G1H1I1FS.

Specimen I:  Received fresh from the Operating Room for intraoperative consultation labeled “anterior deep margin” is a 0.6 x 1.0 x 0.1 cm portion of red soft tissue that is inked blue and entirely submitted for frozen section evaluation, then thawed and submitted in cassette G1H1I1FS.

Specimen J:  Received fresh from the Operating Room for intraoperative consultation labeled “ventral tongue margin” is a0.7 x 0.3 x 0.2 cm portion of tan soft tissue that is inked blue and entirely submitted for frozen section evaluation, then thawed and submitted in cassette F1J1FS.

Specimen K:  Received in formalin labeled “right perifacial lymph node” are two nodules of fibroadipose tissue measuring 1.0 x 0.8 x 0.4 cm and 1.5 x 1.2 x 0.5 cm.  Fat is dissected off to reveal 2 lymph node candidates, 1 measuring 0.8 and the other measuring 1.4 cm.  Both lymph node candidates are bisected and entirely submitted in cassettes K1 and K2.

Frozen Section Diagnosis:

GFJFS)  Squamous mucosa, no high-grade dysplasia or carcinoma identified.

HIFS)  Skeletal muscle with no high-grade dysplasia or carcinoma identified .

Data Item :

Diagnosis Date

Correct Answer :

01/04/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the PTA 01/04/2014 biopsy. The PTA CT on 11/99/2013 does mention increased uptake in the floor of mouth mass but is not stated to be malignant and uptake is not a reportable term.

Data Item :

Primary Site

Correct Answer :

C040

Rationale:

The operative report on 02/25/2014 indicates the primary tumor was resected from the anterior floor of mouth. The tumor was present abutting the anterior mandible and extending to the ventral tongue. The physical exam note on 01/29/2014 states the patient has an anterior and left floor of mouth tumor (overlapping).

The MP/H Rules, Coding Primary Site instructions, state when there is no Tumor Board site assignment or staging form, the surgeon’s statement of the primary site in an operative report has priority when the tumor was completely resected. The clinical findings and pathology report are not used to code the primary site in this case. The surgeon’s assessment in the operative report was an anterior floor of mouth tumor. Apply code C040 (anterior floor of mouth).

Data Item :

Laterality

Correct Answer :

0

Rationale:

Code 0 (not a paired site) when the primary site is not considered a paired site per SEER.

Data Item :

Histology

Correct Answer :

8070

Rationale:

The MP/H Rules (general rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. The patient underwent a PTA biopsy and a composite resection of tongue and floor of mouth with neck dissection. The resection specimen was the most representative specimen, and it showed moderate to poorly differentiated squamous cell carcinoma. Per MP/H Rules, Head and Neck, apply rule H3 and code the histology when only one histologic type is identified. Code histology as 8070 (squamous cell carcinoma).

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology report, this is a malignant tumor. Code the behavior as /3 (malignant) when the primary tumor, or any portion of the primary tumor, is invasive.

Data Item :

Grade

Correct Answer :

3

Rationale:

Code the highest grade given from the primary tumor. Both the biopsy and resection showed moderately to poorly differentiated squamous cell carcinoma.

Use the grade conversion tables in the SEER Manual when there are no special grade systems for solid tumors that apply. Per the terminology conversion table, poorly differentiated is coded as grade code 3.

Data Item :

Clin T

Correct Answer :

X

Rationale:

The PTA CT/PET scan from 11/2013 identified a floor of mouth mass that abutted the mandibular cortex with no destruction, and involved a portion of the “deep musculature” of the floor of mouth. The PTA 01/04/2014 biopsy was positive for squamous cell carcinoma. The 01/29/2014 physical exam noted a mass at the floor of mouth that was not fixed, abutted the lingual cortex of the mandible, and only involved a portion of the floor of mouth musculature. The PTA scan was reviewed and there was no documentation the floor of mouth mass actually involved the deep muscles of the tongue. The physician’s impression was floor of mouth squamous cell carcinoma that appeared to be involving a portion of the ventral tongue and abutting the mandible with no actual destruction of the mandible. There was no definitive evidence of mandibular involvement.

Although clinical work-up was performed (both PTA and at this facility), the tumor was not clinically advanced (does not meet the criteria of T4a or T4b disease) and no clinical tumor size was noted. Tumors of the lip and oral cavity that are not clinically advanced (T4a or T4b disease) are categorized by tumor size alone. The primary tumor cannot be assigned a clinical T category. Apply code X (TX, primary tumor cannot be assessed).

Data Item :

Clin N

Correct Answer :

0

Rationale:

The 01/29/2014 physical exam found no palpable lymphadenopathy. The PTA 11/2013 CT/PET scan showed no evidence of lymphadenopathy in the neck. Apply code 0 (N0, no regional lymph node metastasis).

Data Item :

Clin M

Correct Answer :

0

Rationale:

Per the AJCC Cancer Staging Manual, general instructions, a case with no symptoms or signs of metastasis is classified as clinically M0.

The 01/29/2014 physical exam note and PTA 11/2013 CT/PET scans made no mention of distant metastatic disease. There were no symptoms or findings the physician felt clinically suspicious for metastasis. Apply code 0 (M0, no distant metastasis).

Data Item :

Clin Stg Grp

Correct Answer :

99

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, a clinical Stage Group cannot be assigned when the T or N categories are assigned an X value. One exception: any combination of TX or NX with M1 is classified as Stage IV.

When the TNM is cTX cN0 cM0, apply code 99 (Unknown).

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

1

Rationale:

The 02/25/2014 composite resection pathology report and operative report documented a 2 cm squamous cell carcinoma that extended into the ventral tongue. The greatest tumor extension was ventral tongue involvement. There was no evidence of bone, submandibular gland, or deep (extrinsic) muscle involvement. The final margins were negative and no further extension was identified microscopically or by surgical observation.

Invasion into the ventral tongue alone does not qualify as moderately advanced local disease (T4a disease). Apply code 1 (T1, tumor 2 cm or less in greatest dimension).

Data Item :

Path N

Correct Answer :

0

Rationale:

The 02/25/2014 composite resection included resection of multiple regional lymph nodes (level II – III cervical nodes, peri-facial nodes). The pathology report showed the resected nodes were negative for metastatic carcinoma. Apply code 0 (N0, no regional lymph node metastasis).

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic examination of distant metastasis. Apply code BLANK.

Data Item :

Path Stg Grp

Correct Answer :

1

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, for cases with known pT and pN categories, use the clinical M category to complete the pathologic stage group.

Per the lip and oral cavity staging form, when the pathologic TNM is pT1 pN0 cM0, apply code 1 (Stage I).

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Data Item :

SS 2000

Correct Answer :

2

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has regional stage disease as the primary tumor pathologically extended to the ventral tongue (underside of the anterior 2/3 of the tongue) per the composite resection operative report. Involvement of the anterior 2/3 of the tongue is considered regional by direct extension for an anterior floor of mouth tumor. There were no regional lymph nodes or distant metastases. Apply code 2 (Regional, direct extension only)

Social History

White married male with three children. Here with wife. Born in Idaho. Has managed care private insurance.

Physical Exam

02/22/2014 – HPI: 63 y/o WM who had hemoptysis in February of 2014 which led to a PTA CT Chest on 02/14/2014, which showed multiple bilateral pulmonary nodules as well as liver lesions strongly suggestive of metastatic malignancy. A large right kidney lesion also noted. This led to a PTA liver bx on 02/14/2014 showing clear cell ca, consistent with renal cancer. Started taking dexamethasone after left occipital brain metastasis was found on PTA MRI Brain 02/14/2014. Here to discuss treatment options. PE: non-contributory. IMP: Metastatic clear cell renal cancer. Plan: Referred to radiotherapy group. Not a good candidate for nephrectomy.

Scans

03/04/2014 – MRI Brain: Interval increase in size of left parietal lobe enhancing lesion, c/w mets. Two tiny foci in left frontal lobe, which may represent additional mets. Comparison: 02/14/2014.

06/06/2014 – CT Chest: Numerous pulmonary and hepatic mets which have increased in size. Necrotic mediastinal and hilar lymphadenopathy, some of which also increased in size.

Treatment Plan

02/25/2014 – Plan: Gamma knife stereotactic radiosurgery followed by Pazopanib.

Radiation Text

03/04/2014 – Gamma knife radiosurgery to four metastatic renal cell carcinoma brain metastases.

Chemo Text

04/06/2014 – Started Sunitinib.

02/14/2014 – Path Report #1

Clinical Diagnosis/History:

Slide review.  Large renal mass in right lower pole of kidney (per electronic medical record).

Final Diagnosis:

Outside Hospital(02/14/2014)

Left lobe of liver, CT-guided biopsy:  Positive for carcinoma, see comment.

Diagnosis Comment:

The core needle biopsy has neoplastic groups of cells in nests with clear cytoplasm and prominent nucleoli.  The features can be compatible with metastatic clear cell renal cell carcinoma in the appropriate clinical and radiologic setting.  Immunohistochemistry can be performed upon request if clinically indicated.

Data Item :

Diagnosis Date

Correct Answer :

02/14/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the PTA 02/14/2014 liver biopsy that was positive for metastatic carcinoma.

Data Item :

Primary Site

Correct Answer :

C649

Rationale:

The PTA CT scan on 02/14/2014 showed multiple pulmonary nodules and liver lesions, as well as a large right kidney lesion. The patient underwent a PTA biopsy of a liver mass that was positive for carcinoma, and stated to be compatible with metastatic clear cell renal cell carcinoma. The 02/22/2014 physical exam note states the patient has metastatic clear cell renal cancer. Per the PTA biopsy pathology, the PTA CT scans and the physician’s assessment, the primary tumor was in the right kidney. Apply code C649 (kidney).

Data Item :

Laterality

Correct Answer :

1

Rationale:

The PTA CT scan identified a large right kidney lesion. The patient has metastatic renal cell carcinoma. Although the primary tumor was not biopsied or resected, a right kidney lesion was clinically identified. Code 1 (Right) when the primary site is a paired site and the primary tumor originated on the right.

Data Item :

Histology

Correct Answer :

8310

Rationale:

The MP/H Rules (general rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. In this case the patient had no pathologic examination of the primary tumor. The patient was diagnosed with metastatic clear cell renal cell carcinoma by biopsy of a liver metastasis.

Clinically, the physician states this patient had metastatic clear cell renal cancer. Per the pathologist, the liver biopsy was positive for carcinoma, compatible with metastatic clear cell renal cell carcinoma in the appropriate clinical setting. Based on the liver biopsy pathology and clinical finding, the physician stated this was a kidney primary, clear cell renal cell carcinoma.

Per the MP/H Rules, Kidney, apply rule H2 and code the histology from a metastatic site when there is no pathology or cytology from the primary site. Using the liver biopsy final diagnosis and diagnosis comment, make a second pass through the rules. Stop at rule H5, code the specific histologic type when the diagnosis is carcinoma and a more specific carcinoma. Clear cell renal cell carcinoma is a more specific histologic type. Code the histology as 8310 (Clear cell renal cell carcinoma).

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology report, this is a malignant tumor. The biopsy was taken from a liver metastasis. The presence of metastasis indicates the primary tumor, although not biopsied, is malignant. When the pathology specimen is from a metastatic site, code the behavior as /3 (malignant).

Data Item :

Grade

Correct Answer :

9

Rationale:

The grade is unknown. The patient had no pathologic examination of the primary tumor. The grade cannot be coded when there is no primary site specimen or clinical statement of the primary tumor’s grade specified in the medical record. No grade was given for this patient’s clear cell renal cell carcinoma. Apply code 9 (unknown, not stated).

Data Item :

Clin T

Correct Answer :

X

Rationale:

The PTA 02/14/2014 CT scan showed a large kidney lesion, but the tumor was not clinically described and no clinical tumor size was noted. There was no other description of the primary tumor, so it is unclear whether the tumor was confined to the kidney or invaded beyond it. Even if this tumor was limited to the kidney, the tumor size is required to assign a T category. The primary tumor cannot be assigned a clinical T category. Apply code X (TX, primary tumor cannot be assessed).

Data Item :

Clin N

Correct Answer :

X

Rationale:

The PTA 02/14/2014 CT scan showed lung and liver lesions strongly suggestive of metastases, as well as the large kidney lesion. The presence or absence of regional nodes was not documented on the minimal PTA imaging findings. The patient was found to have extensive metastatic disease, but there is no mention of regional nodes at the time of diagnosis.

Based on the minimal clinical findings available, it is unclear if suspicious nodes were identified on the PTA scan, or whether the lymph node findings were simply not documented. The patient has extensive metastatic disease; therefore, the regional nodes cannot be assumed to be negative or assessed clinically. Apply code X (NX, regional lymph nodes cannot be assessed).

Data Item :

Clin M

Correct Answer :

BLANK

Rationale:

The PTA 02/14/2014 liver biopsy clinically and pathologically confirmed the presence of distant metastasis. The biopsy of a distant site was part of the clinical work-up (was performed during the clinical staging time frame), and is therefore included in the clinical staging. The PTA 02/14/2014 chest CT scan was strongly suggestive of metastases in the lung and liver. The PTA 02/14/2014 brain MRI identified a left occipital brain metastasis. The 02/22/2014 physical exam note indicates the physician’s impression was metastatic clear cell renal cancer.

Although the patient also had imaging evidence of distant metastasis, the PTA liver biopsy is considered pM1 for both the clinical stage and the pathologic stage. A case with pM1 may be grouped as clinical and pathologic when it was proven during the clinical work-up. However, the clinical evidence of metastasis is not recorded in both the clinical and pathologic M categories. The clinical M is only recorded once in the registry fields, either in the cM or in the pM. Since there was pathologic evidence of distant metastasis (pM1) proven during the clinical work-up, the cM is left blank, and the clinical evidence of metastasis is recorded just once in the pM field. Apply code BLANK for cM.

Data Item :

Clin Stg Grp

Correct Answer :

4

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, any combination of T and N, including TX or NX, with M1 is classified as Stage IV.

Per the kidney staging form, when the clinical TNM is cTX cNX pM1, apply code 4 (Stage IV).

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

BLANK

Rationale:

Per Table 1.5, T classification rules, a pathologic T value cannot be assigned in the absence of a surgical resection. Although Table 1.5 also states a biopsy confirming the highest T may be used, it is used only in appropriate circumstances where the pathologic staging criteria for the site has been met.

The treatment plan did not include surgical resection of the primary tumor. The patient was not a good candidate for nephrectomy. The primary tumor was not eligible for pathologic staging. Apply code BLANK.

Data Item :

Path N

Correct Answer :

BLANK

Rationale:

Per Table 1.6, N Classification Rules, a pathologic N value cannot be assigned in the absence of a surgical resection. Although Table 1.6 also states a biopsy confirming the highest N may be used, it is used only in appropriate circumstances where the pathologic staging criteria for the site has been met.

The patient did not undergo a lymph node resection. Surgery was not planned as the patient was not a good candidate for nephrectomy. There was no removal of regional lymph nodes; therefore, the lymph nodes were not eligible for pathologic staging. Apply code BLANK.

Data Item :

Path M

Correct Answer :

1

Rationale:

The patient has pathologic evidence of distant metastasis. The patient underwent a liver biopsy as part of the clinical work-up that was positive for metastatic clear cell renal cell carcinoma. In this case, the biopsy positive liver metastasis qualifies as both clinical and pathologic staging. Apply code 1 (M1, distant metastasis).

Data Item :

Path Stg Grp

Correct Answer :

4

Rationale:

Per the kidney staging form, when the pathologic TNM is pT(Any) pN(Any) pM1, apply code 4 (Stage IV).

Although the T and N categories could not be assigned, not eligible for pathologic staging, any pathologic evidence of M1 disease allows the Stage Group to be determined.

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Data Item :

SS 2000

Correct Answer :

7

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has distant stage disease as the patient was diagnosed with lung, liver, and brain metastases. The primary tumor and regional lymph nodes could not be clinically assessed, and no surgical resection for pathologic assessment was performed. The presence of lung, liver, and brain metastases alone is always coded as distant stage disease for a kidney primary, regardless of the tumor involvement or whether regional lymph nodes were involved. Apply code 7 (Distant site(s)/lymph node(s) involved).

Social History

Married white woman with a 32 year old daughter who is here with her today. Born in Alaska. Primary payer is medicaid administered through a managed care plan.

Physical Exam

03/25/2014 – cc: 50 y/o WF w/ left renal mass. HPI: History of intermittent kidney infections leading to imaging which demonstrated a large, 16 cm left renal mass, with some perihilar lymphadenopathy which may be reactive in nature. PTA CT Chest on 03/18/2014 demonstrated lung nodules susp for metastasis. PE: Abdomen: Palpable mass in the left upper quadrant. IMP: Likely renal cell carcinoma with likely spread to the chest. Pulmonary nodules susp for metastatic disease. Plan: Left radical nephrectomy.

04/08/2014 – HPI: Pt two weeks post extensive left radical nephrectomy for PT3 N0 clear cell renal cell carcinoma with known pulmonary metastasis. Plan: High-dose IL-2 therapy. Tyrosine kinase inhibitor (TKI) therapy also being considered.

05/21/2014 – HPI: After nephrectomy, pt noted progressive neurological symptoms, including paresthesias and numbness of LLE. Imaging: PTA MRI Brain on 04/22/2014 revealed two masses in the occipital region. Pt underwent PTA gross resection of Rt brain tumor on 05/01/2014, c/w mets RCC. IMP: New diagnosis of brain metastasis. Plan: Referred for gamma knife radiosurgery and possible IL-2.

Operative Reports

03/28/2014 – Left open radical nephrectomy with retroperitoneal lymph node dissection: Huge mass in left retroperitoneum, pushing the descending colon medially. Palpable lymphadenopathy.

Radiation Text

05/23/2014 – Stereotactic radiosurgery to right parieto-occipital resection and a left parieto-occipital lobe lesion.

Immuno Text

09/05/2014 – Started Interleukin-2 therapy.

Stage

04/08/2014 – Per MD note: p T3 N0 with known pulmonary mets.

03/28/2014 – Path Report #1

Clinical Diagnosis/History:

Left renal mass.

Final Diagnosis:

  1. A) Left kidney, nephrectomy: Renal cell carcinoma, see summary data below:
  2. B) Lymph nodes, para-aortic, excision: 9 lymph nodes negative for carcinoma.
  3. C) Lymph nodes, pre-aortic, excision: 12 lymph nodes negative for carcinoma.
  4. D) Lymph nodes, left renal hilum, excision: 2 lymph nodes negative for carcinoma.
  5. E) Lymph nodes, left supra hilum, excision: 1 lymph node negative for carcinoma.

Gross Description:

Specimen A:  Received fresh labeled “left kidney” is a 1,496 g, 22 x 17 x 8.5 cm kidney.  There is a moderate amount of attached fat.  Gerota’s fascia is tan, smooth and glistening.  No adrenal gland is identified.  The ureter is identified and measures 3 cm in length.  The stapled ureter margin is removed.  The renal artery and vein are identified and they are not grossly involved by tumor.  They are all opened longitudinally and no lesions are identified.  The kidney is bisected through the renal pelvis, and at the superior pole there is an extremely large lesion that measures 17.5 x 12.5 x 10.5 cm.  It appears encapsulated.  However, there are areas where it appears to be invading into the renal fat.  In the inferior portion of the specimen, there is an extremely dilated atrophic kidney.  Only an approximately 1 cm thin rim of kidney parenchyma is present.  The remainder of the kidney is composed of dilated renal calyces.  The kidney parenchyma appears tan-pink and rubbery.  No additional masses are identified.  The tumor and kidney are serially cross-sectioned to reveal a multilobulated heterogeneous tumor.  The tumor has areas of yellow-orange to hemorrhagic to tan-brown and necrotic.  The tumor abuts the superior surgical margin; however, it is encapsulated.  The tumor does not appears to invade the renal hilum.  However, it does extend to the renal hilar adipose tissue.  No hilar lymph nodes are identified.

Cassette index:  The ureter and vascular margins are submitted in cassette A1 with the ureter inked blue; A2 – tumor to renal calyx; A3 – tumor to margin; A4 – tumor to margin; A5, A6 – portions of tumor; A7 – tumor to kidney; A8 – kidney parenchyma.

Specimen B:  Received in a container of formalin labeled “para-aortic lymph nodes” is a 4.0 x 2.0 x 1.5 cm yellow lobulated portion of fibrofatty tissue.  A few lymph node candidates are identified on cut surfaces ranging in size from 0.2 cm to 1.6 cm.  Representative sections are submitted labeled:  B1 – one bisected lymph node; B2 – three individual lymph node candidates; B3 – four individual lymph node candidates.

Specimen C:  Received in a container of formalin labeled “preaortic lymph nodes” is a 5.5 x 3.5 x 1.5 cm yellow, lobulated, congested portion of adipose tissue.  Numerous lymph nodes are identified on cut surfaces ranging from 0.2 cm to 2 cm.  Representative sections are submitted labeled:  C1 – one bisected lymph node; C2 – one bisected lymph node; C3 – one bisected lymph node; C4 – two bisected lymph nodes, one marked blue; C5 – four individual lymph node candidates; C6 – two individual lymph node candidates.

Specimen D:  Received in a container of formalin labeled “left renal hilum” is a 2.2 x 1.4 x 0.6 cm portion of fibrofatty tissue.  There are possible lymph node candidates.  The specimen is serially-sectioned and two lymph node candidates are identified.  They are bisected.  D1 – one lymph node, bisected, D2 – one lymph node, bisected.

Specimen E:  Received in formalin labeled “left suprahilum” is a 0.2 x 1.5 x 0.8 cm portion of tissue.  It is serially-sectioned and entirely submitted.

Summary Cancer Data:

Specimen and Tumor Location

Specimen type: Radical nephrectomy

Laterality: Left

Tumor focality: Unifocal

Therapy prior to surgery:  Unknown/History not provided

Characteristics and Extent of Neoplasm

Histologic type: Clear cell (conventional) renal carcinoma (83103)

Percent of sarcomatoid component: 0%

Tumor size: Greatest diameter: 17.5cm

Histologic grade: G2 (Fuhrman)

Adrenal gland: Not present

Extent of tumor: Tumor extends into perinephric tissues (pT3)

Final Surgical Resection Margins

Surgical margins: All margins negative for carcinoma

Lymph Node Status

Node summary: Nodes with carcinoma: 0    / Total nodes examined: 24

Minimum Pathologic Stage (AJCC, 7th ed., 2010)

Primary tumor (pT): pT3

Regional lymph nodes (pN): pN0: No regional lymph node metastasis

General Comments:  There is focal extracapsular extension in slide A3

Data Item :

Diagnosis Date

Correct Answer :

03/18/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the PTA 03/18/2014 CT scan that demonstrated lung nodules suspicious for metastases.

Ambiguous terminology may be used to accession a case when the ambiguous terminology is considered reportable. “Suspicious” is a reportable ambiguous term. The clinical diagnosis of malignancy was subsequently confirmed by pathology.

Data Item :

Primary Site

Correct Answer :

C649

Rationale:

The PTA imaging showed a left renal mass. The 03/25/2014 physical exam note states the impression is likely renal cell carcinoma. The patient underwent a left radical nephrectomy positive for renal cell carcinoma. Per the radical nephrectomy, the PTA scans and the physician’s assessment, the primary tumor was in the left kidney. Apply code C649 (kidney).

Data Item :

Laterality

Correct Answer :

2

Rationale:

The patient had a radical nephrectomy identifying a left kidney renal cell carcinoma. Code 2 (Left) when the primary site is a paired site and the primary tumor originated on the left.

Data Item :

Histology

Correct Answer :

8310

Rationale:

The MP/H Rules (general rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. The radical nephrectomy was the only and most representative specimen and it showed renal cell carcinoma, clear cell type. The final diagnosis was renal cell carcinoma, NOS, but the summary cancer data identified a more specific histologic type, clear cell renal cell carcinoma. The summary cancer data can be used to code the histology when it identifies a more specific histologic type.

Per the MP/H Rules, Kidney, apply rule H5, code the specific histologic type when the diagnosis is renal cell carcinoma and one specific renal cell type. Clear cell renal cell carcinoma is a specific type of renal cell carcinoma. Apply code 8310 (clear cell renal cell carcinoma).

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology report, this is a malignant tumor. Code the behavior as /3 (malignant) when the primary tumor, or any portion of the primary tumor, is invasive.

Data Item :

Grade

Correct Answer :

2

Rationale:

Code the highest grade given from the primary tumor. The nephrectomy pathology report stated the renal cell carcinoma was Fuhrman grade 2. There are special grade system rules for the kidney (Fuhrman Nuclear Grade). Use the special grade system, Kidney Parenchyma, grade conversion table to determine the correct grade code. Apply code 2 (Fuhrman grade 2, CS SSF6 code 020).

Data Item :

Clin T

Correct Answer :

2B

Rationale:

The 03/25/2014 physical exam note indicates the PTA imaging identified a large 16 cm left renal mass. There was no further description of the renal mass, including no mention of extra-renal extension. The physical exam noted a palpable mass in the left upper quadrant, but made no mention of tumor fixation to adjacent structures. There is no documentation of tumor invasion beyond the kidney based on the minimal PTA imaging and physical exam findings.

This tumor appears clinically limited to the kidney, and the tumor size was stated to be greater than 10 cm, which allows a minimal stage to be assigned. Apply code 2B (T2b, tumor more than 10 cm, limited to the kidney).

Data Item :

Clin N

Correct Answer :

0

Rationale:

The 03/25/2014 physical exam note indicates the PTA imaging showed the left renal mass and perihilar lymphadenopathy which may be reactive in nature. Reactive lymph nodes are not equivalent to involved nodes. There was no definitive statement that the perihilar lymph nodes were involved or suspicious. Apply code 0 (N0, no regional lymph node metastasis).

Data Item :

Clin M

Correct Answer :

1

Rationale:

The PTA 03/18/2014 chest CT scan demonstrated multiple lung nodules that were suspicious for metastases. The physician confirmed the presence of pulmonary metastasis at diagnosis on the 04/08/2014 Stage note. The PTA 04/22/2014 brain MRI also identified metastases in the brain; however, this represents disease progression since the MRI was performed after surgery, and there was no evidence of brain metastases at diagnosis. Apply code 1 (M1, distant metastasis).

Data Item :

Clin Stg Grp

Correct Answer :

4

Rationale:

Per the kidney staging form, when the clinical TNM is cT2b cN0 cM1, apply code 4 (Stage IV).

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

3A

Rationale:

The 03/28/2014 left radical nephrectomy pathology report and operative report showed a 17.5 cm clear cell renal cell carcinoma of the kidney extending into the perinephric tissues pathologically. The operative report noted a huge mass in the left retroperitoneum that pushed the descending colon medially, but there was no involvement of the colon per the pathology or surgical findings. The tumor extended into the perinephric tissue, which was further specified to be the renal hilar adipose tissue per the gross description. The margins were negative.

Although the physician pathologically staged this as T3, this is not entirely consistent with the resection findings and is not used to assign the T category. The T3 category will be further subcategorized as T3a because the tumor grossly extends into the renal sinus fat. Apply code 3A (T3a, tumor invades perirenal and/or renal sinus fat but not beyond Gerota’s fascia).

Data Item :

Path N

Correct Answer :

0

Rationale:

The 03/28/2014 radical nephrectomy and retroperitoneal lymph node dissection included resection of multiple regional lymph nodes (para-aortic, pre-aortic, renal hilar nodes). The pathology report showed the resected nodes were negative for metastatic carcinoma. Apply code 0 (N0, no regional lymph node metastasis).

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic examination of distant metastasis. Apply code BLANK.

Data Item :

Path Stg Grp

Correct Answer :

4

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, for cases with known pT and pN categories, use the clinical M category to complete the pathologic stage group.

Per the kidney staging form, when the pathologic TNM is pT3a pN0 cM1, apply code 4 (Stage IV).

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Data Item :

SS 2000

Correct Answer :

7

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has distant stage disease as the patient was clinically diagnosed with lung metastases at diagnosis. The primary tumor was regional by direct extension as the resection pathologically identified tumor extension into the perirenal tissues (renal sinus fat). There was no clinical or pathologic evidence of regional lymph node involvement. The presence of lung metastases alone is always coded as distant stage disease for a kidney primary, regardless of the tumor involvement or whether regional lymph nodes were involved. Apply code 7 (Distant site(s)/lymph node(s) involved).

Social History

65 y/o Black/White female w/ 45 years history of smoking. She was born in Arizona. Primary payer at dx is Medicaid administered through a managed care plan.

Physical Exam

02/04/2014 – HPI: Pt w/ bilateral supraclavicular LAD. Pt has been having flu-like symptoms for the past 4-6 weeks. 2 weeks ago, noticed Lt neck mass, which has grown larger since then. PE: Lymphatics: Firm nodularity in Lt neck, supraclavicular region, ~ 3 cm in size. Multiple less than 1 cm nodules in Rt supraclavicular fossa as well. Procedure: Flex laryngoscopy performed and showed partial vocal cord paralysis, but was otherwise WNL. FNA of left neck performed. IMP: Bilat supraclavicular adenopathy. Her exam is quite concerning for a malignant process.

02/13/2014 – Tumor Board note: Imaging reviewed w/ evidence of matted LNs throughout paratracheal region and mediastinum. SCV enlarged LNs, left greater than right. No evidence of any primary lung masses or tumors. Assessment: Extensive LAD w/ unidentifiable primary lung carcinoma. Plan: PET scan to evaluate for mets.

Scans

02/04/2014 – CT Neck/Soft Tissue: Conglomerate LAD within supraclavicular regions bilaterally and mediastinum encasing the trachea and brachiocephalic artery, possibly encasing the lt common carotid artery and superior vena cava. Two small right apical lung nodules measuring 0.6 x 0.4 cm.

02/13/2014 – CT Chest/Abd/Pelvis: Supraclavicular, mediastinal, and lt axillary LAD. Small, indeterminate bilateral lung nodules and 3 tiny calcified granulomas. Small pericardial effusion. No evidence of intra-abdominal tumor or mets disease.

02/20/2014 – PET/CT Body: Diffuse LAD within the mediastinum, lt axilla, and lower cervical regions, c/w malignancy, most likely lymphoma. Multiple foci within the bones c/w mets.

07/01/2014 – CT Chest/Abd/Pelvis: Two stable small right apical lung nodules as noted on 02/04/2014 CT, unchanged. Stable appearance of multiple small indeterminate bilateral pulmonary nodules, unchanged from prior scans. Stable appearance of indeterminate hypodense hepatic lesions. Stable appearance of multiple sclerotic osseous lesions susp for mets disease. No new osseous lesions. No definite LAD in the abdomen, or pelvis. SCV region w/ no significant LAD compared to prior scans. Mediastinum w/ sub-cm LNs, not enlarged by CT size criteria.

Operative Reports

02/04/2014 – Lt supraclavicular neck mass aspirate (procedure only)

02/22/2014 – Lt level V neck nodes excisional bx: Preoperative DX: Pt w/ bilateral level V LAD, previous FNA of SCV LN was positive for carcinoma, excisional bx to obtain additional tissue. Findings: Matted LNs from the deep supraclavicular area identified, multiple nodes dissected out.

Radiation Text

04/03/2014 – Radiation to lt 8th rib, lt axilla. 2,000 cGy. Dates given: 04/03/2014 to 04/09/2014

Chemo Text

03/07/2014 – Started Cisplatin and Pemetrexed.

Hormonal Text

02/08/2014 – Started Prednisone.

Stage

03/07/2014 – Metastatic adenocarcinoma of lung primary, involving lymph nodes of neck and chest and diffuse bone involvement.

02/04/2014 – Path Report #1

Clinical Diagnosis/History:

Bilateral supraclavicular lymphadenopathy.

Cytologic Impression:

Left supraclavicular neck mass, FNA:  Positive for malignancy.  See comment.

Diagnosis Comment:

Four alcohol fixed direct smears are received and subsequently stained with Papanicolaou stain.  Slides contain numerous variably sized cohesive groups of highly atypical epithelial cells in a background of lymphoid elements and extensive necro-inflammatory material.  Atypical cells have enlarged hyperchromatic nuclei with anisonucleosis and sometimes prominent nucleoli as well as irregular nuclear membranes and scant to ample dense cytoplasm.  The findings are positive for malignancy, consistent with poorly differentiated non-small carcinoma.  Additional immunohistochemical studies are pending on a scrape cell block preparation and results will be issued in an addendum report.

IHC Interpretation:

Immunostains are positive for cytokeratin 7 and rare cells stain with high molecular weight cytokeratin.  The tumor cells are negative for P63, cytokeratin 5 and cytokeratin 20.  TTF-1 is not interpretable due to the extremely scant number of cells remaining.  Findings are consistent with non-small cell carcinoma/poorly differentiated carcinoma, but do not point to a specific primary site on this very limited panel.  Insufficient material remains in the cell block for further testing.

02/22/2014 – Path Report #2

Clinical Diagnosis/History:

Neck cancer.

Immunohistochemistry Studies:

Specimen B1:  Population: Tumor cells

Napsin Napsin                                                                 Positive, variably

P 63 P 63, (BC4A4)                                                         Positive, variably

AE1/AE3 Pan-Cytokeratin Cocktail [AE1/AE3]             Positive, uniformly

BerEP4 Epithelial Antigen [Ber-EP4]                              Positive, variably

S100 S-100 [DR96+BC96]                                               Negative

TTF-1 Thyroid Transcription Factor 1 [8G7G3/1], TTF  Positive, uniformly

Final Diagnosis:

  1. A) Lymph node, left neck, excision: Poorly differentiated adenocarcinoma, consistent with lung primary.
  1. B) Lymph nodes, level 5, excision: Poorly differentiated adenocarcinoma, consistent with lung primary (see immunophenotype below).

Gross Description:

  1. A) Received fresh for frozen section analysis labeled “left neck node” is a 1.3 x 0.8 x 0.6 cm tan-white firm fleshy lymph node. One-half of the tissue is used for frozen section analysis.  A touch prep is made.  The frozen section residue is submitted in cassette AFS1 and the residual tissue is submitted in cassette A2.
  1. B) Received in formalin labeled “additional level V lymph node” is a 1.5 x 1.1 x 0.8 cm firm gray-white nodular portion of tissue which is trisected and entirely submitted in cassette B1.

IHC Interpretation:

Positive immunohistochemistry for TTF-1 and Napsin suggests adenocarcinoma of lung primary; negative immunohistochemistry for S-100 argues against metastatic melanoma.

Frozen Section Diagnosis:

AFS)  Positive for high-grade carcinoma.

Addendum Reason:

This addendum is issued to report the results of ALK FISH testing.

Fluorescence In-Situ Hybridization Analysis:

Deparaffinized sections from the indicated specimen and control tissues are hybridized with the ALK Break Apart Rearrangement Probe kit (Dako, Denmark), following the manufacturers directions.  The kit includes two FISH DNA probes.  Fifty interphase signals are scored. FISH-positive occurrences are defined as greater than 10% of tumor cells with split signals.

Specimen B1:  Population: Neoplastic cells

Sample                 % Split-Apart Signals Special Notes/Comments

ALK Sample         0

Negative Control   0

Positive Control   60

Chromosomal rearrangements involving the ALK gene are characteristic of anaplastic large cell lymphoma and have also been reported in other tumors, including a minority of adenocarcinomas arising in lung, breast and colon (1,2).  Disruption of the ALK gene, as detected by this assay, is consistent with a chromosomal translocation or rearrangement involving ALK at 2p23, but does not identify the specific partner gene.

  1. Amin HM; Lai R. Blood. 2007 Oct 1;110(7):2259-67. Epub 2007 May 22.
  2. Lin E, Li L, Guan Y, Soriano R, Rivers CS, Mohan S, Pandita A, Tang J, Modrusan Z. Mol Cancer Res. 2009 Sep;7(9):1466-76.

Addendum Reason:

This addendum is to report results of EGFR mutational analysis.

EGFRL1 Results:  Negative for L858R mutation and exon 19 deletions

Specimen B1:

EGFRL1 Interpretation:  The sample tested is negative for the L858R mutation in exon 21 and for deletion mutations in exon 19 of the EGFR gene, which together account for about 90% of the somatic mutations in the EGFR gene in patients with lung cancer.  If clinically indicated, DNA sequence analysis can be performed separately to detect other rare mutations in the EGFR gene.  This test can normally detect a heterozygous mutation when it is present in more than about 10% (for L858R) or 2% (for deletions) of the cells in the sample.

FISH Interpretation:

There is no evidence of translocation or rearrangement of the ALK gene.  The above diagnosis is otherwise unchanged.

Data Item :

Diagnosis Date

Correct Answer :

02/04/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the 02/04/2014 left supraclavicular mass FNA that was positive for malignancy. A cytology specimen that is positive for malignancy is not a suspicious cytology.

Data Item :

Primary Site

Correct Answer :

C349

Rationale:

The supraclavicular lymph node biopsy on 02/04/2014 was positive for malignancy and consistent with a non-small cell carcinoma. The subsequent left neck lymph node excisions on 02/22/2014 were positive for adenocarcinoma, consistent with a lung primary by IHC studies. The scans failed to demonstrate a primary lung tumor. The CT scans on 02/04/2014 and 02/13/2014 showed indeterminate pulmonary nodules only. The PET scan on 02/20/2014 showed no lung tumor. The patient underwent treatment and the follow-up CT scan on 07/01/2014 showed stable lung nodules that were unchanged from the prior scans.

The Tumor Board note on 02/13/2014 indicates the patient has extensive lymph node metastases with an unidentifiable primary lung carcinoma. Given the physician’s assessment that the primary tumor is unidentifiable, and the lack of response to treatment by the stable, indeterminate pulmonary nodules, these nodules are clearly not considered malignant tumor nodules.

Based on the CT and PET scan findings, the biopsy pathology findings and the physician’s assessment, this patient has a lung primary, NOS. A more specific subsite cannot be determined after a thorough work-up. Apply code C349 (lung, NOS).

Data Item :

Laterality

Correct Answer :

9

Rationale:

The laterality of this patient’s lung primary cannot be determined after a thorough work-up. The patient’s primary lung tumor was unidentifiable. The indeterminate, bilateral pulmonary nodules were not considered malignant. Code 9 (paired site, but no information concerning laterality) when the primary site is a paired site per SEER, but the laterality is unknown.

Data Item :

Histology

Correct Answer :

8140

Rationale:

The MP/H Rules (general rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. In this case, the patient had no pathologic examination of the primary tumor, as the primary tumor was not identified. The patient was diagnosed with metastatic adenocarcinoma by excisional biopsy of the left neck lymph node metastases.

The MP/H Rules (general rules) state that a pathology report has priority over a cytology report. The lymph node FNA from 02/04/2014 is not used to code the histology. The 02/22/2014 left neck excisional biopsies showed poorly differentiated adenocarcinoma, consistent with lung primary.

Per the MP/H Rules, Lung, apply rule H2 and code the histology from a metastatic site when there is no pathology or cytology from the primary site. Using the lymph node excisional biopsy final diagnosis, make a second pass through the rules. Stop at rule H3, code the histology when only one histologic type is identified. Code the histology as 8140 (Adenocarcinoma, NOS).

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology report, this is a malignant tumor. The excisional biopsies were taken from lymph node metastases. The presence of metastases indicate the primary tumor, although not biopsied, is malignant. When the pathology specimen is from a metastatic site, code the behavior as /3 (malignant).

Data Item :

Grade

Correct Answer :

9

Rationale:

The grade is unknown. The patient had no pathologic examination of the primary tumor. The primary tumor was not identified. The grade cannot be coded when there is no primary site specimen or clinical statement of the primary tumor’s grade specified in the medical record. Although the lymph node biopsy showed poorly differentiated adenocarcinoma, the grade is never coded from a metastatic specimen. Apply code 9 (unknown, not stated).

Data Item :

Clin T

Correct Answer :

0

Rationale:

The patient was diagnosed with a primary lung adenocarcinoma by biopsy of lymph node metastases only. The patient underwent a thorough work-up and the CT and PET scans failed to demonstrate the primary lung tumor.

The 02/13/2014 tumor board note indicates the patient has extensive lymphadenopathy with an unidentifiable primary lung carcinoma. The post-treatment 07/01/2014 CT scan showed no change in the previously noted pulmonary nodules, confirming these stable pulmonary nodules were not considered malignant.

When adequate work-up is performed, but fails to identify the primary lung tumor, the appropriate T category is T0. T0 is not the same as TX (primary tumor cannot be assessed). TX is used when the patient was diagnosed with malignancy, but adequate staging to classify the primary tumor was not performed. In this particular case, the patient was diagnosed by a lymph node biopsy in combination with extensive work-up that failed to demonstrate a primary tumor. Apply code 0 (T0, no evidence of primary tumor).

Data Item :

Clin N

Correct Answer :

3

Rationale:

The 02/04/2014 and 02/13/2014 CT scans showed bilateral supraclavicular and mediastinal lymphadenopathy. The 02/20/2014 PET scan identified diffuse lymphadenopathy in the mediastinum and bilateral lower cervical regions (supraclavicular nodes) that was consistent with metastasis. The 02/04/2014 supraclavicular node aspirate was positive for malignancy. Based on imaging and biopsy, the patient has N3 disease. Apply code 3 (N3, metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph node(s)).

Data Item :

Clin M

Correct Answer :

1B

Rationale:

The 02/20/2014 PET scan showed extensive metastatic disease involving distant lymph nodes (left axillary nodes) and multiple metastatic foci within the bones. Involvement of bone and distant lymph nodes is considered M1b (extrathoracic) disease. Apply code 1B (M1b, distant metastasis in extrathoracic organs).

Data Item :

Clin Stg Grp

Correct Answer :

4

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, any combination of T and N, including TX or NX with M1 is classified as Stage IV.

Per the lung staging form, when the TNM is cT0 cN3 cM1b, apply code 4 (Stage IV).

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

BLANK

Rationale:

Per Table 1.5, T classification rules, a pathologic T value cannot be assigned in the absence of a surgical resection. Although Table 1.5 also states a biopsy confirming the highest T may be used, it is used only in appropriate circumstances where the pathologic staging criteria for the site has been met.

The primary lung tumor was never identified; therefore, no resection could be performed. The primary tumor was not eligible for pathologic staging. Apply code BLANK.

Note: Click here to open “TNM_Document.pdf” which describes general rules for developing preferred answers in SEER*Educate.

Data Item :

Path N

Correct Answer :

BLANK

Rationale:

Per Table 1.6, N Classification Rules, a pathologic N value cannot be assigned in the absence of a surgical resection. Although Table 1.6 also states a biopsy confirming the highest N may be used, it is used only in appropriate circumstances where the pathologic staging criteria for the site has been met.

The patient did not undergo a resection of this lung primary. There was only a diagnostic biopsy (clinical staging) proving the highest N category, N3. Although the biopsy proved the highest N category, pathologic staging criteria (surgical resection of the primary tumor) was not met. The treatment plan was for radiation and chemotherapy. The regional lymph nodes were not eligible for pathologic staging. Apply code BLANK.

Note: Click here to open “TNM_Document.pdf” which describes general rules for developing preferred answers in SEER*Educate.

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic assessment of distant metastasis. Apply code BLANK.

Data Item :

Path Stg Grp

Correct Answer :

BLANK

Rationale:

There was no surgical resection of the primary tumor and/or regional lymph nodes. The treatment plan was for radiation and chemotherapy. Apply code BLANK.

Note: Click here to open “TNM_Document.pdf” which describes general rules for developing preferred answers in SEER*Educate.

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Note: Click here to open “TNM_Document.pdf” which describes general rules for developing preferred answers in SEER*Educate.

Data Item :

SS 2000

Correct Answer :

7

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has distant stage disease as the patient was clinically diagnosed with bone and distant (axillary) lymph node metastases. A primary tumor was never identified after thorough work-up. The patient had pathologic confirmation of supraclavicular lymph node involvement. The presence of bone and distant axillary lymph node metastases is always coded as distant stage disease, regardless of whether the primary tumor was identified or whether regional lymph nodes were involved. Apply code 7 (Distant site(s) involved).

Social History

Black female, born in Illinois. Pt is currently single, divorced for over a decade. Payer: HMO Medicaid plan.

Physical Exam

05/03/2014 – cc: Pt is seen for cough symptoms that began in 01/2014. She also complains of drenching night sweats and weight loss. PTA Chest CT 02/21/2014 demonstrated a RUL mass, mediastinal LAD and bilateral pleural effusions. Supraclavicular LAD was noted as well. 04/02/2014 CT Chest performed here demonstrated mediastinal and bilateral hilar LAD. Various bxs performed in past few months have been negative. PE: No mention LNs. IMP: There is concern for malignancy.

Scans

04/02/2014 – CT Chest: Large RUL mass c/w pulmonary neoplasm. Extensive mediastinal, epicardial, bilateral hilar LAD. Stable pleural effusions, new rt supraclavicular adenopathy, new pericardial effusion.

05/03/2014 – CT Chest/Abd/Pelvis: RUL lung mass which invades through the mediastinal pleura into the mediastinum and effaces the fat plane w/ the aorta, main and lt pulmonary artery, the superior lt pericardium and all the aortic branches. No lt pulmonary nodules identified. IMP: Findings c/w either stage IV primary lung carcinoma or lymphoma. Pleural effusion, indeterminate hepatic and pancreatic lesions w/o definitive visceral disease, and innumerable metastatic supraclavicular and mediastinal LNs w/ suspicious prominent retroperitoneal LNs.

05/03/2014 – CT Head: Negative.

05/10/2014 – CT Neck: Extensive adenopathy of the neck, w/ abnormal enlarged nodes at all levels.

05/29/2014 – PET: Intense FDG uptake in the soft tissue mass in the anterior RUL. Numerous foci of increased FDG uptake corresponding to LNs of the neck, mediastinal, internal mammary, cardiophrenic. Findings are c/w lymphoma (more likely) vs. lung cancer. Diffusely increased FDG uptake in the BM and spleen c/w lymphoma as primary disease.

06/19/2014 – CT Neck: There is extensive adenopathy in the neck, including conglomerate adenopathy at the level of the aortic arch. Adenopathy also is present paratracheally. Persistent extensive adenopathy of the neck w/ interval increase in the size of the LNs.

06/19/2014 – CXR: There is prominent hilar and mediastinal adenopathy.

Labs

05/03/2014 – HIV: Negative.

Operative Reports

05/21/2014 – BM aspirate and bx (procedure only)

06/12/2014 – RUL mass CT-guided bx (procedure only)

Chemo Text

06/20/2014 – Started ABVD.

Stage

06/27/2014 – IMP: Stage IV Hodgkin’s Lymphoma, restage after 4 cycles ABVD.

05/21/2014 – Path Report #1

Clinical Diagnosis/History:

Lymphadenopathy, concern for lymphoma.

Final Diagnosis:

Bilateral Bone Marrow Biopsies, Aspirate Smears, And Peripheral Blood:

Hypercellular marrow with normal trilineage hematopoiesis and slight myeloid predominance. No evidence for involvement by lymphoma.

Peripheral blood counts from electronic medical record (05/21/2014):

WBC                   *  16.84    [4.30-10.00]  THOU/uL

RBC                    *  4.21     [4.40-5.60]   mil/uL

Hemoglobin        *  9.6      [13.0-18.0]   g/dL

Hematocrit           *  31       [38-50]       %

MCV                    *  73       [81-98]       fL

MCH                  *  22.8     [27.3-33.6]   pg

MCHC               *  31.3     [32.2-36.5]   g/dL

Platelet Count    *  555      [150-400]     THOU/uL

RDW-CV          *  19.1     [11.6-14.4]   %

% Neutrophils     *  87       [34-71]       %

% Lymphocytes   *  6        [19-53]       %

% Monocytes           7        [5-13]        %

% Eosinophils          0        [0-7]         %

% Basophils             0        [0-1]         %

% Immature Granulocytes      0        [0-1]         %

Neutrophils       *  14.56    [1.80-7.00]   THOU/uL

Lymphocytes         1.03     [1.00-4.80]   THOU/uL

Monocytes         *  1.11     [0.00-0.80]   THOU/uL

Eosinophils            0.05     [0.00-0.50]   THOU/uL

Basophils              0.03     [0.00-0.20]   THOU/uL

Immature Granulocytes

                            *  0.06     [0.00-0.05]   THOU/uL

Comment:

Peripheral blood reveals neutrophilia, thrombocytosis, and hypochromic anemia.  On marrow aspirate, there is a relative myeloid predominance with granulocytosis.  The bone marrow biopsy reveals a hypercellular marrow with normal trilineage hematopoiesis.  Flow cytometry documents absence of neoplastic lymphoid or myeloid population in marrow.  Taken together, these findings suggest no involvement in the marrow by a malignant lymphoid process.  Clinical correlation is recommended.

Gross Description:

Specimen A:  Received in a container labeled “right iliac crest” is a tan-red core of cancellous bone measuring 2.3 cm in length and 0.2 cm in diameter.  The specimen is wrapped and entirely submitted in cassette A1 following decalcification.

Specimen B:  Received in a container labeled “left iliac crest” is a tan-red core of cancellous bone measuring 2.3 cm in length and 0.2 cm in diameter.  The specimen is wrapped and entirely submitted in cassette B1 following decalcification.

Specimen C:  Received are 2 Wright-Giemsa stained peripheral blood smears.

Specimen D:  Received are 2 Wright-Giemsa stained bone marrow aspirate smears.

Microscopic Description:

Peripheral Blood Differential:

Neutrophils:          88%

Lymphocytes:         2%

Monocytes:           10%

Eosinophils:      <1%

Basophils:         <1%

Total cells counted: 100

Peripheral Blood Morphology:

Marked neutrophilia, with occasional (<2%) hypersegmented neutrophils

RBC:      Hypochromia, with anisocytosis and poikilocytosis

Platelets:     Marked thrombocytosis, normal morphology

Bone Marrow Aspirate Smears:

Right posterior iliac crest

Quality:       Adequate particles, good quality

Blasts:   Not increased

Myeloids:      Proportionately increased, complete maturation, no dysplastic features

Erythroids:    Proportionately decreased, normal maturation, no dysplastic features

Megakaryocytes:     Normal numbers, no dysplastic features

Lymphocytes:   Not increased, no aggregates identified

Plasma cells:       Not increased

Bone Marrow Differential:

Aspirate smears

Myeloids:               72%

Erythroids:             25%

Blasts:                <1%

Lymphocytes:          2%

Plasma cells:            1%

M:E Ratio:         2.9 to 1

Total cells counted:  200

Bone Marrow Biopsies:

Right and Left posterior iliac crest

Biopsy length:      2.3 cm

Quality:       Adequate

Cellularity:   80%

Myeloids:      Proportionately increased

Erythroids:    Proportionately decreased

Megakaryocytes:     Normal numbers, no dysplastic features

Infiltrate:    Scattered lymphocytes and plasma cells seen, no lymphoid aggregates identified

Hemosiderin:   Absent

Flow Cytometry:

No immunophenotypic evidence of a myeloid stem cell disorder (e.g. myelodysplastic syndrome or myeloproliferative neoplasm) or non-Hodgkin lymphoma was identified. However, a low-grade stem cell disorder could not be entirely excluded and clinical, cytogenetic, and morphologic correlation is required.

06/12/2014 – Path Report #2

Clinical Diagnosis/History:

History of productive cough and chronic intermittent night sweats, presents with mediastinal adenopathy, right upper lobe lung lesion, and large bilateral pleural effusions.

Cytologic Impression:

A-B)  Anterior mediastinum and right upper lobe lung mass, needle core biopsies: Classical Hodgkin lymphoma.  See comment.

Comment:

Pathology is called to Radiology to assist in the CT-guided needle core biopsies of an anterior mediastinal and right upper lobe lung masses.

  1. A) Anterior mediastinal mass, needle core biopsies:

Evaluation episodes (1):

1 (pass 1):  Inflammatory exudate;

2:  Atypical cells present.

  1. B) Right upper lobe lung needle core biopsies: Evaluation episodes 1-4 (passes 1-4):  Atypical cells present.

Part A consists of three alcohol-fixed touch preparation slides that are subsequently Papanicolaou stained, and one air-dried touch preparation slide that is stained with Wright stain.  A composite length of 0.3 cm cores are made into one cell block with hematoxylin and eosin-stained slides prepared.  Slides contain an atypical lymphoid infiltrate with dense sclerotic bands of fibrous tissue intervening, foci of necrosis, and clusters of large highly atypical cells. These large cells are positive for CD30, Pax-5 (weak) and CD45 (weak, variable), and negative for CD20, CD15, ALK, and CD3.  Background smaller lymphocytes are mixed CD3 and CD20 positive lymphocytes.   Concurrent flow cytometry results showed an abnormal CD30-positive hematopoietic cell population.  The findings are consistent with classical Hodgkin lymphoma.  Further subclassification is not possible given this limited biopsy.

Part B, from the right upper lobe lung mass, consists of eight alcohol-fixed touch preparation slides that are subsequently stained with Papanicolaou stain and a composite length of 0.5 cm cores that are made into one cell block with hematoxylin and eosin-stained slides prepared.  The slides contain highly atypical dispersed lymphoid elements in a background of mixed inflammatory components with an immunophenotype similar to part A.  Concurrent flow cytometry results  showed an abnormal CD30-positive hematopoietic cell population, and large atypical CD30-positive cells are observed with immunohistochemistry.  The findings are consistent with classical Hodgkin lymphoma.

Specimen Source:

Specimen A)  Needle aspirate (anterior mediastinum);

Specimen B)  Needle aspirate (RUL lung)

Specimen Description:

Specimen (A)  3 slides in etoh container, 1 air dry slide, 0.3 cm core in saline fluid;

Specimen (B)  8 slides in etoh container, 0.5 cm core in saline fluid in specimen cup

Cytopreparation:

Specimen (A)  4 smears, 1 cell block;

Specimen (B)  8 smears, 1 cell block

IHC Studies:

Specimen A1:  Population: Cells of interest

PAX5 Pax-5[24]                                (See comment)  Controls appropriately positive

AE1/AE3   Pan-Cytokeratin Cocktail [AE1/AE3]      Negative  Controls appropriately positive

ALK-1     ALK Protein [ALK1]       (See comment)  Controls appropriately positive

CD15 CD15 (Leu-M1) [80HD]        (See comment)  Controls appropriately positive

CD20 CD20 [L26]                            (See comment)  Controls appropriately positive

CD3  CD3 [LN10]                            (See comment)  Controls appropriately positive

CD30 CD30/Ki-1 [Ber-H2]              (See comment)  Controls appropriately positive

CD45 CD45 [2B11 + PD7/26/16]    (See comment)  Controls appropriately positive

Specimen B1:  Population: Cells of interest

AE1/AE3   Pan-Cytokeratin Cocktail [AE1/AE3]      Negative  Controls appropriately positive

ALK-1     ALK Protein [ALK1]       (See comment)  Controls appropriately positive

CD20 CD20 [L26]                            (See comment)  Controls appropriately positive

CD3  CD3 [LN10]                            (See comment)  Controls appropriately positive

CD30 CD30/Ki-1 [Ber-H2]           (See comment)  Controls appropriately positive

CD45 CD45 [2B11 + PD7/26/16]  (See comment)  Controls appropriately positive

TTF-1     Thyroid Transcription Factor 1 [8G7G3/1], TTF          Negative  Controls appropriately positive

IHC Interpretation:

Immunohistochemistry was medically necessary in addition to flow cytometry on both parts to evaluate immunophenotype and histologic correlations.

Data Item :

Diagnosis Date

Correct Answer :

05/03/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the 05/03/2014 CT scan that was c/w either stage IV primary lung carcinoma or lymphoma (both malignancies).

Ambiguous terminology may be used to accession a case when the ambiguous terminology is considered reportable. “C/w” or consistent with, is a reportable ambiguous term. The clinical diagnosis of malignancy was subsequently confirmed by biopsy.

Data Item :

Primary Site

Correct Answer :

C341

Rationale:

The CT scan documentation indicates there is a RUL lung mass, mediastinal, epicardial, bilateral hilar, supraclavicular and neck adenopathy and suspicious prominent retroperitoneal nodes. The PET scan also identified internal mammary uptake and uptake in bone marrow and spleen consistent with lymphoma.

Use the Heme Manual instructions to code primary site. First, check the Heme DB. The Abstractor Notes in the Heme DB entry for Hodgkin lymphoma indicates primary extranodal involvement is rare, but not impossible. Since the patient appears to have a primary extranodal tumor with regional lymph node involvement, the primary site(s) noted in the Heme DB do not apply; this appears to be a rare occurrence of extranodal Hodgkin lymphoma. Because the rare primary site was not given in the Heme DB, the rules in Module 7 must be applied. Module 7 is the correct module to use when coding primary site for lymphoma.

In this case, there is both organ and lymph node involvement. Rule PH25 is the first rule that applies to involvement of a single organ and the organ’s regional lymph nodes. PH25 states to code the primary site to the organ when a lymphoma is present in an organ (lung) and that organ’s regional lymph nodes (mediastinal, epicardial, bilateral hilar, and supraclavicular lymph nodes). Distant lymph node involvement (neck, internal mammary) and the splenic involvement should be ignored for coding primary site, this will be considered in the staging. Apply code C341 (Upper lobe lung).

Data Item :

Laterality

Correct Answer :

1

Rationale:

Per the scan information and the OP report information there was a right upper lobe lung mass. Apply code 1 (right).

Data Item :

Histology

Correct Answer :

9650

Rationale:

The 06/12/2014 anterior mediastinum and RUL biopsies (histologic confirmation) found Classical Hodgkin lymphoma. Module 9, Rule PH30 of the Heme Manual states to use the Heme DB to determine histology when rules PH1-PH29 do not apply. When Classical Hodgkin lymphoma is entered into the Heme DB, code 9650 is most applicable. The Heme Manual Primary Site and Histology Coding Instructions state to code the histology from the Definitive Diagnostic Method(s) identified in the Heme DB. FISH, histologic confirmation and immunophenotyping are listed as definitive diagnostic methods for Classical Hodgkin lymphoma. Apply code 9650 (Classical Hodgkin lymphoma).

Data Item :

Behavior

Correct Answer :

3

Rationale:

The Heme Manual Case Reportability Instructions designate that all cases with morphology codes 9590-9992 be reported with a behavior code of /3 (Instruction 2).

Data Item :

Grade

Correct Answer :

9

Rationale:

The Heme Manual Grade of Tumor Rules, Rule G9, states Grade should be coded to 9, if no cell type is specified. There was no mention of cell type on the pathology report or clinically. Apply code 9 (unknown, not stated).

Data Item :

Clin T

Correct Answer :

88

Rationale:

TNM classification is not applicable to classical Hodgkin lymphoma. Apply code 88 (Not applicable).

Data Item :

Clin N

Correct Answer :

88

Rationale:

TNM classification is not applicable to classical Hodgkin lymphoma. Apply code 88 (Not applicable).

Data Item :

Clin M

Correct Answer :

88

Rationale:

TNM classification is not applicable to classical Hodgkin lymphoma. Apply code 88 (Not applicable).

Data Item :

Clin Stg Grp

Correct Answer :

4B

Rationale:

The patient underwent multiple CT scans (both PTA and at this facility) that demonstrated a right upper lobe (RUL) lung mass, extensive mediastinal, bilateral hilar, supraclavicular, cardiophrenic and neck adenopathy. The scans also demonstrated both pleural and pericardial effusions. The 05/29/2014 PET scan showed uptake in the previously identified nodal regions, as well as uptake in the internal mammary nodes, bone marrow and spleen that was consistent with lymphoma.

The 05/21/2014 bone marrow biopsy was negative for lymphoma; however, the PET scan eight days later did show uptake consistent with bone marrow involvement. The 06/12/2014 mediastinal and right upper lobe mass biopsies were positive for Hodgkin lymphoma.

Any mention of mass, enlargement or adenopathy is considered nodal involvement for lymphomas. Although the scans identified pleural and pericardial effusions, neither were cytologically proven to be involved. Pleural or pericardial effusions with unknown cytology are not considered an E lesion, or involvement, per the AJCC Cancer Staging Manual.

Each stage should be classified as either A or B according to the absence or presence of defined constitutional symptoms. The 05/03/2014 physical exam noted a history of drenching night sweats and weight loss.

Despite the negative bone marrow biopsy preceding the PET scan, the physician staged this as Stage IV disease on 06/27/2014, presumably based on the PET scan involvement of the bone marrow.  While the physician only provided the Stage Group, the documentation in the record clearly identified B symptoms. Apply code 4B (Stage IVB).

Note: For the SEER*Educate TNM 7th Edition exercises, registrars are instructed to assign TNM independent of the physician’s documented stage. There are two exceptions when the registrar may use the physician’s documented stage in these exercises as the preferred answer. Exception 1: The physician’s stage is all that is available to the registrar. Exception 2: The staging documentation in the abstracted text and/or pathology report is unclear and/or incomplete.

In this instance, the physician’s documented stage will be used because the abstracted text or pathology report is unclear and/or incomplete.

Data Item :

Clin Desc

Correct Answer :

5

Rationale:

There was clinical involvement of an extranodal site (lung) and involvement of the spleen on imaging. Apply code 5 (E&S-Extranodal and spleen, lymphomas only).

Data Item :

Path T

Correct Answer :

88

Rationale:

TNM classification is not applicable to classical Hodgkin lymphoma. Apply code 88 (Not applicable).

Data Item :

Path N

Correct Answer :

88

Rationale:

TNM classification is not applicable to classical Hodgkin lymphoma. Apply code 88 (Not applicable).

Data Item :

Path M

Correct Answer :

88

Rationale:

TNM classification is not applicable to classical Hodgkin lymphoma. Apply code 88 (Not applicable).

Data Item :

Path Stg Grp

Correct Answer :

BLANK

Rationale:

There was no staging laparotomy performed. Pathologic staging for lymphomas is reserved for patients who undergo staging laparotomy with intent to assess the presence of abdominal disease. Staging laparotomy and pathologic staging have essentially been abandoned as useful procedures. Apply code BLANK.

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Data Item :

SS 2000

Correct Answer :

7

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has distant stage disease as the patient was diagnosed with Stage IV Hodgkin lymphoma, presumably due to bone marrow involvement identified on imaging. The physician staged this as Stage IV disease.

Stage IV disease is considered distant per the Summary Stage Manual. Apply code 7 (Distant)

Social History

Divorced, Canadian female born and raised in the Northwest. BP: Vancouver, BC. Ins: Medicaid

Physical Exam

03/12/2014 – cc: Pt w/ clinical T3b N0 M0 malignant melanoma on her Rt anterior leg. HPI: Has had lesion on Rt leg for 5 years, ~ 1 year ago it blistered, top of blister came of and has continued to bleed since that time. PCP felt it was pyogenic skin lesion and tx’d with liquid nitrogen, however it has continued to change. Had PTA bx 02/20/2014 which found invasive malignant melanoma, Breslow 3.1 mm, mitotic index of 6 per square mm, no ulceration, no regression. PE: On rt anterior leg ~ 1.8 x 1.8 cm raised lesion. Lymph: No supraclavicular, cervical or inguinal adenop. IMP: Melanoma Rt anterior leg. PLAN: Recommend WLE w/ 2 cm margins and SLN biopsy.

04/08/2014 – IMP: Pt s/p WLE for T4b N1a M0 nodular melanoma. PLAN: Discussed MSLT-II clinical trial, discussed referring to Med Onc for systemic options and additional surg w/ inguinal LN dissection. Pt inclined to join MSLT-II trial, but still considering options.

Scans

04/17/2014 – CT Chest/Abd/Pelvis: RML area of consolidation w/ ground glass opacity, suggestive of infection vs. inflammatory process. Two liver lesions c/w cysts. Indeterminate left adnexal mass, recommend ultrasound for further eval.

04/30/2014 – Abd/Pelvic U/S: Fatty infiltration in liver, lesion seen on CT not well visualized. Multiple uterine fibroids. Mass adj to left ovary seen on prior exam, not visualized on this exam

Labs

06/24/2014 – LDH: 174 U/L (80-190 U/L normal)

Operative Reports

03/25/2014 – Wide local excision, Rt leg skin lesion, Rt inguinal sentinel LN mapping and dissection: Found one hot Rt inguinal sentinel LN, no other palpable abnl nodes. Removed an additional 2 cm radial skin margins around the 2 x 2.5 cm Rt pretibial skin lesion.

Treatment Plan

06/25/2014 – Pt chose not to pursue lymphadenectomy or participation in the MSLT-II trial. She also declined receiving systemic interferon tx and is currently on surveillance.

02/20/2014 – Path Report #1

Clinical Diagnosis/History:

  1. A) BCC, friable 1.5 cm lesion with rolled edges, present x 1 year.
  1. B) Pyogenic granuloma, painful 1.5 cm lesion.

Final Diagnosis:

Outside Laboratory (02/20/2014)

  1. A) Skin, right leg, biopsy: Malignant melanoma, nodular type with the following features:
  2. Approximate Breslow thickness: 3.1 mm.
  3. Clark’s Level: IV.
  4. Ulceration: Not identified.
  5. Mitotic rate: 6/mm2.
  6. Lymphocapillary invasion: Not identified.
  7. Satellitosis: Not identified.
  8. Perineural invasion: Not identified.
  9. Lymphocytic infiltrate: Non-brisk.
  10. Regression: Not identified.
  11. Margins: The peripheral margins are involved, the deep margin is free.
  12. Melanoma in situ: Definitive in-situ component not identified, see comment.
  1. B) Skin, right hand, biopsy: Invasive, moderately-to-well differentiated squamous cell carcinoma, the deep and peripheral margins are involved.  Perineural invasion is not identified.

Diagnosis Comment:

The lack of definitive in-situ component raises the possibility of a metastatic melanoma, although it is unlikely based on the rather intimate association of the lesion with the epidermis.  Clinical correlation remains essential.

Gross Description:

Received include:

One H&E and six IHC slides also labeled “A1” including one negative IHC control, and One H&E slide also labeled “B1”.

Microscopic Description:

Specimen A:  The sections show a nodular proliferation of highly atypical melanocytes in the dermis.  There is no apparent pagetoid spread and epidermal nests of atypical melanocytes.  The cells in the melanocytic nodule are epithelioid with large hyperchromatic vesicular nuclei, prominent nucleoli and abundant cytoplasm without melanin pigments.  Dermal mitoses are readily identified.  There is no ulceration, lymphovascular invasion, satellitosis or perineural invasion.  The lymphocytic infiltrate is non-brisk.  There is no regression present.  There is no definitive melanoma in-situ component.  The overlying epidermis has focal area of vesicular changes covered by fibrin, blood cells and parakeratosis.  The immunohistochemical stains performed at outside institution show that the tumor is diffusely positive for S100 and melan-A, focally positive for HMB45, and negative for CD68 and pan keratin.  The inked peripheral margins are involved.  The inked deep margin is free in sections examined.

Specimen B:  The sections show an atypical keratinocyte proliferation infiltrating into the dermis.  There is paradoxical keratinization and focal areas of glassy cytoplasm. Perineural invasion is not identified.  This lesion involves the peripheral and deep margins.

03/25/2014 – Path Report #2

Clinical Diagnosis/History:

172.7.  Right leg melanoma.

Per electronic medical record:  Malignant melanoma, nodular type; no lymphocapillary invasion; peripheral margins are involved.

Final Diagnosis:

  1. A) Right inguinal sentinel lymph node, resection:

1 lymph node, positive for metastatic melanoma by H&E and immunohistochemistry (1/1):

Location:  subcapsular and within afferent vessels

Dimension:  0.1 X 0.1 mm

Extranodal extension: not identified

  1. B) Skin, right leg, excision: Malignant melanoma, nodular type, with the following features:
  2. Approximate Breslow thickness: 6.5 mm.
  3. Clark’s Level: V.
  4. Ulceration: Present.
  5. Mitotic rate: 15/mm2.
  6. Lymphocapillary invasion: Suspicious.
  7. Satellitosis: Not identified.
  8. Perineural invasion: Not identified.
  9. Lymphocytic infiltrate: Non-brisk.
  10. Regression: Not identified.
  11. Margins: The inked margins are free in the examined sections.
  12. Melanoma in situ: Not identified.
  13. AJCC stage: pT4b, pN1a.
  1. C) Skin, right hand, excision: Crateriform squamous neoplasm consistent with regressing/resolving keratoacanthomatous squamous cell carcinoma; the inked margins are free in the examined sections.
  1. D) Skin, new ulnar margin right hand, resection: Diffuse actinic changes, no carcinoma identified.
  1. E) Skin, new distal margin right hand, resection: Diffuse actinic changes, no carcinoma identified.

Immunohistochemistry Studies:

Specimen A1:  Population: Melanoma cells

S100 S-100 [DR96+BC96]  Positive Highlights subcapsular and intravascular melanoma nests

MELAN A Melan-A [A103]  Positive Highlights subcapsular and intravascular melanoma nests

IHC Interpretation:

The S100 and melan-A stains highlight subcapsular and intravascular melanoma nests, which are also visualized on the H&E sections.

Gross Description:

Specimen A:  Received in formalin labeled “right inguinal sentinel lymph node” is a 2.4 x 2.4 x 1.0 cm yellow, lobulated portion of fibrofatty tissue, bisected to show fatty, white, fibrous-appearing cut surfaces.  The specimen is entirely submitted in cassette A1.

Specimen B:  Received in formalin labeled “right leg skin lesion, short = superior, long = lateral” is a 5 x 5 x 1.2 cm tan-brown, ovoid skin ellipse.  There is a single suture attached to the 12:00 tip (designated as superior), and a long suture attached to the 9:00 tip (designated as lateral).  Centrally there is a 1.7 x 1.3 cm tan-brown, irregular raised nodule.  The lesion is widely free from all margins (1.7 cm from 12:00, 2 cm from 3:00, 1.7 cm from 6:00, and 1.7 cm from 9:00).  The specimen is inked as follows:  12-3- 6:00 = green, 6-9:00 = orange, 9-12:00 = blue, and deep margin = black.  The specimen is serially sectioned from 12:00 to 6:00, revealing a tan-white, irregular lesion as described above.  The depth of invasion is 0.5 cm.  Representative sections are submitted as follows:  B1 – 12:00 and 6:00 tips; B2 – grossly uninvolved section between 12:00 tip and the central lesion; B3 – grossly uninvolved section between the central lesion and 6:00 tip; B4-B5 – composite section of the lesion; B6-B10 – the remaining entire lesion.

Specimen C:  Received in formalin labeled “right hand skin lesion” is a 2.5 x 2.0 x 0.2 cm tan, irregular fragment of skin with a central 1.7 x 1.0 x 0.5 cm tan, crusted lesion.  There is a short suture attached to the proximal end of the specimen and a long suture attached to the ulnar side of the specimen.  The margins of resection are inked as follows:  proximal ulnar blue, distal ulnar orange, entire radial side black.  The specimen is sectioned.  The lesion has crusted cut surfaces which extend into the underlying dermis and approach the deep margin focally.  The specimen is entirely submitted labeled:  C1 – perpendicularly sectioned distal margin; C2 – perpendicularly sectioned proximal margin; C3 – remaining tissue.

Specimen D:  Received in formalin labeled “right hand new ulnar margin” is a non oriented 2.0 x 1.0 x 0.5 cm, tan, triangular-shaped fragment of skin.  The epidermis has been marked purple.  The margins are inked blue.  The specimen is sectioned and has fibrofatty cut surfaces and no masses are identified.  The specimen is entirely submitted in cassette D1.

Specimen E:  Received in formalin labeled “right hand new distal margin” is a 2 x 1.5 x 0.2 cm tan, triangular-shaped, nonoriented skin ellipse.  The margins are inked blue.  The specimen is sectioned and has grossly unremarkable cut surfaces.  The tissue is entirely submitted in cassette E1.

Data Item :

Diagnosis Date

Correct Answer :

02/20/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the 02/20/2014 skin biopsy .

Data Item :

Primary Site

Correct Answer :

C447

Rationale:

Per the abstract information and pathology report, the melanoma was located on the right leg. Apply code C447 (skin of leg).

Data Item :

Laterality

Correct Answer :

1

Rationale:

Code 1 (Right) when the primary site is a paired site and the primary tumor originated on the right.

Data Item :

Histology

Correct Answer :

8721

Rationale:

The MP/H Rules (general rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. The 03/25/2014 excision specimen was the most representative specimen and it showed malignant melanoma, nodular type.

Per the MP/H Rules, Melanoma, apply rule H9 and code the most specific histologic term when the diagnosis is melanoma with a single specific type. Nodular type of melanoma is a more specific histology. Code the histology as 8721.

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology report, this is a malignant tumor. Code the behavior as /3 (malignant) when the primary tumor, or any portion of the primary tumor, is invasive.

Data Item :

Grade

Correct Answer :

9

Rationale:

The grade of the melanoma is unknown. The final diagnosis on either pathology report does not give a grade for this melanoma. Melanomas usually are not graded. Code grade 9 when there is no grade specified on the pathology report prior to neoadjuvant treatment.

Data Item :

Clin T

Correct Answer :

3A

Rationale:

Clinical staging of melanoma is performed after the diagnostic biopsy (which may include a complete excision of the primary melanoma) and clinical/radiographic evaluation for metastases. The clinical T category is limited to the initial biopsy (punch, shave, excisional biopsy, etc.).

The PTA 02/20/2014 right leg biopsy showed nodular melanoma extending to a Breslow thickness of 3.1 mm with no ulceration, and a mitotic rate of 6/mm squared. Clinically, this patient was noted to have a residual 1.8 cm lesion. In this case, the initial PTA biopsy was a diagnostic biopsy only. The biopsy pathology findings will be used to assign the clinical T category. Apply code 3A (T3a, melanomas 2.01 – 4.0 mm, with no ulceration).

Although the 03/12/2014 physician’s clinical TNM indicates this was T3b disease, there was no evidence of ulceration on the review of slides pathology report. The AJCC Manual indicates melanoma ulceration is based on a histopathologic examination of the primary tumor. There was no histopathologic evidence of ulceration on the diagnostic biopsy.

Data Item :

Clin N

Correct Answer :

0

Rationale:

The lymph nodes were clinically negative per the physical exam on 03/12/2014 which noted no supraclavicular, cervical or inguinal adenopathy. There was also no indication of satellite involvement on exam. The physician clinically staged this patient as N0 per the 03/12/2014 physical exam note.

The patient underwent a sentinel lymph node biopsy at the time of complete tumor excision; however, a sentinel lymph node biopsy is considered pathologic staging for a melanoma primary, and not clinical or diagnostic work-up. Apply code 0 (N0, no detectable evidence of distant metastases).

Data Item :

Clin M

Correct Answer :

0

Rationale:

Per the AJCC Cancer Staging Manual, general instructions, a case with no symptoms or signs of metastasis is classified as clinically M0.

The 03/12/2014 physical exam noted no evidence of distant lymph node involvement and the physician clinically staged this patient as M0. Although the imaging was performed following definitive treatment, it confirmed the pre-treatment clinical findings of M0 disease. There were no symptoms or findings the physician felt clinically suspicious for metastasis at diagnosis. Apply code 0 (M0, no detectable evidence of distant metastases).

Data Item :

Clin Stg Grp

Correct Answer :

2A

Rationale:

Per the melanoma of the skin staging form, when the clinical TNM is cT3a cN0 cM0, apply code 2A (Stage IIA).

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

4B

Rationale:

Pathologic staging for melanoma combines the microstaging of the primary melanoma (initial biopsy, which may incidentally represent a complete excision of the primary tumor), with the definitive treatment specimen (wide excision or re-excision), and pathologic evaluation of regional lymph nodes, except for pathologic Stage 0 and Stage IA which do not require evaluation of the lymph nodes.

The wide excision showed nodular melanoma extending to a Breslow thickness of 6.5 mm with ulceration, and a mitotic rate of 15/mm squared. The physician pathologically staged this as T4b. Apply code 4B (T4b, melanomas more than 4.0 mm with ulceration).

Data Item :

Path N

Correct Answer :

1A

Rationale:

The 03/25/2014 wide excision with sentinel lymph node dissection included resection of one regional lymph node. The right inguinal sentinel lymph node was positive for micrometastatic melanoma measuring 0.1 mm in greatest dimension. There were no clinically detectable nodal metastases prior to surgery; therefore, the lymph node metastasis qualifies as a micrometastasis. The physician pathologically staged this as N1a. Apply code 1A (N1a, metastasis in 1 node, micrometastasis only).

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic examination of distant metastasis. Apply code BLANK (Not recorded).

Data Item :

Path Stg Grp

Correct Answer :

3B

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, for cases with known pT and pN categories, use the clinical M category to complete the pathologic stage group.

Per the melanoma of the skin staging form, when the pathologic TNM is pT4b pN1a cM0, apply code 3B (Stage IIIB).

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Data Item :

SS 2000

Correct Answer :

4

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has regional stage disease as the primary tumor pathologically extended to Clark’s level V (subcutaneous tissue) on the wide excision. Additionally, the patient had pathologic evidence of regional lymph node metastases. The sentinel lymph node biopsy was positive for metastatic melanoma involving a single right inguinal sentinel lymph node. There were no distant metastases. Apply code 4 (Regional, direct extension and regional lymph nodes).

Social History

Single Kenyan female. Born in Kenya. Not insured, charity care.

Physical Exam

05/28/2014 – cc: Newly dx’d Lt adnexal mass. HPI: Pt initially presented to outside hospital ER complaining of progressive pelvic pain on left, radiating to right. Had a CT scan done PTA on 05/17/2014 that revealed a left adnexal mass, 4.8 x 8.1 x 4.8 cm, with cystic and solid portions. PE: Pelvic: Exam notable for fullness in posterior and left sided exam. External genitalia WNL. Cervix and uterus surgically absent. Large left sided semi-movable mass. IMP: Lt adnexal mass. Plan: Surgery.

06/18/2014 – Stage IIIC pelvic node positive high-grade serous ovarian cancer s/p optimal debulking. Recommend: Chemo.

Labs

05/28/2014 – CA-125: 55 U/mL (0-35 U/mL normal)

Operative Reports

05/30/2014 – Robotic-assisted laparoscopic oophorectomy converted to open exploratory surgery, BSO, tumor debulking of extensive peritoneal implants in pelvis, incl resection argon beam ablation, left ureterolysis, complete ometectomy, bxs, destruction of tumor implants: On entering, upper abd looked nml, diaphragm nml. By camera, several adhesions in pelvis. Large left adnexal mass, bxs taken of miliary ds that appeared outside ovary. Rt tube/ovary slightly abnl. Multiple miliary implants throughout pelvis ranging from 1-4 mm in size. Omentum looked nml. No suspicious LNs. Pelvis was able to be completely rendered disease free with no gross residual.

Chemo Text

07/01/2014 – Started Taxol and Carboplatin.

05/30/2014 – Path Report #1

Clinical Diagnosis/History:

(789.30) Pelvic mass.

Final Diagnosis:

A-E and I)  Sigmoid nodule, right and left fallopian tube and ovary, sigmoid epiploica, left pelvic lymph nodes, sigmoid epiploica, biopsies and bilateral salpingo-oophorectomy:  High-grade serous carcinoma with the following features:

  1. Consistent with ovarian primary involving right and left ovary (2.5 cm right ovarian mass and 5.5 cm left ovarian mass), left fallopian tube (4 cm mass), and sigmoid epiploica.
  1. Detached pieces of carcinoma present in left pelvic lymph nodes specimen and 4 lymph nodes, no carcinoma identified. (See comment)
  1. Right and left fallopian tube, no intraepithelial neoplasia identified.

F-H, J-L)  Left periaortic, right pelvic, right periaortic lymph nodes, omentum, right and left hemidiaphragm, excision and biopsies:

  1. 2 left periaortic lymph nodes negative for carcinoma (0/2).
  2. 5 right pelvic lymph nodes negative for metastatic carcinoma (0/5).
  3. 1 right periaortic lymph node negative for metastatic carcinoma (0/1).
  4. Omentum, right and left hemidiaphragm negative for carcinoma.

Comment:

The detached pieces of carcinoma in the specimen designated left pelvic lymph nodes (specimen E) may represent an entirely replaced lymph node metastasis.

Intraoperative Consultation:

AFS)  Poorly differentiated carcinoma.

Gross Description:

Specimen A:  Received fresh in a container for frozen labeled “sigmoid nodule” is a 0.2 x 0.2 x 0.1 cm tan, irregular soft tissue, entirely submitted for frozen.  The frozen section residue is submitted in block AFS1.

Specimen B:  Received in formalin labeled “right tube and ovary” is a 24 g (post-fixation), 4 x 4 x 2.8 cm nodularly distorted, focally cystic, stated right ovary.  The serosa is tan-white, lobulated, and focally studded by tan-yellow nodules.  The ovary is sectioned, and there is a 2.5 x 2.0 x 1.2 cm tan-white, fleshy, solid area admixed with a 2.2 x 2.2 x 2.0 cm cystic space.  The cystic surface is tan-white, smooth, and glistening, and no obvious nodules or lesions are identified.  No normal ovarian parenchyma is identified.  Attached to the ovary is a 5 x 0.5 x 0.5 cm fallopian tube.  The serosa is tan-pink, smooth, and glistening.  The fallopian tube is serially sectioned, and there are tan, rubbery cut surfaces with a patent stellate lumen.  The attached mesosalpinx is sectioned and has fibrofatty, vascular, unremarkable cut surfaces.  Representative sections are submitted as follows:  B1, B2 – ovarian mass; B3 – entire fallopian tube.

Specimen C:  Received fresh labeled “left tube and ovary” is a 101 g (post-fixation), 9 x 6 x 3.5 cm nodularly distorted stated left ovary.  The serosa is tan-pink, focally hemorrhagic, and focally studded by tan-white, papilliferous, friable lesions.  The ovary is sectioned, revealing a 5.5 x 4.5 x 1 cm, tan-yellow, fleshy, solid mass.  There is also a 2.5 x 1.5 x 1.0 cm cystic space.  The cystic surface is tan-white, smooth, and glistening, and no obvious lesion is identified.  No normal ovarian parenchyma is identified.  Attached to the ovary is a 4 x 1.5 x 1.0 cm, tan-brown, focally hemorrhagic, fallopian tube candidate.  The serosa is tan-red, smooth, and focally hemorrhagic.  The fallopian tube is serially sectioned, and it has tan, rubbery cut surfaces.  Representative sections are submitted as follows:  C1, C2 – ovarian mass; C3-C7 – entire fallopian tube candidate.

Specimen D:  Received in a container of formalin labeled “sigmoid epiploica” is a 3.5 x 2.2 x 0.5 cm epiploic appendage.  The serosa is variegated, hemorrhagic, and studded by multiple white tumor nodules ranging in size from 0.2 cm to 0.5 cm.  One of these nodules is located at the margin of resection, which is marked with blue ink.  The nodules are sectioned and focally extend into the underlying adipose tissue and appear to be arising from the serosa.  Representative sections are submitted in cassette D1.

Specimen E:  Received in formalin labeled “left pelvic lymph nodes” are multiple yellow, lobulated fragments of adipose tissue measuring 4.5 x 4.5 x 1.0 cm in aggregate dimension.  Four lymph node candidates are identified on cut surfaces ranging in size from 1 cm to 3.5 cm.  Also noted on cut surfaces is a 3 x 3 x 0.5 cm hemorrhagic, soft, friable possible lesion.  Representative sections are submitted labeled:  E1 – 3 individual lymph node candidates; E2, E3 – 1 quadrisected lymph node candidate; E4 – 1/2 of possible friable intramural lesion.

Specimen F:  Received in formalin labeled “left periaortic lymph nodes” is a 2.5 x 1.0 x 0.5 cm fragment of adipose tissue.  Two lymph node candidates are identified on cut surfaces averaging 1.5 cm in greatest dimension, entirely submitted in cassette F1.

Specimen G:  Received in formalin labeled “right pelvic lymph nodes” are multiple yellow, lobulated fragments of adipose tissue measuring 6.0 x 5.0 x 1.0 cm in aggregate dimension.  Seven lymph node candidates are identified on cut surfaces ranging in size from 1 cm to 3 cm.  Representative sections are submitted labeled:  G1 – 3 individual lymph node candidates; G2 – 2 individual lymph node candidates; G3 – 1 bisected lymph node; G4 – 1 bisected lymph node.

Specimen H:  Received in formalin labeled “right periaortic lymph nodes” is a 2.5 x 1.5 x 0.5 cm yellow, lobulated portion of fibrofatty tissue, submitted in toto in cassette H1.

Specimen I:  Received in formalin labeled “sigmoid epiploica” are eight yellow, lobulated epiploic appendages measuring 9 x 5 x 1.5 cm in aggregate dimension.  The serosal surfaces are variegated, focally hemorrhagic, and diffusely studded by white apparent tumor nodules averaging 0.3 cm.  There are fatty cut surfaces and the tumor nodules appear to be confined to the serosa.  Representative sections of the serosal nodules are submitted in cassette I1.

Specimen J:  Received fresh labeled “omentum” is a 30 x 23 x 1.5 cm portion of greater omentum.  The serosa is tan-yellow, smooth, and glistening.  The omentum is serially sectioned and has fibrofatty cut surfaces.  No obvious nodules or masses are identified.  Representative sections submitted in J1-J2.

Specimen K:  Received in formalin labeled “right hemidiaphragm” is a 1 x 0.5 x 0.5 cm tan-brown, rubbery portion of tissue, bisected and entirely submitted in cassette K1.

Specimen L:  Received in formalin labeled “left hemidiaphragm” is a 0.5 x 0.5 cm tan, rubbery mass which is submitted in toto in cassette L1.

05/30/2014 – Path Report #2

Clinical Diagnosis/History:

Patient presented with acute abdominal pain, workup revealed a large 7 x 9 cm complex cystic and solid mass in the left adnexa with CA-125 was mildly elevated at 55, and presents now for surgical management.

Cytologic Impression:

  1. A) Upper Abdominal Washing: Positive for malignancy.  See comment.
  2. B) Peritoneal Washing: Positive for malignancy.  See comment.

Comment:

  1. A) 70 mls grossly hemorrhagic fluid is received from which two alcohol-fixed Papanicolaou stained smears and one hematoxylin and eosin stained cell block slide are prepared. Slides contain cohesive clusters of markedly atypical epithelial cells with nuclear enlargement, anisonucleosis, hyperchromasia, macronucleoli, and pale cytoplasm.  The findings are positive for malignancy suggestive of high-grade carcinoma.
  1. B) 60 mls hemorrhagic fluid is received from which two alcohol-fixed Papanicolaou stained smears and one hematoxylin and eosin stained cell block slide are prepared. Slides contain scattered cohesive clusters of markedly atypical epithelial cells with nuclear enlargement, anisonucleosis, hyperchromasia, macronucleoli, and pale cytoplasm.  The findings are positive for malignancy, suggestive of high-grade carcinoma.

Note:

Please refer to concurrent surgical pathology case for definitive diagnosis.

Specimen Source:

  1. A) Upper Abdominal Washing;
  2. B) Peritoneal wash

Specimen Description:

(A)  70 ml grossly hemorrhaigc fluid in specimen cup with “upper abdominal washing” written on label;

(B)  60 ml hemorrhagic fluid in specimen cup with “peritoneal wash” written on label

Cytopreparation:

(A)  2 smears, 1 cell block;

(B)  2 smears, 1 cell block

Data Item :

Diagnosis Date

Correct Answer :

05/30/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the 05/30/2014 resection pathology report that showed serous carcinoma.

Data Item :

Primary Site

Correct Answer :

C569

Rationale:

The pathology report indicated serous carcinoma consistent with an ovarian primary and the physician also clinically stated this was an ovarian primary. Apply code C569 (Ovary).

Data Item :

Laterality

Correct Answer :

4

Rationale:

The pathology report indicated that the serous carcinoma was involving the right and left ovary. Per the SEER Manual, ovary is a paired site. Apply code 4 when both ovaries are involved simultaneously and there is a single histology.

Data Item :

Histology

Correct Answer :

8441

Rationale:

The MP/H Rules (general rules) state the priority for coding histology is from the pathology report of the most representative specimen. In this case, the patient had a resection of the primary site/tumor and the pathology report showed serous carcinoma. Per the MP/H Rules, Other Sites, apply rule H23 and code the histology when only one histologic type is identified. Code the histology as 8441 (serous carcinoma, NOS).

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology report, this is a malignant tumor (serous carcinoma). Code the behavior as /3 (malignant) when the primary tumor, or any portion of the primary tumor, is invasive.

Data Item :

Grade

Correct Answer :

4

Rationale:

Code the highest grade given from the primary tumor. In this case, the pathology report stated “high-grade serous carcinoma, consistent with ovarian primary.” Use the grade conversion tables in the SEER Manual when there are no site-specific coding guidelines that apply. Per the Terminology Conversion table, high grade is coded as SEER code 4.

Data Item :

Clin T

Correct Answer :

BLANK

Rationale:

The PTA 05/17/2014 CT scan showed an 8.1 cm left adnexal mass with cystic and solid portions. The 05/28/2014 physical exam noted a large left-sided semi-movable mass. No further work-up or imaging was performed at this facility. The minimal documented PTA imaging findings do not indicate whether a malignant tumor was suspected prior to the resection.

The 05/28/2014 physical exam note indicates the impression was a left adnexal mass (NOS) and the plan was to proceed directly to surgery. An ovarian malignancy was not clinically suspected or diagnosed prior to the surgical resection on 05/30/2014. There was no clinical diagnosis of a reportable ovarian primary, and, therefore, a clinical stage cannot be assigned. Apply code BLANK.

Note: Assigning BLANK indicates clinical staging was not done.

Data Item :

Clin N

Correct Answer :

BLANK

Rationale:

The PTA 05/17/2014 CT scan showed an 8.1 cm left adnexal mass with cystic and solid portions. The 05/28/2014 physical exam noted a large left-sided semi-movable mass. No further work-up or imaging was performed at this facility. The minimal documented PTA imaging findings do not indicate whether a malignant tumor was suspected prior to the resection.

The 05/28/2014 physical exam note indicates the impression was a left adnexal mass (NOS) and the plan was to proceed directly to surgery. An ovarian malignancy was not clinically suspected or diagnosed prior to the surgical resection on 05/30/2014. There was no clinical diagnosis of a reportable ovarian primary, and, therefore, a clinical stage cannot be assigned. Apply code BLANK.

Note: Assigning BLANK indicates clinical staging was not done.

Data Item :

Clin M

Correct Answer :

0

Rationale:

Per the AJCC Cancer Staging Manual, general instructions, a case with no symptoms or signs of metastasis is classified as clinically M0.

The PTA 05/17/2014 CT scan showed an 8.1 cm left adnexal mass with cystic and solid portions. The 05/28/2014 physical exam noted a large left-sided semi-movable mass. No further work-up or imaging was performed at this facility. The minimal documented PTA imaging findings do not indicate whether a malignant tumor was suspected prior to the resection.

The 05/28/2014 physical exam note indicates the impression was a left adnexal mass (NOS) and the plan was to proceed directly to surgery. An ovarian malignancy was not clinically suspected or diagnosed prior to the surgical resection on 05/30/2014. However, imaging was performed prior to surgery and there appeared to be no definitive clinical evidence of distant metastasis.

In the absence of pathologic evidence of metastasis, the clinical M category is required to assign the pathologic stage group when applicable. As the patient meets the criteria for pathologic staging, the clinical M category cannot be left blank in the registry fields. Both the cM and pM categories cannot be left blank in the registry field. While the patient did not meet the criteria for clinical staging, the cM category cannot be blank in this case. The primary tumor was not identified or clinically staged, but the clinical absence of metastasis was documented. Per the CAnswer Forum, apply code 0 (M0, no distant metastasis).

Data Item :

Clin Stg Grp

Correct Answer :

99

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, a clinical Stage Group cannot be assigned when the T or N categories are assigned an X value. One exception: any combination of TX or NX with M1 is classified as Stage IV.

Per the ovary staging form, when the TNM is cT (BLANK) cN (BLANK) cM0, apply code 99 (Unknown).

Note: Code 99 (Unknown) is most appropriate in cases where clinical staging could not be done.  CoC requires a non-BLANK value for the Clinical Stage Group.

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

2C

Rationale:

The 05/30/2014 bilateral oophorectomy and tumor debulking operative report and pathology report showed an ovarian primary involving the bilateral ovaries, left fallopian tube, sigmoid epiploica, and extensive miliary implants throughout the pelvis. The omentum and upper abdomen were negative for tumor. The upper abdominal washing and peritoneal washing were both positive for malignancy.

The patient had involvement of pelvic tissues and positive peritoneal washings, which is considered T2c involvement. Although the AJCC definition of T3c disease includes regional lymph node metastasis, if the T category does not meet the extension definition, it would not be assigned as T3c. This patient’s pathologic T category only meets the definition for T2c disease. Apply code 2C (T2c, pelvic extension and/or implants (T2a or T2b) with malignant cells in ascites or peritoneal washings).

Data Item :

Path N

Correct Answer :

1

Rationale:

The 05/30/2014 bilateral oophorectomy and tumor debulking included resection of multiple regional lymph nodes (bilateral pelvic and periaortic nodes). The pathology report showed “detached pieces of carcinoma present in left pelvic lymph nodes specimen” as well as four negative pelvic nodes. The diagnosis comment indicates this may represent an entirely replaced lymph node metastasis. The rest of the resected nodes were negative. The patient had at least one pelvic node positive for metastatic carcinoma. Apply code 1 (N1, regional lymph node metastasis).

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic examination of distant metastasis. This patient had a clinical assessment only, clinically M0. Apply code BLANK.

Data Item :

Path Stg Grp

Correct Answer :

3C

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, for cases with known pT and pN categories, use the clinical M category to complete the pathologic stage group.

Per the ovary staging form, when the pathologic TNM is pT2c pN1 cM0, apply code 3C (Stage IIIC).

Data Item :

Path Desc

Correct Answer :

3

Rationale:

The 05/30/2014 debulking pathology report showed multiple tumors of the ovary, one in the left ovary and one in the right ovary. Apply code 3 (M-Multiple primary tumors in a single site).

Data Item :

SS 2000

Correct Answer :

4

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has regional stage disease as there were tumor implants in the pelvis only and positive pelvic and abdominal washings. Tumor implants limited to pelvic structures (sigmoid epiploica) with positive peritoneal washings are considered regional by direct extension only. Additionally, the patient had regional lymph node metastasis. Positive pelvic lymph nodes were identified on resection. There were no distant metastases. Apply code 4 (Regional, direct extension and regional lymph nodes).

Social History

Filipina here with husband and children. BP: Philippines. Insured.

Physical Exam

03/12/2014 – cc: Pelvic mass. HPI: Pt w/hx bilateral breast cancer in 2011, tx’d w/ bilat mastectomy, adjuvant chemo and radiation. Presented for reconstruction eval and pre-operative CT aortogram revealed a large pelvic mass, 12.4 x 13.5 x 13.9 cm in Rt adnexa. Her CA-125 is 10 U/mL (WNL). PE: Pelvic: No lesions in vagina. Bimanual exam limited by discomfort. Appears to be a large mass extending above the umbilicus. Not possible to distinguish between adnexa, uterus and mass. No nodularity in rectovaginal septum. IMP: Large pelvic mass, recommend surgical removal.

Scans

02/28/2014 – CT Aorta: 14 cm cystic/soft tissue Rt adnexal cystic and solid mass concerning for an ovarian cystic neoplasm.

Operative Reports

03/21/2014 – Expl lap, TAH/BSO: On entering abd, there was mass arising from Rt tube/ovary, not attached to any bowel or sidewall. No excresecences noted on outside. Removed without rupture. Upper abd, liver, diaphragm and uterus grossly nml. On gross inspection there was an endometrial polyp and leiomyomata. Left tube/ovary nml. Surgically absent appendix.

Treatment Plan

04/23/2014 – Chemotherapy not recommended given low grade of tumor and confined to one ovary. FU every 3 months.

Stage

04/23/2014 – Stage IA primarily borderline mucinous neoplasm of the ovary with a small focus of adenocarcinoma per MD.

03/21/2014 – Path Report #1

Clinical Diagnosis/History:

Right ovarian mass, breast cancer.  Surgery:  Total abdominal hysterectomy/bilateral salpingo-oophorectomy/tumor debulking.

Final Diagnosis:

  1. A) Right fallopian tube and ovary (1309 gm), unilateral salpingo-oophorectomy:
  2. Adenocarcinoma, microscopic foci, in a background of a mucinous cystic neoplasm with extensive in situ epithelial neoplasia, low-grade and high-grade, with associated necrosis. Please see Comment.
  3. Fallopian tube with no evidence of neoplasia.
  1. B) Uterus, left fallopian tube and ovary, hysterectomy and unilateral salpingo-oophorectomy:
  2. Uterus with weakly proliferative endometrium and benign endometrial polyp, negative for hyperplasia or carcinoma.
  3. Cervix and endocervix, negative for neoplasia.
  4. Ovary and fallopian tube, negative for neoplasia.
  5. Leiomyomata (1.8 cm) of myometrium.

IHC Interpretation:

Neoplastic cells lack expression of estrogen and progesterone receptors; background ovarian stroma is appropriately positive.  The above Final Diagnosis remains unaltered by this Addendum report.

Gross Description:

Specimen A:  Received fresh in a container labeled “right tube and ovary – frozen” for intraoperative consultation is a 1309 g, 16 x 15 x 10 cm round cystic mass with a smooth tan- pink surface.  Fallopian tube is present along one aspect of the specimen and measures up to 9 cm in width x up to 0.6 cm in maximum diameter.  The fimbriated end is free.  The specimen is opened to reveal clear thin liquid.  After the liquid is drained, the specimen weighs 264 gm.  Within the main cystic cavity are multiple other smaller cysts, the largest measuring up to 7.5 x 3 x 3 cm.  The larger cyst is incised to reveal tan, mucinous material.  At one aspect of the larger cyst is an area of firm tissue measuring up to 2 x 1 x 0.8 cm.  A representative section of the smaller firm piece of tissue and piece of the larger cystic mass are submitted for frozen section analysis.  The frozen section remnants are thawed in formalin and submitted entirely in cassette A1FS.  The area of hard white tissue is excised and serially sectioned to reveal a well circumscribed, tan-yellow tissue without gross invasion into the underlying capsule (0.1 cm thick).  The largest mucin filled cystic mass is serially sectioned to reveal numerous smaller cysts ranging in size from 0.4 up to 2 cm in maximum dimension.  The cysts are filled with gelatinous tan-yellow mucin without definitive papillary excrescences within the cyst wall.  The fallopian tube is removed and serially sectioned to reveal internal luminal diameter of 0.1 cm grossly.  No intraluminal masses are identified.  The remaining cyst is serially sectioned to reveal numerous smaller cysts underlying the main cyst wall.  The cysts range in size from 0.4 up to 1.5 cm.  The cysts are filled with gelatinous, tan-yellow mucin.  Small areas of more solid tan-yellow tissue are present distributed throughout the smaller cystic areas.  More solid areas are excised, photographed, and representative sections are submitted.

Cassette index:

A1FS – Frozen section remnants

A2-A3 – cross-sections of solid mass within large cyst;

A4-A5 – representative sections of largest cystic mass ampled at frozen section;

A6-A8 – fallopian tube serially sectioned and entirely submitted;

A9-A17 – representative sections of more solid and cystic areas underlying main cystic ovarian mass.

  1. B) Received fresh in a container labeled “uterus, cervix, left tube and ovary” is a 10.5 x 6.5 x 4 cm uterus with a smooth, tan serosal surface. There is a single attached fallopian tube and ovary.  The ovary measures 2.8 x 1.3 x 1.1 cm.  The attached fallopian tube measures up to 7 cm in length by 0.7 cm in maximum width.  The serosal surface is tan-deep brown with no masses on the surface.  The ovary is lobulated, tan-white without excrescences on the surface.  The cervix measures 4 x 3.9 cm with a centrally located os.  The anterior aspect of the specimen is inked blue, posterior is inked black.  The specimen is bivalved to reveal a cystic endometrial polyp arising at the right aspect of the uterus.  The endometrial polyp measures 3 x 2 x 0.5 cm maximally.  The endometrial thickness is 0.3 cm maximally.  The anterior posterior aspect of the uterus are sectioned to reveal unremarkable endomyometrium without gross lesions seen.  There is an intramural leiomyoma up to 1 cm in maximum dimension with an irregular, whorled, tan appearance.  Along the anterior left aspect of the specimen is subserosal leiomyoma up to 1.8 cm in maximum dimension.  The ovary and fallopian tube are amputated.  The fallopian tube is serially sectioned to reveal internal luminal diameter of 0.1 cm.  No gross masses or lesions are identified.  The ovary is trisected to reveal lobulated, tan parenchyma without masses or lesions.  A single corpus albicans is identified measuring up to 0.3 cm grossly.  The endometrium is further sectioned to reveal multiple other intramural leiomyomas ranging in size from 0.5 to 1.0 cm along the anterior and posterior aspects of the specimen.  Leiomyomas are serially sectioned in situ to reveal firm, white, whorled parenchyma without areas of necrosis or gross degeneration.

Cassette index:

B1 – representative sections of fallopian tube

B2 – 1/3 of ovary

B3 – anterior cervix and lower uterine segment

B4 – posterior cervix and lower uterine segment

B5 – full thickness anterior endomyometrium

B6 – full thickness posterior endomyometrium

B7 – posterior full thickness endomyometrium at site of polyp attachment

B8, B9 – bisected polyp entirely submitted (resection surface inked blue)

B10 – representative sections of multiple leiomyoma

Frozen Section Diagnosis:

AFS1)  Right ovary:  Mucinous cystadenoma with focal borderline changes involving <2% of the lesion.

B Gross)  Uterus: Endometrial polyp and leiomyomas.

Addendum:

Immunohistochemistry Studies:

Specimen A1:  Population: Neoplastic cells

ER Estrogen Receptor [SP1]               Negative     Controls appropriately positive

PR88 Progesterone Receptor [PR88]  Negative     Controls appropriately positive

Specimen A12:  Population: Neoplastic cells

ER Estrogen Receptor [SP1]               Negative     Controls appropriately positive

PR88 Progesterone Receptor [PR88]  Negative     Controls appropriately positive

Addendum Reason:

To report results of IHC for ER and PR

Diagnosis Comment:

  1. A) The ovary is markedly enlarged and cystic, and it is lined by mucinous epithelium, predominantly Mullerian type but also with areas of goblet cell differentiation, with micro-papillary architecture. Much of the neoplastic epithelium has low-grade cytoarchitectural features, but there are also areas of high-grade cytology, with complex micropapillae, high nuclear to cytoplasmic ratios, enlarged nuclear to cytoplasmic ratios, loss of nuclear polarity and nuclear stratification.  In addition, there is extensive necrosis, and there are focal areas with invasive adenocarcinoma (best seen on slide A12).  Although this may be a primary ovarian neoplasm, in which case the pathological stage is FIGO 1A, the histological features also raise consideration of a metastasis to the ovary, from a gastrointestinal or pancreatic source.  We recommend correlation with the clinical and radiological features.  Results of immunohistochemistry for estrogen and progesterone receptors will be reported as an Addendum.

The difference between the Final Diagnosis and the initial frozen section interpretation for part A reflects both sampling and the fact that the initial interpretation of “focal borderline changes” was based on gross examination.  Once fixed, there were more apparent velvety, papillary areas in the cystic neoplasm, which involves many of the blocks taken after fixation.  In addition, the foci of carcinoma were not seen in the frozen section block.

My colleague has also reviewed slide A12 and concurs with the diagnosis of focal adenocarcinoma in a background of a mucinous cystic neoplasm.

03/21/2014 – Path Report #2

Clinical Diagnosis/History:

Right ovarian mass.

Cytologic Impression:

Peritoneal wash:  No cytologically malignant cells are identified.  See comment.

Diagnosis Comment:

80 mls hemorrhagic fluid is received from which two Papanicolaou-stained concentrated smears are made.  Smears contain mesothelial cells in sheets with wash artifact.  No cytologically malignant cells are identified.  Please refer to the concurrent surgical case for more information.

Data Item :

Diagnosis Date

Correct Answer :

03/21/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the 03/21/2014 resection pathology report that showed a foci of adenocarcinoma arising in a mucinous cystic neoplasm.

Data Item :

Primary Site

Correct Answer :

C569

Rationale:

The patient’s 03/21/2014 pathology report identified a foci of adenocarcinoma in the ovarian cystic neoplasm, which was thought to be a primary ovarian neoplasm but also raised consideration of a metastasis to the ovary per the comment. Clinical correlation recommended. The 04/23/2014 treatment plan and staging indicated an ovarian primary. Apply code C569 (Ovary).

Data Item :

Laterality

Correct Answer :

1

Rationale:

The pathology report indicated that the adenocarcinoma involved the right ovary. Per the SEER Manual, ovary is a paired site. Apply code 1 when the right side of a paired site is involved.

Data Item :

Histology

Correct Answer :

8140

Rationale:

The MP/H Rules (general rules) state the priority for coding histology is from the pathology report of the most representative specimen. In this case, the patient had a resection of the primary site/tumor and the pathology report showed a microscopic foci of adenocarcinoma. Per the MP/H Rules, Other Sites, apply rule H11 and code the histology when only one histologic type is identified. Code the histology as 8140 (adenocarcinoma, NOS).

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology report, this is a malignant tumor (adenocarcinoma). Code the behavior as /3 (malignant) when the primary tumor, or any portion of the primary tumor, is invasive.

Data Item :

Grade

Correct Answer :

9

Rationale:

The grade is unknown. The resection pathology report did not give a grade for the primary tumor. The patient’s adenocarcinoma arose in a background of low to high grade neoplasia. The “low to high grade” is describing the neoplasia, not the adenocarcinoma. The grade cannot be coded when no grade is given on the pathology specimen or there is no clinical statement of the primary tumor’s grade specified in the medical record. Apply code 9 (unknown, not stated).

Data Item :

Clin T

Correct Answer :

BLANK

Rationale:

The 02/28/2014 CT scan showed a 14 cm cystic and solid right adnexal mass concerning for an ovarian cystic neoplasm. The 03/12/2014 physical exam note stated there was a large mass extending above the umbilicus and it was not possible to distinguish between adnexa, uterus and mass. No further work-up or imaging was performed at this facility. The minimal documented clinical findings do not indicate whether a malignant tumor was suspected prior to the resection.

The 03/12/2014 physical exam note indicates the impression was a large pelvic mass (NOS). The physician recommended a surgical removal of the pelvic mass and the plan was to proceed directly to surgery. An ovarian malignancy was not clinically suspected or diagnosed prior to the surgical resection on 03/21/2014. There was no clinical diagnosis of a reportable ovarian primary, and, therefore, a clinical stage cannot be assigned. Apply code BLANK.

Note: Assigning BLANK indicates clinical staging was not done.

Data Item :

Clin N

Correct Answer :

BLANK

Rationale:

The 02/28/2014 CT scan showed a 14 cm cystic and solid right adnexal mass concerning for an ovarian cystic neoplasm. The 03/12/2014 physical exam note stated there was a large mass extending above the umbilicus and it was not possible to distinguish between adnexa, uterus and mass. No further work-up or imaging was performed at this facility. The minimal documented clinical findings do not indicate whether a malignant tumor was suspected prior to the resection.

The 03/12/2014 physical exam note indicates the impression was a large pelvic mass (NOS). The physician recommended a surgical removal of the pelvic mass and the plan was to proceed directly to surgery. An ovarian malignancy was not clinically suspected or diagnosed prior to the surgical resection on 03/21/2014. There was no clinical diagnosis of a reportable ovarian primary, and, therefore, a clinical stage cannot be assigned. Apply code BLANK.

Note: Assigning BLANK indicates clinical staging was not done.

Data Item :

Clin M

Correct Answer :

0

Rationale:

Per the AJCC Cancer Staging Manual, general instructions, a case with no symptoms or signs of metastasis is classified as clinically M0.

The 02/28/2014 CT scan showed a 14 cm cystic and solid right adnexal mass concerning for an ovarian cystic neoplasm. The 03/12/2014 physical exam note stated there was a large mass extending above the umbilicus and it was not possible to distinguish between adnexa, uterus and mass. No further work-up or imaging was performed at this facility. The minimal documented clinical findings do not indicate whether a malignant tumor was suspected prior to the resection.

The 03/12/2014 physical exam note indicates the impression was a large pelvic mass (NOS). The physician recommended a surgical removal of the pelvic mass and the plan was to proceed directly to surgery. An ovarian malignancy was not clinically suspected or diagnosed prior to the surgical resection on 03/21/2014. However, imaging was performed prior to surgery and there appeared to be no definitive clinical evidence of distant metastasis.

In the absence of pathologic evidence of metastasis, the clinical M category is required to assign the pathologic stage group when applicable. As the patient meets the criteria for pathologic staging, the clinical M category cannot be left blank in the registry fields. Both the cM and pM categories cannot be left blank in the registry field. While the patient did not meet the criteria for clinical staging, the cM category cannot be blank in this case. The primary tumor was not identified or clinically staged, but the clinical absence of metastasis was documented. Per the CAnswer Forum, apply code 0 (M0, no distant metastasis).

Data Item :

Clin Stg Grp

Correct Answer :

99

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, a clinical Stage Group cannot be assigned when the T or N categories are assigned an X value. One exception: any combination of TX or NX with M1 is classified as Stage IV.

Per the ovary staging form, when the TNM is cT (BLANK) cN (BLANK) cM0, apply code 99 (Unknown).

Note: Code 99 (Unknown) is most appropriate in cases where clinical staging could not be done.  CoC requires a non-BLANK value for the Clinical Stage Group.

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

1A

Rationale:

The 03/21/2014 TAH/BSO and exploratory laparotomy operative report and pathology report showed an ovarian primary involving the right ovary only. The patient had a large mucinous cystic neoplasm with microscopic foci of adenocarcinoma confined to the ovary, without involvement of the ovarian surface. The operative report noted the mass was arising from the right tube/ovary, was not attached to bowel or sidewall, and had no excrescences on the outside of the ovary. The tumor was removed without rupture. The peritoneal wash was also negative for malignancy. The patient had involvement of one ovary only. Apply code 1A (T1a, tumor limited to one ovary; capsule intact, no tumor of ovarian surface. No malignant cells in ascites or peritoneal washings).

Data Item :

Path N

Correct Answer :

X

Rationale:

Per Table 1.6, N Classification Rules, a pathologic N value cannot be assigned in the absence of a surgical resection. Although Table 1.6 also states a biopsy confirming the highest N may be used, it is used only in appropriate circumstances where the pathologic staging criteria for the site has been met.

In order to assign the pN0 category, histologic examination of regional nodes is required. The surgical observation of nodes at the time of resection, without pathologic examination, is not recorded in the pathologic stage. The patient did not undergo a lymph node resection during the TAH/BSO and exploratory laparotomy; therefore, the regional lymph nodes cannot be assessed pathologically. Apply code X (NX, regional lymph nodes cannot be assessed).

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic examination of distant metastasis. This patient had a clinical assessment only, clinically M0. Apply code BLANK.

Data Item :

Path Stg Grp

Correct Answer :

99

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, a pathologic Stage Group cannot be assigned when the T or N categories are assigned an X value. One exception: any combination of TX or NX with M1 is classified as Stage IV.

Although the tumor was pathologically T1a (FIGO Stage IA) by resection, no pathologic examination of the regional lymph nodes was performed and the pathologic lymph node category cannot be assessed (pNX). Apply code 99 (Unknown).

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Data Item :

SS 2000

Correct Answer :

1

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has local stage disease as there was pathologic evidence of microscopic foci of adenocarcinoma involving the right ovary only. The patient has no regional lymph node or distant metastases. Apply code 1 (Localized only).

Social History

Social History: 68 y/o black female. BP: WA. Insurance: Medicare Advantage. Divorced.

Physical Exam

03/20/2014 – HPI: Recently diagnosed neoplasm of pancreatic tail. 35 lb weight loss, workup included CT showing a 4.4 cm mass in pancreatic tail. PE: HEENT: No thyromegaly or cervical adenopathy. Lungs: Clear. Abd: Flat, soft, nontender w/ no masses or organomegaly. IMP: Probable islet cell tumor of pancreatic tail.

04/05/2014 – HPI: 4.4 cm pancreatic tail mass, needle aspirate w/ IHC confirmed a neuroendocrine tumor. Pt had glucagon levels checked during workup, returned at 2,000 ng/mL, diagnostic for glucagonoma. IMP: Islet cell tumor of pancreatic tail, glucagonoma, in setting of new-onset diabetes, glucosuria and 35 lb weight loss.

Scans

03/11/2014 – CT Abd/Pelvis: 4.4 cm pancreatic tail mass abutting splenic vessels and spleen, suspicious for pancreatic cancer or islet cell tumor/neuroendocrine tumor. Multiple liver hypodensities, some cysts. 4.8 cm cystic lesion in Rt ovary, suspicious for ovarian malignancy. Re-eval on US or pelvic MRI.

03/14/2014 – Pelvic U/S: IMP: Tubular cystic mass in Rt adnexa likely a hydrosalpinx.

03/21/2014 – CT Chest/Abd: Enhancing pancreatic neoplasm c/w known neuroendocrine tumor (5.0 x 4.0 x 4.2 cm), displaces splenic vessels without splenic or splenic vessel invasion. No evidence of mets disease.

09/06/2014 – CT Abd/Pelvis: No signs of local recurrence. Multiple hepatic cysts are unchanged.

Scopes

03/14/2014 – Upper EUS: Pancreatic duct normal. Single, solid, bilobed mass off tail of pancreas. Solid, heterogenous, hypoechoic mass w/ no evidence of invasion of splenic vein. Mass bx’d. Pancreas otherwise normal. No celiac or peripancreatic LAD. IMP: Single solid mass of tail of pancreas extending to splenic hilum.

Labs

03/14/2014 – CA 19-9: 27 U/mL (0 – 54 U/mL normal)

03/14/2014 – Chomogranin A (CgA): 196 ng/mL (< 93 normal)

Operative Reports

04/08/2014 – Laparoscopic distal pancreatectomy w/ splenectomy: No sign of mets disease. Large firm mass in tail of pancreas, normal proximal pancreas.

Treatment Plan

03/22/2014 – Surgical Consult: Recommend surgical resection involving distal pancreatectomy w/ splenectomy for pancreatic neuroendocrine tumor, susp for glucagonoma.

Stage

04/19/2014 – Per MD note: p T3 N0 glucagonoma of pancreatic tail.

03/14/2014 – Path Report #1

Clinical Diagnosis/History:

Pancreatic mass.

Final Diagnosis:

  1. A) Abdominal mass, ultrasound-guided core needle biopsy: Positive for neoplastic cells, comprising well-differentiated neuroendocrine neoplasm.  Please see comment.

Diagnosis Comment:

The H&E-stained sections show predominantly blood with a few detached small fragments of epithelioid cells with eosinophilic cytoplasm and centrally-located small nuclei, with powdery chromatin.  No mitotic figures are identified.  No tissue necrosis is present.  Immunohistochemical studies demonstrate uniform chromogranin and synaptophysin immunoreactivity in the epithelioid cells.  The findings are diagnostic of a well-differentiated neuroendocrine neoplasm.  Please correlate with the concurrent cytological report.

Gross Description:

Specimen A:  Received in neutral buffered formalin and labeled with the patient’s name is a specimen designated “abdominal mass,” comprising multiple pieces of tan white tissue measuring 0.1 cm to 1.7 cm.  Submitted in total in 1 cassette.

Immunohistochemistry Studies:

Specimen A1:  Population: Neoplastic cells

PHE5/CG Chromogranin [Phe5/CG LK2H10]    (See comment)   Positive

SYNAPTO Synaptophysin [SY38]                      (See comment)   Positive

Addendum Reason:

To report additional studies, including heabs stain and IHC for KI-67.

IHC Interpretation:

Fewer than 1% of the neoplastic cells are reactive with the antibody recognizing Ki-67, consistent with neuroendocrine neoplasm.  The above Final Diagnosis remains unaltered by this Addendum report.

Addendum:

A HEABS stain assists in evaluation of the tissue architecture and is negative for cytoplasmic mucin.

03/14/2014 – Path Report #2

Clinical Diagnosis/History:

Patient with weight loss, abnormal glucose handling, and an abdominal mass in the splenic hilum, who presents for evaluation.

Cytologic Impression:

Abdominal Mass, Fine Needle Aspiration:

Positive for neoplasia, favor endocrine neoplasm.  See comment.

Diagnosis Comment:

Ten alcohol fixed direct smears are received and subsequently stained with Papanicolaou stain.  The slides contain a highly cellular sample composed of numerous singly dispersed cells and cells in loose, variably sized aggregates.  Cells appear atypical and have enlarged nuclei with stippled chromatin and frequent conspicuous nucleoli.  Some cells have a plasmacytoid appearance.  The findings are positive for neoplasia.  The morphologic features appear most compatible with an endocrine neoplasm.  In the absence of cell block material, a scrap preparation will be made from selected direct smears.  Ancillary studies will be performed and resulted separately in an addended report.

04/08/2014 – Path Report #3

********** This Is A Revised Or Corrected Report ***********

**** Please See End Of Report For Detail Of Corrections ****

********** This Is An Addendum Report **********

Revision #1 (See end of report for new text): More Material or Decals Examined

Revision #2 (See end of report for new text): Additional Histological Findings

Revision #3 (See end of report for new text): Additional Studies

Clinical Diagnosis/History:

Neuroendocrine tumor.

Surgery:  Distal pancreatectomy, possible splenectomy (laparoscopic).

Final Diagnosis:

  1. A) Pancreas and spleen, distal pancreatectomy and splenectomy: Well differentiated neuroendocrine tumor with the following features:
  2. Size: 5.5 cm in greatest dimension.
  3. Well circumscribed, but focally invading into spleen and peripancreatic fat.
  4. Pancreatic margin negative for neoplasm.
  5. Less than 1 mitotic figure per 10 HPF.
  6. Minimum pathologic stage: pT3 NX.

Comment:

Given the absence of lymph node metastases, the minimum pathologic stage is now pT3 N0.  The previous diagnoses are otherwise unchanged.  Per request of the patient’s family, a representative block of the tumor will be sent to Outside Laboratory (A3).

Gross Description:

  1. A) Received fresh labeled “distal pancreas and spleen ” is a 246 g spleen and portion of pancreas. The spleen measures 11.0 x 9.0 x 3.0 cm.  The attached pancreas and peripancreatic adipose tissue measures 6.0 x 5.0 x 5.0 cm.  There is a 3.8 cm staple line at the pancreas margin.  The staple line is 6.5 cm from the spleen.  The stapled margin is inked blue  The peripheral part of the pancreas and peripancreatic adipose tissue is inked black.  The specimen is serially-sectioned revealing a 5.5 x 4.5 x 4.0 cm irregular firm tan nodule, which appears to be adjacent to the spleen and pancreas.  No definitive invasion is seen.  Samples not needed for diagnostic purposes were taken for research.  The specimen is placed in formalin and allowed to fix overnight.  Following fixation, the specimen is further sectioned and no other masses or lesions are identified.  Representative sections are submitted as follows:  A1-A4 – composite section of mass and adjacent spleen, A5 – mass with adjacent pancreas, A6 – samples of perpendicular pancreatic stapled margin.

Addendum Reason:

This addendum is report additional potential prognostic information in response to physician’s query about the difference between the reported mitotic rate and MIB labeling index.

New slides were cut from the tumor and mitotic figures were counted from an additional 10 fields in each of 5 slides.  The overall mitotic rate is 0.4 mitoses/10 hpf, which is very low.

The MIB labeling index was repeated on the section of tumor taken from where it invaded the spleen.  Three different fields were counted in detail.  43 MIB-positive cells were identified amidst and estimated 2,152 cells for an overall labeling index of 2.00%.

There is no change to the previous diagnoses.

Addendum Reason:

This addendum is to summarize NextGen molecular sequencing results performed by Outside Laboratory.  They report a genomic alteration in the DAXX gene (E37*).  No abnormalities were identified among 235 other genes and 47 introns tested.  A complete copy of their report is on file in the Pathology Department.

Addendum Reason:

This addendum is issued to include additional diagnoses related to lymph nodes and tumor necrosis.

Addendum:

  1. A) Pancreas and spleen, distal pancreatomy and splenectomy:
  2. Twelve lymph nodes, all negative for metastatic neuroendocrine tumor (see comment).
  3. No tumor necrosis identified on review of histologic sections.

Addendum Gross Description:

Specimen A:  The specimen was re-examined specifically to identify lymph nodes.  There are 13 lymph node candidates identified ranging from 0.3 to 0.8 cm in greatest dimension.  The lymph node candidates are entirely submitted as follows:  A7 – five individual lymph node candidates, A8 – five individual lymph node candidates, A9 – three individual lymph node candidates.

Data Item :

Diagnosis Date

Correct Answer :

03/11/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the 03/11/2014 CT scan that identified a 4.4 cm mass in the pancreatic tail. The CT impression was suspicious for pancreatic cancer or islet cell tumor/neuroendocrine tumor.

Both terms given in the differential diagnosis are reportable. Islet cell tumor/neuroendocrine tumors of the pancreas are reportable. Pancreatic neuroendocrine tumors (NET) are malignant and reportable per the WHO Classification of Digestive System Tumors. An islet cell tumor is a pancreatic endocrine tumor; per WHO, pancreatic endocrine tumor is now the preferred name for an islet cell tumor. Both pancreatic neuroendocrine tumors and pancreatic endocrine tumors (PanNETs) are reportable per SEER. The clinical diagnosis of malignancy was subsequently confirmed by pathology.

Data Item :

Primary Site

Correct Answer :

C252

Rationale:

The upper EUS, CT scans, and operative report showed the primary tumor was in the tail of the pancreas. Apply code C252 (tail of pancreas).

Data Item :

Laterality

Correct Answer :

0

Rationale:

Code 0 (not a paired site) when the primary site is not considered a paired site per SEER.

Data Item :

Histology

Correct Answer :

8240

Rationale:

The MP/H Rules (general rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. The patient underwent a distal pancreatectomy with splenectomy. The surgical resection was the most representative specimen, and it showed well differentiated neuroendocrine tumor of the pancreas. Per the MP/H Rules, Other Sites, apply rule H11 and code the histology when only one histologic type is identified. Code the histology as 8240 (NET, G1, well differentiated neuroendocrine tumor).

While the abstracted information clinically refers to this as an islet cell tumor or glucagonoma, the pathology report final diagnosis has priority over a clinical diagnosis per the MP/H Rules. Per SINQ, well differentiated neuroendocrine tumors of the pancreas are reportable and the histology is coded to 8240/3.

Data Item :

Behavior

Correct Answer :

3

Rationale:

A carcinoid tumor (well differentiated neuroendocrine tumor) in the pancreas is a malignant tumor per the ICD-O-3. Code the behavior as /3 (malignant).

Data Item :

Grade

Correct Answer :

1

Rationale:

Code the highest grade given from the primary tumor prior to neoadjuvant treatment. The pancreatic mass biopsy on 03/14/2014 showed well differentiated neuroendocrine neoplasm. The surgical resection pathology final diagnosis also showed well differentiated neuroendocrine tumor.

Use the grade conversion tables in the SEER Manual when there are no site-specific coding guidelines that apply. Per the Terminology Conversion table, well differentiated is coded as SEER code 1.

Data Item :

Clin T

Correct Answer :

3

Rationale:

The 03/11/2014 CT scan showed a 4.4 cm pancreatic tail mass that abutted the splenic vessels and spleen. The repeat CT scan on 03/21/2014 also showed the known neuroendocrine tumor measuring 5 cm, without splenic or splenic vessel invasion. The tumor “abuts” adjacent sites, but there is no indication the tumor actually involves them. The 03/14/2014 endoscopic ultrasound (EUS) showed the pancreatic tail mass with no evidence of splenic vein invasion, but extension to the splenic hilum. The EUS proved involvement of the splenic hilum. The 03/14/2014 core biopsy confirmed a well differentiated neuroendocrine tumor.

The splenic hilum is located on the surface of the spleen, and extension to the splenic hilum implies imaging evidence of tumor extending beyond the pancreas. Although the CT scans were not definitive for splenic or splenic vessel involvement, the EUS confirmed a primary pancreatic neoplasm with at least extension beyond the pancreas. Apply code 3 (T3, tumor extends beyond the pancreas but without involvement of the celiac axis or the superior mesenteric artery).

Data Item :

Clin N

Correct Answer :

0

Rationale:

The 03/11/2014 CT scan made no mention of regional lymph nodes. The 03/14/2014 endoscopic ultrasound (EUS) identified no celiac or peripancreatic adenopathy. The 03/21/2014 CT scan stated there was no evidence of metastatic disease. The 03/20/2014 physical exam of the abdomen was negative. Apply code 0 (N0, no regional lymph node metastasis).

Data Item :

Clin M

Correct Answer :

0

Rationale:

Per the AJCC Cancer Staging Manual, general instructions, a case with no symptoms or signs of metastasis is classified as clinically M0.

The 03/11/2014 CT scan showed muliple liver hypodensities and an ovarian cystic lesion. The 03/14/2014 pelvic ultrasound proved the ovarian lesion to a be a hydrosalpinx. The repeat CT scan on 03/21/2014 showed no evidence of metastasis. The physical exam was negative. There were no symptoms or findings the physician felt clinically suspicious for metastasis. Apply code 0 (M0, no distant metastasis).

Data Item :

Clin Stg Grp

Correct Answer :

2A

Rationale:

Per the exocrine and endocrine pancreas staging form, when the clinical TNM is cT3 cN0 cM0, apply code 2A (Stage IIA).

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

3

Rationale:

The 04/08/2014 distal pancreatectomy with splenectomy resection pathology report showed a 5.5 cm well differentiated neuroendocrine tumor of the pancreas focally invading into the spleen and peripancreatic fat. The margins were negative and no further extension was identified microscopically or by surgical observation. The physician staged this as T3, which is consistent with the surgical findings. Apply code 3 (T3, tumor extends beyond the pancreas but without involvement of the celiac axis or the superior mesenteric artery).

Data Item :

Path N

Correct Answer :

0

Rationale:

The 04/08/2014 distal pancreatectomy with splenectomy included resection of multiple regional lymph nodes, NOS. The pathology report addendum diagnosis showed the resected nodes were negative for metastatic carcinoma. Apply code 0 (N0, no regional lymph node metastasis).

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic examination of distant metastasis. Apply code BLANK.

Data Item :

Path Stg Grp

Correct Answer :

2A

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, for cases with known pT and pN categories, use the clinical M category to complete the pathologic stage group.

Per the exocrine and endocrine pancreas staging form, when the pathologic TNM is pT3 pN0 cM0, apply code 2A (Stage IIA).

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Data Item :

SS 2000

Correct Answer :

2

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has regional stage disease as the primary tumor pathologically invaded the peripancreatic fat and spleen per the resection pathology report. Both extension to the peripancreatic fat and spleen for a pancreatic tail primary are considered regional by direct extension. There were no regional lymph nodes or distant metastases. Apply code 2 (Regional, direct extension only).

Social History

White/Chinese male lives with his wife currently and they do not have any children. Primary payer at dx: Medicaid. Birthplace: New York.

Physical Exam

03/01/2014 – cc: Elevated PSA. HPI: The patient’s PSA’s have always been in the normal range. Unfortunately, in 12/2013, his PSA was 4.3 and a repeat PSA in 01/2014 was found to be persistently elevated at just about 5. He denies any major lower urinary tract symptoms, but has had a history of kidney stones. PE: Abd: He has a benign-feeling abdomen. Rectal: He has somewhat of an asymmetric prostate with mild amount of firmness on the right side. There were no overt nodules. Plan: Biopsy.

05/24/2014 – Treatment options discussed, including external beam, brachytherapy, combo of both and radical prostatectomy. Pt originally leaning towards external beam rads, but now leaning more toward surgery.

Labs

12/12/2013 – PTA PSA: elevated at 4.26

01/16/2014 – PSA: 5.37 ng/mL (0-4 nml range)

Operative Reports

03/22/2014 – Transrectal US guided prostate needle bx: Seminal vesicles normal. No hypoechoic peripheral zones noted w/in the prostate.

Stage

04/12/2014 – Clinical T1c, Gleason 3 + 4 = 7, PSA 5 with low volume disease per MD.

03/22/2014 – Path Report #1

Clinical Diagnosis/History:

Elevated PSA.

Final Diagnosis:

Prostate needle core biopsies as designated:

Right base: Carcinoma       Cancer length: 0.6cm    Total length: 3.2cm

Pos. cores: 1 of 3

Right mid: Non-neoplastic prostate tissue

Right apex: Non-neoplastic prostate tissue

Left base: Carcinoma       Cancer length: 0.3cm    Total Length: 2.9cm    Pos. cores: 1 of 3

Left mid: Non-neoplastic prostate tissue

Left apex: Non-neoplastic prostate tissue

Histologic Type: Adenocarcinoma (conventional type), NOS (81403)

Gleason grade: Primary: 3  Secondary: 4  = Score: 7

Secondary pattern represents <10% of the cancer

Perineural invasion: Not identified

Gross Description:

The following needle biopsies are received in formalin:

Specimen A:  Designated “right base, medial inked,” one inked, three cores; ranging from 0.2 to 1.7 cm in length.

Specimen B:  Designated “right mid, medial inked,” one inked, three cores; ranging from 0.3 to 2.2 cm in length.

Specimen C:  Designated “right apex, medial inked,” two inked, six cores; ranging from 0.4 to 1.7 cm in length.

Specimen D:  Designated “left base, medial inked,” three inked, three cores; ranging from 0.4 to 1.8 cm in length.

Specimen E:  Designated “left mid, medial inked,” two inked, three cores; ranging from 1.1 to 1.7 cm in length.

Specimen D:  Designated “left apex, medial inked,” one inked, four cores; ranging from 0.3 to 2.1 cm in length.

All are stained with hematoxylin, wrapped and submitted in corresponding cassettes.

Data Item :

Diagnosis Date

Correct Answer :

03/22/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the 03/22/2014 transrectal US guided prostate needle biopsy.

Data Item :

Primary Site

Correct Answer :

C619

Rationale:

The transrectal US guided prostate needle biopsy showed the primary tumor was in the prostate. Apply code C619 (prostate).

Data Item :

Laterality

Correct Answer :

0

Rationale:

Code 0 (not a paired site) when the primary site is not considered a paired site per SEER.

Data Item :

Histology

Correct Answer :

8140

Rationale:

The MP/H Rules (general rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. The patient underwent a transrectal US guided prostate needle biopsy on 03/22/2014 showing adenocarcinoma, NOS. The biopsy is the only and most representative specimen.

Per the MP/H Rules, Other Sites, apply rule H11 and code the histology when only one histological type is identified. Code the histology as 8140 (adenocarcinoma, NOS).

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology report, this is a malignant tumor. Code the behavior as /3 (malignant) when the primary tumor, or any portion of the primary tumor, is invasive.

Data Item :

Grade

Correct Answer :

2

Rationale:

Code the highest grade given from the primary tumor prior to neoadjuvant treatment using the special grade systems for solid tumors when applicable. The Gleason score is the special grade system for the prostate. Record the highest Gleason score from the biopsy, TURP or prostatectomy. This patient underwent a core biopsy showing Gleason primary pattern 3, secondary pattern 4, and Gleason score 7. Apply grade code 2.

Data Item :

Clin T

Correct Answer :

1C

Rationale:

The patient was noted to have an elevated PSA PTA. The digital rectal exam (DRE) on 03/01/2014 noted an asymmetric prostate with mild firmness, but no overt nodules were palpated. The 03/22/2014 transrectal ultrasound (TRUS) showed the seminal vesicles to be normal with no evidence of hypoechoic zones within the prostate.

The physician clinically staged this as T1c. This is consistent with the physical exam and imaging findings of a clinically inapparent prostate tumor. Adenocarcinoma was confirmed by biopsy. Apply code 1C (T1c, tumor identified by needle biopsy (e.g., because of elevated PSA)).

Data Item :

Clin N

Correct Answer :

0

Rationale:

The lymph nodes can be considered clinically negative based on the inapparent prostate tumor, clinically low stage disease, PSA less than 20 ng/ml, and treatment plan indicating treatment options usually given for a clinically localized tumor. Per the AJCC, most patients diagnosed in an environment of ubiquitous PSA screening will be at a low risk of positive nodes or metastases. When Gleason score is less than 7 and the PSA is less than 20 ng/ml, imaging studies are not helpful and seldom recommended for these patients. There was no clinical suspicion for regional lymph node involvement. Apply code 0 (N0, no regional lymph node metastasis).

Data Item :

Clin M

Correct Answer :

0

Rationale:

Per the AJCC Cancer Staging Manual, general instructions, a case with no symptoms or signs of metastasis is classified as clinically M0.

The transrectal ultrasound did not reveal extensive disease. The physical exam was negative. There were no symptoms or findings the physician felt clinically suspicious for metastasis. Apply code 0 (M0, no clinical or radiographic evidence of distant metastases).

Data Item :

Clin Stg Grp

Correct Answer :

2A

Rationale:

Per the prostate staging form, when the clinical TNM is cT1c CN0 cM0 with a PSA less than 20 ng/ml, and a Gleason score of 7, apply code 2A (Stage IIA).

Note: This patient does not have Stage I disease. Gleason X indicates the Gleason score cannot be processed; it does not indicate any Gleason score value applies.

For prostate, prognostic factors are required to assign the clinical stage group. Use findings from the clinical assessment only (e.g., prostate biopsy). Findings from the pathologic assessment (e.g., prostatectomy) are excluded.

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

BLANK

Rationale:

Per the site-specific pathologic staging rules for prostate (Chapter 41), a pathologic T value cannot be assigned in the absence of a surgical resection, or a biopsy proving T3 or T4 disease for a prostate primary.

There was no resection of the primary tumor. The patient was leaning towards surgery, but it has not been performed yet. The primary tumor was not eligible for pathologic staging. Apply code BLANK.

Note: Click here to open “TNM_Document.pdf” which describes general rules for developing preferred answers in SEER*Educate.

Data Item :

Path N

Correct Answer :

BLANK

Rationale:

Per Table 1.6, N Classification Rules, a pathologic N value cannot be assigned in the absence of a surgical resection. Although Table 1.6 also states a biopsy confirming the highest N may be used, it is used only in appropriate circumstances where the pathologic staging criteria for the site has been met.

The patient did not undergo a lymph node resection. The patient was leaning towards surgery, but it has not been performed yet. The regional lymph nodes were not eligible for pathologic staging. Apply code BLANK.

Note: Click here to open “TNM_Document.pdf” which describes general rules for developing preferred answers in SEER*Educate.

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic examination of distant metastasis. Apply code BLANK (Not recorded).

Data Item :

Path Stg Grp

Correct Answer :

BLANK

Rationale:

There was no surgical resection of the primary tumor and/or regional lymph nodes. The patient was leaning towards surgery, but it has not been performed yet. Apply code BLANK.

Note: Click here to open “TNM_Document.pdf” which describes general rules for developing preferred answers in SEER*Educate.

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Note: Click here to open “TNM_Document.pdf” which describes general rules for developing preferred answers in SEER*Educate.

Data Item :

SS 2000

Correct Answer :

1

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has local stage disease as the primary tumor is a clinically inapparent tumor (T1c). The patient has no regional lymph node or distant metastases. Apply code 1 (Localized only).

Social History

22 y/o BM, single w/ no children. Pt is South African but lived in Europe prior to immigrating to the US. HMO patient.

Physical Exam

04/18/2014 – cc: New dx of nonseminomatous germ cell tumor here for consult and management of mets disease. HPI: Pt was in normal health until he presented PTA w/ long-standing left testicular mass. He felt the mass was due to a trauma to his testicle approximately 2 years ago. U/S of scrotum revealed a likely mass. PTA CT Abd 03/20/2014 w/ 2 masses inferior to Lt kidney and anterior to psoas, one 7.7 cm the other 5 cm. No other abnl. Tumor markers normal with AFP of 1.5 ng/mL, hCG less than 2 mIU/mL and LDH 179 U/L. PTA Lt-sided orchiectomy on 03/27/2014 was stage pT1. PTA Chest CT 04/16/2014 w/ NE malignant spread. PE: Abd: No clear palpable masses. Genitourinary: Normal remaining Rt testicle. Lt scrotal contents w/ palpable abnormality, probable hematoma. IMP: Nonseminoma with immature teratoma and apparent retroperitoneal spread of disease. Marker negative. PLAN: Consulted colleagues at Outside Hospital who agreed that induction chemo is warranted in this case.

Scans

04/18/2014 – Scrotal U/S: Lt side testis removed. There is a Lt scrotal complex mass w/ surrounding complex fluid. This could represent a hematoma w/ surrounding hematocele.

07/17/2014 – CT Abd/Pelvis: Two cystic metastases (4.5 X 3.2 cm and 5.3 X 5.1 cm) overlying the left psoas muscle, one is stable while the other has decreased in size.

Labs

08/17/2014 – LDH: 179 U/L (80-190 U/L normal)

08/17/2014 – AFP: <5.0 ng/mL (0.0-8.5 ng/mL normal)

08/17/2014 – HCG: <1 mIU/mL (0-5 mIU/mLnormal)

Operative Reports

08/29/2014 – Cystoscopy, Lt retrograde pyelogram, Lt ureteric stent placement, Lt ureterolysis and bilateral RPLND: Two large para-aortic masses. Lt ureter was densely adherent to both masses.

Treatment Plan

07/23/2014 – After much consultation, it was decided to proceed w/ BEP chemotherapy ending approximately 3 weeks ago PTA, which caused shrinkage of these masses. Next step should be removal of these retroperitoneal masses, begin surgical planning.

Chemo Text

05/01/2014 – PTA Started Bleomycin, Etoposide, Platinum.

03/27/2014 – Path Report #1

Clinical Diagnosis/History:

Slide review.  Testis cancer.

Final Diagnosis:

Outside Laboratory (03/27/2014)

Left testicle, radical orchiectomy:  Non-seminomatous germ cell tumor consisting only of immature teratoma with the following features:

  1. Size: 6.0 cm.
  2. Extent of invasion: Immature teratoma confined to testis.
  3. Intratubular germ cell neoplasia: Present.
  4. Spermatic cord margin: Negative.
  5. Angiolymphatic invasion: Not identified.
  6. Minimum pathologic stage: pT1NX (AJCC 7th Edition, 2010).

Materials Received:

Specimen A: Left testicle, radical orchiectomy

08/29/2014 – Path Report #2

Clinical Diagnosis/History:

Testicular cancer.

Final Diagnosis:

  1. A) Designated “tissue for disposal,” excision: Mature adipose tissue with no significant pathologic abnormalities.
  1. B) Designated “left abdominal mass,” excision: Mass (11.0 x 7.5 x 5.0 cm) with immature teratoma with histologic features consistent with treatment effect.
  1. C) Designated “psoas mass,” excision: Skeletal muscle with no germ cell tumor.
  1. D) Designated “aortocaval mass,” excision: Three lymph nodes with no germ cell tumor.
  1. E) Lymph nodes, paracaval and right iliac, lymphadenectomy: One lymph node with no germ cell tumor.
  1. F) Distal left spermatic cord, excision: Spermatic cord with no significant pathologic abnormalities.

Gross Description:

Specimen A:  Received fresh labeled “tissue for disposal” is an 11.0 x 6.5 x 2.0 cm irregular fragment of fibrofatty tissue partially covered by smooth white membranes.  No firms masses are identified upon palpation.  A representative section is submitted in cassette A1.

Specimen B:  Received fresh labeled “left abdominal mass” is a 201 g, 11.0 x 7.5 x 5.0 cm unoriented, boggy, fluctuant mass.  The surfaced is inked black.  Sectioning of the mass reveals multiple cystic areas lined by granular bright yellow material and solid, white, tessellated areas.  The white tessellated areas come to within 0.2 cm of the surgical margin.  The frozen section residue is transferred to cassette B1.  Cassette B2 – white tessellated area including closest margin, B3 – tumor, representative sections.

Specimen C:  Received fresh labeled “psoas mass” are two tan-pink nodules of tissue, one is 1.2 x 0.8 x 0.3 cm and the other is 1.6 x 1.1 x 0.6 cm.  The frozen section residue is transferred to cassette C1 and the remainder of the specimen is entirely submitted in cassette C2.

Specimen D:  Received fresh labeled “aortocaval mass” is a tan-pink irregular portion of soft tissue (4.0 x 3.2 x 1.5 cm).  The specimen is palpated and no firm masses are identified.  Serial-sectioning reveals fibrofatty cut surfaces and portions of skeletal muscle.  Representative sections are submitted in cassettes D1-D2.

Specimen E:  Received in formalin labeled “paracaval and right iliac” is a 7.0 x 1.5 x 0.7 cm tan-yellow fatty portion of tissue containing a small amount of lymph node tissue.  The specimen is sectioned and entirely submitted in cassettes E1-E2.

Specimen F:  Received in formalin labeled “distal left spermatic cord” is a tubular structure (8.0 cm in length, 0.2 cm to 0.4 cm in diameter) and attached adipose tissue.  There is a long suture attached to one end.  The margin with the long suture is inked blue and the other margin is inked black.  There is a small amount of attached adipose tissue.  Representative sections are submitted in cassette F1.

Frozen Section Diagnosis:

BFS)  Left abdominal mass:  Metastatic germ cell tumor with features of immature teratoma.

CFS)  Psoas mass:  Skeletal muscle with no neoplasm identified.

Data Item :

Diagnosis Date

Correct Answer :

03/27/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the PTA 03/27/2014 left orchiectomy. The PTA CT scan on 03/20/2014 did not give a reportable, clinical diagnosis.

Data Item :

Primary Site

Correct Answer :

C621

Rationale:

The PTA scrotal ultrasound and PTA surgical resection on 03/27/2014 showed the primary tumor was in the left testicle. While the physical exam information and pathology report do not specifically state the testicle was descended, this can be inferred from the physical exam information. The patient noted a long-standing history of a left testicular mass which was confirmed on scrotal ultrasound. A self-palpated mass in the testicle implies that this testicle is a descended testicle. An undescended testis (a testis absent from the normal scrotal position) would be non-palpable. Apply code C621 (descended testis, scrotal testis).

Data Item :

Laterality

Correct Answer :

2

Rationale:

Code 2 (Left) when the primary site is a paired site and the primary tumor originated on the left.

Data Item :

Histology

Correct Answer :

9080

Rationale:

The MP/H Rules (general rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. The PTA left orchiectomy is the most representative specimen in this case, and it showed a non-seminomatous germ cell tumor consisting only of immature teratoma.

The final diagnosis gives two reportable histologies. Non-seminomatous germ cell tumor (histology code 9065/3) and immature teratoma (histology code 9080/3). Both are types of germ cell neoplasms per the ICD-O-3. This is not a mixed tumor. The non-seminomatous germ cell tumor was further characterized as being entirely an immature teratoma. Per the MP/H Rules, Other Sites, apply rule H17 and code the histology with the numerically higher ICD-O-3 code. Code the histology as 9080 (immature teratoma, NOS).

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the orchiectomy pathology report, this is a malignant tumor. Code the behavior as /3 (malignant) when the primary tumor, or any portion of the primary tumor, is invasive.

Data Item :

Grade

Correct Answer :

9

Rationale:

The grade is unknown. The review of slide of the orchiectomy pathology did not give a grade for the immature teratoma. The grade cannot be coded when no grade is given on the pathology specimen or there is no clinical statement of the primary tumor’s grade specified in the medical record. No grade was given for this patient’s testicular primary. Apply code 9 (unknown, not stated).

Data Item :

Clin T

Correct Answer :

X

Rationale:

Per the AJCC Cancer Staging Manual and CAnswer Forum, the clinical TX category is assigned for most cases of testicular cancer. The extent of the primary tumor is usually classified after radical orchiectomy and only a pathologic stage is assigned. Although the patient underwent a PTA scrotal ultrasound showing a mass, the extent of the tumor within the testicle/scrotum is not assessed clinically. Apply code X (TX, primary tumor cannot be assessed).

Data Item :

Clin N

Correct Answer :

3

Rationale:

The PTA 03/20/2014 CT scan identified two masses inferior to the left kidney and anterior to the psoas muscle (in the retroperitoneal region) measuring 7.7 cm and 5 cm in size. The physician’s impression was that this patient had apparent retroperitoneal spread of disease per the 04/18/2014 physical exam note.

Although the masses were not specifically stated to represent involvement of retroperitoneal lymph nodes, in the absence of conflicting information, it can be assumed the retroperitoneal involvement was lymph node involvement. The patient’s presentation with retroperitoneal masses (retroperitoneal nodal involvement) is characteristic of the usual spread of testicular cancer, and the patient received chemotherapy for the retroperitoneal metastasis.

The patient has clinical evidence of at least one metastatic lymph node mass measuring more than 5 cm. The largest retroperitoneal mass measured 7.7 cm prior to chemotherapy. Apply code 3 (N3, metastasis with a lymph node mass more than 5 cm in greatest dimension).

Data Item :

Clin M

Correct Answer :

0

Rationale:

Per the AJCC Cancer Staging Manual, general instructions, a case with no symptoms or signs of metastasis is classified as clinically M0.

The PTA 03/20/2014 CT scan demonstrated the retroperitoneal masses, but no other abnormalities. The PTA 04/16/2014 chest CT scan showed no evidence of metastatic disease. The physical exam was negative. There were no symptoms or findings the physician felt clinically suspicious for metastasis. Apply code 0 (M0, no distant metastasis).

Data Item :

Clin Stg Grp

Correct Answer :

2C

Rationale:

Serum tumor markers are required to determine the Stage Group for testicular primaries. The serum tumor marker studies used to assign the stage must be the studies performed immediately after orchiectomy, taking into account the half-life of AFP and hCG (5-7 days and 1-3 days respectively). While pre-operative tumor markers are usually performed, they are not taken into account when assigning the Stage Group. An exception: when the pre-operative tumor markers are negative and no post-operative studies are performed, use the pre-operative studies for the purpose of assigning stage.

The patient’s pre-orchiectomy serum tumor markers were negative, consistent with S0 disease. Per the testis staging form, when the clinical TNM is cTX cN3 cM0 with Serum Tumor Markers S0, apply code 2C (Stage IIC).

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

1

Rationale:

The PTA 03/27/2014 left radical orchiectomy identified immature teratoma, 6 cm in size, that was confined to the testis. Intratubular germ cell neoplasia was present, but there was no lymphatic invasion and the margins were negative. The pathologist staged this as T1, which is consistent with the pathology findings. Apply code 1 (T1, tumor limited to the testis and epididymis without vascular/lymphatic invasion).

Data Item :

Path N

Correct Answer :

3

Rationale:

The patient has clinical and pathologic evidence of N3 disease. The patient clinically had retroperitoneal lymph node metastases and proceeded with chemotherapy following orchiectomy. The 08/29/2014 bilateral retroperitoneal lymph node dissection (RPLND) intraoperatively identified the two large para-aortic masses (the clinically identified retroperitoneal masses).

The 08/29/2014 pathology report showed treatment effect, but identified an 11.0 cm “left abdominal mass” that was positive for immature teratoma. In addition, a “psoas mass” was negative, three aortocaval lymph nodes were negative and a paracaval/right iliac lymph node was negative. The “left abdominal mass” is one of the para-aortic masses identified intraoperatively, and should be assumed to represent at least one positive lymph node.

Per the AJCC Cancer Staging Manual (Chapter 42, Testis), in post-treatment specimens it may be difficult to distinguish individual nodes from a mass. Since the pathology report does not clarify the number of positive nodes, this patient has at least one lymph node metastasis in the large 11.0 cm mass. Apply code 3 (N3, metastasis with a lymph node mass more than 5 cm in greatest dimension).

Although the left abdominal mass was not pathologically stated to represent an involved retroperitoneal lymph node, in the absence of conflicting information, it can be assumed this was retroperitoneal lymph node involvement. The patient’s presentation with retroperitoneal masses (retroperitoneal nodal involvement) is characteristic of the usual spread of testicular cancer.

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic examination of distant metastasis. Apply code BLANK (Not recorded).

Data Item :

Path Stg Grp

Correct Answer :

2C

Rationale:

Serum tumor markers are required to determine the Stage Group for testicular primaries. The serum tumor marker studies used to assign the stage must be the studies performed immediately after orchiectomy, taking into account the half-life of AFP and hCG (5-7 days and 1-3 days respectively). While pre-operative tumor markers are usually performed, they are not taken into account when assigning the Stage Group. An exception: when the pre-operative tumor markers are negative and no post-operative studies are performed, use the pre-operative studies for the purpose of assigning stage.

The patient’s pre-orchiectomy serum tumor markers were negative, consistent with S0 disease. Per the testis staging form, when the pathologic TNM is pT1 pN3 cM0 with Serum Tumor Markers S0, apply code 2C (Stage IIC).

Data Item :

Path Desc

Correct Answer :

0

Rationale:

Per Table 1.9, yp is used for pathologic postneoadjuvant systemic or radiation therapy followed by surgical resection.

There are no pathologic descriptors that apply to this case. To be considered neoadjuvant treatment, radiation or systemic treatment must be the first treatment.  In this case, the patient had primary site surgery first.  Apply code 0.

Data Item :

SS 2000

Correct Answer :

3

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has regional lymph node(s) involved only. The primary testis tumor was pathologically confined to the testis. The patient had clinical and pathologic evidence of metastatic disease involving the retroperitoneal lymph nodes. There were no distant metastases. Apply code 3 (Regional, regional lymph node(s) involved only).

Social History

Social History: 54 y/o female. BP: OK. Mother is Cherokee. Father, Caucasian. Presents today w/ partner. Insurance: IHS.

Physical Exam

02/14/2014 – HPI: Recently diagnosed adenocarcinoma of GE junction. Last several months noticed worsening reflux, treated w/ Prilosec w/ some improvement. PTA underwent EGD on 01/31/2014 which showed a 3 cm ulcerated, fungating mass in GE junction, bx positive for moderately differentiated adenocarcinoma. PTA PET scan revealed mets disease. PTA oncology consult recommended chemo. Here for 2nd opinion. IMP: GE junction adenocarcinoma w/ mets to liver and abd LNs.

04/23/2014 – Oncology consult: GE junction adenocarcinoma w/ mets to liver and gastrohepatic LNs. Good response radiographically to FOLFOX (completed 4 cycles). Decrease in sizes of primary tumor, hepatic mets and gastrohepatic LNs.

Scans

02/04/2014 – PTA PET: Staging PET scan showed primary tumor in gastric cardia/GE junction w/ multiple avid LNs in para-aortic and retroperitoneal regions, multiple mets throughout both lobes of liver.

02/20/2014 – CT Chest/Abd/Pelvis: Large GE junction mass extending along lesser and greater curvatures measures 4.0 x 3.7 cm (previously measured 4.2 x 3.6 cm on PTA scan). Enlarged gastrohepatic and para-aortic LNs, interval increase in size of multiple liver foci. No bone mets.

04/22/2014 – CT Chest/Abd/Pelvis: Decrease in size of primary tumor, hepatic metastases, and gastrohepatic LNs.

09/10/2014 – CT Chest/Abd/Pelvis: Stable appearance of primary GE junction tumor and liver mets. Stable gastrohepatic LN.

Treatment Plan

02/14/2014 – Plan: Disease is incurable, no surgery or radiation recommended, but pt is a good candidate for chemotherapy. Proceed w/ FOLFOX chemotherapy plus/minus Trastuzumab depending on HER2 status.

03/01/2014 – FISH negative for HER2, pt will not be treated with Trastuzumab.

Chemo Text

03/01/2014 – Started FOLFOX.

08/27/2014 – Started Capecitabine. Pt transitioned to single agent Capecitabine on 08/10/2014 following nine cycles of FOLFOX w/ good response but escalating toxicities.

02/13/2014 – Path Report #1

Clinical Diagnosis/History:

Slide review.

Final Diagnosis:

Outside Laboratory (1/31/2014)

Duodenum, second part, biopsy (part A):  Small bowel mucosa with no diagnostic alterations.

Stomach, antrum, biopsy (part B):  Antral mucosa with no diagnostic alterations, including no intestinal metaplasia or dysplasia.

Gastroesophageal junction, mass, biopsy (part C):  Invasive moderately differentiated adenocarcinoma undermining squamous mucosa and two fragments of gastric mucosa.

Microscopic Description:

A recut slide confirms residual invasive carcinoma in the block.

IHC Interpretation:

Moderate basolateral membranous reactivity by immunohistochemical stain, equivocal for over-expression.

Addendum Reason:

This addendum is issued to report the results of HER2/neu studies, as requested by the clinician.

Note:

By analogy to ASCO/CAP Guideline Recommendations for HER2/neu testing in breast cancer (Arch Pathol Lab Med 131: 18-43, 2007), ratios of less than 1.8 are interpreted as negative, ratios of more than 2.2 are interpreted as positive, and ratios between 1.8 and 2.2 are interpreted as equivocal for gene amplification.  Alternatively, cancers having > 6 signals of HER2 per nucleus are considered positive, < 4 signals per cell are negative and 4-6 signals/cell are equivocal.

Note:

The interpretation criteria for gastric cancer are those of Hofmann, et al with a HER2/CEP17 ratio of >= 2.0 being considered positive (Hofmann, et al. Histopathology 2008; 52:797-805.  Assessment of a HER2 Scoring System for Gastric Cancer: Results from a Validation Study).

Immunohistochemistry Studies:

Specimen A3:  Population: Carcinoma cells

HER2 (w/HEIR) C-erbB-2,  (w/ HIER)  Equivocal for over-expression (2+)

.

DNA Analysis:

Unstained sections are prepared and regions of invasive carcinoma are marked by comparison with H&E-stained sections from the same block.  Fluorescence in situ hybridization for the HER2/neu gene is then carried out using the FDA-approved Vysis Path Vysion HER2 DNA probe kit.  The prepared slides are then viewed under a fluorescent microscope with appropriate filters for the chromosome 17 probe (green), the HER2/neu probe (orange) and DNA (blue) to localize nuclei.  Signals are counted from up to 60 cells and the ratio of HER2/neu to chromosome 17 signals is computed.  Control slides from non-amplified and low-level amplified tumor cells are prepared simultaneously to ensure reproducibility between assays.  Results are listed in the table below:

Specimen A3:  Population: Carcinoma cells

FISH H2N/17 ICC FISH Chromosome 17 PROBE 2.3 signals/cell

FISH H2N/17 ICC FISH HER2Neu PROBE 3.7 signals/cell

Ratio: 1.6  Interpretation: Not amplified

Addendum – Final Diagnosis:

Outside Laboratory (01/31/2014)

Gastroesophageal junction, mass, biopsy (part C):  Invasive moderately differentiated adenocarcinoma NEGATIVE for gene amplification of HER2/neu by fluorescence in situ hybridization technique.

Data Item :

Diagnosis Date

Correct Answer :

01/31/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the PTA 01/31/2014 endoscopy with biopsy (EGD).

Data Item :

Primary Site

Correct Answer :

C160

Rationale:

The endoscopic biopsies, CT scans and PET scan showed the primary tumor was in the GE junction. Apply code C160 (gastroesophageal junction).

Data Item :

Laterality

Correct Answer :

0

Rationale:

Code 0 (not a paired site) when the primary site is not considered a paired site per SEER.

Data Item :

Histology

Correct Answer :

8140

Rationale:

The MP/H Rules (general rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. In this case the patient underwent a biopsy of the GE junction mass only. The biopsy is the only and most representative specimen, and it showed invasive adenocarcinoma. Per the MP/H Rules, Other Sites, apply rule H11 and code the histology when only one histologic type is identified. Code the histology as 8140 (adenocarcinoma, NOS).

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology report, this is a malignant tumor. Code the behavior as /3 (malignant) when the primary tumor, or any portion of the primary tumor, is invasive.

Data Item :

Grade

Correct Answer :

2

Rationale:

Code the highest grade given from the primary tumor. Use the grade conversion tables in the SEER Manual when there are no site-specific coding guidelines that apply. Per the Terminology Conversion table, moderately differentiated is coded as SEER code 2.

Data Item :

Clin T

Correct Answer :

X

Rationale:

The PTA 01/31/2014 EGD (endoscopy) showed a 3 cm ulcerated, fungating mass in the GE junction that was biopsy positive for adenocarcinoma. The PTA 02/04/2014 PET scan showed a primary tumor in the gastric cardia/GE junction. The 02/20/2014 CT scan showed a 4.0 cm GE junction mass (previously measured 4.2 cm on PTA scan) extending along the lesser and greater curvatures of the stomach.

None of the scans documented the depth of the tumor invasion. The T category is assigned based on depth of invasion, not based on tumor size. The imaging only noted the location and the size.  Based on imaging, it is unclear if the primary tumor invaded surrounding tissues or organs or if the primary tumor was confined to the esophageal wall; therefore, the extent of the primary tumor is unknown.  Apply code X (TX, primary tumor cannot be assessed).

Data Item :

Clin N

Correct Answer :

1

Rationale:

The PTA 02/04/2014 PET scan identified avid lymph nodes in the para-aortic and retroperitoneal regions. Both para-aortic and retroperitoneal nodes are distant nodes for a GE junction primary. The 02/20/2014 CT scan showed enlarged gastrohepatic and para-aortic nodes.

The 02/14/2014 physical exam note indicates the physician’s impression was GE junction adenocarcinoma with metastases to the liver and abdominal lymph nodes. The 04/23/2014 oncology note indicates the patient has metastases to the liver and gastrohepatic lymph nodes. Based on the oncologist’s assessment, this patient has regional abdominal (gastrohepatic) lymph node metastases.

The number of involved gastrohepatic lymph nodes was not clinically noted, and there is no documentation that can be used to estimate the number of involved nodes. Per the AJCC Cancer Staging Manual, when the N category is unclear (e.g., N1 vs. N2), assign the lower N category. The patient has at least N1 disease; therefore, apply code 1 (N1, metastasis in 1-2 regional lymph nodes).

Data Item :

Clin M

Correct Answer :

1

Rationale:

The PTA 02/04/2014 PET scan showed multiple metastases throughout both lobes of the liver. The PET scan also showed avid para-aortic and retroperitoneal lymph nodes (distant nodes), but there was no definitive statement that these distant nodes were involved. The 04/23/2014 oncology note only indicated regional lymph node and liver metastases.

The 02/20/2014 CT scan again identified the liver metastases, but showed no bone metastases. Although the distant nodes were not clearly stated to be involved, the patient does have definitive evidence of liver metastases. Apply code 1 (M1, distant metastasis).

Data Item :

Clin Stg Grp

Correct Answer :

4

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, a clinical Stage Group cannot be assigned when the T or N categories are assigned an X value. One exception: any combination of TX or NX with M1 is classified as Stage IV.

Per the esophagus (adenocarcinoma) staging form, when the clinical TNM is cTX cN1 cM1 with any primary tumor grade, apply code 4 (Stage IV).

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

BLANK

Rationale:

Per Table 1.5, T classification rules, a pathologic T value cannot be assigned in the absence of a surgical resection. Although Table 1.5 also states a biopsy confirming the highest T may be used, it is used only in appropriate circumstances where the pathologic staging criteria for the site has been met.

The treatment plan did not include surgical resection of the primary tumor. The patient’s disease was incurable and surgery was not recommended. The primary tumor was not eligible for pathologic staging. Apply code BLANK.

Data Item :

Path N

Correct Answer :

BLANK

Rationale:

Per Table 1.6, N Classification Rules, a pathologic N value cannot be assigned in the absence of a surgical resection. Although Table 1.6 also states a biopsy confirming the highest N may be used, it is used only in appropriate circumstances where the pathologic staging criteria for the site has been met.

The patient did not undergo a lymph node resection. The patient’s disease was incurable and surgery was not recommended. There was no removal of regional lymph nodes; therefore, the lymph nodes were not eligible for pathologic staging. Apply code BLANK.

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic examination of distant metastasis. Apply code BLANK (Not recorded).

Data Item :

Path Stg Grp

Correct Answer :

BLANK

Rationale:

There was no surgical resection of the primary tumor and/or regional lymph nodes. The patient’s disease was incurable and the treatment plan was for systemic treatment alone. Apply code BLANK.

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Data Item :

SS 2000

Correct Answer :

7

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has distant stage disease as the patient was diagnosed with metastases to the liver on imaging. The primary tumor extension could not be determined, but there was clinical evidence of regional lymph node involvement.

The presence of liver metastases alone is always coded as distant stage disease, regardless of the tumor involvement or whether regional lymph nodes were involved. Apply code 7 (Distant site(s)/lymph node(s) involved).

Social History

Social History: 36 y/o Jamaican male. BP: Jamaica. Pt recently divorced and moved here to live w/ his sister. Not currently insured (self-pay).

Physical Exam

03/01/2014 – HPI: Pre-op assessment for GE junction adenocarcinoma.

03/12/2014 – GI Oncology Note: Several month hx of epigastric pain and progressive dysphagia. EGD on 02/05/2014 showed a nearly obstructing mass in distal esophagus from 38 to 45 cm (Abstractor note: path negative). Endoscopy w/ bx on 02/13/2014 was positive for poorly differentiated adenocarcinoma. On 02/13/2014 EUS, lesion appeared to be at least T3. IMP: Metastatic adenocarcinoma of the GE junction. Plan: Discussed systemic therapy w/ FOLFOX and option of supportive care only. Pt is interested in systemic therapy. Pt will have a port-a-cath placed.

03/19/2014 – Palliative Care Consult: Pt had G-tube dysfunction on 03/14/2014 resulting in peritonitis. IMP: Currently not eligible for chemotherapy. Recommend discharge home w/ hospice.

Scans

02/07/2014 – CT Chest/Abd/Pelvis: Large eccentric mass (3.8 x 3.0 x 8.4 cm) centered around the GE junction extending superiorly into the distal esophagus and inferiorly into the gastric cardia, with necrosis. Mass abuts left gastric artery and extends to celiac axis, w/ no evidence of vascular invasion. No large paraesophageal LNs. Small amount free fluid in pelvis.

02/27/2014 – PET/CT Mid-body: Uptake in distal esophagus and gastric cardia c/w primary malignancy w/ mucosal spread. Hypermetabolic LNs in paraesophageal region, porta hepatis and posterior to Lt renal vein. Perihepatic ascites. Lungs and bones negative.

Scopes

02/13/2014 – EUS/EGD with biopsies: In distal esophagus, there was large mass, appeared to measure 2.1 x 3.7 cm, clearly involved the muscularis propria (T2) and in some areas concerning for T3 disease. No LNs that met EUS criteria for malignancy. Staging EUS c/w T3 N0 lesion, although it should be noted that this staging was incomplete because not able to pass scope through mass, nor were we able to examine for lymphadenopathy distal to mass.

Operative Reports

03/05/2014 – Diagnostic laparoscopy, aspiration of ascites, peritoneal bx, placement of feeding gastrostomy tube: 1 liter malignant green ascites removed. Evidence of peritoneal mets both in upper abd and pelvis. Representative area from left upper quadrant peritoneum biopsied and sent to pathology, clearly a metastasis.

Stage

03/05/2014 – Per MD note: Stage IV gastroesophageal junction adenocarcinoma w/ malignant ascites and peritoneal metastasis.

02/13/2014 – Path Report #1

Clinical Diagnosis/History:

Dysphagia.  Mass at GE junction.  Question adenocarcinoma.

Final Diagnosis:

Specimen A,B:  Esophageal mass, biopsies:  Adenocarcinoma, moderately-to-poorly differentiated, involving squamocolumnar junctional mucosa.  No definite goblet cell metaplasia identified by HEABS stain in each part.

Specimen C:  Gastric cardia, biopsy:  Adenocarcinoma, diffuse type with occasional signet ring cells, involving gastric cardiac-type mucosa.  No Helicobacter pylori organisms identified by Genta stain with an appropriately positive control.

Addendum Reason:

This addendum is issued to report FISH study for HER2 gene.

FISH Interpretation:

Specimen A:  Adenocarcinoma is positive for HER2 gene amplification by FISH study.

Note:

Per the ASCO/CAP Guideline Recommendations for HER2/neu testing in breast cancer (Arch Pathol Lab Med 131: 18-43, 2007), ratios of less than 1.8 are interpreted as negative, ratios of more than 2.2 are interpreted as positive, and ratios between 1.8 and 2.2 are interpreted as equivocal for gene amplification.  Alternatively, cancers having > 6 signals of HER2 per nucleus are considered positive, < 4 signals per cell are negative and 4-6 signals/cell are equivocal.

Gross Description:

Specimen A:  Received in neutral buffered formalin and labeled with the patient’s name is a specimen designated “esophageal mass,” comprising multiple pieces of tan white tissue measuring 0.1 cm to 0.5 cm.  Submitted in total in 1 cassette.

Specimen B:  Received in neutral buffered formalin and labeled with the patient’s name is a specimen designated “esophageal mass,” comprising multiple pieces of tan white tissue measuring 0.1 cm to 0.7 cm.  Submitted in total in 1 cassette.

Specimen C:  Received in neutral buffered formalin and labeled with the patient’s name is a specimen designated “gastric cardia,” comprising 4 pieces of tan white tissue measuring 0.2 cm to 0.6 cm.  Submitted in total in 1 cassette.

Microscopic Description:

A recut slide confirms residual invasive carcinoma in the block A1.

DNA Analysis:

Unstained sections are prepared and regions of invasive carcinoma are marked by comparison with H&E-stained sections from the same block.  Fluorescence in situ hybridization for the HER2/neu gene is then carried out using the FDA-approved Vysis Path Vysion HER2 DNA probe kit.  The prepared slides are then viewed under a fluorescent microscope with appropriate filters for the chromosome 17 probe (green), the HER2/neu probe (orange) and DNA (blue) to localize nuclei.  Signals are counted from up to 60 cells and the ratio of HER2/neu to chromosome 17 signals is computed.  Control slides from non-amplified and low-level amplified tumor cells are prepared simultaneously to ensure reproducibility between assays.  Results are listed in the table below:

Specimen A1:  Population: Neoplastic cells

FISH H2N/17 ICC FISH Chromosome 17 PROBE 1.4 signals/cell

FISH H2N/17 ICC FISH HER2Neu PROBE 3.6 signals/cell

Ratio: 2.57  Interpretation: Positive for HER2 gene amplification

03/05/2014 – Path Report #2

Clinical Diagnosis/History:

Esophageal cancer G-tube placement.  150.9.

Final Diagnosis:

Peritoneum, biopsy: Positive for poorly differentiated malignant neoplasm consistent with adenocarcinoma.

Diagnosis Comment:

Concurrent ascitic fluid is positive for malignancy, consistent with adenocarcinoma.

Gross Description:

Specimen A:  Received in a container of formalin labeled “peritoneum” is a 1.5 x 0.6 x 0.2 cm tan, rubbery portion of tissue.  The specimen is bisected and entirely submitted in cassette A1.

03/05/2014 – Path Report #3

Clinical Diagnosis/History:

Patient with recently diagnosed esophageal adenocarcinoma in Feb 2014, presents for surgical management.

Diagnosis Comment:

A total of 240 mls of orange fluid is received, from which two alcohol fixed, Papanicolaou stained smears and one H&E stained cell block slide are prepared.  Slides contain numerous markedly atypical epithelial cells, present singly and in small, loosely cohesive groups.  Atypical cells have nuclear enlargement, hyperchromasia, prominent macronucleoli, and pale, sometimes vacuolated cytoplasm.  The findings are positive for malignancy, most consistent with adenocarcinoma and compatible with this patient’s known history of gastroesophageal junction adenocarcinoma.  Please refer to concurrent surgical pathology case for additional details.

Cytologic Impression:

Fluid:  Positive for malignancy, consistent with adenocarcinoma.  See comment.

Data Item :

Diagnosis Date

Correct Answer :

02/13/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the 02/13/2014 endoscopy with biopsy (EGD). The CT scan on 02/07/2014 did not conclusively diagnose a malignancy.

Data Item :

Primary Site

Correct Answer :

C160

Rationale:

The endoscopic biopsies, CT and PET scans and Oncology Note indicates the primary tumor arose from the GE junction. While the biopsies showed both esophageal and gastric involvement, this tumor was centered at the GE junction and extended into the distal esophagus and gastric cardia per the scan information. Apply code C160 (gastroesophageal junction), the site the tumor originated in, even if it extends to an adjacent site.

Data Item :

Laterality

Correct Answer :

0

Rationale:

Code 0 (not a paired site) when the primary site is not considered a paired site per SEER.

Data Item :

Histology

Correct Answer :

8145

Rationale:

The MP/H Rules (general rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue, from the primary tumor. This patient underwent biopsies of the overlapping GE junction tumor from the distal esophagus as well as the gastric cardia. The biopsy of the peritoneal metastasis is not used to code the histology because it is a metastatic site.

The distal esophagus biopsy showed adenocarcinoma (NOS). The gastric cardia biopsy showed adenocarcinoma, diffuse type. Per the MP/H Rules, Other Sites, apply rule H13 and code the most specific histologic term when the diagnosis is adenocarcinoma and a more specific type of adenocarcinoma. Adenocarcinoma, diffuse type is a more specific histology. Code the histology as 8145 (adenocarcinoma, diffuse type).

Note: The presence of occasional signet ring cells does not change the histology coding. The term “occasional” is not used to code a more specific histology per the MP/H Rules. The pathologist also did not state this tumor had “signet ring cells features,” or had “signet ring cell differentiation,” etc. The tumor did not meet the criteria for signet ring cell adenocarcinoma; the tumor was not predominantly composed of signet ring cells. The pathologist only identified occasional signet ring cells throughout the biopsy.

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology report, this is a malignant tumor. Code the behavior as /3 (malignant) when the primary tumor, or any portion of the primary tumor, is invasive.

Data Item :

Grade

Correct Answer :

3

Rationale:

Code the highest grade given from the primary tumor. Use the grade conversion tables in the SEER Manual when there are no site-specific coding guidelines that apply. Per the Terminology Conversion table, moderately to poorly differentiated is coded as SEER code 3.

Data Item :

Clin T

Correct Answer :

3

Rationale:

The 02/07/2014 CT scan identified a large 8.4 cm mass centered in the GE junction that extended into the distal esophagus and gastric cardia. The mass was noted to abut the left gastric artery and extend to the celiac axis with no evidence of vascular invasion. The 02/13/2014 endoscopic ultrasound with esophagogastroduodenoscopy (EUS/EGD) identified a 3.7 cm mass in the distal esophagus involving the muscularis propria and in some areas concerning for T3 disease. The oncologist’s assessment was that the staging EUS was consistent with a T3 lesion. The 02/27/2014 PET scan noted mucosal spread only.

The celiac axis is located in the adjacent connective tissue and is in the same area as the left gastric artery. The tumor extended to the celiac axis, but did not invade the celiac artery. The tumor abutted the gastric artery only, there was no clear involvement of the gastric artery.

The staging work-up definitively proved involvement of the adventitia (adjacent connective tissue), but did not definitively identify involvement of adjacent structures (T4 disease). Apply code 3 (T3, tumor invades adventitia).

Data Item :

Clin N

Correct Answer :

X

Rationale:

The SEER*Educate panel was divided between X and 0. For the purpose of providing a single answer, X was selected.

The 02/07/2014 CT scan found no large paraesophageal lymph nodes. The 02/13/2014 endoscopic ultrasound (EUS) found no lymph nodes that met EUS criteria for malignancy (N0); however, it was also noted that the exam was incomplete and they were not able to examine for lymphadenopathy distal to the mass. The 02/27/2014 PET scan identified hypermetabolic lymph nodes in the paraesophageal region, porta hepatis and posterior to the left renal vein. No lymph nodes were noted during the diagnostic laparoscopy on 03/05/2014.

There was no further indication whether the “hypermetabolic” lymph nodes were felt to be involved, so it is unclear whether these represent lymph node metastases. The patient has extensive metastatic disease with no clear documentation whether the regional nodes are also involved. Apply code X (NX, regional lymph nodes cannot be assessed).

Note: The SEER*Educate panel was divided in their reconciliation of proposed answers. This issue has been forwarded to the standard setters as an area needing further clarification and training.

Data Item :

Clin M

Correct Answer :

BLANK

Rationale:

The 03/05/2014 peritoneum biopsy and paracentesis (performed at the time of the diagnostic laparoscopy) clinically and pathologically confirmed the presence of distant metastasis. The biopsy of a distant site was part of the clinical work-up, and is therefore included in the clinical M. The 03/05/2014 laparoscopy showed evidence of peritoneal metastases in both the upper abdomen and in the pelvis, though only one area of the upper peritoneum was biopsied. The physician’s assessment per the 03/12/2014 physical exam note confirmed metastatic adenocarcinoma of the GE junction.

The peritoneum biopsy and positive ascites are considered pM1 for both the clinical stage and the pathologic stage. A case with pM1 may grouped as clinical and pathologic when it was proven during the clinical work-up. The clinical evidence of metastasis is not recorded in both the clinical and pathologic M categories. Apply code BLANK for cM.

Data Item :

Clin Stg Grp

Correct Answer :

4

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, a clinical Stage Group cannot be assigned when the T or N categories are assigned an X value. One exception: any combination of TX or NX with M1 is classified as Stage IV.

Per the esophagus (adenocarcinoma) staging form, when the clinical TNM is cT3 cNX pM1 with any primary tumor grade, apply code 4 (Stage IV).

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

BLANK

Rationale:

Per Table 1.5, T classification rules, a pathologic T value cannot be assigned in the absence of a surgical resection. Although Table 1.5 also states a biopsy confirming the highest T may be used, it is used only in appropriate circumstances where the pathologic staging criteria for the site has been met.

The treatment plan did not include surgical resection of the primary tumor. The patient was not eligible treatment. The primary tumor was not eligible for pathologic staging. Apply code BLANK.

Data Item :

Path N

Correct Answer :

BLANK

Rationale:

Per Table 1.6, N Classification Rules, a pathologic N value cannot be assigned in the absence of a surgical resection. Although Table 1.6 also states a biopsy confirming the highest N may be used, it is used only in appropriate circumstances where the pathologic staging criteria for the site has been met.

The patient did not undergo a lymph node resection. The patient was not eligible for treatment. There was no removal of regional lymph nodes; therefore, the lymph nodes were not eligible for pathologic staging. Apply code BLANK.

Data Item :

Path M

Correct Answer :

1

Rationale:

The patient has pathologic evidence of distant metastasis. The patient underwent a peritoneal biopsy and paracentesis at the time of the diagnostic laparoscopy that were positive for malignancy, and were consistent with adenocarcinoma. In this case, the biopsy positive peritoneal metastasis and cytologically positive ascites qualify as both clinical and pathologic staging. Apply code 1 (M1, distant metastasis).

Data Item :

Path Stg Grp

Correct Answer :

4

Rationale:

Per the esophagus (adenocarcinoma) staging form, when the pathologic TNM is pT(Any) pN(Any) pM1 with any primary tumor grade, apply code 4 (Stage IV).

Although the T and N categories could not be assigned, not eligible for pathologic staging, any pathologic evidence of M1 disease allows the Stage Group to be determined.

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Data Item :

SS 2000

Correct Answer :

7

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has distant stage disease, as the patient was diagnosed with metastases to the peritoneum on diagnostic laparoscopy and biopsy. The primary tumor was regional stage, as the primary tumor extended into the adventitia (adjacent connective tissue) on imaging. Extension to the adjacent connective tissue is considered regional by direct extension. The status of the regional lymph nodes could not be determined.

The presence of peritoneal metastases alone is always coded as distant stage disease, regardless of the tumor involvement or whether regional lymph nodes were involved. Apply code 7 (Distant site(s)/lymph node(s) involved).

Social History

Spanish speaking male. Patient’s birthplace is Mexico. Marital status is divorced. Primary payer at diagnosis: Insurance, NOS.

Physical Exam

01/16/2014 – HPI: Pt admitted from ER w/ back and hip pain over last 2 months and painless hematuria. IMP: Gross hematuria concerning for neoplasm. Plan: CT IVP and TURBT/cytoscopy.

02/07/2014 – cc: Pt w/ metastatic TCC of bladder w/ bony mets, here to establish oncologic care. IMP: Aggressive TCC of bladder w/ bony mets, mets iliac and retroperitoneal adenopathy and partially resected bladder mass. Plan: Discussed chemo, would mainly be palliative, would like to improve symptom management before starting while patient thinks about this option.

03/26/2014 – Received notification from Hospice that patient died today.

Scans

01/16/2014 – CT IVP: Fungating soft tissue w/in bladder completely obstructing Rt ureteral orifice. Extensive retroperitoneal adenopathy highly suspicious for mets.

01/16/2014 – CT Lumbar Spine: Innumerable sclerotic lesions concerning for mets. These involve nearly all vertebral bodies, sacrum, bilat femurs and pelvic bones.

01/16/2014 – CT Abd/Pelvis: Moderate Rt hydroureteronephrosis to level of bladder. 3 mm calculus in bladder and hemorrhage c/w passed stone. Abnl soft tissue thickening of posterior bladder wall, suspicious for neoplasm. Areas of bony sclerosis and inguinal adenopathy, concerning for mets. Attending Comment: Very high suspicion for malignancy given bladder wall thickening, adenopathy, sclerotic bone lesions. There is also bilat iliac and retroperitoneal adenopathy.

01/17/2014 – Bone Scan: Diffuse osseous mets.

Operative Reports

02/01/2014 – TURBT: Large fungating mass at bladder neck, appeared to involve both bladder and prostatic tissue on both sides. An extremely large amount of tumor was removed.

Treatment Plan

02/19/2014 – Pt opted for Hospice.

01/18/2014 – Path Report #1

Clinical Diagnosis/History:

History of worsening back pain and painless hematuria with radiographic findings concerning for malignancy.

Cytologic Impression:

Urine (voided):  Malignant cells present.  Histologic evaluation is required for definitive diagnosis.  See comment.

Diagnosis Comment:

60 mls grossly hemorrhagic fluid is received from which two Papanicolaou-stained concentrated smears are made.  Smears contain numerous cytologically malignant cells scattered singly and in cohesive clusters characterized by enlarged size with increased nuclear to cytoplasmic ratios, hyperchromatic nuclei with coarse chromatin, irregular nuclear contours, and anisonucleosis.  There are features of squamous differentiation with keratinized squamous cells and keratin debris.  The findings are positive for malignancy, suggest poorly differentiated carcinoma.  Although urothelial carcinoma with squamous differentiation is favored, there is insufficient material available for cell block preparation and marker studies.  Please note that cytology alone cannot distinguish in situ from invasive carcinoma.  Histologic evaluation is required for definitive diagnosis and tumor subclassification.

02/01/2014 – Path Report #2

Clinical Diagnosis/History:

History of bladder mass, painless hematuria.

Procedure:  Transurethral biopsy.

Per electronic medical record: 25 pack year history of smoking, previously employed as a painter and light construction worker.

Final Diagnosis:

  1. A) Bladder, transurethral resection of tumor:

High-grade urothelial carcinoma with focal squamous differentiation and multifocal necrosis.

Invasion into muscularis propria.

No definite lymphovascular invasion is identified, see comment.

Diagnosis Comment:

Immunohistochemical staining for CD31 highlights abundant vasculature around tumor nests, but fails to confirm true vascular invasion.

Immunohistochemistry Studies:

Specimen: A3

Population: Carcinoma cells

CD31 CD31 [JC/70A]  Diffuse interstitial and vascular reactivity

Intensity:  Strong

Gross Description:

Specimen A:  Received in formalin labeled “bladder mass” are numerous pieces of tan, brown, and hemorrhagic tissue weighing in aggregate 32 g and measuring in aggregate 10 x 7 x 0.5 cm.  Approximately 1/2 the tissue is submitted in cassettes A1-A5.

Data Item :

Diagnosis Date

Correct Answer :

01/16/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the 01/16/2014 CT IVP scan stating “suspicious for mets”.

Ambiguous terminology may be used to accession a case when the ambiguous terminology is considered reportable. “Suspicious” is a reportable ambiguous term.

[2014 SEER Manual, Date of Diagnosis.]

Data Item :

Primary Site

Correct Answer :

C675

Rationale:

The TURBT operative report indicates there is a large mass at the bladder neck. Per the SEER coding guidelines, the priority for coding primary site is from the operative report (TURBT). Apply code C675 (bladder neck).

[2014 SEER Manual, Primary Site; 2014 SEER Manual, Appendix C, Bladder, Coding Guidelines.]

Data Item :

Laterality

Rationale:

Code 0 (not a paired site) when the primary site is not considered a paired site per SEER.

[2014 SEER Manual, Laterality.]

Data Item :

Histology

Correct Answer :

8120

Rationale:

The MP/H Rules (general rules) state the priority for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. In this case, the patient had a TURBT (transurethral resection of bladder tumor) with pathology showing high-grade urothelial carcinoma with focal squamous differentiation.

Per the MP/H Rules, Urinary, apply rule H5 and code the histology to transitional cell carcinoma when that is the only histology present. The term “focal” is not used to code a more specific histology, so the focal squamous differentiation can be ignored. Code the histology as 8120 (transitional cell carcinoma).

[2007 Multiple Primary and Histology Coding Rules]

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology report, this is a malignant (invasive) tumor. Code the behavior as /3 (malignant) when the primary tumor, or any portion of the primary tumor, is invasive.

[2014 SEER Manual, Behavior Code.]

Data Item :

Grade

Correct Answer :

4

Rationale:

Code the highest grade given from the primary tumor prior to neoadjuvant treatment. In this case, the TURBT pathology report identified high-grade urothelial carcinoma. Per the instructions for coding grade for transitional cell carcinoma of the bladder, the terminologies high grade TCC and low grade TCC are coded in the two-grade system. Per the two-grade system conversion table, high grade urothelial carcinoma of the bladder is coded as SEER code 4.

Data Item :

Clin T

Correct Answer :

4A

Rationale:

The 01/16/2014 CT scan showed abnormal soft tissue thickening of the bladder wall that was suspicious for malignancy. There is no documentation whether the bladder mass was palpable, mobile, or fixed. The 02/01/2014 TURBT operative report identified a large, fungating mass at the bladder neck that involved both the bladder and prostatic tissue.

The patient did not have a complete resection of the tumor per the operative report and 02/07/2014 physical exam note. While there was no removal of involved prostatic tissue, it was involved clinically by TURBT visualization. Imaging evidence of extravesical (prostatic) invasion can be used to assign the clinical T category. Apply code 4A (T4a, tumor invades prostatic stroma).

[AJCC Cancer Staging Manual, 7th Edition]

Data Item :

Clin N

Correct Answer :

2

Rationale:

The 01/16/2014 CT Abd/Pelvis showed bilateral iliac and retroperitoneal adenopathy. The 02/07/2014 physical exam note indicates the physician diagnosed the patient with metastatic iliac and retroperitoneal adenopathy. While retroperitoneal nodes are considered distant nodes, iliac nodes are regional for the bladder. Because the patient has bilateral iliac adenopathy, it can be assumed the patient has multiple regional nodes involved. Apply code 2 (N2, multiple regional lymph node metastasis in the true pelvis (iliac nodes)).

[AJCC Cancer Staging Manual, 7th Edition]

Data Item :

Clin M

Correct Answer :

1

Rationale:

The patient has clinical evidence of distant metastatic disease. The 01/17/2014 bone scan showed diffuse osseous metastases. The 01/16/2014 CT scan showed retroperitoneal adenopathy. Retroperitoneal nodes are distant lymph nodes for a bladder primary. The 02/07/2014 physical exam note indicates the patient has bony metastases as well as metastatic retroperitoneal adenopathy. Apply code 1 (M1, distant metastasis).

[AJCC Cancer Staging Manual, 7th Edition]

Data Item :

Path Stg Grp

Correct Answer :

BLANK

Rationale:

There was no surgical resection of the primary site (cystectomy) and/or regional lymph nodes. Surgery was not planned. Apply code BLANK.

Note: Click here to open “TNM_Document.pdf” which describes general rules for developing preferred answers in SEER*Educate.

[AJCC Cancer Staging Manual, 7th Edition]

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Note: Click here to open “TNM_Document.pdf” which describes general rules for developing preferred answers in SEER*Educate.

[AJCC Cancer Staging Manual, 7th Edition]

Data Item :

SS 2000

Correct Answer :

7

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has distant stage disease as the patient was clinically diagnosed with bone and distant (retroperitoneal) lymph node metastases. The primary tumor was considered regional by direct extension to the prostate on imaging. The patient also had clinical evidence of regional (iliac) lymph node involvement. The presence of bone and distant retroperitoneal lymph node metastases is always coded as distant stage disease, regardless of the tumor involvement or whether regional lymph nodes were involved. Apply code 7 (Distant site(s)/lymph node(s) involved).

[2014 SEER Manual, SEER Summary Stage 2000.; SEER Summary Staging Manual 2000.]

Social History

Alaska native male lives with his wife. Born in Alaska. Primary payer at dx is Insurance, NOS.

Physical Exam

05/13/2014 – HPI: 57 yo male who first noticed gross hematuria approximately 1 year ago. He did not seek medical attention until approximately 01/2014. PTA 01/10/2014, TUR found large bladder tumor c/w invasive urothelial carcinoma. Started PTA neoadjuvant chemotherapy on 01/30/2014with 4 cycles of gemcitabine and cisplatin. Last cycle ended on 04/22/2014. Radiology: PTA CT scan 01/23/2014 with residual bladder mass, original read did not notice any adenopathy, but on my review, there appears to be an ~ 2 cm enlarged LN along Rt external iliac. IMP: Muscle invasive bladder cancer, status post 4 cycles of neoadjuvant gemcitabine and cisplatin. Plan: After discussion of treatment, the patient wishes to undergo cystectomy. Tentative operative date: 06/06/2014

Scans

06/03/2014 – CT Abd/Pelvis: Decreased urinary bladder wall thickening. Decreased size of metastatic left external iliac LN, previously measured 2.3 x 1.6 cm. FIND: Not suspicious for osseous mets.

Operative Reports

06/05/2014 – Radical cystectomy, radical retropubic prostatectomy, bilat extended pelvic LN dissection, ileal neobladder formation, omental flap: Matted portion of nodes along common iliac vein and artery.

Chemo Text

01/30/2014 – PTA chemo: 4 cycles of Gemcitabine and Cisplatin.

01/10/2014 – Path Report #1

Clinical Diagnosis/History:

Slide review.

Final Diagnosis:

Outside Laboratory (01/10/2014)

Urinary bladder, transurethral resection:

High-grade urothelial carcinoma with micropapillary features, invading muscularis propria.

Lymphovascular invasion:  Present.

Materials Received:

Specimen A:  Urinary Bladder Transurethral Resection

06/05/2014 – Path Report #2

Clinical Diagnosis/History:

188.9.  Bladder CA.  Per electronic medical record:  History of high-grade urothelial carcinoma with micropapillary features with biopsy proven invasion into muscularis propria and lymphovascular invasion, status post neoadjuvant chemotherapy.

Final Diagnosis:

  1. A) Left pelvic lymph nodes, dissection: Positive for carcinoma, present in 1 of 4 lymph nodes, approximately 3.0 cm in greatest dimension (1/4).
  1. B) Left common iliac lymph nodes, dissection: Positive for carcinoma, present in 1 of 1 lymph node, 0.6 cm in greatest dimension (1/1).
  1. C) Right external iliac lymph nodes, dissection: 3 lymph nodes, negative for carcinoma (0/3).
  1. D) Right pelvic lymph nodes, dissection: Fibroadipose tissue, no lymph nodes, no carcinoma identified.
  1. E) Right obturator lymph nodes, dissection: Positive for carcinoma, present in 1 of 2 lymph nodes, 0.8 cm in greatest dimension (1/2).
  1. F) Right common iliac lymph nodes, dissection: 1 lymph node, negative for carcinoma (0/1).

G-I)  Margins, left ureteral, right ureteral and urethral, excisions:  No high grade dysplasia or carcinoma identified.

  1. J) Bladder and prostate, cystoprostatectomy:

Focal urothelial atypia consistent with high grade intraepithelial neoplasia/carcinoma in situ; no residual invasive carcinoma identified.  (See comment)

Edema, fibrosis, hemosiderin deposition and focal foreign body type giant cell reaction in lamina propria, suggestive of previous therapy effect.

Prostatic parenchyma, no carcinoma identified.

  1. K) Perirectals, excision: Fibroadipose and fibrovascular tissue with nerve trunks, no carcinoma identified.

L,M)  Final left ureteral and  final right ureteral margins, excision:  Segment of ureter, no high grade dysplasia or carcinoma identified.

Comment:

The scarred area in the bladder is submitted entirely for histologic evaluation and no residual carcinoma is identified.  Metastatic foci show focal micropapillary features.

Intraoperative Consultation:

GFS)  Left ureteral margin:   Negative for carcinoma.

HFS) Right ureteral margin:  Negative for carcinoma.

IFS)   Urethral margin:          Negative for carcinoma.

Gross Description:

Specimen A:  Received in formalin labeled “left pelvic lymph nodes” is a 6.0 x 3.0 x 2.0 cm yellow fatty portion of tissue.  Within this tissue are four possible tan-yellow/red lymph nodes that range from 1.1 to 5.0 cm in length.  The lymph nodes are entirely submitted as follows:  A1 – one bisected node; A2 – one serially sectioned node; A3 – one serially sectioned node; A4-A6 – one serially sectioned lymph node.

Specimen B:  Received in formalin labeled “left common iliac lymph nodes” is a 2.0 x 1.0 x 0.5 cm focally firm, gray-red lymph node which is serially sectioned and entirely submitted in cassette B1.

Specimen C:  Received in formalin labeled “right external iliac lymph nodes” is a 4.5 x 2.5 x 1.1 cm yellow, fatty portion of tissue.  Within this tissue are three tan lymph nodes which range from 1.1 to 2.0 cm in greatest dimension.  The lymph nodes are entirely submitted as follows:  C1 – one serially sectioned lymph node; C2 – one inked bisected node and one whole node.

Specimen D:  Received in formalin labeled “right pelvic lymph nodes” is a 3.0 x 2.0 x 0.6 cm yellow, fatty portion of tissue.  There is no grossly obvious lymph node tissue identified.  The specimen is sectioned and entirely submitted in cassette D1.

Specimen E:  Received in formalin labeled “right obturator lymph nodes” is a 5.0 x 3.0 x 1.5 cm yellow-red, fatty portion of tissue.  Within this tissue are two tan lymph nodes measuring 1.0 and 4.0 cm in greatest dimension.  The smaller lymph node is bisected and entirely submitted in cassette E1, and the larger lymph node is serially sectioned and entirely submitted in cassettes E2-E4.

Specimen F:  Received in formalin labeled “right common iliac lymph nodes” is a 1.5 x 0.7 x 0.5 cm yellow-red lymph node which is bisected and entirely submitted in cassette F1.

Specimen G:  Received fresh in a container for frozen labeled “left ureteral margin” is a 0.4 cm in diameter and 0.2 cm in length tan, rubbery, tubular portion of tissue which is entirely submitted for frozen.  The frozen section residue is submitted in block GFS1.

Specimen H:  Received fresh in a container for frozen labeled “right ureteral margin” is a 0.4 cm in diameter and 0.2 cm in length rubbery, tubular, tan portion of tissue which is entirely submitted for frozen.  The frozen section residue is submitted in block HFS1.

Specimen I:  Received fresh in a container for frozen labeled “urethral margin” is a 0.8 x 0.5 x 0.2 cm tan, rubbery portion of tissue which is entirely submitted for frozen.  The frozen section residue is submitted in block IFS1.

Specimen J:  Received fresh labeled “bladder/prostate” is a 7.5 x 6.5 x 4.5 cm bladder with an attached 4.5 x 4.3 x 4.0 cm prostate.  The attached peritoneal reflection is tan-pink, smooth and shiny, with no obvious lesions or masses. It is opened with a Y-shaped incision through the prostatic urethra and the anterior face of the bladder to reveal tan-pink trabeculated bladder mucosa.  Located in the posterior right aspect of the bladder is a 1.0 x 0.5 cm scarred retracted area.  The scarred retracted area encompasses the right ureteral orifice.  No other masses or lesions are identified.  The prostate is serially-sectioned revealing yellow-white uniform rubbery cut surfaces with no discrete masses or lesions identified.  The perivesicular fibroadipose tissue is serially-sectioned revealing yellow lobulated fibrofatty cut surfaces.  The specimen is inked as follows:  anterior left blue, anterior right black, posterior left orange, and posterior right green.  Representative sections are submitted labeled as follows:  J1 – ureteral and urethral margins, J2-J4 – representative cross-sections of prostate, J5 – right ureteral orifice and random section trigone, J6-J10 – entirety of scarred area, including left ureteral orifice, J11 – random sections of dome/anterior wall, J12 – random sections left posterior wall, J13 – one candidate lymph node.

Specimen K:  Received in formalin labeled “perirectal mass” is a 4.0 x 2.2 x 1.8 cm focally firm, pale yellow portion of tissue and a separate soft, yellow, fatty portion of tissue.  The fatty portion of tissue measures 3.0 x 2.2 x 1.0 cm.  There are no lymph nodes identified grossly.  The firm portion of tissue has an attached linear staple line along one edge.  The specimen is inked and the staples are removed.  The cut surfaces have a focally firm, nodular, gray-white to yellow-red appearance.  The firm portion of tissue is entirely submitted in cassettes K1-K3.  A representative section of the loose, yellow fatty tissue is submitted in K4.

Specimen L:  Received in formalin labeled “final left ureteral margin” is a rubbery, tan-pink, tubular portion of tissue consistent with a segment of ureter measuring 0.7 cm in length and 0.4 cm in outside diameter.  The lumen is grossly patent.  There is an attached surgical clip at the midpoint of the ureter.  The specimen is inked, trisected, and entirely submitted in cassette L1.

Specimen M:  Received in formalin labeled “final right ureteral margin” is a segment of ureter measuring 0.7 cm in length and 0.5 cm in outside diameter.  The ureter has a patent lumen.  There is a surgical clip at the midpoint of the ureter.  The specimen is inked, trisected, and entirely submitted in cassette M1.

Data Item :

Diagnosis Date

Correct Answer :

01/10/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the PTA 01/10/2014 TURB (transurethral resection of bladder) showing high grade urothelial carcinoma with micropapillary features.

Data Item :

Primary Site

Correct Answer :

C679

Rationale:

The physical exam states that the 01/10/2014 TURB found a large bladder tumor, with no mention of subsite. The review of the TURB pathology did not mention a subsite. The cystoprostatectomy operative report and pathology report also do not mention a specific subsite of where the tumor arose. There was mention of a “scarred retracted area” in the posterior right aspect of the bladder, but there is no statement of there being a mass at this location or that this was the location of the primary tumor. Per the SEER coding guidelines, the priority for coding primary site is from the operative report, TURB and the cystoprostatectomy. No bladder subsite was stated. Apply code C679 (bladder, NOS).

[2014 SEER Manual, Primary Site]

Data Item :

Laterality

Correct Answer :

0

Rationale:

Code 0 (not a paired site) when the primary site is not considered a paired site per SEER.

Data Item :

Histology

Correct Answer :

8131

Rationale:

The MP/H Rules (general rules) state the priority for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. In this case, the patient had a TURB (transurethral resection of bladder) with pathology showing high-grade urothelial carcinoma with micropapillary features. The cystoprostatectomy showed carcinoma in situ with no residual invasive carcinoma. The most representative specimen would be the TURB specimen, taken prior to neoadjuvant treatment.

Per the MP/H Rules, Urinary, apply rule H7 and code the most specific histology term, urothelial carcinoma with micropapillary features. See Table 1- Urothelial Tumors to determine specific histology term. Code the histology as 8131 (micropapillary urothelial carcinoma).

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology report, this is a malignant (invasive) tumor. Code the behavior as /3 (malignant) when the primary tumor, or any portion of the primary tumor, is invasive.

Data Item :

Grade

Correct Answer :

4

Rationale:

Code the highest grade given from the primary tumor prior to neoadjuvant treatment. In this case, the TURB (prior to neoadjuvant treatment) pathology report identified high-grade urothelial carcinoma. Per the instructions for coding grade for transitional cell carcinoma of the bladder, the terminologies high grade TCC and low grade TCC are coded in the two-grade system. Per the two-grade system conversion table, high grade urothelial carcinoma of the bladder is coded as SEER code 4.

Data Item :

Clin T

Correct Answer :

2

Rationale:

The PTA 01/10/2014 TURBT showed a large bladder tumor consistent with invasive carcinoma. The PTA pathology report proved invasive urothelial carcinoma with micropapillary features that invaded the muscularis propria. The PTA CT scan on 01/23/2014 (following TURBT) showed residual bladder tumor, but no further documentation of extension.

The patient started neoadjuvant chemotherapy and the 06/03/2014 CT scan following treatment showed decreased urinary bladder wall thickening. Per the AJCC, bladder wall thickening suggests T3 disease, but there was no documented evidence the bladder mass invaded perivesical tissue.

Because there was no documentation to support the presence of T3 disease prior to treatment, T3 disease cannot be coded. Clinically, the greatest documented extent was the PTA TURBT findings of muscularis propria invasion. A TURBT is considered a clinical staging procedure for the bladder. Apply code 2 (T2, tumor invades muscularis propria).

Data Item :

Clin N

Correct Answer :

1

Rationale:

The PTA 01/23/2014 CT scan was reviewed by the physician at this facility and showed an enlarged right external iliac lymph node. A repeat CT scan was performed on 06/03/2014 after neoadjuvant chemotherapy. Although this should be excluded from clinical staging because it was performed after definitive treatment began, the follow-up scan refers back to the pre-treatment scan indicating a decrease in size of a metastatic external iliac node.

The follow-up CT scan confirmed the PTA clinical findings of regional lymph node metastasis. Although not explicitly documented, it appears this patient was being treated with neoadjuvant treatment for known metastatic disease. The patient has at least one involved regional node. Apply code 1 (N1, single regional lymph node metastasis in the true pelvis (external iliac node)).

Data Item :

Clin M

Correct Answer :

0

Rationale:

Per the AJCC Cancer Staging Manual, general instructions, a case with no symptoms or signs of metastasis is classified as clinically M0.

The PTA 01/23/2014 CT scan made no mention of distant metastatic disease. There were no symptoms or findings the physician felt clinically suspicious for metastasis. Apply code 0 (M0, no distant metastasis).

Data Item :

Clin Stg Grp

Correct Answer :

4

Rationale:

Per the urinary bladder staging form, when the clinical TNM is cT2 cN1 cM0, apply code 4 (Stage IV).

For bladder primaries, any lymph node involvement, with or without distant metastatic disease, is considered Stage IV disease.

Data Item :

Clin Desc

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

IS

Rationale:

The 06/05/2014 post-neoadjuvant treatment radical cystectomy pathology report showed no residual invasive carcinoma. The bladder showed focal carcinoma in situ only. Although the previous TURBT showed invasive urothelial carcinoma with micropapillary features, post-neoadjuvant treatment pathologic staging (ypT staging) is based on the radical or partial cystectomy findings after treatment only.

This classification is used to demonstrate the response to treatment, and also to help determine whether further adjuvant treatment is needed. The cystectomy pathologically proved in situ disease only following neoadjuvant treatment. Apply code IS (Tis, carcinoma in situ: “flat tumor”).

Data Item :

Path N

Correct Answer :

3

Rationale:

The 06/05/2014 post-neoadjuvant treatment radical cystectomy included resection of multiple primary (pelvic, external iliac, obturator) and secondary (common iliac) regional lymph nodes. The pathology report showed metastatic carcinoma in one left pelvic, one right obturator and one common iliac node. The rest of the resected nodes were negative. The patient had multiple nodes in the true pelvis, plus a common iliac node involved. Apply code 3 (N3, lymph node metastasis to the common iliac lymph nodes).

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic examination of distant metastasis. This patient had a clinical assessment only, clinically M0. Apply code BLANK.

Data Item :

Path Stg Grp

Correct Answer :

4

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, for cases with known pT and pN categories, use the clinical M category to complete the pathologic stage group.

Per the urinary bladder staging form, when the TNM is ypTis ypN3 cM0, apply code 4 (Stage IV).

This patient has post-neoadjuvant pathologic (yp) Stage IV disease with ypTis and ypN3 disease. For bladder primaries, any lymph node involvement, with or without distant metastatic disease, is considered Stage IV disease.

Data Item :

Path Desc

Correct Answer :

4

Rationale:

The patient received neoadjuvant chemotherapy (systemic) treatment with Gemcitabine and Cisplatin on 01/30/2014 and surgery was performed on 06/05/2014. Apply code 4 (Y-Classification during or after initial multimodality therapy–pathologic staging only).

Data Item :

SS 2000

Correct Answer :

7

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has distant stage disease as there was pathologic evidence of metastasis to the regional common iliac nodes following neoadjuvant treatment. Prior to neoadjuvant treatment, the tumor was clinically localized and only regional external iliac node involvement was noted. Post-neoadjuvant treatment resection showed no residual invasive disease, but pathologic evidence of common iliac nodal involvement. Although the common iliac nodes are considered regional nodes for a bladder primary per the AJCC, they derive a distant SEER Summary Stage. There were no distant metastases. Apply code 7 (Distant, distant lymph node(s) involved).

Social History

Retired African-American female with four adult children. Divorced, born in New York City. Insurance: Medicare and Medicaid.

Physical Exam

07/18/2014 – cc: 71 y/o w/ abnormal left mammogram. HPI: Abnormal mammogram of the left breast done PTA on 03/29/2014. This was followed by PTA needle bxs on 04/08/2014 and 04/17/2014 both of which revealed an atypical intraductal papillary lesion, bordering on DCIS. Pt also underwent PTA bilateral breast MRI on 04/22/2014, with the right breast negative, but the left breast was found to have a clumped non-mass-like enhancement measuring 7 x 1.8 x 1.4 cm. Several prominent left axillary nodes also found, measuring up to 15 mm. PE: LN’s: Palpable, mobile, normal-appearing left axillary node. Breast: No erythema or peau d’orange or any skin retraction, tethering or dimpling. No evidence of eczematoid change or crusting or discharge. No discrete masses palpable on either breast. IMP: Lt breast atypical indtraductal papillary lesions. Plan: Excisional bx.

08/06/2014 – IMP: Left breast intermediate grade DCIS, status post excisional biopsy, with persistently positive margins. Plan: Clearly needs additional surgery, with radiation possible depending on type of surgery.

08/23/2014 – Patient has decided to go forward with mastectomy. Radiation will not be needed.

Operative Reports

07/22/2014 – Left breast mammographic wire localized excisional biopsy times 2: 3 o’clock posterior and anterior biopsy. No gross palpable lesions in either specimen. Total extent excised measured approximately 7 cm.

09/09/2014 – Left skin-sparing mastectomy, left axillary sentinel lymph node dissection: No gross mass lesions within breast, and both sentinel lymph nodes grossly normal on inspection and palpation intraoperatively.

04/08/2014 – Path Report #1

Clinical Diagnosis/History:

Slide review.

Final Diagnosis:

  1. A) Outside Hospital (04/08/2014)

Left breast, calcifications and adjacent tissue, core needle biopsy:  Atypical intraductal papillary lesion, bordering on ductal carcinoma in situ, with associated microcalcifications.  No invasive carcinoma identified.

  1. B) Outside Hospital (04/17/2014)

Left breast, calcifications and adjacent tissue, core needle biopsy:  Atypical intraductal papillary lesion, bordering on ductal carcinoma in situ, with associated microcalcifications.  No invasive carcinoma identified

Materials Received:

Specimen A:  L Breast Stereotactic Core Bx

Specimen B:  L Breast Stereotactic Guided Bx

07/22/2014 – Path Report #2

Clinical Diagnosis/History:

Per electronic medical record:  History of left breast mammogram calcifications with biopsy demonstrating atypical intraductal papillary lesions, suspicious for DCIS, separated by approximately 5.0 cm.

Final Diagnosis:

  1. A) Left breast, 3:00 anterior, excisional biopsy: Papillary ductal carcinoma in situ with the following:
  2. Extent: Spanning 2.2 cm.
  3. Nuclear grade: Intermediate.
  4. Margins: DCIS present at anterior, posterior, medial, lateral and superior margins; present <0.1 cm from inferior margin.
  5. Calcifications present in association with papillary lesion.
  6. Estrogen receptor positive (Allred score 8 of 8).
  7. No invasive carcinoma identified.
  8. Biopsy site changes.
  1. B) Left breast, 3:00 posterior, excisional biopsy:
  2. Usual ductal hyperplasia.
  3. No atypical hyperplasia, in situ or invasive carcinoma identified.
  4. Biopsy site changes.

Comment:

  1. A) The left breast anterior biopsy demonstrates a spectrum of papillary neoplasia with features ranging from intraductal papilloma to papillary atypical ductal hyperplasia to papillary ductal carcinoma in situ. Immunohistochemical stains for myoepithelial cells confirm a non-invasive process, and demonstrate absence of myoepithelial cells within the majority of the intraductal papillary proliferation, consistent with in situ papillary carcinoma.

Gross Description:

Specimen A:  Received labeled “left breast 3:00 anterior biopsy” is a 3.2 g lumpectomy specimen measuring 2.2 SI x 2.0 ML x 1.3 AP cm.  The specimen has been previously inked per protocol by the surgeon with anterior green, inferior blue, lateral orange, medial yellow, posterior black, superior red.  It is serially sectioned from superior to inferior into five slices, with the first and last slice measuring 0.7 cm and the remaining slices averaging 0.4 cm in thickness.  A possible biopsy site is identified and no definite lesions.  Total formalin fixation time:  26 hours. The entire specimen is submitted:

A1 – superior margin

A2-A4 – slices 2-4, respectively

A5 – inferior margin

Specimen B:  Received labeled “left breast 3:00 posterior biopsy” is a 4.9 g lumpectomy specimen measuring 3.9 ML x 2.4 SI x 1.5 AP cm.  The specimen has been previously inked per protocol by the surgeon with anterior green, inferior blue, lateral orange, medial yellow, posterior black, superior red.  It is serially sectioned from medial to lateral into six slices, with the first and last slice measuring 1.0 cm and the remaining slices averaging 0.4 cm in thickness.  No distinct lesions are identified. Total formalin fixation time:  26 hours. The entire specimen is submitted as follows:

B1 – slice 1, lateral margin

B2 – slice 2

B3 – slice 3

B4 – slice 4

B5 – slice 5

B6 – slice 6, lateral margin

IHC Studies:

Specimen A2:  Population: Cells of interest

P63  P 63, (BC4A4)                     Positive, see comment    Controls appropriately positive

CALPONIN  Calponin [3(16)]    Positive, see comment    Controls appropriately positive

ER   Estrogen Receptor [SP1]     95% positive cells           Intensity: Strong

IHC Interpretation:

Variable loss of myoepithelial cells within papillary proliferations. Preserved myoepithelial staining around ducts.

IHC Report:

ER/PR and HER2 immunohistochemical analyses are performed in accordance with CAP/ASCO guidelines [Hammond et al, Wolf et al]. Department of Pathology protocols dictate that breast cancer containing tissue will be fixed in neutral buffered formalin for a minimum of 6 hours to a maximum of 48 hours for HER2 and 72 hours for ER/PR, unless otherwise noted in this report. ER and PR stains are interpreted using a modified H-score system (Allred) based on the proportion of cells staining and intensity of staining, with >1% of cells with weak staining intensity (Allred score 3 of 8) is the clinically validated threshold for a positive result [Harvey et al]. HER2 interpretative criteria recommended by CAP/ASCO are used with modification [Grimm et al], where 3+ staining (intense, uniform, homogeneous circumferential membrane staining in >30% of tumor cells) is required for a positive (“high over-expression”) result.  Cases with 2+ (equivocal) HER2 staining or those that fail our inclusion criteria for IHC testing will be tested for gene amplification using a validated fluorescent in-situ hybridization (FISH) technique.  These assays have not been validated on decalcified tissues.  Results should be interpreted with caution given the likelihood of false negativity on decalcified specimens.

References:

Grimm EE, et al. Am J Clin Pathol (2010) 14; 284-92. Hammond ME, et al. J Clin Oncol (2010) 28; 2784-95. Harvey et al. J Clin Oncol (1999) 17; 1474-81. Wolff AC, et al. Arch Pathol Lab Med (2007) 131; 18-43.

Specimen A2:  Population: Cells of interest

Fixation time QA    Fixation time QA on predictive markers       Meets Requirements  Controls appropriately positive

09/09/2014 – Path Report #3

Clinical Diagnosis/History:

233.0 DCIS, left breast mastectomy, DIEP sentinel node biopsy.  Per electronic medical record:  Papillary ductal carcinoma in situ.  Imaging demonstrated segmental amorphous calcifications in the 3:00 position spanning approximately 6.5 cm corresponding to segmental non-mass enhancement by MRI.

Final Diagnosis:

  1. A) Left breast, mastectomy: Papillary ductal carcinoma in situ with the following:
  2. Nuclear grade: Intermediate.
  3. Size/extent: Two foci, 2.3 cm and 1.3 cm in the lower outer quadrant.
  4. Margins: Papillary DCIS is present 0.2 cm from inferior superficial margin in the lower outer quadrant and free of other margins by >0.5 cm.
  5. Previously reported to be estrogen receptor positive (Allred score 8; Path Report #2)
  6. Calcifications present in association with DCIS.
  7. Surgical site changes.
  8. No invasive carcinoma identified.

B, C)  Left axillary sentinel nodes #1 and #2 as designated, excisions:  3 lymph nodes negative for carcinoma by H&E-stain (1 lymph node in part B and 2 in part C).

  1. D) Left breast, lower outer quadrant, superficial margin, excision:
  2. Fat necrosis and foreign body giant cell reaction.
  3. No atypical hyperplasia, in situ or invasive carcinoma identified.
  4. E) Left breast skin, excision: Skin with no neoplasm identified.

Gross Description:

Specimen A:  Received fresh labeled “left breast” is a 346 g skin-sparing mastectomy specimen measuring 16 (ML) x 14.5 (SI) x 3 (AP) cm with 5.5 cm diameter portion of pigmented skin including a 1.5 cm diameter everted nipple.  The specimen is inked as follows:  superior superficial = orange, inferior superficial = blue, posterior = black and serially sectioned from medial to lateral to reveal a 2.5 x 2.0 x 1.6 cm firm, white region with ill-defined borders and associated biopsy site and clip, which is located in approximately the 3-4:00 position 2.5 cm from the nipple and present 2.0 cm from the nearest blue inked margin, 4.0 cm from the nearest black-inked black margin, 4.2 cm from the nearest orange-inked margin.  A second 2.2 x 1.5 x 1.0 cm somewhat firm, cystic region is also present in the lower outer quadrant, located 1.7 cm inferior to the lateral-most aspect of the above-mentioned lesion, and present 0.1 cm from the nearest blue-inked margin, 1.5 cm from the nearest black-inked margin, and distant from the orange-inked margin.  The remainder of the specimen demonstrates approximately 60% yellow, lobulated fatty tissue and 40% white more fibrous tissue.  No other masses or lesions are identified.  Representative sections, including the entire firm white mass with associated biopsy site are submitted.  Total formalin fixation time:  23 hours.

A1 – nipple

A2-A9 – entire lesion, medial to lateral (A6, A7 = composite, A8, A9 = composite)

A10 – second lesion, irregular fibrous region lower outer quadrant

A11 – upper outer quadrant

A12 – upper inner quadrant

A13 – lower inner quadrant

A14-15 tissue between lesion #1 and #2, composite

Specimen B:  Received in formalin labeled “left axillary sentinel node #1” is a 2.5 x 1.6 x 1.0 cm tan lymph node which shows focal injected blue dye staining.  The lymph node is serially sectioned and entirely submitted in cassettes B1 and B2.

Specimen C:  Received in formalin labeled “left axillary sentinel node #2” are two tan lymph nodes measuring 1.0 x 0.7 x 0.5 cm and 1.8 x 1.0 x 0.7 cm.  The smaller lymph node is bisected and submitted in cassette C1, and the larger lymph node is trisected and entirely submitted in cassette C2.

Specimen D:  Received in formalin labeled “left breast lower outer quadrant” is a 1 g breast excision measuring 2.5 x 1.9 x 0.5 cm with one surface previously inked green per protocol by the surgeon.  The specimen is serially sectioned and entirely submitted in two cassettes.

Specimen E:  Received in formalin labeled “left breast skin” are two strips of dark brown skin measuring 3.2 cm in length and 21 cm in length.  The smaller skin measures 0.5 cm in diameter, and the larger skin measures 0.8 cm in diameter.  No gross lesions are noted.  Representative sections from each are submitted in cassette E1

Data Item :

Diagnosis Date

Correct Answer :

07/22/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the 07/22/2014 excisional biopsy.

The patient did have a PTA 04/08/2014 biopsy showing an atypical intraductal papillary lesion, bordering on ductal carcinoma in situ. However, “bordering on” is not an ambiguous term indicating malignancy. No reportable diagnosis was made on the PTA biopsies or PTA scans.

Data Item :

Primary Site

Correct Answer :

C505

Rationale:

The mastectomy pathology report indicates that there are two tumors located in the lower outer quadrant. The excisional biopsy indicates tumor was taken from the 3:00 position, but the gross description on the mastectomy report shows the excisional biopsy site was at the 3:00-4:00 position. The biopsied tumor was in the lower outer quadrant. The mastectomy pathology report has priority over the biopsy pathology as the entire breast was removed with a clear statement of the primary tumor location. The 2014 SEER Manual (Appendix C, Breast) indicates that when multifocal tumors are all within one quadrant, the specific quadrant should be coded. Apply code C505 (lower outer quadrant).

Data Item :

Laterality

Correct Answer :

2

Rationale:

Code 2 (left) when the primary site is a paired site and the primary tumor originated on the left.

Data Item :

Histology

Correct Answer :

8503

Rationale:

The MP/H Rules (general rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. The patient underwent both an excisional biopsy and a mastectomy. The mastectomy is the most representative specimen, as it removed the most tumor tissue, and it showed papillary ductal carcinoma in situ. Per the MP/H Rules, Breast, apply rule H23 and code the histology when only one histologic type is identified. Code the histology as 8503 (Papillary ductal carcinoma).

Data Item :

Behavior

Correct Answer :

2

Rationale:

Per the pathology report, this is an in situ tumor. Code the behavior as /2 (in situ) when the primary tumor is non-invasive.

Data Item :

Grade

Correct Answer :

2

Rationale:

Code the highest grade given from the primary tumor prior to neoadjuvant treatment. Both the excisional biopsy and the mastectomy state the tumor is intermediate nuclear grade. There are special grade system rules for the breast (Bloom-Richardson or Nottingham score/grade). However, no Bloom-Richardson grade is given. Continue on to the next grade rule. Apply Coding for Solid Tumors, Rule 7b. Use the nuclear grade and the three-grade system conversion table to determine the correct grade code. Apply code 2 (intermediate grade, exception for breast grade code).

Data Item :

Clin T

Correct Answer :

BLANK

Rationale:

The rule for documenting carcinoma in situ is listed on page 12, Table 1.8 in the AJCC Cancer Staging Manual: “Carcinoma in situ, stage pTis cN0 cM0 as both clinical and pathologic stage 0.”

The CAnswer Forum, AJCC TNM Staging Forum, “Chapter 32, page 353?” Thread, provides further clarification. Clinical and pathologic stage group 0 is reflected in the cancer registry data fields as follows:

CLINICAL              T (blank)              N0          M0         Stage 0

PATHOLOGIC     Tis           N (blank)             M (blank)            Stage 0

Data Item :

Clin N

Correct Answer :

0

Rationale:

The 04/22/2014 MRI found several prominent left axillary nodes measuring up to 15 mm, but there is no statement of nodal involvement. The 07/18/2014 physical exam noted palpable, mobile, normal-appearing left axillary nodes. Because the patient was diagnosed with carcinoma in situ, the nodes are considered clinically negative. By definition, in situ carcinoma cells cannot metastasize. Apply code 0 (N0, no regional lymph node metastases).

Data Item :

Clin M

Correct Answer :

0

Rationale:

Per the AJCC Cancer Staging Manual, general instructions, a case with no symptoms or signs of metastasis is classified as clinically M0.

Because the patient was diagnosed with carcinoma in situ, the patient is considered clinically free of distant metastasis. By definition, in situ carcinoma cannot metastasize. Apply code 0 (M0, no clinical or radiographic evidence of distant metastases).

Data Item :

Clin Stg Grp

Correct Answer :

0

Rationale:

Per the AJCC Cancer Staging Manual general instructions, carcinoma in situ should be reported as both clinical and pathologic Stage Group 0. Apply code 0 (Stage Group 0).

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0 (None).

Data Item :

Path T

Correct Answer :

IS

Rationale:

The 07/22/2014 excisional biopsy and the 09/09/2014 mastectomy both showed papillary ductal carcinoma in situ only. Apply code IS (Tis, carcinoma in situ).

Data Item :

Path N

Correct Answer :

0

Rationale:

Per Table 1.6, N Classification Rules, a pathologic N value cannot be assigned in the absence of a surgical resection. Although Table 1.6 also states a biopsy confirming the highest N may be used, it is used only in appropriate circumstances where the pathologic staging criteria for the site has been met.

The 09/09/2014 mastectomy included resection of three sentinel lymph nodes. The nodes were pathologically negative. Although in situ carcinomas by definition cannot metastasize, this patient also had sentinel lymph nodes removed that pathologically confirmed this. Apply code 0 (N0, no regional lymph node metastasis identified histologically).

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither M0 nor MX are valid categories and they may not be assigned.

Assessment of metastases to group a patient by pathologic TNM grouping may be either clinical (cM0, cM1) or pathologic (pM1). This patient had a clinical assessment only, clinically M0. There was no pathologic examination of distant metastasis. Apply code BLANK (Not recorded).

Data Item :

Path Stg Grp

Correct Answer :

0

Rationale:

Per the AJCC Cancer Staging Manual general instructions, carcinoma in situ should be reported as pathologic Stage Group 0. Apply code 0 (Stage Group 0).

Data Item :

Path Desc

Correct Answer :

3

Rationale:

The 07/22/2014 left breast excisional biopsy showed a single 2.2 cm tumor. The 09/09/2014 mastectomy pathology report showed two separate tumors in the lower outer quadrant measuring 2.3 and 1.3 cm. Although the excisional biopsy margins were positive, three measured tumors were removed, one by excisional biopsy and two by mastectomy. Apply code 3 (M-Multiple primary tumors in a single site).

Data Item :

SS 2000

Correct Answer :

0

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has in situ disease involving the left breast only. The patient has no regional lymph node or distant metastases as in situ disease, by definition, cannot metastasize. Apply code 0 (In situ).

Social History

Divorced caucasian woman with no children. Lives alone. Born in Nebraska. Insurance: Blue Cross

Physical Exam

03/12/2014 – cc: 47 y/o woman w/ left breast cancer. HPI: Pt noted a mass on self-breast exam on UOQ of left breast in late January 2014. Her outside MD found a left breast superficial nodule measuring ~ 5 mm in the UOQ. She underwent PTA diagnostic imaging on 02/04/2014, which revealed no abnormalities, only pt’s retropectoral silicone implants. A diagnostic targeted left ultrasound of that region did demonstrate a 6 x 3 x 6 mm mass adjacent to the implant capsule. She underwent a PTA needle bx on 02/05/2014 which demonstrated an invasive ductal carcinoma. PE: LN’s: No cervical, supraclavicular, or axillary adenopathy palpable bilaterally. Breasts: No erythema, peau d’orange or skin retraction. Left breast has a palpable implant as well as a 6 mm nodule at 3 o’clock, mobile, and does not appear to be fixed. IMP: c T1a -T2 N0 ductal ca left breast. Plan: Surgery. Candidate for endocrine tx, depending on surgery results may want to order gene recurrence score assay to make decision about chemo, discussed rads.

Scans

03/11/2014 – Interpretation of outside breast imaging from 2/4/2014 (mammo); 2/5/2014 (lt breast bx post clip mammo); 2/12/2014 (breast MRI); 2/13/2014 (Lt axillary US): Rt breast: benign. Lt breast: Biopsy proven malignancy at 3:00 in left breast, 4 cm from the nipple, measuring up to 6 mm and not seen on breast MRI. Findings consistent with known malignancy. Prominent axillary LN.

03/13/2014 – Breast Lt U/S: Prominent axillary LN measuring up to 15 mm. Findings demonstrate a suspicious abnormality.

Operative Reports

03/27/2014 – Bilateral skin-sparing mastectomies, Lt axillary sentinel node dissection: all 6 L axillary SLNs neg for CA.

03/27/2014 – Immediate reconstruction, bilateral breasts using 400 ml Moderate Plus profile silicone implants, AlloDerm sling of inerior pole, 6 x 16 cm sheet used bilterally, Bilateral free-nipple graft (procedure only).

Hormonal Text

04/18/2014 – Started Tamoxifen.

Stage

04/05/2014 – Per MD note: p T1c N0 M0.

02/05/2014 – Path Report #1

Clinical Diagnosis/History:

Slide review.

Final Diagnosis:

Outside Hospital (02/05/2014)

Left breast, core needle biopsy:  Invasive ductal carcinoma with the following features:

Nottingham grade 1 of 3 derived as follows: poor tubule formation (3), low nuclear grade (1), low mitotic activity (1).

Involving two tissue cores with a maximum contiguous length of 0.3 cm in this sample.

Associated in situ component is not identified.

Microcalcifications are not identified.

Angiolymphatic invasion is not identified.

Prognostic/predictive markers (performed at referring institution and reviewed at this facility:

  1. Positive for estrogen and progesterone receptor expression (Allred score 4+2 = 6 of 8 and 3+2 = 5 of 8, respectively).
  2. Negative for HER2/neu overexpression by immunohistochemical technique (0+).

Diagnosis Comment:

By additional immunohistochemistry performed at the referring institution and reviewed at this facility, there is no immunoreactivity for p63 and smooth muscle myosin around nests of neoplastic cells, supporting the histologic impression of invasive carcinoma.

03/22/2014 – Path Report #2

Clinical Diagnosis/History:

Left lymph node biopsy.

Final Diagnosis:

  1. A) Lymph node, left axillary, needle core biopsy: Lymph node fragment negative for carcinoma.

Gross Description:

  1. A) Received in formalin labeled “left axilla lymph node” are approximately six gray-tan to yellow cores of fibroadipose tissue ranging from 0.2 x 0.1 cm to 1.1 x 0.1 cm. The specimen is wrapped, inked yellow, and entirely submitted in cassette A1.  Total fixation time:  66 hours.

03/27/2014 – Path Report #3

Clinical Diagnosis/History:

Left breast cancer.

Final Diagnosis:

  1. I) Left breast, mastectomy (306 grams): Invasive ductal carcinoma, 1.7 cm in greatest dimension and extending to within 0.1 cm of the posterior margin; see Summary Data.

B-G)  Sentinel lymph nodes, #1-#6, excisions: 6 lymph nodes with no carcinoma identified (one in each of parts B-G).

  1. A) Right breast, mastectomy (220 grams): Breast with axillary suture granulomas; no atypical hyperplasia, in situ or invasive carcinoma identified.
  1. H) “Old breast implants” removal: Breast prostheses (gross exam only).

Summary Cancer Data:

Left breast

Invasive carcinoma with the following features:

Histologic type: Invasive ductal carcinoma, NOS (85003)

Size (largest focus): 1.7cm

Comment about size determination: Measured grossly.

Focality of invasive carcinoma: Single contiguous focus

Nottingham Grade: Grade I: 3-5 points

Tubule Formation: 2  points (10 – 75%)

Nuclear Pleomorphism: 2 points (moderate)

Mitotic Activity: 1 point

Ancillary Studies

Source: Outside pathology lab (slides reviewed)

Estrogen receptor: Positive (Allred score = 6 of 8)

Progesterone receptor: Positive (Allred score = 5 of 8) c-erb-B2 (HER2/neu) by IHC: Negative for HER2/neu overexpression by IHC

HER2/neu by FISH: Not performed/reported

Skin status: Cannot assess (skin not present)

Nipple status: Cannot assess (nipple not present)

Skeletal muscle status: Skeletal muscle not present

Ductal carcinoma in-situ (DCIS): Present (85002)

Nuclear grade of DCIS: Intermediate

Necrosis associated with DCIS: Not identified

Distance spanned by DCIS: 0.1cm

DCIS qualifies as “extensive intraductal component”: No

Lobular carcinoma in-situ (LCIS): Absent

Changes consistent with previous biopsy site: Present

Final surgical resection margins (including separately submitted margins):

Invasive carcinoma margins:

Invasive carcinoma is <0.1 cm from the posterior margin and 1 cm or greater from all other margins.

DCIS Margins: DCIS is 0.3 cm from the posterior margin and 1 cm or greater from other margins.

Lymph node involvement

Sentinel nodes: Sentinel nodes with carcinoma 0    / Total sentinel nodes 6

Non-sentinel nodes: Non-sentinel nodes with carcinoma: 0    / Total non-sentinel nodes: 0

Total number of nodes with macrometastases: 0

Total number of nodes with micrometastases: 0

Total number of nodes with isolated tumor cells: 0

Minimum pathologic stage (AJCC, 7th ed., 2010)

Primary tumor [pT]: pT1c: Tumor > 1.0 cm and <= 2.0 cm – greatest dimension

Regional nodes [pN]: pN0: No regional lymph node metastasis histologically

(ITCs may be present)

N stage modifier: (sn): Only sentinel node(s) evaluated.

Distant metastasis [pM]: Not applicable or no pathologic information

Gross Description:

Specimen A:  Received fresh in a container labeled “right breast” is a 220 g, 21 (SI)x 14 (ML) x 2.5 (AP) cm right skin sparing simple mastectomy with a short suture attached to the superior edge of the breast and a long suture attached to the lateral side of the breast.  The breast margins are tan-yellow and shaggy and the deep fascia is freely moveable over the breast.  The margins of resection are inked as follows:  lateral side orange anteriorly, medial side anterior blue, entire posterior margin black.  The apparent nipple location is marked green.  The breast is serially sectioned from inferior to superior and approximately 60% of the cut surfaces consist of yellow, lobulated adipose tissue, the remaining composed of white, fibrous, focally dense breast tissue.  No masses are identified.  At the lateral edge of the breast, two lymph node candidates are identified measuring 0.5 and 1.5 cm in greatest dimension.  Representative sections are submitted labeled:  A1, A2 – random superior outer quadrant; A3, A4 – random inferior outer quadrant; A5, A6 – random superior inner quadrant; A7, A8 – random inferior inner quadrant; A9 – breast tissue beneath possible nipple site; A10 – 2 axillary lymph node candidates.

Specimen B:  Received fresh in a container for frozen labeled “left axillary sentinel lymph node #1” is a 2.0 x 1.0 x 0.5 cm blue-stained lymph node.  The specimen is bisected and a cytological touch preparation is prepared.  The lymph node is entirely submitted in cassette B1.

Specimen C:  Received fresh in a container for frozen labeled “left axillary sentinel lymph node #2” is a 2.0 x 1.0 x 0.5 cm blue-stained lymph node candidate.  The specimen is bisected and a cytological touch preparation is prepared.  The lymph node is entirely submitted in cassette C1.

Specimen D:  Received fresh in a container for frozen labeled “left axillary sentinel lymph node #3” is a 1.0 x 1.0 x 0.4 cm blue-stained lymph node.  The specimen is bisected and a cytological touch preparation is prepared.  The lymph node is entirely submitted in cassette D1.

Specimen E:  Received fresh in a container for frozen labeled “left axillary sentinel lymph node #4” is a 1.0 x 1.0 x 0.4 cm blue-stained lymph node.  The specimen is bisected and a cytological touch preparation is prepared.  The lymph node is entirely submitted in cassette E1.

Specimen F:  Received fresh in a container for frozen labeled “left axillary sentinel lymph node #5” is a 1.0 x 1.0 x 0.2 cm blue-stained lymph node candidate.  A cytological touch preparation is prepared.  The lymph node is entirely submitted in cassette F1.

Specimen G:  Received fresh in a container for frozen labeled “left axillary sentinel lymph node #6” is a 0.4 cm tan rubbery blue-stained lymph node candidate.  The specimen is bisected and a cytological touch preparation is prepared.  The lymph node is entirely submitted in cassette G1.

Specimen H:  Received fresh in a container labeled “old breast implants” are two translucent discoid breast implants with an average weight of 116 g and average measurements of 12.0 x 12.0 x 2.0 cm.  The implants are intact and no soft tissue is received.  The implants are labeled, respectively, “Style 10, Lot 1695892 Allergan 210 cc” and “Style 10, Lot 1548561 Allergan 210 cc.”

Specimen I:  Received fresh in a container labeled “left breast” is a 306 g, 22 (ML) x 17 (SI) x 2 (AP) cm left skin sparing simple mastectomy.  The breast margins are tan-yellow and shaggy and the deep fascia is freely moveable over the breast.  There is a short suture attached to the superior side of the breast and a long suture attached to the lateral edge of the breast.  The margins of resection are inked as follows:  superior anterior orange, inferior anterior blue, posterior black, possible nipple site green.  The breast is serially sectioned from medial to lateral and between the superior outer and inferior outer quadrants of the breast in the 3:00 position approximately 3.8 cm from the possible nipple site is a 1.7 x 1.0 x 1.0 cm firm mass located 0.3 cm from the blue-inked anterior margin, 0.2 cm from the black-inked deep margin.  The deep fascia is freely moveable over the mass.  The mass is sectioned further and there is a centrally inserted metallic spring-like clip.  No additional masses are identified.  Representative sections are submitted labeled:  I1 – normal breast tissue lateral side of mass; I2 – lateral extent of mass adjacent to site of clip; I3 – medial extent of mass; I4 – normal breast tissue medial side of mass; I5 – random superior outer quadrant adjacent to mass; I6 – random inferior outer quadrant adjacent to mass; I7 – random superior inner quadrant; I8 – random inferior inner quadrant; I9 – breast tissue beneath site of possible green-inked nipple location.

Frozen Section Diagnosis:

B-G)  Touch prep, lymph node:  Negative for carcinoma.

Data Item :

Diagnosis Date

Correct Answer :

02/05/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the PTA 02/05/2014 left breast core biopsy.

Data Item :

Primary Site

Correct Answer :

C508

Rationale:

The 03/12/2014 physical examination documents an UOQ (upper outer quadrant) mass identified on self-exam and by outside physician. The physical exam on that visit identified a nodule at 3 o’clock. The 03/11/2014 interpretation of outside breast imaging describes a nodule or biopsy proven malignancy at 3:00 in the left breast. The PTA 02/05/2014 biopsy pathology report does not mention a subsite. The 03/27/2014 mastectomy pathology report does not mention a subsite in the final diagnosis, but the gross description of the left breast identifies a mass in the 3:00 position.

Per 2014 SEER Manual, Appendix C, Breast, the pathology report has priority for coding a subsite when there is conflicting information. Apply code C508 (overlapping lesion of breast).

Data Item :

Laterality

Correct Answer :

2

Rationale:

Code 2 (left) when the primary site is a paired site and the primary tumor originated on the left.

Data Item :

Histology

Correct Answer :

8500

Rationale:

The MP/H Rules (General Rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. The patient underwent a bilateral mastectomy. The mastectomy is the most representative specimen, as it removed the most tumor tissue, and it showed ductal carcinoma, NOS. Per the MP/H Rules, Breast, apply rule H14 and code the histology when only one histologic type is identified. Code the histology as 8500 (ductal carcinoma, NOS).

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the core biopsy pathology report and the mastectomy pathology report, this is a malignant tumor. Code the behavior as /3 when the primary tumor, or any portion of the primary tumor, is invasive.

Data Item :

Grade

Correct Answer :

1

Rationale:

Code the highest grade given from the primary tumor prior to neoadjuvant treatment. Both the core biopsy and the mastectomy state the tumor is Nottingham grade 1. Both pathology reports also provide scores for the morphologic features used to determine Bloom-Richardson (BR): degree of tubule formation, mitotic activity, and nuclear grade. These three scores added together provide the BR score. The BR score is 5 on both pathology reports. There are special grade system rules for the breast (Bloom-Richardson or Nottingham score/grade). Use the Nottingham or Bloom-Richardson (BR) table to determine the correct grade code. Apply code 1 (Score of 5).

Data Item :

Clin T

Correct Answer :

1B

Rationale:

The patient noted a mass, and the physician palpated a left breast mass measuring about 5 mm. The PTA left breast ultrasound showed a 6 mm mass that was biopsy proven to be invasive ductal carcinoma. The physician clinically staged this as cT1a – T2, but this is inconsistent with the given information in this case. The range in T values may reflect uncertainty in size because the mass was adjacent to a silicone implant in the breast. The best clinical size appears to be 6 mm; therefore, apply code 1B (T1b, tumor greater than 5 mm but less than or equal to 10 mm in greatest dimension).

Data Item :

Clin N

Correct Answer :

0

Rationale:

The 03/12/2014 physical exam indicated no cervical, supraclavicular, or axillary adenopathy palpable bilaterally. The physician clinically staged this patient as N0 per the 03/12/2014 physical exam note. The subsequent left axillary ultrasound and axillary lymph node biopsy were negative for metastatic carcinoma, confirming the physician’s clinical assessment that the lymph nodes were negative. A pathologic examination (lymph node core biopsy in this case) of a single node in the absence of pathologic evaluation of the primary site is considered a clinical staging procedure. Apply code 0 (N0, no regional lymph node metastases).

Data Item :

Clin M

Correct Answer :

0

Rationale:

Per the AJCC Cancer Staging Manual, general instructions, a case with no symptoms or signs of metastasis is classified as clinically M0.

The limited PTA imaging made no mention of suspicious findings. The physical exam was negative. There were no symptoms or findings the physician felt clinically suspicious for metastasis. Apply code 0 (M0, no clinical or radiographic evidence of distant metastases).

Data Item :

Clin Stg Grp

Correct Answer :

1A

Rationale:

Per the breast staging form, when the clinical TNM is cT1b cN0 cM0, apply code 1A (Stage IA).

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0 (None).

Data Item :

Path T

Correct Answer :

1C

Rationale:

The 03/27/2014 mastectomy showed a single invasive ductal carcinoma tumor measuring 1.7 cm (17 mm) that was localized to the breast tissue with negative margins. The physician pathologically staged this tumor as T1c per the 04/05/2014 Stage note. Apply code 1C (T1c, tumor greater than 10 mm but less than or equal to 20 mm in greatest dimension).

Data Item :

Path N

Correct Answer :

0

Rationale:

The 03/27/2014 mastectomy included resection of six sentinel lymph nodes. The nodes were pathologically negative. No immunohistochemistry stains or isolated tumor cells appear to have been performed on the sentinel nodes per the pathology report. The physician pathologically staged this as N0 per the 04/05/2014 Stage note. Apply code 0 (N0, no regional lymph node metastasis identified histologically).

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic examination of distant metastasis. Apply code BLANK (Not recorded).

Data Item :

Path Stg Grp

Correct Answer :

1A

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, for cases with known pT and pN categories, use the clinical M category to complete the pathologic stage group.

Per the breast staging form, when the pathologic TNM is pT1c pN0 cM0, apply code 1A (Stage IA).

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0 (None).

Data Item :

SS 2000

Correct Answer :

1

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has local stage disease as there was pathologic evidence of a single invasive ductal carcinoma tumor confined to the left breast tissue only. The patient has no regional lymph node or distant metastases. Apply code 1 (Localized only).

Social History

Married female here with her oldest child. Born in Alaska. Pt mixed Alaskan Native/Caucasian. Primary payer is medicare with supplement, NOS.

Physical Exam

03/05/2014 – cc: 58 y/o woman with endometrial adenocarcinoma here to discuss tx options. HPI: On 02/19/2014 pt woke up in the middle of the night w/ vaginal bleeding heavier than menses and went to outside ER. U/S revealed soft tissue mass w/in endometrial cavity, 5 x 3 x 2 cm, suspicious for neoplasia. Had PTA D&C and ECC on 02/21/2014 that showed endometrial adenocarcinoma, FIGO grade 3 (poorly differentiated), with histologic evidence of smooth muscle invasion. Endocervical tissue with fragments of endometrial adenocarcinoma. PE: Pelvic: External genitalia normal. Vagina and cervix normal. No active or purulent discharge from cervix. Adnexa nonpalpable. Plan: TAH/BSO.

Scans

03/04/2014 – CT Chest/Abd/Pelvis: heterogenous uterus larger than expected for age c/w hx of endometrial cancer. Multiple retroperitoneal, pelvic and inguinal prominent LN’s, indeterminate by size criteria. At least 3 indeterminate pulmonary nodules.

Operative Reports

03/07/2014 – Robotic-assisted laparoscopic hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic and periaortic lymph node dissection: On entering the abdomen, normal-appearing structures, normal liver and diaphragm. No suspicious findings in the pelvis. No evidence of disease outside the pelvis. Depth of invasion appears to be less than 50%. No suspicious LN’s.

Treatment Plan

03/15/2014 – Recommended 6 cycles taxol/carboplatin chemo and vaginal brachytherapy.

02/21/2014 – Path Report #1

Clinical Diagnosis/History:

Post-menopausal bleeding. Slide review.

Final Diagnosis:

Outside Hospital (02/21/2014)

Endometrium, curettage (part A): Endometrioid adenocarcinoma, FIGO grade 3 of 3; see comment.

Endocervix, curettage (part B): Fragments of endometrioid adenocarcinoma admixed with strips of benign endocervical mucosa.

Diagnosis Comment:

Sections of the endometrial curettage specimen include possible invasion of smooth muscle bundles by carcinoma, suggestive of myometrial invasion.

03/07/2014 – Path Report #2

Clinical Diagnosis/History:

Endometrial cancer.  Per electronic medical record:  Endometrial adenocarcinoma, FIGO grade 3 (endometrial cavity mass measuring 5 x 3 x 2 cm in size).

Final Diagnosis:

  1. A) Uterus, bilateral fallopian tubes and ovaries, hysterectomy, bilateral salpingo-oophorectomy:
  2. Endometrioid adenocarcinoma, FIGO grade 3 of 3, with secretory features. See summary cancer data.
  3. Adenomyosis and multiple leiomyomata (largest 1.8 cm).
  4. Cervix with no evidence of neoplasia.
  5. Left and right ovaries with no evidence of neoplasia.
  6. Left and right fallopian tubes with no evidence of neoplasia.
  7. See comment.

B-D)  Lymph nodes, right pelvic, left pelvic, peri-aortic, dissections:  Multiple lymph nodes with no neoplasm identified, including 5 right pelvic, 9 left pelvic, and 5 periaortic lymph nodes.

IHC Interpretation:

Pancytokeratin and Pax8 immunostains support the final diagnosis of a carcinoma of mullerian origin.

Frozen Section Diagnosis:

Specimen A:  Gross endometrial tumor less than half of thickness of myometrium.

Gross Description:

Specimen A:  Received fresh labeled “uterus, cervix, bilateral tubes and ovaries, gross-depth of invasion” is a 92 g (post-fixation), 10 x 4.5 x 3.0 cm uterus, a 3.5 x 2 x 1 cm right ovary, a 8 x 0.5 x 0.5 cm right fallopian tube, a 3 x 1.5 x 0.8 cm left ovary, and a 7 x 0.5 x 0.5 cm left fallopian tube.  The uterine serosa is tan-pink, smooth, and glistening.  The ectocervix is tan-white, smooth, and glistening; there is a patent 0.5 cm cervical os.  The margins of resection are marked as follows:  anterior = blue and posterior = black.  On the right anterior surgical margin, there is a 1.8 x 1.5 x 0.5 cm tan-white, ovoid nodule.  The uterus and cervix are bivalved, and the endocervical canal and cervical cut surfaces are unremarkable.  Filling the endometrial cavity, attached to both anterior and posterior walls, is a 3 x 2 x 0.5 cm tan-white, exophytic, soft, friable lesion which occupies approximately 90% of the endometrial lining.  The lesion is focally approaching the anterior lower uterine segment.  The uterus is serially sectioned, and the lesion extends into the anterior and posterior myometrium and comes to within 0.5 cm from the anterior serosal surface and 1.5 cm from the posterior serosal surface.  The depth of invasion in the anterior and posterior myometrium is 1 cm and 0.5 cm, respectively.  The uninvolved myometrium is tan-pink and rubbery and measures up to 2.5 cm in thickness.  The serosa of the right ovary is tan-white, smooth, and glistening.  The right ovary is sectioned and has tan, rubbery cut surfaces with normal internal architecture.  No lesion is identified.  The serosal surface of the right fallopian tube is tan-pink, smooth, and glistening.  The right fallopian tube is serially cross-sectioned, and there are tan-pink, rubbery cut surfaces with a patent 0.2 cm lumen.  No lesion is identified.  The serosa of the left ovary is tan-white, smooth, and glistening.  The left ovary is sectioned and has tan, rubbery cut surfaces with normal internal architecture.  No lesion is identified.  The serosal surface of the left fallopian tube is tan-pink, smooth and glistening.  The left fallopian tube is serially cross-sectioned, and there are tan-pink, rubbery cut surfaces with a patent 0.2 cm lumen.  No lesion is identified.  Representative sections are submitted as follows:  A1-A2 – posterior cervix and lower uterine segment; A3-A4 – full thickness sections of anterior endomyometrium with deepest invasion;  A5-A6 – full thickness sections of posterior endomyometrium with deepest invasion; A7 – another full thickness section of posterior endomyometrium with the deepest invasion; A8 – anterior lower uterine segment grossly involved by the lesion; A9 – anterior cervix and ovoid nodule; A10 – left ovary; A11 – left fallopian tube; A12 – right ovary; A13 – right fallopian tube.

Specimen B:  Received in formalin labeled “right pelvic lymph nodes” are two yellow, lobulated fragments of adipose tissue measuring 6.0 x 5.5 x 1.0 cm in aggregate dimension.  Six individual lymph node candidates are identified on cut surfaces ranging in size from 0.1 cm to 3.6 cm.  The larger lymph nodes are sectioned and have tan, indurated cut surfaces.  However, no masses are appreciated.  Representative sections are submitted labeled:  B1 – 2 individual lymph node candidates; B2 – 2 bisected lymph nodes, one marked blue; B3 – 1 bisected lymph node; B4, B5 – one bisected lymph node.

Specimen C:  Received in formalin labeled “left pelvic lymph nodes” are a few yellow, lobulated fragments of adipose tissue measuring 6.0 x 4.5 x 1.5 cm in aggregate dimension.  Numerous lymph node candidates are identified on cut surfaces ranging in size from 0.5 cm to 3.0 cm.  Representative sections are submitted labeled:  C1 – 1 bisected lymph node; C2 – 1 bisected lymph node; C3 – 1 bisected lymph node; C4 – 1 bisected lymph node; C5 – 1 bisected lymph node; C6 – 1 bisected lymph node; C7 – 3 individual lymph node candidates.

Specimen D:  Received in formalin labeled “peri aortic lymph nodes” is a 4.5 x 1.5 x 1.0 cm yellow, lobulated portion of fibrofatty tissue, sectioned to reveal four lymph node candidates ranging in size from 1.0 to 1.5 cm.  Lymph node candidates are entirely submitted in cassette D1.

Summary Cancer Data:

Specimen type: Hysterectomy

Other organs present: Right ovary

Left ovary

Right fallopian tube

Left fallopian tube

Specimen integrity: Intact hysterectomy specimen

Chemotherapy and/or radiation therapy prior to surgery: Unknown/History not provided

Characteristics and Extent of Neoplasm

Histologic type: Endometrioid adenocarcinoma, secretory variant (83823)

Histologic grade:

FIGO G3: More than 50% nonsquamous solid growth OR 6-50% solid with high nuclear grade

Tumor size: Greatest diameter: 3cm

Tumor size comment:

Although the tumor is close to the endocervix, we see no convincing evidence of extension into the endocervix (slide A2).

Tumor site (epicenter): Endometrium of fundus (C54.1)

Myometrial invasion: Depth of invasion: 1cm    / Myometrial thickness: 1.4cm

Comment about myometrial invasion:

Myometrium measures up to 2.5 cm in thickness; however, the deepest invasion of 1 cm is found in the section of myometrium that has a thickness of 1.4 cm (slide A4)

Lower uterine segment: Carcinoma involves LUS mucosa only

Cervix and endocervix: Negative for carcinoma

Extra-uterine involvement: No extra-uterine involvement

Venous/lymphatic (large/small vessel) invasion: Indeterminate

Lymph Node Status

Pelvic node summary: Nodes with carcinoma: 0    / Total nodes examined: 14

Para-aortic node summary: Nodes with carcinoma 0    / Total nodes examined 5

Minimum Pathologic Stage (AJCC, 7th ed., 2010)

Primary tumor (pT): pT1b: Tumor invades one-half or more of the myometrium

Regional lymph nodes (pN): pN0: No regional lymph node metastasis

Minimum FIGO Stage

FIGO Stage (2010): IB: Tumor invades one-half or more of myometrium

Diagnosis Comment:

  1. A) Although at the time of surgery, the tumor appeared to invade less than 50% of myometrial wall thickness, the gross examination of the fixed specimen, confirmed by microscopy, shows invasion that is greater than 50% of myometrial wall thickness.

Immunohistochemistry Studies:

Specimen A6:  Population: Carcinoma cells

Pax8 Pax8                                                      Positive, uniformly Controls appropriately positive

AE1/AE3 Pan-Cytokeratin Cocktail             Positive, uniformly Controls appropriately positive

ER Estrogen Receptor [SP1]                         Positive, uniformly

Amendment Reason:

This case was amended to correct the type of carcinoma in the final diagnosis and template from clear cell adenocarcinoma to endometrioid carcinoma with secretory features, to correct the template to suspicious for lymphatic vascular space invasion, to add estrogen receptor immunohistochemical data and to add a second paragraph to the comment below.

Amentment Comment:

This case is challenging because the neoplastic cells have a clear cytoplasm.  However they do not have the high nuclear grade that is characteristic of “clear cell” carcinoma of the endometrium.  Nor do the tumor cells express intense estrogen receptor immunoreactivity (clear cell carcinomas of endometrium typically do not express intense ER).

Data Item :

Diagnosis Date

Correct Answer :

02/21/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the PTA 02/21/2014 endometrial curettage. The physical exam notes the patient underwent an ultrasound on 02/19/2014 that showed a soft tissue mass in the endometrial cavity that was suspicious for neoplasia. Neoplasia alone is not a reportable term; it is not equivalent to malignancy.

Data Item :

Primary Site

Correct Answer :

C541

Rationale:

The PTA curettage, CT scan, and surgical resection showed the primary tumor was in the endometrium. Apply code C541 (endometrium).

Data Item :

Laterality

Correct Answer :

0

Rationale:

Code 0 (not a paired site) when the primary site is not considered a paired site per SEER.

Data Item :

Histology

Correct Answer :

8382

Rationale:

The MP/H Rules (general rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. In this case, the patient underwent both an endometrial curettage and a hysterectomy. The hysterectomy pathology report is the most representative specimen, and the final diagnosis was endometrioid adenocarcinoma with secretory features. The summary cancer data further specified the histologic type as endometrioid adenocarcinoma, secretory variant.

Endometrioid adenocarcinoma, secretory variant is a specific histologic type. Per the MP/H Rules, Other Sites, apply rule H11 and code the histology when only one histologic type is identified. Code the histology as 8382 (endometrioid adenocarcinoma, secretory variant).

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology reports, this is a malignant tumor. Code the behavior as /3 (malignant) when the primary tumor, or any portion of the primary tumor, is invasive.

Data Item :

Grade

Correct Answer :

3

Rationale:

Code the highest grade given from the primary tumor prior to neoadjuvant treatment using the solid tumor coding rules. The FIGO grade is not used to code the grade field; this is collected in a SSF if applicable. Both the PTA endometrial curettage review of slides and the hysterectomy pathology showed a FIGO grade 3 adenocarcinoma. The physical exam note on 03/05/2014 states the PTA curettage showed poorly differentiated endometrial adenocarcinoma.

Code the grade of the primary tumor documented in the medical record as the available pathology reports only indicated a FIGO grade. Use the four-grade system conversion table to convert poorly differentiated to the appropriate code. Apply grade code 3.

Data Item :

Clin T

Correct Answer :

1

Rationale:

The PTA ultrasound showed a 5 cm mass in the endometrial cavity. The PTA 02/21/2014 D&C showed evidence of smooth muscle bundle (myometrial) invasion, while the endocervical curettage (ECC) showed adenocarcinoma admixed with strips of benign endocervical mucosa. It is unclear if the endocervix was actually involved pathologically. The cervix was negative on physical exam.

The 03/04/2014 CT scan showed no evidence of involvement beyond the corpus uteri. The tumor is clinically at least T1 with invasion of the myometrium. There was no definitive cervical (T2) involvement clinically identified, and the T1 category cannot be further subclassified as T1a or T1b. The depth of myometrial invasion was not determined clinically. Per the AJCC, when there is uncertainty in assigning a T category, default to the lower of the two categories in the uncertain range. Apply code 1 (T1, tumor confined to corpus uteri).

Data Item :

Clin N

Correct Answer :

0

Rationale:

The 03/04/2014 CT scan identified multiple prominent lymph nodes (retroperitoneal, pelvic and inguinal), but noted they were indeterminate by size. There is no definitive statement these nodes are involved. The regional nodes are presumed to be clinically negative. Imaging and physical exam were performed and there was no mention of any involved or clinically suspicious regional nodes. Apply code 0 (N0, no regional lymph node metastasis).

Data Item :

Clin M

Correct Answer :

0

Rationale:

Per the AJCC Cancer Staging Manual, general instructions, a case with no symptoms or signs of metastasis is classified as clinically M0.

The 03/04/2014 CT scan identified indeterminate pulmonary nodules only. The physical exam was negative for any suspicious findings, and there was no definitive statement of metastasis. There were no symptoms or findings the physician felt clinically suspicious for metastasis. Apply code 0 (M0, no distant metastasis).

Data Item :

Clin Stg Grp

Correct Answer :

1

Rationale:

Per the corpus uteri carcinoma staging form, when the clinical TNM is cT1 cN0 cM0, apply code 1 (Stage I).

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

1B

Rationale:

The 03/07/2014 hysterectomy pathology report showed endometrioid adenocarcinoma invading 1 cm into a 1.4 cm thick myometrium. There was no involvement of the cervix or evidence of extra-uterine involvement. Apply code 1B (T1b, tumor invades one half or more of the myometrium).

Data Item :

Path N

Correct Answer :

0

Rationale:

The 03/07/2014 hysterectomy included resection of multiple regional lymph nodes (pelvic and periaortic). The pathology report showed the resected nodes were negative for metastatic carcinoma. Apply code 0 (N0, no regional lymph node metastasis).

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic examination of distant metastasis. Apply code BLANK.

Data Item :

Path Stg Grp

Correct Answer :

1B

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, for cases with known pT and pN categories, use the clinical M category to complete the pathologic stage group.

Per the corpus uteri staging form, when the pathologic TNM is pT1b pN0 cM0, apply code 1B (Stage IB).

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Data Item :

SS 2000

Correct Answer :

1

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has local stage disease as there was pathologic evidence of invasion of the myometrium only. The primary tumor involved one half or more of the myometrium per the hysterectomy pathology report. The patient has no regional lymph node or distant metastases. Apply code 1 (Localized only).

Social History

Divorced Caucasian woman w/ two children. Born in Texas. Has private insurance: Managed care.

Physical Exam

03/21/2014 – cc: 48 y/o w/ atypical endometrial hyperplasia. HPI: Pt recently presented to gynecologist in February of 2014 w/ worsening heavy vaginal bleeding, w/ new abdominal and pelvic cramping with bloating. PTA endometrial bx on 02/25/2014 showed low-grade endometrial neoplasm w/ features of at least complex atypical hyperplasia. There’s concern that there’s underlying cancer. PE: Pelvic: Normal external genitalia and normal-appearing cervix. Mobile uterus. IMP: Suspicious for an endometrioid neoplasm. Plan: Surgery scheduled for next week.

Operative Reports

03/25/2014 – Robotic assisted laparoscopic total hysterectomy, bilateral salpingo-oophorectomy: Some mild adhesions of the omentum to the right lower quadrant of the ileocecal junction to the right adnexa, and adhesions of intestines to the left ovary (not unexpected given that she had a hx of prior open appendectomy and left ovarian cystectomy). No evidence of mets disease on intra-abdominal exploration. Intraoperatively, uterus had a small tumor in lower uterine segment that was less than 2 cm. No obvious myometrial invasion.

Treatment Plan

03/28/2014 – No further treatment planned for this localized endometrial carcinoma.

02/25/2014 – Path Report #1

Clinical Diagnosis/History:

Slide review.

Final Diagnosis:

Outside Laboratory (02/25/2014)

Endometrium, biopsy:  Low-grade endometrioid neoplasm with features of at least complex atypical hyperplasia.

03/25/2014 – Path Report #2

Clinical Diagnosis/History:

Obese patient with irregular vaginal bleeding, biopsy showing low-grade endometrioid neoplasm with features of complex atypical hyperplasia.  Per electronic medical record:  Endometrium with low-grade endometrioid neoplasm with features of at least complex atypical hyperplasia.

Final Diagnosis:

  1. A) Uterus, bilateral ovaries and fallopian tubes, hysterectomy, bilateral salpingo-oophorectomy:

Low-grade endometrioid neoplasm with features of at least complex atypical hyperplasia (involving much of endometrium) to focal low grade endometrioid carcinoma with no myometrial invasion and no lymphatic -vascular space invasion (Figo Stage IA).

Cervix with no evidence of neoplasia.

Myometrium with no diagnostic alterations.

Right and left ovaries with no evidence of neoplasia.

Right and left fallopian tubes with no evidence of neoplasia.

Diagnosis Comment:

Most cases of HNPCC are associated with mutations in, or abnormal expression of DNA mismatch repair enzymes.  More than 95% of the time, the abnormalities are in MLH1 or MSH2 although MSH6 and pMS2 may also be affected (1).  Immunohistochemistry detects approximately 86% of MLH1 disorders and 92% of MSH2 disorders (2).  Most cases of HNPCC exhibit microsatellite instability (MSI) length alterations in simple, repetitive microsatellite sequences due to failure of mismatch repair during DNA replication.  Approximately 93-94% of HNPCC tumors with MSI have abnormal IHC expression of MLH1 or MSH2 (2,3).  Colorectal carcinomas without MSI virtually never have IHC abnormalities (1,3).  Both IHC and MSI are screening tests with false-positive and false-negative results (2,4,5) and the diagnosis of HNPCC must be made in conjunction with family history and other genetic or molecular tests.

(1)  Ruszkiewsicz A, et al.  Correlation of mismatch repair genes immunohistochemistry and microsatellite instability status in HNPCC-associated tumours.  Pathology (2002) 34:541-547.

(2)  Hendriks Y, et al.  Conventional and tissue microarray immunohistochemical expression analysis of mismatch repair in hereditary colorectal tumors.  Am J Pathol (2003) 162:469-477.

(3)  Lanza, et al.  Immunohistochemical pattern of MLH1/MSH2 expression is related to clinical and pathological features in colorectal adenocarcinomas with microsatellite instability.  Mod Pathol (2002) 15:741-749.

(4)  Salahshor S, et al.  Microsatellite instability and hMLH1 and hMSH2 expression analysis in familial and sporadic colorectal cancer.  Lab Invest (2001) 81:535-541.

(5)  Reyes AM, et al.  Comparison of selection strategies for genetic testing of patients with hereditary nonpolyposis colorectal carcinoma: effectiveness and cost-effectiveness.  Cancer (2002) 95:1848-1856.

Gross Description:

Specimen A:  Received fresh labeled “uterus, cervix, tube and ovary” is a 172 g, 13 x 6.8 x 3.5 cm uterus, 3 x 2 x 1 cm right ovary, 6 x 0.5 x 0.5 cm right fallopian tube, 3.5 x 3 x 1.5 cm left ovary, and 6 x 0.5 x 0.5 cm left fallopian tube.  The uterine serosa is tan-pink, smooth, and glistening.  The ectocervix is tan-white, smooth, and glistening; there is a patent 1.2 cm cervical os.  The margins of resection are marked with black ink.  The uterus and cervix are bivalved, and the endocervical canal and cervical cut surfaces are unremarkable.  Filling the endometrial cavity, attached to both anterior and posterior walls, is a 4 x 3.5 cm exophytic, soft, friable lesion which occupies 90% of the endometrial lining.  The lesion does not appear to involve the lower uterine segment.  The uterus is serially sectioned, and the lesion does not extend into the anterior or posterior myometrium.  The uninvolved myometrium is tan-pink and rubbery, and it measures up to 3 cm in thickness.  The serosa of the right ovary is tan-white, smooth, and glistening.  The right ovary is sectioned and has tan, rubbery cut surfaces with normal internal architecture.  No masses or lesions are identified.  The serosal surface of the right fallopian tube is tan-pink, smooth, and glistening.  The right fallopian tube is serially sectioned, and there are tan-pink, rubbery cut surfaces with a patent 0.2 cm lumen.  No masses are identified.  The serosa of the left ovary is tan-white, smooth, and glistening.  The left ovary is sectioned and has tan, rubbery cut surfaces with normal internal architecture.  No masses or lesions are identified.  The serosal surface of the left fallopian tube is tan-pink, smooth, and glistening.  The left fallopian tube is serially cross-sectioned, and there are tan-pink, rubbery cut surfaces with a patent 0.2 cm lumen.  No masses are identified.  Representative sections are submitted as follows:  A1FS – frozen section thawed and resubmitted; A2-A3 – anterior cervix and lower uterine segment; A4-A5 – composite section of full-thickness anterior endomyometrium; A6-A7 – anterior endometrium; A8-A9 – posterior cervix and lower uterine segment; A10, A11 – composite section of full-thickness posterior endomyometrium; A12-A13 – posterior endometrium; A14 – left ovary; A15 – left fallopian tube; A16 – right ovary; A17 – right fallopian tube.

Immunohistochemistry Studies:

Specimen A6:  Population:  Neoplastic cells

MLH1 MLH1 [G168-728]   No loss of expression

MSH2 MSH2 [G219-1129]  No loss of expression

MSH6 MSH6 (BC/44)          No loss of expression

PMS2 PMS2                         No loss of expression

IHC Interpretation:

No loss of mismatch repair protein expression.

Frozen Section Diagnosis:

Specimen A:  Endometrioid lesion without gross myometrial invasion.  No tubal or ovarian neoplasm.

Specimen AFS:  Complex atypical hyperplasia; no invasive carcinoma in representative section of thickest area.

Addendum Reason:

Reporting of immunohistochemistry for mismatch repair proteins performed at the request of physician.

Addendum – Final Diagnosis:

Specimen A:  Uterus, bilateral ovaries and fallopian tubes, hysterectomy, bilateral salpingo-oophorectomy:  Low-grade endometrioid neoplasm without loss of the mismatch repair proteins MSH2, MSH6, MLH1, and PMS2.  See comment.

03/25/2014 – Path Report #3

Clinical Diagnosis/History:

Obese patient with irregular vaginal bleeding and biopsy showing low-grade endometrioid neoplasm.

Diagnosis Comment:

55 mls slightly hemorrhagic fluid is received from which two Papanicolaou-stained concentrated smears are made.  Smears contain mesothelial cells with wash artifact in a bloody background.  Negative for malignancy.  Please also refer to the concurrent surgical case for more information.

Cytologic Impression:

Peritoneal wash:  Negative for malignancy.  See comment.

Data Item :

Diagnosis Date

Correct Answer :

03/25/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the 03/25/2014 total hysterectomy. The physical exam and PTA endometrial biopsy note the patient has an endometrial neoplasm with features of at least complex atypical hyperplasia. There was concern that the patient has underlying cancer. Atypical hyperplasia, endometrial neoplasm or concerning for cancer are not reportable terms and are not equivalent to malignancy.

Data Item :

Primary Site

Correct Answer :

C541

Rationale:

The total hysterectomy pathology report showed the primary tumor was in the endometrium. Apply code C541 (endometrium).

Data Item :

Laterality

Correct Answer :

0

Rationale:

Code 0 (not a paired site) when the primary site is not considered a paired site per SEER.

Data Item :

Histology

Correct Answer :

8380

Rationale:

The MP/H Rules (general rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. In this case the patient underwent an endometrial biopsy that was non-reportable and a total hysterectomy. The hysterectomy pathology report is the only and most representative specimen that identified malignancy, and the final diagnosis was endometrioid carcinoma.

Endometrioid carcinoma is a specific histologic type. Per the MP/H Rules, Other Sites, apply rule H11 and code the histology when only one histologic type is identified. Code the histology as 8380 (endometrioid carcinoma).

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology report, this is a malignant tumor. Code the behavior as /3 (malignant) when the primary tumor, or any portion of the primary tumor, is invasive.

Data Item :

Grade

Correct Answer :

2

Rationale:

Code the highest grade given from the primary tumor prior to neoadjuvant treatment. The total hysterectomy pathology report final diagnosis showed focal low grade endometrioid carcinoma. Use the grade conversion tables in the SEER Manual when there are no special grade systems for solid tumors that apply. Per the terminology conversion table, low grade is coded as grade code 2.

Data Item :

Clin T

Correct Answer :

X

Rationale:

The patient’s endometrial tumor cannot be assigned a clinical T category. The PTA 02/25/2014 endometrial biopsy showed at least complex atypical hyperplasia, but no definitive evidence of malignancy. The 03/21/2014 physical exam notes that, despite the negative biopsy, there is still concern for underlying cancer. Although the PTA biopsy was negative for malignancy, the physical exam was concerning. The subsequent surgery appears to have been done due to concern for cancer. Specific physical exam and clinical findings attributable to the primary tumor were not noted. The tumor cannot be clinically assessed. Though there was clinical concern for malignancy, the primary tumor was only evaluated pathologically. Apply code X (TX, primary tumor cannot be assessed).

Data Item :

Clin N

Correct Answer :

X

Rationale:

The regional nodes cannot be assigned a clinical N category. The patient underwent a PTA endometrial biopsy, but there is no indication any imaging was performed PTA or at this facility. There is no mention of regional lymph nodes on the physical exam note.

The minimal PTA and physical exam findings documented do not allow for clinical staging of the regional nodes. There is no indication whether suspicious nodes were clinically identified. Apply code X (NX, regional lymph nodes cannot be assessed).

Data Item :

Clin M

Correct Answer :

0

Rationale:

Per the AJCC Cancer Staging Manual, general instructions, a case with no symptoms or signs of metastasis is classified as clinically M0.

The physical exam was negative for any suspicious findings. There were no symptoms or findings the physician felt clinically suspicious for metastasis. Apply code 0 (M0, no distant metastasis).

Data Item :

Clin Stg Grp

Correct Answer :

99

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, a clinical Stage Group cannot be assigned when the T or N categories are assigned an X value. One exception: any combination of TX or NX with M1 is classified as Stage IV.

When the TNM is cTX cNX cM0, apply code 99 (Unknown).

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

1A

Rationale:

The 03/25/2014 hysterectomy pathology report showed focal low grade endometrioid carcinoma with no myometrial invasion (the carcinoma was limited to the endometrium). There was no involvement of the cervix or evidence of extra-uterine involvement. Apply code 1A (T1a, tumor limited to endometrium or invades less than one half of the myometrium).

Data Item :

Path N

Correct Answer :

X

Rationale:

Per Table 1.6, N Classification Rules, a pathologic N value cannot be assigned in the absence of a surgical resection. Although Table 1.6 also states a biopsy confirming the highest N may be used, it is used only in appropriate circumstances where the pathologic staging criteria for the site has been met.

The patient did not undergo a lymph node resection during the TAH/BSO. In order to assign the pN0 category, histologic examination of regional nodes is required. The regional lymph nodes cannot be assessed pathologically. The surgical observation of nodes at the time of resection, without pathologic examination, is not recorded in the pathologic stage. Apply code X (NX, regional lymph nodes cannot be assessed).

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic examination of distant metastasis. Apply code BLANK.

Data Item :

Path Stg Grp

Correct Answer :

99

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, a pathologic Stage Group cannot be assigned when the T or N categories are assigned an X value. One exception: any combination of TX or NX with pM1 is classified as Stage IV.

When the pathologic TNM is pT1a pNX cM0, apply code 99 (Unknown).

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Data Item :

SS 2000

Correct Answer :

1

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has local stage disease as there was pathologic evidence of tumor confined to the endometrium only. The primary tumor did not involve the myometrium per the hysterectomy pathology report. The patient has no regional lymph node or distant metastases. Apply code 1 (Localized only).

Social History

30 y/o single Filipino woman, was born in the Philippines and moved here in 2003. Primary payer at dx is Medicaid.

Physical Exam

05/28/2014 – HPI: Pt being seen 8 days after being discharged from hospital for perforated diverticulitis or underlying malig with abscess. Initially presented to ER for LLQ pain. Left AMA. Plan: Surg admit tomorrow.

08/29/2014 – Pt s/p total proctocolectomy with end ileostomy for rectosigmoid adenocarcinoma. Post-op CT on 08/08/2014 w/ new large enhancing pelvic mass associated w/ retroperitoneal and pelvic LAD, susp for aggressive tumor recurrence. Mass bx positive for carcinoma. Pt not deemed further surgical candidate and started on palliative chemo. Pt now s/p cycle 1 of FOLFIRI after rapid recurrence in pelvis. Re-image after 4 cycles to assess radiologic response.

Scans

05/18/2014 – CT Abd/Pelvis: Extensive mural thickening of sigmoid colon w/ adjacent extensive pelvic inflammation, susp for diverticulitis, with focus of pneumatosis sugg of perforation. Omentum herniating between rectus muscles, likely related to previous laparotomy incision. Adnexa not well visualized. Findings: Liver, lungs WNL. No osseous lesions. Likely reactive mesenteric and retroperitoneal LN’s.

05/28/2014 – CT Abd/Pelvis: Development of two abscesses w/in RLQ adjacent to sigmoid colon. Diff dx includes GI lymphoma, adenocarcinoma, Crohn’s, trauma and possibly diverticulitis. Enlarged retroperitoneal LNs, non-specific, either reactive or possibly related to an underlying malignancy.

06/04/2014 – CT Chest: No pulmonary mets. No LAD.

Labs

06/04/2014 – CEA: <0.7 ng/mL (0-5 ng/ml normal)

Operative Reports

05/30/2014 – Rigid sigmoidoscopy, bx rectal mass, diagnostic laparoscopy, washout abd abscess, intra-op US: Ulcerated appearing mass at 18 cm, bx’d. Mild amount ascites in colic gutters and over liver. No carcinomatosis. No liver masses. No addl abdominal masses. Matted bowel in pelvis w/ adhesions in LLQ w/ known abscess. Appendix normal.

07/02/2014 – Total proctocolectomy with end ileostomy, endometrial bx. Findings: Perforated rectosigmoid adenocarcinoma. No carcinomatosis or mets disease to liver on visual inspection. Large adherent mass w/ noted tumor, abscess, colon, uterus and fallopian tubes attached. Performed subtotal colectomy w/ distal margin just distal to peritoneal reflection. Removed tumor and abscess mass by peeling it off uterus. Tumor noted along the border of uterus, confirmed by frozen section of uterine fundus tissue. Due to evidence of tumor involvement of uterus, GYN intraoperative consult performed.

08/09/2014 – Complex pelvic mass bx.

Treatment Plan

06/19/2014 – IMP: Primary tumor in high rectum/distal sigmoid. Significant adhesions throughout entire area due to perforation of carcinoma. Plan sigmoid resection and primary anastomosis or subtotal colectomy with ileorectal anastomosis. Will likely need chemotherapy postoperatively.

07/25/2014 – Onc Note: T4b N0 M0, Stage IIC w/ tumor left on uterus due to desire to preserve fertility. Pt s/p subtotal colectomy (R1 resection) w/ positive margins. Recommend beginning FOLFOX 6 weeks from surgery.

Chemo Text

08/20/2014 – Started FOLFIRI.

05/30/2014 – Path Report #1

********** This Is An Addendum Report **********

Revision #1 (See end of report for new text): Additional Studies

Clinical Diagnosis/History:

Status post perforated diverticulitis

Final Diagnosis:

  1. A) Rectum, biopsy: Fragments of colonic mucosa with poorly-differentiated, non-small cell carcinoma that involves muscularis propria; see comment.

Comment:

Histologically this carcinoma is characterized by sheets and aggregates of tumor cells.

Gross Description:

Specimen A:  Received in formalin labeled “rectosigmoid biopsy” are four tan-pink tissue fragments measuring 0.5 to 0.2 cm in greatest dimension.  They are wrapped and entirely submitted in one cassette.

Addendum Issued To Report Results Of Immunohistochemical Stains For Microsatellite Instability Markers:

At the request of physician, immunohistochemical stains for microsatellite instability markers are performed with the following results:

IHC Studies:

Specimen A1:  Population: Neoplastic cells

CK 5 Cytokeratin 5 (EP1601Y)            Negative                 Controls appropriately positive

AE1/AE3   Pan-Cytokeratin Cocktail   Positive, uniformly Controls appropriately positive

S100 S-100 [DR96+BC96]                   Negative                  Controls appropriately positive

IHC Studies:

Specimen  A1:  Population:      Neoplastic cells

MLH1 MLH1 [G168-728]        Negative  Controls appropriately positive

MSH2 MSH2 [G219-1129]       Positive, variably  Controls appropriately positive

MSH6 MSH6 (BC/44)               Positive, variably  Controls appropriately positive

PMS2 PMS2                              Negative  Controls appropriately positive

IHC Interpretation:

Pankeratin positivity is characteristic of carcinoma.  Lack of keratin 5 expression argues against a squamous cell carcinoma and against a urothelial carcinoma.  Lack of S100 expression argues against a melanoma.

IHC Interpretation:

Loss of mismatch proteins MLH1 (with secondary loss of PMS2), consistent with sporadic microsatellite instability colorectal carcinoma due to methylation of MLH1 or Lynch syndrome due to germline mutation of MLH1.  MLH1 and PMS2 exist as heterodimers, with MLH1 dominant.  With loss of MLH1 there is also loss of PMS2, which is not due to a mutation in the PMS2 gene.  Most cases of loss of MLH1 (90%) are due to somatic inactivation of MLH1 due to promoter hypermethylation of the gene (sporadic MSI carcinoma) but about 10% are due to germline mutation of the MLH1 gene (Lynch Syndrome).  To distinguish, additional tests may be performed.  These tests include germline sequencing and testing for V600E mutation of BRAF (which is almost always present in cases of sporadic MSI carcinoma with MLH1 hypermethylation, and is almost always absent in Lynch Syndrome-associated carcinoma).

05/30/2014 – Path Report #2

Clinical Diagnosis/History:

Pelvic abscess.

Cytologic Impression:

Peritoneal fluid:  No cytologically malignant cells are identified.  See comment.

Comment:

10 mls hemorrhagic fluid is received from which two Papanicolaou-stained concentrated smears and one cellblock with hematoxylin and eosin-stained slide are made.  Slides contain mesothelial cells with wash artifact in a background of red and white blood cell components.  No cytologically malignant cell subpopulation is identified.  Please also refer to the concurrent surgical pathology case for more information.

Specimen Source:

Specimen A:  Peritoneal Fluid

Specimen Description:

10 ml hemorrhagic fluid in specimen tube

Cytopreparation:

Smears, 1 cell block

07/02/2014 – Path Report #3

********** This Is An Amended Report **********

Revision #1 (See end of report for new text): Additional Studies

Revision #2 (See end of report for new text): Additional Studies

Clinical Diagnosis/History:

Not provided.

Final Diagnosis:

  1. A) Colon, ascending, transverse, and descending, resection:

Colon (46.5 cm) with focal moderately active serositis and no evidence of carcinoma.

B, C, F)  Designated “tumor biopsy #1 and #2,” “pelvic tumor,” biopsies:

Poorly differentiated carcinoma with extensive necrosis.

  1. D) Endometrium, biopsy:

Shedding endometrium with no evidence of neoplasia.

  1. E) Sigmoid colon and rectum, resection:

Poorly differentiated carcinoma, see summary data below. Portion of adherent ovary. See comment.

  1. G) Designated “abscess cavity,” biopsies:

Poorly differentiated carcinoma with extensive necrosis and fibrinopurulent exudate involving a portion of bowel.

Comment:

The invasive carcinoma seen in this specimen has prominent tumor infiltrating lymphocytes and the histology of medullary carcinoma.  These two histologic features can be seen in microsatellite unstable carcinomas and in carcinomas arising in the setting of HNPCC.  Immunohistochemical stains for mismatch repair proteins were performed on the previous biopsy specimen and showed loss of expression of both MLH1 and PMS2, suggesting a defect in this pathway.  While patients with sporadic carcinomas can have microsatellite unstable tumors, loss of expression of two proteins, as well as the patients age, are concerning for a germline mutation associated with HNPCC.  The diagnosis of HNPCC must be made in conjunction with family history and other genetic/molecular testing.  BRAF testing will be preformed and reported in an addendum.

Summary Cancer Data:

Specimen and Tumor Location

Specimen type: Rectal/rectosigmoid colon (low anterior resection)

Specimen length:    38.5cm

Tumor site:    Rectosigmoid (C19.9)

Intactness of mesorectum:     Incomplete

Characteristics and Extent of Neoplasm

Histologic type:    Medullary carcinoma (85103)

Histologic grade:   Poorly differentiated

Tumor size:    Greatest diameter: 13.5cm

Tumor perforation (macroscopic):   Present

Microscopic tumor extent:     Tumor is adherent to other organs or structures

Adherent structure/organ:     Uterus and ovary

Tumor deposits:     Indeterminate

Lymphatic [small vessel] Invasion  (L): Not identified

Venous [large vessel] Invasion (V):     Not identified

Perineural invasion:     Absent

Final Surgical Resection Margins

Grossly positive margin(s):   None

Microscopically positive margin(s):     None

Lymph Node Status

Node summary:  Nodes with carcinoma: 0    / Total nodes examined: 24

Minimum Pathologic Stage (AJCC, 7th ed., 2010)

Primary tumor (pT): pT4b: Tumor directly invades or is adherent to other organs or structures

Regional lymph nodes (pN):    pN0: No regional lymph node metastasis

Other Findings

Tumor-Infiltrating Lymphocytes per high-power field:   11

Peri-tumoral lymphocytic response: Marked (>=3 aggregates/section) or Crohn-like reaction

Gross Description:

Specimen A:  Received fresh labeled “ascending transverse and descending colon” is a 46.5 cm in length colon including cecum dilated up to 9 cm and a 5.1 cm in length appendix.  There is a moderate amount of attached epiploic fat.  There is a small amount of omentum.  The serosal surface appears to have a few adhesions near the area of the descending colon.  The majority of the serosal surface appears smooth and glistening.  The cecum appears discolored to a red-tan to purple.  The ileocecal valve margin staple line is removed.  The underlying surface is inked blue.  The bowel is opened and a moderate amount of fecal material is present.  The mucosa is rinsed.  The mucosa appears red-tan and focally hemorrhagic.  The area near the cecum has green-stained portion.  The appendiceal orifice is unremarkable.  The mucosa is carefully examined for lesions and none are identified.  The mucosa appears mostly flattened with fine foldings.  Cassette index:

A1 – small bowel margin, en face

A2 – distal margin

A3-A6 – random large bowel

Specimen B:  Received fresh labeled “tumor biopsy #1” are two pieces of tan-red tissue fragments measuring 2.8 x 1 x 0.5 cm and 1.8 x 0.8 x 0.5 cm.  As per the surgeon, these were cut from the surface of the uterus.  A portion is submitted for frozen section.  Cassette index:

BFS – frozen section residue

B2 – remaining tissue

Specimen C:  Received fresh labeled “tumor biopsy #2” are three pieces of tan-pink tissue measuring 1.5 x 1 x 1 cm, 1.8 x 1 x 0.8 cm, 2.5 x 1.3 x 1.0 cm.  A portion is submitted for frozen section.  Cassette index:

CFS – frozen section residue

C2 – remaining tissue

Specimen D:  Received in formalin labeled “uterine contents” are multiple fragments of tan-red mucoid tissue measuring 2.5 x 1.5 x 0.5 cm in aggregate.  They are wrapped and entirely submitted in cassette D1.

Specimen E:  Received fresh labeled “sigmoid colon and rectum” is a 38.5 x 11.5 x 8 cm portion of bowel with a large, necrotic, exophytic, white-tan tumor.  It is located 2 cm from the distal margin of resection.  The specimen is largely disrupted.  The tumor appears to erode significantly through the bowel wall.  The tumor measures 13.5 x 11 x 8 cm.  The proximal margin is 10.5 cm away from the tumor.  This margin is taken en face. There is portion of colonic mucosa that is present and has normal foldings.  It has moderate amount of hemorrhagic material within.  After the margins are taken, the tumor is cross sectioned.  The exophytic portion of the tumor is noted by the surgeon to be adherent to the uterus.  After cross sectioning, the tumor appears to be pushing the bowel lumen, causing stenosis.  One portion of the bowel lumen is 2 cm in diameter.  No retroperitoneal margin is identified due to the distortion of the specimen and perforation by the tumor.  Cassette index:

E1 – representative sections of distal margin

E2 – tumor to proximal margin

E3 – perpendicular sections through distal margin

E4 – additional tumor to distal margin

E5- E7 – tumor

E8 – tumor to bowel

E9 – bowel to tumor

E10 – tissue near adherent loop

E11 – tumor and fat

E12-E19 – representative lymph node candidates

Specimen F:  Received in formalin labeled “pelvic tumor” are multiple fragments of tan-pink and rubbery tissue.  Some areas appear necrotic.  There is a moderate amount of hemorrhage.  They measure 4.5 x 4 x 1 cm in aggregate dimensions.  The non-necrotic portions are submitted in cassette F1.

Specimen G:  Received in formalin labeled “abscess cavity” are multiple fragments of tan-pink, hemorrhagic, firm, rubbery tissue measuring 4.5 x 4 x 2 cm.  Representative portions are submitted in cassette G1.

IHC Interpretation:

The neoplastic cells are of epithelial origin without neuroendocrine differentiation.

Intraoperative Consultation:

BFS)  Positive for malignancy.

CFS)  Malignant cells present with extensive necrosis.  )

E Gross)  Closest distal margin about 2 cm.

IHC Studies:

Specimen E2:  Population: Neoplastic cells

AE1/AE3   Pan-Cytokeratin Cocktail      ]      Positive, uniformly Controls appropriately positive

CKIT CKIT (C-19)/ CD117 [polyclonal]        Negative                 Controls appropriately positive

Specimen E8:  Population: Cells of interest

SYNAPTO   Synaptophysin [SY38]                Negative                 Controls  appropriately positive

Addendum Reason:

This addendum is to report results of BRAF mutational analysis.

BRAF Results: NEGATIVE for V600E mutation

Specimen E8:

BRAF Interpretation:  The tissue sample tested is negative for the T to A mutation in codon 600 (V600E mutation) of the BRAF gene.  In patients with microsatellite unstable (MSI) cancer, absence of this mutation would be consistent with possible Lynch Syndrome.

Amendment Reason:

This amendment is issued to report results of KRAS mutational analysis.

KRAS Results: Positive for mutation in codon 12 or 13.

Specimen:  E8

KRAS Interpretation:  The tissue sample tested is positive for a mutation in codon 12 or 13 of the KRAS gene.  In patients with metastatic colon cancer, mutations in these condons are associated with lack of response to therapeutic antibodies against the EGF receptor.

08/09/2014 – Path Report #4

Clinical Diagnosis/History:

History of HNPCC.  Now with abdominal mass.  Requested special advanced testing (from electronic order):  r/o HNPCC

Final Diagnosis:

  1. A) Abdominal mass, biopsy: Poorly-differentiated carcinoma, histologically identical to previously diagnosed carcinoma.

Gross Description:

Specimen A:  Received in formalin labeled “A – pelvic soft tissue mass” are multiple irregular fragments of white soft tissue measuring in aggregate 2 x 0.2 x 0.2 cm.  The entire specimen is submitted for microscopic examination.  Summary of sections:

A1 – soft tissue

Data Item :

Diagnosis Date

Correct Answer :

05/30/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the 05/30/2014 sigmoidoscopy with biopsy. The abdominal and pelvic CT scans gave no reportable diagnosis of malignancy.

Data Item :

Primary Site

Correct Answer :

C199

Rationale:

Per the 07/02/2014 operative report and the resection pathology report, the primary tumor was located in the rectosigmoid. Although there was a clinical description of a rectal mass during the sigmoidoscopy, the lower margin of the tumor was at 18 cm and the operative findings indicated this tumor was not in the rectum. A tumor is classified as rectal if the lower margin is less than 16 cm from the anal verge. Apply code C199 (rectosigmoid).

Data Item :

Laterality

Correct Answer :

0

Rationale:

Code 0 (not a paired site) when the primary site is not considered a paired site per SEER.

Data Item :

Histology

Correct Answer :

8510

Rationale:

The MP/H Rules (general rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. This patient underwent a biopsy of the mass followed by a total proctocolectomy. The resection pathology report was the most representative specimen, and the final diagnosis was poorly differentiated carcinoma. The summary cancer data indicated the histologic type was medullary carcinoma. The summary cancer data can be used to code the histology when it provides a more specific histologic type.

Per the MP/H Rules, Other Sites, apply rule H13 and code the most specific histologic term when the diagnosis is carcinoma, NOS and a more specific carcinoma. Code the histology as 8510 (medullary carcinoma).

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology reports, this is a malignant tumor. Code the behavior as /3 (malignant) when the primary tumor, or any portion of the primary tumor, is invasive.

Data Item :

Grade

Correct Answer :

3

Rationale:

Code the highest grade given from the primary tumor, prior to neoadjuvant treatment, when multiple grades are given. Both the biopsy and resection showed poorly differentiated carcinoma. Use the grade conversion tables in the SEER Manual when there are no special grade systems for solid tumors that apply. Per the terminology conversion table, poorly differentiated is coded as grade code 3.

Data Item :

Clin T

Correct Answer :

X

Rationale:

The patient’s rectosigmoid tumor cannot be assigned a clinical T category. The 05/18/2014 and 05/28/2014 CT scans showed mural thickening of the colon with adjacent inflammation and subsequent development of abscess surrounding the sigmoid colon. The scans were suggestive of perforation. The 05/30/2014 sigmoidoscopy with diagnostic laparoscopy identified matted bowel in the pelvis with adhesions in the LLQ with known abscess.

The biopsy proved carcinoma invaded the muscularis propria, but the laparoscopy and imaging indicate the possibility that the tumor extended further. It is unclear clinically whether the perforation and/or adhesions were actually due to tumor involvement or to inflammation/abscess involvement. Per the CAnswer Forum, perforation alone is not sufficient to assign the T category. The 06/19/2014 treatment plan note states there are adhesions throughout the area due to perforation of carcinoma, but at laparoscopy, this was identified as matted bowel and adhesions due to abscess. The extent of the primary tumor was not identified by clinical means. Apply code X (TX, primary tumor cannot be assessed).

Data Item :

Clin N

Correct Answer :

0

Rationale:

The 05/18/2014 CT scan identified likely reactive mesenteric and retroperitoneal lymph nodes. The 05/28/2014 CT scan identified enlarged retroperitoneal lymph nodes that were non-specific, either reactive or possibly related to an underlying malignancy. The 05/30/2014 laparoscopy showed no carcinomatosis and made no mention of clinically suspicious regional lymph nodes.

There was no definitive imaging or laparoscopic evidence of lymph node involvement. There was no definitive statement from the physician or other indication in the record that the “enlarged” nodes actually were considered involved. Apply code 0 (N0, no regional lymph node metastasis).

Data Item :

Clin M

Correct Answer :

0

Rationale:

Per AJCC Cancer Staging Manual, general instructions, a case with no symptoms or signs of metastasis is classified as clinically M0.

The CT scans on 05/18/2014, 05/28/2014, and 06/04/2014 all showed no evidence of distant metastatic disease, and the 05/30/2014 laparoscopy showed no carcinomatosis, liver masses or abdominal masses. There were no symptoms or findings the physician felt clinically suspicious for distant metastasis at diagnosis. Apply code 0 (M0, no distant metastasis).

Data Item :

Clin Stg Grp

Correct Answer :

99

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, a clinical Stage Group cannot be assigned when the T or N categories are assigned an X value. One exception: any combination of TX or NX with M1 is classified as Stage IV.

Colorectal primaries are often staged following pathologic examination of a resected specimen. When the TNM is cTX cN0 cM0, apply code 99 (Unknown).

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

4B

Rationale:

Total proctocolectomy was performed on 07/02/2014. Pathologic staging includes pathologic examination of the resected specimen in addition to surgical observations. The pathology report identified medullary carcinoma in the rectosigmoid colon that was adherent to the uterus and ovary. The operative report indicated there was evidence of tumor involvement of the uterus, but the uterus was not resected in an effort to preserve the patient’s fertility.

The greatest pathologic extent of disease was the adherent tumor on the uterus and ovary and direct invasion of the uterus. The oncologist pathologically staged this as T4b per the 07/25/2014 oncology note. Apply code 4B (T4b, tumor directly invades or is adherent to other organs or structures).

Data Item :

Path N

Correct Answer :

0

Rationale:

The 07/02/2014 proctocolectomy included resection of multiple regional lymph nodes, NOS. The nodes were pathologically negative. Apply code 0 (N0, no regional lymph node metastasis).

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic examination of distant metastasis. This patient had a clinical assessment only, clinically M0. Apply code BLANK.

Data Item :

Path Stg Grp

Correct Answer :

2C

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, for cases with known pT and pN categories, use the clinical M category to complete the pathologic stage group.

Per the colon and rectum staging form, when the pathologic TNM is pT4b pN0 cM0, apply code 2C (Stage IIC).

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Data Item :

SS 2000

Correct Answer :

7

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has distant stage disease as the primary tumor pathologically showed involvement of the uterus. The operative report confirmed uterine involvement at surgery. Direct tumor extension to the uterus is considered distant by direct extension. There were no regional lymph nodes or distant metastases. Apply code 7 (Distant, distant site(s) involved by extension).

Social History

65 y/o married Black/White man. Born in Louisiana. Primary payer at dx is private insurance, managed care.

Physical Exam

08/10/2014 – ED Note: Bloody stool and 25-pound weight loss over the last month. DRE w/ large rectal mass. Plan: Urgent bx/scope by GI service.

Scans

08/10/2014 – CT Abd/Pelvis: Large presacral mass infiltrates rectal wall w/ associated irregular rectal wall thickening, inseparable from bladder and prostate, multiple enlarged mesenteric and iliac LNs. Appearance c/w a malignant tumor, likely of rectal origin. Mild Rt hydroureteronephrosis due to compression of ureteropelvic junction by the mass. Indeterminate lucent focus in iliac bone. No evidence of peritoneal or liver mets, lung bases clear. FINDINGS: 10.1 x 9.4 cm mass involving rectal wall, bladder, prostate, and seminal vesicles. Pelvic mesentery and iliac lymphadenopathy.

08/30/2014 – MRI Pelvis: Large necrotic mass w/ obliteration of mesorectal fascia, gross invasion of the prostate and bladder, posterior extension of tumor into presacral space and bilateral obturator internus muscles. Involvement of ischiorectal fat and upper portions of bilateral sphincters. Gross invasion of upper sphincters. Enlarged common iliac and external iliac LNs present bilaterally. IMP: Low rectal cancer.

08/30/2014 – CT Chest: Five indeterminate 2 mm pulmonary nodules. Three additional foci ground glass opacity in RUL, may represent inflammation, but appearance is indistinguishable from adenoca in situ. FU in 3 months.

Scopes

08/15/2014 – Colonoscopy w/ biopsies: Large rectal mass, suspect this is rectal cancer. CT scan demonstrated large pre-sacral mass that involves rectal wall as well as urinary bladder, prostate and seminal vesicles. Based on CT scan, this appears to be a T4 lesion and at least N1. There is also a 1.1 cm left external iliac enlarged LN, most likely represents mets. Plan: Refer to oncology, will likely require chemo as well as radiation.

Treatment Plan

08/22/2014 – Plan neoadjuvant chemo/rad. After completion in 2-3 months, plan surg. Will probably need total pelvic exenteration. After surg, pt will receive further chemo.

Chemo Text

09/10/2014 – Started FOLFOXIRI.

08/15/2014 – Path Report #1

********** This Is A Revised Or Corrected Report ***********

**** Please See End Of Report For Detail Of Corrections ****

********** This Is An Addendum Report **********

Revision #1 (See end of report for new text): IHC/IF Results

Clinical Diagnosis/History:

Rectal mass on CT.  Endoscopic findings:  Rectal mass.  Questions to pathologist:  Rule out adenoma/cancer

Final Diagnosis:

A,B)  Rectum, mass #1, #2, biopsies:  Invasive adenocarcinoma, well-differentiated.  A HEABS stain highlights the architectural changes.

Gross Description:

Specimen A:  Received in neutral buffered formalin and labeled with the patient’s name is a specimen designated “rectal mass # 1,” comprising 6 pieces of tan white tissue measuring 0.2 cm to 0.9 cm.  Submitted in total in 1 cassette.

Specimen B:  Received in neutral buffered formalin and labeled with the patient’s name is a specimen designated “rectal mass # 2,” comprising 5 pieces of tan white tissue measuring 0.5 cm to 0.8 cm.  Submitted in total in 1 cassette.

IHC Studies:

Specimen B1:  Population: Carcinoma cells

MLH1 MLH1 [G168-728]          No loss of expression

MSH2 MSH2 [G219-1129]         No loss of expression

MSH6 MSH6 (BC/44)                 No loss of expression

PMS2 PMS2                                No loss of expression

Addendum Reason:

An addendum is issued to report the results of additional immunohistochemical studies.  The final diagnosis is unchanged.

Addendum:

  1. B) Rectum, mass #2, biopsy: Invasive adenocarcinoma with no loss of expression of mismatch repair gene products (MLH1, MSH2, MSH6, or PMS2), by immunohistochemical technique.

Data Item :

Diagnosis Date

Correct Answer :

08/10/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the 08/10/2014 CT scan that showed a large presacral mass that was consistent with a malignant tumor.

Ambiguous terminology may be used to accession a case when the ambiguous terminology is considered reportable. “Consistent with” is a reportable ambiguous term. The clinical diagnosis of malignancy was subsequently confirmed by biopsy.

Data Item :

Primary Site

Correct Answer :

C209

Rationale:

The 08/10/2014 CT scan identified a presacral mass with infiltration and associated rectal wall thickening. The CT scan did not definitively identify the mass as a rectal mass, but did state it was likely of rectal origin. The 08/30/2014 MRI showed an extensive low rectal cancer and the 08/15/2014 colonoscopy identified a large rectal mass that was suspicious for rectal cancer. The primary tumor was in the rectum per the imaging and colonoscopy findings. Apply code C209 (rectum).

Data Item :

Laterality

Correct Answer :

0

Rationale:

Code 0 (not a paired site) when the primary site is not considered a paired site per SEER.

Data Item :

Histology

Correct Answer :

8140

Rationale:

The MP/H Rules (general rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. This patient underwent a biopsy of the rectal mass only. The biopsy pathology report was the most representative specimen, and it showed adenocarcinoma.

Per the MP/H Rules, Other Sites, apply rule H11 and code the histology when only one histologic type is identified. Code the histology as 8140 (adenocarcinoma, NOS).

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology report, this is a malignant tumor. Code the behavior as /3 (malignant) when the primary tumor, or any portion of the primary tumor, is invasive.

Data Item :

Grade

Correct Answer :

1

Rationale:

Code the highest grade given from the primary tumor prior to neoadjuvant treatment. The rectal mass biopsy pathology report showed well differentiated adenocarcinoma. Use the grade conversion tables in the SEER Manual when there are no special grade systems for solid tumors that apply. Per the terminology conversion table, well differentiated is coded as grade code 1.

Data Item :

Clin T

Correct Answer :

4B

Rationale:

The 08/10/2014 CT scan showed a large presacral mass involving the rectal wall, bladder, prostate and seminal vesicles. The 08/30/2014 MRI showed a large necrotic mass that obliterated the mesorectal fascia and invaded the prostate, bladder, presacral space, obturator internus muscles, ischiorectal fat and bilateral sphincters.

The 08/15/2014 colonoscopy with biopsy identified a large rectal mass that, based on the CT scan, appears to be a T4 lesion. The biopsy confirmed adenocarcinoma in the rectal mass. There was clinical imaging evidence of direct invasion into multiple organs (at least the bladder, prostate, and seminal vesicles). Apply code 4B (T4b, tumor directly invades or is adherent to other organs or structures).

Data Item :

Clin N

Correct Answer :

1

Rationale:

The 08/10/2014 CT scan identified multiple enlarged mesenteric and iliac lymph nodes. The 08/30/2014 MRI identified enlarged common iliac and external iliac lymph nodes bilaterally; however, common and external iliac nodes are not regional nodes for a rectal primary.

The 08/15/2014 colonoscopy report indicates the physician staged this as at least N1 disease based on the CT scan. The only regional nodes mentioned on the CT scan were mesenteric (NOS) nodes. Because there is no documentation regarding the specific number of regional nodes involved, a more specific N category cannot be determined. Apply code 1 (N1, metastasis in 1-3 regional lymph nodes).

Data Item :

Clin M

Correct Answer :

1A

Rationale:

The 08/10/2014 CT scan and 08/30/2014 MRI showed iliac adenopathy (enlarged common and external iliac nodes). Neither scan definitively called these metastases, but also showed no evidence of other distant metastases. The 08/15/2014 colonoscopy report states there was a 1.1 cm left external iliac enlarged lymph node that most likely represents metastasis.

External iliac nodes are considered distant lymph nodes for a rectal primary. There was no other definitive evidence of distant metastasis in other organs or sites. Involvement of a single metastatic site (including distant nodes) is considered M1a disease. Apply code 1A (M1a, metastasis confined to one organ or site).

Note: It is unclear whether the enlarged common iliac is actually involved in this case. If the enlarged common iliac node was involved, this would be considered M1b disease.  However, the colonoscopy report states the physician reviewed the CT scan (most likely the 08/10/2014 CT scan) at the time of the colonoscopy and only indicated the enlarged left external iliac node most likely represented metastasis. The physician reviewed the imaging and still didn’t provide any clarification whether this “enlarged” common iliac node is truly involved. M1a is felt to be the most defensible M category based on the physician’s assessment.

Data Item :

Clin Stg Grp

Correct Answer :

4A

Rationale:

Per colon and rectum staging form, when the TNM is cT4b cN1 cM1a, apply code 4A (Stage IVA).

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

BLANK

Rationale:

Per Table 1.5, T classification rules, a pathologic T value cannot be assigned in the absence of a surgical resection. Although Table 1.5 also states a biopsy confirming the highest T may be used, it is used only in appropriate circumstances where the pathologic staging criteria for the site has been met.

There was no resection of the primary tumor. Surgery was planned following neoadjuvant chemotherapy and radiation, but has not been performed. The primary tumor was not eligible for pathologic staging. Apply code BLANK.

Data Item :

Path N

Correct Answer :

BLANK

Rationale:

Per Table 1.6, N Classification Rules, a pathologic N value cannot be assigned in the absence of a surgical resection. Although Table 1.6 also states a biopsy confirming the highest N may be used, it is used only in appropriate circumstances where the pathologic staging criteria for the site has been met.

The patient did not undergo a lymph node resection. Surgery was planned following neoadjuvant chemotherapy and radiation, but has not been performed. There was no removal of regional lymph nodes; therefore, the lymph nodes were not eligible for pathologic staging. Apply code BLANK.

Note: Click here to open “TNM_Document.pdf” which describes general rules for developing preferred answers in SEER*Educate.

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic assessment of distant metastasis. Apply code BLANK.

Data Item :

Path Stg Grp

Correct Answer :

BLANK

Rationale:

There was no surgical resection of the primary tumor and/or regional lymph nodes. Surgery was planned following neoadjuvant treatment, but has not been performed yet. Apply code BLANK.

Note: Click here to open “TNM_Document.pdf” which describes general rules for developing preferred answers in SEER*Educate.

Data Item :

Path Desc

Correct Answer :
0
Rationale:
There are no pathologic descriptors that apply to this case. Apply code 0.
Note: Click here to open “TNM_Document.pdf” which describes general rules for developing preferred answers in SEER*Educate.

Data Item :

SS 2000

Correct Answer :

7

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has distant stage disease as the patient was clinically diagnosed with distant (external iliac) lymph node metastases. The primary tumor was considered distant by direct extension to the presacral space and ischiorectal fat on imaging. The patient also had clinical evidence of regional mesenteric lymph node metastases. The presence of distant external iliac lymph node metastases is always coded as distant stage disease, regardless of the tumor involvement or whether regional lymph nodes were involved. Apply code 7 (Distant lymph node(s) involved).

Social History

Ethiopian male, 64 y/o, born in NY. Pt is married w/3 adult children, currently retired. Insurance: Medicaid administered through HMO.

Physical Exam

02/06/2014 – cc: Pt referred for evaluation of Rt oral cavity mass. HPI: Presented to dentist approximately 2 months ago and found to have fleshiness around the gingiva of tooth #31. He reportedly had the area cauterized and treated w/ laser. Lesion was persistent during follow-up and PTA biopsy was taken on 01/29/2014, which was c/w moderately differentiated SCC. PE: Pt denies dysphagia, or changes to voice. HEENT: Nose, normal. Oral cavity and oropharynx demonstrates a fleshy erythematous mass along the buccal and lingual surface of tooth #30 and 31. Mass does not involve the tongue or floor of mouth. Neck: Normal, no masses or lymphadenopathy. PTA CT from January reviewed, which does not demonstrate any significant bony erosion along tooth #30 and 31. IMP: At least T2 N0 SCC of the right oral cavity. Outside scan is limited, repeat CT of the head and neck to rule out any neck disease. Surg discussed, pt is ready to move forward.

Scans

02/14/2014 – CT Head/Neck: Mild asymmetric soft tissue thickening along the buccal mucosa adjacent to teeth number 30 and 31, w/ mild stranding of adjacent fat likely consistent w/ pt’s known SCC. No evidence of any met lymphadenopathy in the neck. Small area of nodular consolidation in the Lt lung apex may be secondary to aspiration/infection.

05/29/2014 – CT Head: New enhancing soft tissue in the Rt submandibular region suspicious for disease recurrence. No cervical lymphadenopathy.

Operative Reports

02/19/2014 – Rt modified neck dissection, Rt marginal mandibulectomy, composite resection including bone, FOM and ventral tongue: Exophytic tumor on the buccal aspect of teeth numbers 29 to 31. There did not appear to be any invasion into the marrow space or the inferior alveolar nerve. Small LNs in levels 1 and 2 of Rt neck. Postop Dx: T2 SCC of the Rt gingivial mucosa, lateral floor of mouth.

Treatment Plan

02/28/2014 – Tumor Board Note: Given that margins were negative and there were no cervical LNs, we will continue to observe the patient clinically.

Stage

02/28/2014 – Tumor Board: T2 N0 M0 stage II SCC of the mandibular alveolus.

02/19/2014 – Path Report #1

Clinical Diagnosis/History:

Floor of mouth cancer.

Final Diagnosis:

  1. A) Right submandibular gland, excision: Salivary gland with no diagnostic abnormalities.

B, C)  Lymph nodes, right level I and right levels II and III, respectively, neck dissection: 17 lymph nodes negative for carcinoma as follows: 6 level I nodes, 7 level II nodes and 4 level III nodes.

  1. D) Mandible, right composite resection: Squamous cell carcinoma with the following features:
  2. Well-differentiated.
  3. Size: 2.5 cm.
  4. Carcinoma does not invade mandible but does erode the cortex of a tooth socket.
  5. Margins: Carcinoma is focally present at black-inked (medial) soft tissue margin near skeletal muscle, 0.2 cm from blue-inked (lateral) soft tissue margin, 0.2 cm from anterior soft tissue margin.  Mandibular bone margins are negative for carcinoma.
  6. Perineural invasion is not identified.
  7. Minimum pathologic stage pT2 NX (AJCC 7th Edition 2010).

E-I)  Margins, sites as designated, biopsies: Negative for carcinoma.

Gross Description:

Specimen A:  Received in a container of formalin labeled “right submandibular gland” is a 3.5 x 2.7 x 1.5 cm tan, lobulated salivary gland.  There are unremarkable cut surfaces.  Representative sections are submitted in cassette A1.

Specimen B:  Received in a container of formalin labeled “right level I neck dissection” are multiple tan, focally hemorrhagic, rubbery portions of tissue measuring 3.0 x 2.5 x 1 cm in aggregate dimension.  A few lymph node candidates are identified on cut surfaces ranging in size from 0.5 cm to 1.3 cm.  Representative sections are submitted labeled:  B1 – four individual lymph node candidates; B2 – two bisected lymph nodes, one marked blue.

Specimen C:  Received in a container of formalin labeled “right neck dissection, levels II and III” is a 7.0 x 4.5 x 1 cm yellow, lobulated, indurated portion of fibrofatty tissue.  There is a single suture attached to the level II end of the specimen and a double suture attached to level III end of the specimen.  The tissue is arbitrarily divided into levels II and III, and there are fatty cut surfaces admixed with numerous lymph node candidates ranging in size from 0.2 cm to 1.4 cm.  Representative sections are submitted labeled:  C1-C3 – level II nodes designated:  C1 – one blue-inked individual lymph node candidate, and one bisected lymph node candidate; C2 – four individual lymph node candidates; C3 – two bisected lymph nodes, one marked blue; C4 – one bisected lymph node, level III; C5 – five individual lymph node candidates, level III.

Specimen D:  Received in formalin labeled “right composite resection, single stitch anterior buccal, double stitch posterior lingual” is a 4.5 AP x 2.2 ML x 2.5 cm SI portion of right mandible with two gold teeth measuring 1.2 x 0.9 and 1 x 1 cm.  On the lateral aspect of the specimen is a 2.5 x 1.5 x 1.5 cm tumor mass invading into buccal mucosa in between two teeth and possibly invading into the bone.  The tumor is grossly 0.1 cm from the blue- inked lateral margin and 0.6 cm from the green-inked posterior soft tissue margin, 0.8 cm from anterior orange-inked margin, and 1.5 cm from the black-inked medial margin.  Representative sections are submitted as follows:  D1 – perpendicular section of the black-inked medial margin; D2 – perpendicular section of the orange-inked anterior margin; D3 – perpendicular section of the green-inked posterior soft tissue margin; D4-D5 – tumor closest to the blue- inked lateral margin; D6 – en face anterior bone margin; D7-D8 – cross sections of mandible; D9 – en face posterior bone margin.  The remaining tissue will be decalcified and submitted later, including en face bone margin (green ink posterior, orange ink anterior, and red ink inferior).

Specimen E:  Received fresh for frozen section labeled “anterior margin” is a 0.7 x 0.3 x 0.1 cm tan-red soft tissue inked black and entirely submitted for frozen section together with parts F and G and then thawed and submitted in cassettes E1/F1/G1FS.

Specimen F:  Received fresh for frozen section labeled “lateral margin” is a 0.6 x 0.2 x 0.1 cm soft tissue, inked blue and submitted together with specimens E and G then thawed and submitted in E1/F1/G1FS.

Specimen G:  Received fresh for frozen section labeled “posterior margin” is a 1 x 0.4 x 0.2 cm soft tissue, inked green and frozen together with parts E and F then thawed and submitted in cassette E1/F1/G1FS.

Specimen H:  Received fresh for frozen section labeled “medial margin” is a 0.6 x 0.2 x 0.1 cm soft tissue inked black and submitted together with part I then thawed and submitted in cassette H1/I1FS.

Specimen I:  Received fresh for frozen section labeled “deep margin” is a 0.6 x 0.3 x 0.2 cm soft tissue, inked blue and submitted together with part H then thawed and submitted in cassette H1/I1FS.

Frozen Section Diagnosis:

EFS, FFS, GFS, HFS, IFS:  No carcinoma

Data Item :

Diagnosis Date

Correct Answer :

01/29/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the PTA 01/29/2014 biopsy noted in the physical exam.

Data Item :

Primary Site

Correct Answer :

C031

Rationale:

The MP/H Rules, Coding Primary Site instructions, state the Tumor Board’s primary site assignment has priority over an operative report or pathology report when the primary site is indeterminate or unclear. The Tumor Board staging note indicates the tumor was located in the mandibular alveolus. The operative report also notes this tumor was on the right gingivial mucosa, lateral floor of mouth. Code the primary site based on the Tumor Board’s assessment. Apply code C031 (Mandibular gingiva).

Data Item :

Laterality

Correct Answer :

0

Rationale:

Code 0 (not a paired site) when the primary site is not considered a paired site per SEER.

Data Item :

Histology

Correct Answer :

8070

Rationale:

The MP/H Rules (general rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. The patient underwent a PTA biopsy and a mandibulectomy with neck dissection. The resection specimen was the most representative specimen, and it showed well-differentiated squamous cell carcinoma of the gingival mucosa. Per MP/H Rules, Head and Neck, apply rule H3 and code the histology when only one histologic type is identified. Code the histology as 8070 (squamous cell carcinoma).

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology report, this is a malignant tumor. Code the behavior as /3 (malignant) when the primary tumor, or any portion of the primary tumor, is invasive.

Data Item :

Grade

Correct Answer :

2

Rationale:

Code the highest grade given from the primary tumor. The PTA biopsy of the lesion on 01/29/2014 showed moderately differentiated squamous cell carcinoma. The surgical resection pathology final diagnosis showed well differentiated squamous cell carcinoma.

Use the grade conversion tables in the SEER Manual when there are no special grade systems for solid tumors that apply. Per the terminology conversion table, moderately differentiated is coded as grade code 2.

Data Item :

Clin T

Correct Answer :

2

Rationale:

The PTA 01/29/2014 gingival mass (lower gum) biopsy was positive for squamous cell carcinoma. The gingival mass did not involve the tongue or floor of mouth on physical exam. The PTA CT scan from January 2014 showed no evidence of bony erosion. There was no statement of the clinical tumor size on imaging or physical exam, but the physician clinically staged this as “at least T2” disease.

The physician’s T category assignment is the only indication of the clinical tumor size and can be used when no other documentation is given. This tumor must clinically be greater than 2 cm in size. Apply code 2 (T2, tumor more than 2 cm but not more than 4 cm in greatest dimension).

Data Item :

Clin N

Correct Answer :

0

Rationale:

The 02/06/2014 physical exam found no masses or lymphadenopathy. The 02/14/2014 CT scan also showed no evidence of any metastatic lymphadenopathy in the neck. The physician clinically staged this as N0 disease per the 02/06/2014 physical exam note. Based on the physical exam and imaging findings, this is clinically N0. Apply code 0 (N0, no regional lymph node metastasis).

Data Item :

Clin M

Correct Answer :

0

Rationale:

Per the AJCC Cancer Staging Manual, general instructions, a case with no symptoms or signs of metastasis is classified as clinically M0.

The 02/14/2014 CT scan noted a small area of nodular consolidation in the left lung apex, possibly secondary to aspiration or infection. The limited imaging was otherwise negative and did not specifically mention distant metastasis. There were no symptoms or findings the physician felt clinically suspicious for metastasis. Apply code 0 (M0, no distant metastasis).

Data Item :

Clin Stg Grp

Correct Answer :

2

Rationale:

Per the lip and oral cavity staging form, when the clinical TNM is cT2 cN0 cM0, apply code 2 (Stage II).

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

2

Rationale:

The 02/19/2014 composite resection pathology report showed a 2.5 cm squamous cell carcinoma invading into the cortical bone, but not through the cortical bone into the trabecular bone (mandible). The tumor is limited to the cortex of the alveolar bone (the bone lining the tooth socket). The margins were negative and no further extension was identified microscopically or by surgical observation.

Per the AJCC Cancer Staging Manual, superficial erosion of the cortex of bone (or tooth socket) by a gingival primary is not sufficient to classify a tumor as T4a. Apply code 2 (T2, tumor more than 2 cm but not more than 4 cm in greatest dimension).

Data Item :

Path N

Correct Answer :

0

Rationale:

The 02/19/2014 composite resection included resection of multiple regional lymph nodes (levels I-III cervical nodes). The pathology report showed the resected nodes were negative for metastatic carcinoma. Apply code 0 (N0, no regional lymph node metastasis).

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic examination of distant metastasis. Apply code BLANK.

Data Item :

Path Stg Grp

Correct Answer :

2

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, for cases with known pT and pN categories, use the clinical M category to complete the pathologic stage group.

Per the lip and oral cavity staging form, when the pathologic TNM is pT2 pN0 cM0, apply code 2 (Stage II).

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Data Item :

SS 2000

Correct Answer :

2

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has regional stage disease as the primary tumor pathologically involved the cortical bone of the mandible. The tumor eroded the cortical bone, but did not extend into the trabecular bone of the mandible. Any involvement of the mandible (cortical or trabecular) is considered regional by direct extension when determining the Summary Stage. There were no regional lymph nodes or distant metastases. Apply code 2 (Regional, direct extension only).

Social History

Filipino male, 80 y/o, single. BP: CA. Has insurance.

Physical Exam

01/29/2014 – HPI: Pt w/ a history of lung adenoca. Has been doing relatively well with FU PTA CT/PET 11/99/2013 demonstrating increased uptake in the floor of mouth. Underwent PTA FOM biopsy 01/04/2014 which was positive for moderately to poorly differentiated squamous cell carcinoma. PE: HEENT: Nasal exam normal. Exam of oral cavity demonstrates a nodularity at the floor of mouth and there appears to be induration to the submental region. It starts w/ in the middle and extends towards the Lt side. There is mild tethering of the ventral surface of the tongue. The mass is abutting the lingual cortex of the mandible (no size). LNs: No palpable lymphadenopathy in the Rt neck nor Lt neck. IMP: An anterior and Lt floor of mouth SCC that appears to be involving a portion of the ventral tongue and abutting of the mandible. Does not appear to be destruction of the mandible but there is involvement of a portion of the floor of mouth musculature. PLAN: Recommend FOM resection for complete clearance and subsequent reconstruction.

Scans

11/99/2013 – PTA CT: Lt side floor of mouth mass that is abutting the mandibular cortex on the Lt side. There does not appear to be destruction on the cortex. It does involve a portion of the deep musculature of the floor of mouth. No lymphadenopathy identified. Increased uptake in floor of mouth and no cervical lymphadenopathy uptake.

Operative Reports

02/25/2014 – Composite resection of ventral tongue and anterior floor of mouth carcinoma. Neck dissection, levels IA, right level IB through III. Findings: A submucosal nodule was present in FOM abutting the anterior mandible and extending into the ventral tongue. No penetration of the periosteum or bone.

Treatment Plan

03/19/2014 – No further therapy with the exception of cancer surveillance is anticipated.

02/25/2014 – Path Report #1

Clinical Diagnosis/History:

Cancer, floor of mouth.

Final Diagnosis:

  1. A) Right submandibular gland, excision: Salivary gland; no neoplasm identified.

B, C, K)  Lymph nodes, as designated, excisions: 6 lymph nodes negative for metastatic carcinoma (0/6), including 1 right level 2, 3 right level 2 and 3, and 2 right peri-facial lymph nodes.

  1. D) Tissue designated “right level 1a,” excision: Fibroadipose tissue and skeletal muscle; no neoplasm identified.
  1. E) Ventral tongue floor of mouth, composite resection: Invasive squamous cell carcinoma, moderately to poorly differentiated, with the following features:
  2. 2.0 cm in maximum dimension.
  3. Carcinoma focally touches the left lateral and posterior margins and is 0.2 cm from the deep margin. It is at least 0.5 cm from right lateral margin.  See comment.
  4. Perineural invasion present.
  5. No angiolymphatic invasion identified.
  6. Minimum pathologic stage: pT1N0MX.

F, J)  Margins, as designated, excisions: Squamous mucosa and skeletal muscle; no neoplasm identified.

G-I)  Margins, as designated, excisions: Skeletal muscle and fibrovascular tissue; no neoplasm identified.

Diagnosis Comment:

Definitive evaluation of the anterior margin was complicated by intraoperative sampling of tissue.

Gross Description:

Specimen A:  Received in formalin labeled “right submandibular gland” are three nodules of fibrovascular tissue measuring 1.0 cm, 1.0 cm, and 2.5 x 1.5 x 1.0 cm.  Cut sections show multilobulated, tan-white, fibrous tissue interspersed amongst yellow adipose tissue.  No discrete masses are appreciated and no foci of hemorrhage or necrosis are appreciated.  Representative sections are submitted in cassettes A1 and A2.

Specimen B:  Received in formalin labeled “right level 2” is a nodule of fibroadipose tissue measuring 2 x 1 x 0.5 cm.  The adipose tissue is dissected away to reveal a single 0.8 cm lymph node candidate that is bisected.  The specimen is submitted in its entirety in a single cassette designated B1.

Specimen C:  Received in formalin labeled “right level 2 and 3” is an irregular portion of fibroadipose tissue measuring 8 x 1.5 x 1.0 cm.  The fat and fibroconnective tissue are dissected to reveal several lymph node candidates measuring 0.3 to 0.9 cm.  The 4 lymph node candidates are entirely submitted in a single cassette designated C1.

Specimen D:  Received in formalin labeled “right level 1a” is an irregular fragment of tan fibrovascular tissue measuring 1.5 x 1.2 x 0.2 cm.  No definitive lymph node candidate is identified.  The specimen is submitted entirely in a single cassette designated D1.

Specimen E:  Received in formalin designated “composite resection of ventral tongue floor of mouth” is an irregular nodule of tan-white and brown soft tissue measuring 3.5 (ML) x 2.0 (AP) x 2.0 (SI) cm.  There is a double short stitch marking the anterior aspect of the specimen and a single long stitch marking the right lateral floor of mouth margin.  There are two additional double-loop sutures in the superior aspect of the specimen designating areas where the surgeon took tissue for research purposes prior to receipt of the specimen by Pathology.  The specimen is inked as follows: anterior blue, right lateral orange, posterior green, left lateral yellow, deep black.  The mucosal surface is tan-pink in color with a central subepithelial nodule that has been incised previously.  The specimen is serially sectioned from medial to lateral to reveal a subepithelial tan-white nodule measuring 1.7 (AP) x 1.0 (SI) x 2.0 (ML) cm.  No areas of hemorrhage or necrosis are appreciated with the mass.  There is a thin rim of skeletal muscle beneath the pushing border of the mass.  It appears to approach to 0.1 cm from the anterior mucosal aspect of the specimen and to within 0.2 to 0.3 cm from the deep aspect of the specimen.  It is at least 0.7 cm from the left lateral aspect of the specimen and no more than 0.1 cm from the right lateral aspect of the specimen.  It is focally 0.1 cm from the posterior inked margin.  The specimen is entirely submitted as follows:  E1-E2 – entire right lateral margin perpendicularly sectioned; E3-E6 – serial sections from right lateral to left lateral; E7 – entire left lateral margin perpendicularly sectioned.

Specimen F:  Received fresh from the Operating Room for intraoperative consultation labeled “right floor of mouth” is a 1.0 x 0.3 x 0.2 cm portion of tan tissue that is inked in black and entirely submitted for frozen section evaluation, then thawed and submitted in cassette F1J1FS.

Specimen G:  Received fresh from the Operating Room for intraoperative consultation labeled “central deep margin” is a 1.5 x 0.7 x 0.2 cm portion of red soft tissue that is inked red and entirely submitted for frozen section evaluation, then thawed and submitted in cassette G1H1I1FS.

Specimen H:  Received fresh from the Operating Room for intraoperative consultation labeled “left deep margin” is a 0.7 x 0.9 x 0.1 cm portion of red soft tissue that is inked black and entirely submitted for frozen section evaluation, then thawed and submitted in cassette G1H1I1FS.

Specimen I:  Received fresh from the Operating Room for intraoperative consultation labeled “anterior deep margin” is a 0.6 x 1.0 x 0.1 cm portion of red soft tissue that is inked blue and entirely submitted for frozen section evaluation, then thawed and submitted in cassette G1H1I1FS.

Specimen J:  Received fresh from the Operating Room for intraoperative consultation labeled “ventral tongue margin” is a0.7 x 0.3 x 0.2 cm portion of tan soft tissue that is inked blue and entirely submitted for frozen section evaluation, then thawed and submitted in cassette F1J1FS.

Specimen K:  Received in formalin labeled “right perifacial lymph node” are two nodules of fibroadipose tissue measuring 1.0 x 0.8 x 0.4 cm and 1.5 x 1.2 x 0.5 cm.  Fat is dissected off to reveal 2 lymph node candidates, 1 measuring 0.8 and the other measuring 1.4 cm.  Both lymph node candidates are bisected and entirely submitted in cassettes K1 and K2.

Frozen Section Diagnosis:

GFJFS)  Squamous mucosa, no high-grade dysplasia or carcinoma identified.

HIFS)  Skeletal muscle with no high-grade dysplasia or carcinoma identified .

Data Item :

Diagnosis Date

Correct Answer :

01/04/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the PTA 01/04/2014 biopsy. The PTA CT on 11/99/2013 does mention increased uptake in the floor of mouth mass but is not stated to be malignant and uptake is not a reportable term.

Data Item :

Primary Site

Correct Answer :

C040

Rationale:

The operative report on 02/25/2014 indicates the primary tumor was resected from the anterior floor of mouth. The tumor was present abutting the anterior mandible and extending to the ventral tongue. The physical exam note on 01/29/2014 states the patient has an anterior and left floor of mouth tumor (overlapping).

The MP/H Rules, Coding Primary Site instructions, state when there is no Tumor Board site assignment or staging form, the surgeon’s statement of the primary site in an operative report has priority when the tumor was completely resected. The clinical findings and pathology report are not used to code the primary site in this case. The surgeon’s assessment in the operative report was an anterior floor of mouth tumor. Apply code C040 (anterior floor of mouth).

Data Item :

Laterality

Correct Answer :

0

Rationale:

Code 0 (not a paired site) when the primary site is not considered a paired site per SEER.

Data Item :

Histology

Correct Answer :

8070

Rationale:

The MP/H Rules (general rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. The patient underwent a PTA biopsy and a composite resection of tongue and floor of mouth with neck dissection. The resection specimen was the most representative specimen, and it showed moderate to poorly differentiated squamous cell carcinoma. Per MP/H Rules, Head and Neck, apply rule H3 and code the histology when only one histologic type is identified. Code histology as 8070 (squamous cell carcinoma).

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology report, this is a malignant tumor. Code the behavior as /3 (malignant) when the primary tumor, or any portion of the primary tumor, is invasive.

Data Item :

Grade

Correct Answer :

3

Rationale:

Code the highest grade given from the primary tumor. Both the biopsy and resection showed moderately to poorly differentiated squamous cell carcinoma.

Use the grade conversion tables in the SEER Manual when there are no special grade systems for solid tumors that apply. Per the terminology conversion table, poorly differentiated is coded as grade code 3.

Data Item :

Clin T

Correct Answer :

X

Rationale:

The PTA CT/PET scan from 11/2013 identified a floor of mouth mass that abutted the mandibular cortex with no destruction, and involved a portion of the “deep musculature” of the floor of mouth. The PTA 01/04/2014 biopsy was positive for squamous cell carcinoma. The 01/29/2014 physical exam noted a mass at the floor of mouth that was not fixed, abutted the lingual cortex of the mandible, and only involved a portion of the floor of mouth musculature. The PTA scan was reviewed and there was no documentation the floor of mouth mass actually involved the deep muscles of the tongue. The physician’s impression was floor of mouth squamous cell carcinoma that appeared to be involving a portion of the ventral tongue and abutting the mandible with no actual destruction of the mandible. There was no definitive evidence of mandibular involvement.

Although clinical work-up was performed (both PTA and at this facility), the tumor was not clinically advanced (does not meet the criteria of T4a or T4b disease) and no clinical tumor size was noted. Tumors of the lip and oral cavity that are not clinically advanced (T4a or T4b disease) are categorized by tumor size alone. The primary tumor cannot be assigned a clinical T category. Apply code X (TX, primary tumor cannot be assessed).

Data Item :

Clin N

Correct Answer :

0

Rationale:

The 01/29/2014 physical exam found no palpable lymphadenopathy. The PTA 11/2013 CT/PET scan showed no evidence of lymphadenopathy in the neck. Apply code 0 (N0, no regional lymph node metastasis).

Data Item :

Clin M

Correct Answer :

0

Rationale:

Per the AJCC Cancer Staging Manual, general instructions, a case with no symptoms or signs of metastasis is classified as clinically M0.

The 01/29/2014 physical exam note and PTA 11/2013 CT/PET scans made no mention of distant metastatic disease. There were no symptoms or findings the physician felt clinically suspicious for metastasis. Apply code 0 (M0, no distant metastasis).

Data Item :

Clin Stg Grp

Correct Answer :

99

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, a clinical Stage Group cannot be assigned when the T or N categories are assigned an X value. One exception: any combination of TX or NX with M1 is classified as Stage IV.

When the TNM is cTX cN0 cM0, apply code 99 (Unknown).

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

1

Rationale:

The 02/25/2014 composite resection pathology report and operative report documented a 2 cm squamous cell carcinoma that extended into the ventral tongue. The greatest tumor extension was ventral tongue involvement. There was no evidence of bone, submandibular gland, or deep (extrinsic) muscle involvement. The final margins were negative and no further extension was identified microscopically or by surgical observation.

Invasion into the ventral tongue alone does not qualify as moderately advanced local disease (T4a disease). Apply code 1 (T1, tumor 2 cm or less in greatest dimension).

Data Item :

Path N

Correct Answer :

0

Rationale:

The 02/25/2014 composite resection included resection of multiple regional lymph nodes (level II – III cervical nodes, peri-facial nodes). The pathology report showed the resected nodes were negative for metastatic carcinoma. Apply code 0 (N0, no regional lymph node metastasis).

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic examination of distant metastasis. Apply code BLANK.

Data Item :

Path Stg Grp

Correct Answer :

1

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, for cases with known pT and pN categories, use the clinical M category to complete the pathologic stage group.

Per the lip and oral cavity staging form, when the pathologic TNM is pT1 pN0 cM0, apply code 1 (Stage I).

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Data Item :

SS 2000

Correct Answer :

2

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has regional stage disease as the primary tumor pathologically extended to the ventral tongue (underside of the anterior 2/3 of the tongue) per the composite resection operative report. Involvement of the anterior 2/3 of the tongue is considered regional by direct extension for an anterior floor of mouth tumor. There were no regional lymph nodes or distant metastases. Apply code 2 (Regional, direct extension only)

Social History

White married male with three children. Here with wife. Born in Idaho. Has managed care private insurance.

Physical Exam

02/22/2014 – HPI: 63 y/o WM who had hemoptysis in February of 2014 which led to a PTA CT Chest on 02/14/2014, which showed multiple bilateral pulmonary nodules as well as liver lesions strongly suggestive of metastatic malignancy. A large right kidney lesion also noted. This led to a PTA liver bx on 02/14/2014 showing clear cell ca, consistent with renal cancer. Started taking dexamethasone after left occipital brain metastasis was found on PTA MRI Brain 02/14/2014. Here to discuss treatment options. PE: non-contributory. IMP: Metastatic clear cell renal cancer. Plan: Referred to radiotherapy group. Not a good candidate for nephrectomy.

Scans

03/04/2014 – MRI Brain: Interval increase in size of left parietal lobe enhancing lesion, c/w mets. Two tiny foci in left frontal lobe, which may represent additional mets. Comparison: 02/14/2014.

06/06/2014 – CT Chest: Numerous pulmonary and hepatic mets which have increased in size. Necrotic mediastinal and hilar lymphadenopathy, some of which also increased in size.

Treatment Plan

02/25/2014 – Plan: Gamma knife stereotactic radiosurgery followed by Pazopanib.

Radiation Text

03/04/2014 – Gamma knife radiosurgery to four metastatic renal cell carcinoma brain metastases.

Chemo Text

04/06/2014 – Started Sunitinib.

02/14/2014 – Path Report #1

Clinical Diagnosis/History:

Slide review.  Large renal mass in right lower pole of kidney (per electronic medical record).

Final Diagnosis:

Outside Hospital(02/14/2014)

Left lobe of liver, CT-guided biopsy:  Positive for carcinoma, see comment.

Diagnosis Comment:

The core needle biopsy has neoplastic groups of cells in nests with clear cytoplasm and prominent nucleoli.  The features can be compatible with metastatic clear cell renal cell carcinoma in the appropriate clinical and radiologic setting.  Immunohistochemistry can be performed upon request if clinically indicated.

Data Item :

Diagnosis Date

Correct Answer :

02/14/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the PTA 02/14/2014 liver biopsy that was positive for metastatic carcinoma.

Data Item :

Primary Site

Correct Answer :

C649

Rationale:

The PTA CT scan on 02/14/2014 showed multiple pulmonary nodules and liver lesions, as well as a large right kidney lesion. The patient underwent a PTA biopsy of a liver mass that was positive for carcinoma, and stated to be compatible with metastatic clear cell renal cell carcinoma. The 02/22/2014 physical exam note states the patient has metastatic clear cell renal cancer. Per the PTA biopsy pathology, the PTA CT scans and the physician’s assessment, the primary tumor was in the right kidney. Apply code C649 (kidney).

Data Item :

Laterality

Correct Answer :

1

Rationale:

The PTA CT scan identified a large right kidney lesion. The patient has metastatic renal cell carcinoma. Although the primary tumor was not biopsied or resected, a right kidney lesion was clinically identified. Code 1 (Right) when the primary site is a paired site and the primary tumor originated on the right.

Data Item :

Histology

Correct Answer :

8310

Rationale:

The MP/H Rules (general rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. In this case the patient had no pathologic examination of the primary tumor. The patient was diagnosed with metastatic clear cell renal cell carcinoma by biopsy of a liver metastasis.

Clinically, the physician states this patient had metastatic clear cell renal cancer. Per the pathologist, the liver biopsy was positive for carcinoma, compatible with metastatic clear cell renal cell carcinoma in the appropriate clinical setting. Based on the liver biopsy pathology and clinical finding, the physician stated this was a kidney primary, clear cell renal cell carcinoma.

Per the MP/H Rules, Kidney, apply rule H2 and code the histology from a metastatic site when there is no pathology or cytology from the primary site. Using the liver biopsy final diagnosis and diagnosis comment, make a second pass through the rules. Stop at rule H5, code the specific histologic type when the diagnosis is carcinoma and a more specific carcinoma. Clear cell renal cell carcinoma is a more specific histologic type. Code the histology as 8310 (Clear cell renal cell carcinoma).

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology report, this is a malignant tumor. The biopsy was taken from a liver metastasis. The presence of metastasis indicates the primary tumor, although not biopsied, is malignant. When the pathology specimen is from a metastatic site, code the behavior as /3 (malignant).

Data Item :

Grade

Correct Answer :

9

Rationale:

The grade is unknown. The patient had no pathologic examination of the primary tumor. The grade cannot be coded when there is no primary site specimen or clinical statement of the primary tumor’s grade specified in the medical record. No grade was given for this patient’s clear cell renal cell carcinoma. Apply code 9 (unknown, not stated).

Data Item :

Clin T

Correct Answer :

X

Rationale:

The PTA 02/14/2014 CT scan showed a large kidney lesion, but the tumor was not clinically described and no clinical tumor size was noted. There was no other description of the primary tumor, so it is unclear whether the tumor was confined to the kidney or invaded beyond it. Even if this tumor was limited to the kidney, the tumor size is required to assign a T category. The primary tumor cannot be assigned a clinical T category. Apply code X (TX, primary tumor cannot be assessed).

Data Item :

Clin N

Correct Answer :

X

Rationale:

The PTA 02/14/2014 CT scan showed lung and liver lesions strongly suggestive of metastases, as well as the large kidney lesion. The presence or absence of regional nodes was not documented on the minimal PTA imaging findings. The patient was found to have extensive metastatic disease, but there is no mention of regional nodes at the time of diagnosis.

Based on the minimal clinical findings available, it is unclear if suspicious nodes were identified on the PTA scan, or whether the lymph node findings were simply not documented. The patient has extensive metastatic disease; therefore, the regional nodes cannot be assumed to be negative or assessed clinically. Apply code X (NX, regional lymph nodes cannot be assessed).

Data Item :

Clin M

Correct Answer :

BLANK

Rationale:

The PTA 02/14/2014 liver biopsy clinically and pathologically confirmed the presence of distant metastasis. The biopsy of a distant site was part of the clinical work-up (was performed during the clinical staging time frame), and is therefore included in the clinical staging. The PTA 02/14/2014 chest CT scan was strongly suggestive of metastases in the lung and liver. The PTA 02/14/2014 brain MRI identified a left occipital brain metastasis. The 02/22/2014 physical exam note indicates the physician’s impression was metastatic clear cell renal cancer.

Although the patient also had imaging evidence of distant metastasis, the PTA liver biopsy is considered pM1 for both the clinical stage and the pathologic stage. A case with pM1 may be grouped as clinical and pathologic when it was proven during the clinical work-up. However, the clinical evidence of metastasis is not recorded in both the clinical and pathologic M categories. The clinical M is only recorded once in the registry fields, either in the cM or in the pM. Since there was pathologic evidence of distant metastasis (pM1) proven during the clinical work-up, the cM is left blank, and the clinical evidence of metastasis is recorded just once in the pM field. Apply code BLANK for cM.

Data Item :

Clin Stg Grp

Correct Answer :

4

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, any combination of T and N, including TX or NX, with M1 is classified as Stage IV.

Per the kidney staging form, when the clinical TNM is cTX cNX pM1, apply code 4 (Stage IV).

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

BLANK

Rationale:

Per Table 1.5, T classification rules, a pathologic T value cannot be assigned in the absence of a surgical resection. Although Table 1.5 also states a biopsy confirming the highest T may be used, it is used only in appropriate circumstances where the pathologic staging criteria for the site has been met.

The treatment plan did not include surgical resection of the primary tumor. The patient was not a good candidate for nephrectomy. The primary tumor was not eligible for pathologic staging. Apply code BLANK.

Data Item :

Path N

Correct Answer :

BLANK

Rationale:

Per Table 1.6, N Classification Rules, a pathologic N value cannot be assigned in the absence of a surgical resection. Although Table 1.6 also states a biopsy confirming the highest N may be used, it is used only in appropriate circumstances where the pathologic staging criteria for the site has been met.

The patient did not undergo a lymph node resection. Surgery was not planned as the patient was not a good candidate for nephrectomy. There was no removal of regional lymph nodes; therefore, the lymph nodes were not eligible for pathologic staging. Apply code BLANK.

Data Item :

Path M

Correct Answer :

1

Rationale:

The patient has pathologic evidence of distant metastasis. The patient underwent a liver biopsy as part of the clinical work-up that was positive for metastatic clear cell renal cell carcinoma. In this case, the biopsy positive liver metastasis qualifies as both clinical and pathologic staging. Apply code 1 (M1, distant metastasis).

Data Item :

Path Stg Grp

Correct Answer :

4

Rationale:

Per the kidney staging form, when the pathologic TNM is pT(Any) pN(Any) pM1, apply code 4 (Stage IV).

Although the T and N categories could not be assigned, not eligible for pathologic staging, any pathologic evidence of M1 disease allows the Stage Group to be determined.

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Data Item :

SS 2000

Correct Answer :

7

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has distant stage disease as the patient was diagnosed with lung, liver, and brain metastases. The primary tumor and regional lymph nodes could not be clinically assessed, and no surgical resection for pathologic assessment was performed. The presence of lung, liver, and brain metastases alone is always coded as distant stage disease for a kidney primary, regardless of the tumor involvement or whether regional lymph nodes were involved. Apply code 7 (Distant site(s)/lymph node(s) involved).

Social History

Married white woman with a 32 year old daughter who is here with her today. Born in Alaska. Primary payer is medicaid administered through a managed care plan.

Physical Exam

03/25/2014 – cc: 50 y/o WF w/ left renal mass. HPI: History of intermittent kidney infections leading to imaging which demonstrated a large, 16 cm left renal mass, with some perihilar lymphadenopathy which may be reactive in nature. PTA CT Chest on 03/18/2014 demonstrated lung nodules susp for metastasis. PE: Abdomen: Palpable mass in the left upper quadrant. IMP: Likely renal cell carcinoma with likely spread to the chest. Pulmonary nodules susp for metastatic disease. Plan: Left radical nephrectomy.

04/08/2014 – HPI: Pt two weeks post extensive left radical nephrectomy for PT3 N0 clear cell renal cell carcinoma with known pulmonary metastasis. Plan: High-dose IL-2 therapy. Tyrosine kinase inhibitor (TKI) therapy also being considered.

05/21/2014 – HPI: After nephrectomy, pt noted progressive neurological symptoms, including paresthesias and numbness of LLE. Imaging: PTA MRI Brain on 04/22/2014 revealed two masses in the occipital region. Pt underwent PTA gross resection of Rt brain tumor on 05/01/2014, c/w mets RCC. IMP: New diagnosis of brain metastasis. Plan: Referred for gamma knife radiosurgery and possible IL-2.

Operative Reports

03/28/2014 – Left open radical nephrectomy with retroperitoneal lymph node dissection: Huge mass in left retroperitoneum, pushing the descending colon medially. Palpable lymphadenopathy.

Radiation Text

05/23/2014 – Stereotactic radiosurgery to right parieto-occipital resection and a left parieto-occipital lobe lesion.

Immuno Text

09/05/2014 – Started Interleukin-2 therapy.

Stage

04/08/2014 – Per MD note: p T3 N0 with known pulmonary mets.

03/28/2014 – Path Report #1

Clinical Diagnosis/History:

Left renal mass.

Final Diagnosis:

  1. A) Left kidney, nephrectomy: Renal cell carcinoma, see summary data below:
  2. B) Lymph nodes, para-aortic, excision: 9 lymph nodes negative for carcinoma.
  3. C) Lymph nodes, pre-aortic, excision: 12 lymph nodes negative for carcinoma.
  4. D) Lymph nodes, left renal hilum, excision: 2 lymph nodes negative for carcinoma.
  5. E) Lymph nodes, left supra hilum, excision: 1 lymph node negative for carcinoma.

Gross Description:

Specimen A:  Received fresh labeled “left kidney” is a 1,496 g, 22 x 17 x 8.5 cm kidney.  There is a moderate amount of attached fat.  Gerota’s fascia is tan, smooth and glistening.  No adrenal gland is identified.  The ureter is identified and measures 3 cm in length.  The stapled ureter margin is removed.  The renal artery and vein are identified and they are not grossly involved by tumor.  They are all opened longitudinally and no lesions are identified.  The kidney is bisected through the renal pelvis, and at the superior pole there is an extremely large lesion that measures 17.5 x 12.5 x 10.5 cm.  It appears encapsulated.  However, there are areas where it appears to be invading into the renal fat.  In the inferior portion of the specimen, there is an extremely dilated atrophic kidney.  Only an approximately 1 cm thin rim of kidney parenchyma is present.  The remainder of the kidney is composed of dilated renal calyces.  The kidney parenchyma appears tan-pink and rubbery.  No additional masses are identified.  The tumor and kidney are serially cross-sectioned to reveal a multilobulated heterogeneous tumor.  The tumor has areas of yellow-orange to hemorrhagic to tan-brown and necrotic.  The tumor abuts the superior surgical margin; however, it is encapsulated.  The tumor does not appears to invade the renal hilum.  However, it does extend to the renal hilar adipose tissue.  No hilar lymph nodes are identified.

Cassette index:  The ureter and vascular margins are submitted in cassette A1 with the ureter inked blue; A2 – tumor to renal calyx; A3 – tumor to margin; A4 – tumor to margin; A5, A6 – portions of tumor; A7 – tumor to kidney; A8 – kidney parenchyma.

Specimen B:  Received in a container of formalin labeled “para-aortic lymph nodes” is a 4.0 x 2.0 x 1.5 cm yellow lobulated portion of fibrofatty tissue.  A few lymph node candidates are identified on cut surfaces ranging in size from 0.2 cm to 1.6 cm.  Representative sections are submitted labeled:  B1 – one bisected lymph node; B2 – three individual lymph node candidates; B3 – four individual lymph node candidates.

Specimen C:  Received in a container of formalin labeled “preaortic lymph nodes” is a 5.5 x 3.5 x 1.5 cm yellow, lobulated, congested portion of adipose tissue.  Numerous lymph nodes are identified on cut surfaces ranging from 0.2 cm to 2 cm.  Representative sections are submitted labeled:  C1 – one bisected lymph node; C2 – one bisected lymph node; C3 – one bisected lymph node; C4 – two bisected lymph nodes, one marked blue; C5 – four individual lymph node candidates; C6 – two individual lymph node candidates.

Specimen D:  Received in a container of formalin labeled “left renal hilum” is a 2.2 x 1.4 x 0.6 cm portion of fibrofatty tissue.  There are possible lymph node candidates.  The specimen is serially-sectioned and two lymph node candidates are identified.  They are bisected.  D1 – one lymph node, bisected, D2 – one lymph node, bisected.

Specimen E:  Received in formalin labeled “left suprahilum” is a 0.2 x 1.5 x 0.8 cm portion of tissue.  It is serially-sectioned and entirely submitted.

Summary Cancer Data:

Specimen and Tumor Location

Specimen type: Radical nephrectomy

Laterality: Left

Tumor focality: Unifocal

Therapy prior to surgery:  Unknown/History not provided

Characteristics and Extent of Neoplasm

Histologic type: Clear cell (conventional) renal carcinoma (83103)

Percent of sarcomatoid component: 0%

Tumor size: Greatest diameter: 17.5cm

Histologic grade: G2 (Fuhrman)

Adrenal gland: Not present

Extent of tumor: Tumor extends into perinephric tissues (pT3)

Final Surgical Resection Margins

Surgical margins: All margins negative for carcinoma

Lymph Node Status

Node summary: Nodes with carcinoma: 0    / Total nodes examined: 24

Minimum Pathologic Stage (AJCC, 7th ed., 2010)

Primary tumor (pT): pT3

Regional lymph nodes (pN): pN0: No regional lymph node metastasis

General Comments:  There is focal extracapsular extension in slide A3

Data Item :

Diagnosis Date

Correct Answer :

03/18/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the PTA 03/18/2014 CT scan that demonstrated lung nodules suspicious for metastases.

Ambiguous terminology may be used to accession a case when the ambiguous terminology is considered reportable. “Suspicious” is a reportable ambiguous term. The clinical diagnosis of malignancy was subsequently confirmed by pathology.

Data Item :

Primary Site

Correct Answer :

C649

Rationale:

The PTA imaging showed a left renal mass. The 03/25/2014 physical exam note states the impression is likely renal cell carcinoma. The patient underwent a left radical nephrectomy positive for renal cell carcinoma. Per the radical nephrectomy, the PTA scans and the physician’s assessment, the primary tumor was in the left kidney. Apply code C649 (kidney).

Data Item :

Laterality

Correct Answer :

2

Rationale:

The patient had a radical nephrectomy identifying a left kidney renal cell carcinoma. Code 2 (Left) when the primary site is a paired site and the primary tumor originated on the left.

Data Item :

Histology

Correct Answer :

8310

Rationale:

The MP/H Rules (general rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. The radical nephrectomy was the only and most representative specimen and it showed renal cell carcinoma, clear cell type. The final diagnosis was renal cell carcinoma, NOS, but the summary cancer data identified a more specific histologic type, clear cell renal cell carcinoma. The summary cancer data can be used to code the histology when it identifies a more specific histologic type.

Per the MP/H Rules, Kidney, apply rule H5, code the specific histologic type when the diagnosis is renal cell carcinoma and one specific renal cell type. Clear cell renal cell carcinoma is a specific type of renal cell carcinoma. Apply code 8310 (clear cell renal cell carcinoma).

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology report, this is a malignant tumor. Code the behavior as /3 (malignant) when the primary tumor, or any portion of the primary tumor, is invasive.

Data Item :

Grade

Correct Answer :

2

Rationale:

Code the highest grade given from the primary tumor. The nephrectomy pathology report stated the renal cell carcinoma was Fuhrman grade 2. There are special grade system rules for the kidney (Fuhrman Nuclear Grade). Use the special grade system, Kidney Parenchyma, grade conversion table to determine the correct grade code. Apply code 2 (Fuhrman grade 2, CS SSF6 code 020).

Data Item :

Clin T

Correct Answer :

2B

Rationale:

The 03/25/2014 physical exam note indicates the PTA imaging identified a large 16 cm left renal mass. There was no further description of the renal mass, including no mention of extra-renal extension. The physical exam noted a palpable mass in the left upper quadrant, but made no mention of tumor fixation to adjacent structures. There is no documentation of tumor invasion beyond the kidney based on the minimal PTA imaging and physical exam findings.

This tumor appears clinically limited to the kidney, and the tumor size was stated to be greater than 10 cm, which allows a minimal stage to be assigned. Apply code 2B (T2b, tumor more than 10 cm, limited to the kidney).

Data Item :

Clin N

Correct Answer :

0

Rationale:

The 03/25/2014 physical exam note indicates the PTA imaging showed the left renal mass and perihilar lymphadenopathy which may be reactive in nature. Reactive lymph nodes are not equivalent to involved nodes. There was no definitive statement that the perihilar lymph nodes were involved or suspicious. Apply code 0 (N0, no regional lymph node metastasis).

Data Item :

Clin M

Correct Answer :

1

Rationale:

The PTA 03/18/2014 chest CT scan demonstrated multiple lung nodules that were suspicious for metastases. The physician confirmed the presence of pulmonary metastasis at diagnosis on the 04/08/2014 Stage note. The PTA 04/22/2014 brain MRI also identified metastases in the brain; however, this represents disease progression since the MRI was performed after surgery, and there was no evidence of brain metastases at diagnosis. Apply code 1 (M1, distant metastasis).

Data Item :

Clin Stg Grp

Correct Answer :

4

Rationale:

Per the kidney staging form, when the clinical TNM is cT2b cN0 cM1, apply code 4 (Stage IV).

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

3A

Rationale:

The 03/28/2014 left radical nephrectomy pathology report and operative report showed a 17.5 cm clear cell renal cell carcinoma of the kidney extending into the perinephric tissues pathologically. The operative report noted a huge mass in the left retroperitoneum that pushed the descending colon medially, but there was no involvement of the colon per the pathology or surgical findings. The tumor extended into the perinephric tissue, which was further specified to be the renal hilar adipose tissue per the gross description. The margins were negative.

Although the physician pathologically staged this as T3, this is not entirely consistent with the resection findings and is not used to assign the T category. The T3 category will be further subcategorized as T3a because the tumor grossly extends into the renal sinus fat. Apply code 3A (T3a, tumor invades perirenal and/or renal sinus fat but not beyond Gerota’s fascia).

Data Item :

Path N

Correct Answer :

0

Rationale:

The 03/28/2014 radical nephrectomy and retroperitoneal lymph node dissection included resection of multiple regional lymph nodes (para-aortic, pre-aortic, renal hilar nodes). The pathology report showed the resected nodes were negative for metastatic carcinoma. Apply code 0 (N0, no regional lymph node metastasis).

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic examination of distant metastasis. Apply code BLANK.

Data Item :

Path Stg Grp

Correct Answer :

4

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, for cases with known pT and pN categories, use the clinical M category to complete the pathologic stage group.

Per the kidney staging form, when the pathologic TNM is pT3a pN0 cM1, apply code 4 (Stage IV).

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Data Item :

SS 2000

Correct Answer :

7

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has distant stage disease as the patient was clinically diagnosed with lung metastases at diagnosis. The primary tumor was regional by direct extension as the resection pathologically identified tumor extension into the perirenal tissues (renal sinus fat). There was no clinical or pathologic evidence of regional lymph node involvement. The presence of lung metastases alone is always coded as distant stage disease for a kidney primary, regardless of the tumor involvement or whether regional lymph nodes were involved. Apply code 7 (Distant site(s)/lymph node(s) involved).

Social History

65 y/o Black/White female w/ 45 years history of smoking. She was born in Arizona. Primary payer at dx is Medicaid administered through a managed care plan.

Physical Exam

02/04/2014 – HPI: Pt w/ bilateral supraclavicular LAD. Pt has been having flu-like symptoms for the past 4-6 weeks. 2 weeks ago, noticed Lt neck mass, which has grown larger since then. PE: Lymphatics: Firm nodularity in Lt neck, supraclavicular region, ~ 3 cm in size. Multiple less than 1 cm nodules in Rt supraclavicular fossa as well. Procedure: Flex laryngoscopy performed and showed partial vocal cord paralysis, but was otherwise WNL. FNA of left neck performed. IMP: Bilat supraclavicular adenopathy. Her exam is quite concerning for a malignant process.

02/13/2014 – Tumor Board note: Imaging reviewed w/ evidence of matted LNs throughout paratracheal region and mediastinum. SCV enlarged LNs, left greater than right. No evidence of any primary lung masses or tumors. Assessment: Extensive LAD w/ unidentifiable primary lung carcinoma. Plan: PET scan to evaluate for mets.

Scans

02/04/2014 – CT Neck/Soft Tissue: Conglomerate LAD within supraclavicular regions bilaterally and mediastinum encasing the trachea and brachiocephalic artery, possibly encasing the lt common carotid artery and superior vena cava. Two small right apical lung nodules measuring 0.6 x 0.4 cm.

02/13/2014 – CT Chest/Abd/Pelvis: Supraclavicular, mediastinal, and lt axillary LAD. Small, indeterminate bilateral lung nodules and 3 tiny calcified granulomas. Small pericardial effusion. No evidence of intra-abdominal tumor or mets disease.

02/20/2014 – PET/CT Body: Diffuse LAD within the mediastinum, lt axilla, and lower cervical regions, c/w malignancy, most likely lymphoma. Multiple foci within the bones c/w mets.

07/01/2014 – CT Chest/Abd/Pelvis: Two stable small right apical lung nodules as noted on 02/04/2014 CT, unchanged. Stable appearance of multiple small indeterminate bilateral pulmonary nodules, unchanged from prior scans. Stable appearance of indeterminate hypodense hepatic lesions. Stable appearance of multiple sclerotic osseous lesions susp for mets disease. No new osseous lesions. No definite LAD in the abdomen, or pelvis. SCV region w/ no significant LAD compared to prior scans. Mediastinum w/ sub-cm LNs, not enlarged by CT size criteria.

Operative Reports

02/04/2014 – Lt supraclavicular neck mass aspirate (procedure only)

02/22/2014 – Lt level V neck nodes excisional bx: Preoperative DX: Pt w/ bilateral level V LAD, previous FNA of SCV LN was positive for carcinoma, excisional bx to obtain additional tissue. Findings: Matted LNs from the deep supraclavicular area identified, multiple nodes dissected out.

Radiation Text

04/03/2014 – Radiation to lt 8th rib, lt axilla. 2,000 cGy. Dates given: 04/03/2014 to 04/09/2014

Chemo Text

03/07/2014 – Started Cisplatin and Pemetrexed.

Hormonal Text

02/08/2014 – Started Prednisone.

Stage

03/07/2014 – Metastatic adenocarcinoma of lung primary, involving lymph nodes of neck and chest and diffuse bone involvement.

02/04/2014 – Path Report #1

Clinical Diagnosis/History:

Bilateral supraclavicular lymphadenopathy.

Cytologic Impression:

Left supraclavicular neck mass, FNA:  Positive for malignancy.  See comment.

Diagnosis Comment:

Four alcohol fixed direct smears are received and subsequently stained with Papanicolaou stain.  Slides contain numerous variably sized cohesive groups of highly atypical epithelial cells in a background of lymphoid elements and extensive necro-inflammatory material.  Atypical cells have enlarged hyperchromatic nuclei with anisonucleosis and sometimes prominent nucleoli as well as irregular nuclear membranes and scant to ample dense cytoplasm.  The findings are positive for malignancy, consistent with poorly differentiated non-small carcinoma.  Additional immunohistochemical studies are pending on a scrape cell block preparation and results will be issued in an addendum report.

IHC Interpretation:

Immunostains are positive for cytokeratin 7 and rare cells stain with high molecular weight cytokeratin.  The tumor cells are negative for P63, cytokeratin 5 and cytokeratin 20.  TTF-1 is not interpretable due to the extremely scant number of cells remaining.  Findings are consistent with non-small cell carcinoma/poorly differentiated carcinoma, but do not point to a specific primary site on this very limited panel.  Insufficient material remains in the cell block for further testing.

02/22/2014 – Path Report #2

Clinical Diagnosis/History:

Neck cancer.

Immunohistochemistry Studies:

Specimen B1:  Population: Tumor cells

Napsin Napsin                                                                 Positive, variably

P 63 P 63, (BC4A4)                                                         Positive, variably

AE1/AE3 Pan-Cytokeratin Cocktail [AE1/AE3]             Positive, uniformly

BerEP4 Epithelial Antigen [Ber-EP4]                              Positive, variably

S100 S-100 [DR96+BC96]                                               Negative

TTF-1 Thyroid Transcription Factor 1 [8G7G3/1], TTF  Positive, uniformly

Final Diagnosis:

  1. A) Lymph node, left neck, excision: Poorly differentiated adenocarcinoma, consistent with lung primary.
  1. B) Lymph nodes, level 5, excision: Poorly differentiated adenocarcinoma, consistent with lung primary (see immunophenotype below).

Gross Description:

  1. A) Received fresh for frozen section analysis labeled “left neck node” is a 1.3 x 0.8 x 0.6 cm tan-white firm fleshy lymph node. One-half of the tissue is used for frozen section analysis.  A touch prep is made.  The frozen section residue is submitted in cassette AFS1 and the residual tissue is submitted in cassette A2.
  1. B) Received in formalin labeled “additional level V lymph node” is a 1.5 x 1.1 x 0.8 cm firm gray-white nodular portion of tissue which is trisected and entirely submitted in cassette B1.

IHC Interpretation:

Positive immunohistochemistry for TTF-1 and Napsin suggests adenocarcinoma of lung primary; negative immunohistochemistry for S-100 argues against metastatic melanoma.

Frozen Section Diagnosis:

AFS)  Positive for high-grade carcinoma.

Addendum Reason:

This addendum is issued to report the results of ALK FISH testing.

Fluorescence In-Situ Hybridization Analysis:

Deparaffinized sections from the indicated specimen and control tissues are hybridized with the ALK Break Apart Rearrangement Probe kit (Dako, Denmark), following the manufacturers directions.  The kit includes two FISH DNA probes.  Fifty interphase signals are scored. FISH-positive occurrences are defined as greater than 10% of tumor cells with split signals.

Specimen B1:  Population: Neoplastic cells

Sample                 % Split-Apart Signals Special Notes/Comments

ALK Sample         0

Negative Control   0

Positive Control   60

Chromosomal rearrangements involving the ALK gene are characteristic of anaplastic large cell lymphoma and have also been reported in other tumors, including a minority of adenocarcinomas arising in lung, breast and colon (1,2).  Disruption of the ALK gene, as detected by this assay, is consistent with a chromosomal translocation or rearrangement involving ALK at 2p23, but does not identify the specific partner gene.

  1. Amin HM; Lai R. Blood. 2007 Oct 1;110(7):2259-67. Epub 2007 May 22.
  2. Lin E, Li L, Guan Y, Soriano R, Rivers CS, Mohan S, Pandita A, Tang J, Modrusan Z. Mol Cancer Res. 2009 Sep;7(9):1466-76.

Addendum Reason:

This addendum is to report results of EGFR mutational analysis.

EGFRL1 Results:  Negative for L858R mutation and exon 19 deletions

Specimen B1:

EGFRL1 Interpretation:  The sample tested is negative for the L858R mutation in exon 21 and for deletion mutations in exon 19 of the EGFR gene, which together account for about 90% of the somatic mutations in the EGFR gene in patients with lung cancer.  If clinically indicated, DNA sequence analysis can be performed separately to detect other rare mutations in the EGFR gene.  This test can normally detect a heterozygous mutation when it is present in more than about 10% (for L858R) or 2% (for deletions) of the cells in the sample.

FISH Interpretation:

There is no evidence of translocation or rearrangement of the ALK gene.  The above diagnosis is otherwise unchanged.

Data Item :

Diagnosis Date

Correct Answer :

02/04/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the 02/04/2014 left supraclavicular mass FNA that was positive for malignancy. A cytology specimen that is positive for malignancy is not a suspicious cytology.

Data Item :

Primary Site

Correct Answer :

C349

Rationale:

The supraclavicular lymph node biopsy on 02/04/2014 was positive for malignancy and consistent with a non-small cell carcinoma. The subsequent left neck lymph node excisions on 02/22/2014 were positive for adenocarcinoma, consistent with a lung primary by IHC studies. The scans failed to demonstrate a primary lung tumor. The CT scans on 02/04/2014 and 02/13/2014 showed indeterminate pulmonary nodules only. The PET scan on 02/20/2014 showed no lung tumor. The patient underwent treatment and the follow-up CT scan on 07/01/2014 showed stable lung nodules that were unchanged from the prior scans.

The Tumor Board note on 02/13/2014 indicates the patient has extensive lymph node metastases with an unidentifiable primary lung carcinoma. Given the physician’s assessment that the primary tumor is unidentifiable, and the lack of response to treatment by the stable, indeterminate pulmonary nodules, these nodules are clearly not considered malignant tumor nodules.

Based on the CT and PET scan findings, the biopsy pathology findings and the physician’s assessment, this patient has a lung primary, NOS. A more specific subsite cannot be determined after a thorough work-up. Apply code C349 (lung, NOS).

Data Item :

Laterality

Correct Answer :

9

Rationale:

The laterality of this patient’s lung primary cannot be determined after a thorough work-up. The patient’s primary lung tumor was unidentifiable. The indeterminate, bilateral pulmonary nodules were not considered malignant. Code 9 (paired site, but no information concerning laterality) when the primary site is a paired site per SEER, but the laterality is unknown.

Data Item :

Histology

Correct Answer :

8140

Rationale:

The MP/H Rules (general rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. In this case, the patient had no pathologic examination of the primary tumor, as the primary tumor was not identified. The patient was diagnosed with metastatic adenocarcinoma by excisional biopsy of the left neck lymph node metastases.

The MP/H Rules (general rules) state that a pathology report has priority over a cytology report. The lymph node FNA from 02/04/2014 is not used to code the histology. The 02/22/2014 left neck excisional biopsies showed poorly differentiated adenocarcinoma, consistent with lung primary.

Per the MP/H Rules, Lung, apply rule H2 and code the histology from a metastatic site when there is no pathology or cytology from the primary site. Using the lymph node excisional biopsy final diagnosis, make a second pass through the rules. Stop at rule H3, code the histology when only one histologic type is identified. Code the histology as 8140 (Adenocarcinoma, NOS).

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology report, this is a malignant tumor. The excisional biopsies were taken from lymph node metastases. The presence of metastases indicate the primary tumor, although not biopsied, is malignant. When the pathology specimen is from a metastatic site, code the behavior as /3 (malignant).

Data Item :

Grade

Correct Answer :

9

Rationale:

The grade is unknown. The patient had no pathologic examination of the primary tumor. The primary tumor was not identified. The grade cannot be coded when there is no primary site specimen or clinical statement of the primary tumor’s grade specified in the medical record. Although the lymph node biopsy showed poorly differentiated adenocarcinoma, the grade is never coded from a metastatic specimen. Apply code 9 (unknown, not stated).

Data Item :

Clin T

Correct Answer :

0

Rationale:

The patient was diagnosed with a primary lung adenocarcinoma by biopsy of lymph node metastases only. The patient underwent a thorough work-up and the CT and PET scans failed to demonstrate the primary lung tumor.

The 02/13/2014 tumor board note indicates the patient has extensive lymphadenopathy with an unidentifiable primary lung carcinoma. The post-treatment 07/01/2014 CT scan showed no change in the previously noted pulmonary nodules, confirming these stable pulmonary nodules were not considered malignant.

When adequate work-up is performed, but fails to identify the primary lung tumor, the appropriate T category is T0. T0 is not the same as TX (primary tumor cannot be assessed). TX is used when the patient was diagnosed with malignancy, but adequate staging to classify the primary tumor was not performed. In this particular case, the patient was diagnosed by a lymph node biopsy in combination with extensive work-up that failed to demonstrate a primary tumor. Apply code 0 (T0, no evidence of primary tumor).

Data Item :

Clin N

Correct Answer :

3

Rationale:

The 02/04/2014 and 02/13/2014 CT scans showed bilateral supraclavicular and mediastinal lymphadenopathy. The 02/20/2014 PET scan identified diffuse lymphadenopathy in the mediastinum and bilateral lower cervical regions (supraclavicular nodes) that was consistent with metastasis. The 02/04/2014 supraclavicular node aspirate was positive for malignancy. Based on imaging and biopsy, the patient has N3 disease. Apply code 3 (N3, metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph node(s)).

Data Item :

Clin M

Correct Answer :

1B

Rationale:

The 02/20/2014 PET scan showed extensive metastatic disease involving distant lymph nodes (left axillary nodes) and multiple metastatic foci within the bones. Involvement of bone and distant lymph nodes is considered M1b (extrathoracic) disease. Apply code 1B (M1b, distant metastasis in extrathoracic organs).

Data Item :

Clin Stg Grp

Correct Answer :

4

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, any combination of T and N, including TX or NX with M1 is classified as Stage IV.

Per the lung staging form, when the TNM is cT0 cN3 cM1b, apply code 4 (Stage IV).

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

BLANK

Rationale:

Per Table 1.5, T classification rules, a pathologic T value cannot be assigned in the absence of a surgical resection. Although Table 1.5 also states a biopsy confirming the highest T may be used, it is used only in appropriate circumstances where the pathologic staging criteria for the site has been met.

The primary lung tumor was never identified; therefore, no resection could be performed. The primary tumor was not eligible for pathologic staging. Apply code BLANK.

Note: Click here to open “TNM_Document.pdf” which describes general rules for developing preferred answers in SEER*Educate.

Data Item :

Path N

Correct Answer :

BLANK

Rationale:

Per Table 1.6, N Classification Rules, a pathologic N value cannot be assigned in the absence of a surgical resection. Although Table 1.6 also states a biopsy confirming the highest N may be used, it is used only in appropriate circumstances where the pathologic staging criteria for the site has been met.

The patient did not undergo a resection of this lung primary. There was only a diagnostic biopsy (clinical staging) proving the highest N category, N3. Although the biopsy proved the highest N category, pathologic staging criteria (surgical resection of the primary tumor) was not met. The treatment plan was for radiation and chemotherapy. The regional lymph nodes were not eligible for pathologic staging. Apply code BLANK.

Note: Click here to open “TNM_Document.pdf” which describes general rules for developing preferred answers in SEER*Educate.

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic assessment of distant metastasis. Apply code BLANK.

Data Item :

Path Stg Grp

Correct Answer :

BLANK

Rationale:

There was no surgical resection of the primary tumor and/or regional lymph nodes. The treatment plan was for radiation and chemotherapy. Apply code BLANK.

Note: Click here to open “TNM_Document.pdf” which describes general rules for developing preferred answers in SEER*Educate.

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Note: Click here to open “TNM_Document.pdf” which describes general rules for developing preferred answers in SEER*Educate.

Data Item :

SS 2000

Correct Answer :

7

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has distant stage disease as the patient was clinically diagnosed with bone and distant (axillary) lymph node metastases. A primary tumor was never identified after thorough work-up. The patient had pathologic confirmation of supraclavicular lymph node involvement. The presence of bone and distant axillary lymph node metastases is always coded as distant stage disease, regardless of whether the primary tumor was identified or whether regional lymph nodes were involved. Apply code 7 (Distant site(s) involved).

Social History

Black female, born in Illinois. Pt is currently single, divorced for over a decade. Payer: HMO Medicaid plan.

Physical Exam

05/03/2014 – cc: Pt is seen for cough symptoms that began in 01/2014. She also complains of drenching night sweats and weight loss. PTA Chest CT 02/21/2014 demonstrated a RUL mass, mediastinal LAD and bilateral pleural effusions. Supraclavicular LAD was noted as well. 04/02/2014 CT Chest performed here demonstrated mediastinal and bilateral hilar LAD. Various bxs performed in past few months have been negative. PE: No mention LNs. IMP: There is concern for malignancy.

Scans

04/02/2014 – CT Chest: Large RUL mass c/w pulmonary neoplasm. Extensive mediastinal, epicardial, bilateral hilar LAD. Stable pleural effusions, new rt supraclavicular adenopathy, new pericardial effusion.

05/03/2014 – CT Chest/Abd/Pelvis: RUL lung mass which invades through the mediastinal pleura into the mediastinum and effaces the fat plane w/ the aorta, main and lt pulmonary artery, the superior lt pericardium and all the aortic branches. No lt pulmonary nodules identified. IMP: Findings c/w either stage IV primary lung carcinoma or lymphoma. Pleural effusion, indeterminate hepatic and pancreatic lesions w/o definitive visceral disease, and innumerable metastatic supraclavicular and mediastinal LNs w/ suspicious prominent retroperitoneal LNs.

05/03/2014 – CT Head: Negative.

05/10/2014 – CT Neck: Extensive adenopathy of the neck, w/ abnormal enlarged nodes at all levels.

05/29/2014 – PET: Intense FDG uptake in the soft tissue mass in the anterior RUL. Numerous foci of increased FDG uptake corresponding to LNs of the neck, mediastinal, internal mammary, cardiophrenic. Findings are c/w lymphoma (more likely) vs. lung cancer. Diffusely increased FDG uptake in the BM and spleen c/w lymphoma as primary disease.

06/19/2014 – CT Neck: There is extensive adenopathy in the neck, including conglomerate adenopathy at the level of the aortic arch. Adenopathy also is present paratracheally. Persistent extensive adenopathy of the neck w/ interval increase in the size of the LNs.

06/19/2014 – CXR: There is prominent hilar and mediastinal adenopathy.

Labs

05/03/2014 – HIV: Negative.

Operative Reports

05/21/2014 – BM aspirate and bx (procedure only)

06/12/2014 – RUL mass CT-guided bx (procedure only)

Chemo Text

06/20/2014 – Started ABVD.

Stage

06/27/2014 – IMP: Stage IV Hodgkin’s Lymphoma, restage after 4 cycles ABVD.

05/21/2014 – Path Report #1

Clinical Diagnosis/History:

Lymphadenopathy, concern for lymphoma.

Final Diagnosis:

Bilateral Bone Marrow Biopsies, Aspirate Smears, And Peripheral Blood:

Hypercellular marrow with normal trilineage hematopoiesis and slight myeloid predominance. No evidence for involvement by lymphoma.

Peripheral blood counts from electronic medical record (05/21/2014):

WBC                   *  16.84    [4.30-10.00]  THOU/uL

RBC                    *  4.21     [4.40-5.60]   mil/uL

Hemoglobin        *  9.6      [13.0-18.0]   g/dL

Hematocrit           *  31       [38-50]       %

MCV                    *  73       [81-98]       fL

MCH                  *  22.8     [27.3-33.6]   pg

MCHC               *  31.3     [32.2-36.5]   g/dL

Platelet Count    *  555      [150-400]     THOU/uL

RDW-CV          *  19.1     [11.6-14.4]   %

% Neutrophils     *  87       [34-71]       %

% Lymphocytes   *  6        [19-53]       %

% Monocytes           7        [5-13]        %

% Eosinophils          0        [0-7]         %

% Basophils             0        [0-1]         %

% Immature Granulocytes      0        [0-1]         %

Neutrophils       *  14.56    [1.80-7.00]   THOU/uL

Lymphocytes         1.03     [1.00-4.80]   THOU/uL

Monocytes         *  1.11     [0.00-0.80]   THOU/uL

Eosinophils            0.05     [0.00-0.50]   THOU/uL

Basophils              0.03     [0.00-0.20]   THOU/uL

Immature Granulocytes

                            *  0.06     [0.00-0.05]   THOU/uL

Comment:

Peripheral blood reveals neutrophilia, thrombocytosis, and hypochromic anemia.  On marrow aspirate, there is a relative myeloid predominance with granulocytosis.  The bone marrow biopsy reveals a hypercellular marrow with normal trilineage hematopoiesis.  Flow cytometry documents absence of neoplastic lymphoid or myeloid population in marrow.  Taken together, these findings suggest no involvement in the marrow by a malignant lymphoid process.  Clinical correlation is recommended.

Gross Description:

Specimen A:  Received in a container labeled “right iliac crest” is a tan-red core of cancellous bone measuring 2.3 cm in length and 0.2 cm in diameter.  The specimen is wrapped and entirely submitted in cassette A1 following decalcification.

Specimen B:  Received in a container labeled “left iliac crest” is a tan-red core of cancellous bone measuring 2.3 cm in length and 0.2 cm in diameter.  The specimen is wrapped and entirely submitted in cassette B1 following decalcification.

Specimen C:  Received are 2 Wright-Giemsa stained peripheral blood smears.

Specimen D:  Received are 2 Wright-Giemsa stained bone marrow aspirate smears.

Microscopic Description:

Peripheral Blood Differential:

Neutrophils:          88%

Lymphocytes:         2%

Monocytes:           10%

Eosinophils:      <1%

Basophils:         <1%

Total cells counted: 100

Peripheral Blood Morphology:

Marked neutrophilia, with occasional (<2%) hypersegmented neutrophils

RBC:      Hypochromia, with anisocytosis and poikilocytosis

Platelets:     Marked thrombocytosis, normal morphology

Bone Marrow Aspirate Smears:

Right posterior iliac crest

Quality:       Adequate particles, good quality

Blasts:   Not increased

Myeloids:      Proportionately increased, complete maturation, no dysplastic features

Erythroids:    Proportionately decreased, normal maturation, no dysplastic features

Megakaryocytes:     Normal numbers, no dysplastic features

Lymphocytes:   Not increased, no aggregates identified

Plasma cells:       Not increased

Bone Marrow Differential:

Aspirate smears

Myeloids:               72%

Erythroids:             25%

Blasts:                <1%

Lymphocytes:          2%

Plasma cells:            1%

M:E Ratio:         2.9 to 1

Total cells counted:  200

Bone Marrow Biopsies:

Right and Left posterior iliac crest

Biopsy length:      2.3 cm

Quality:       Adequate

Cellularity:   80%

Myeloids:      Proportionately increased

Erythroids:    Proportionately decreased

Megakaryocytes:     Normal numbers, no dysplastic features

Infiltrate:    Scattered lymphocytes and plasma cells seen, no lymphoid aggregates identified

Hemosiderin:   Absent

Flow Cytometry:

No immunophenotypic evidence of a myeloid stem cell disorder (e.g. myelodysplastic syndrome or myeloproliferative neoplasm) or non-Hodgkin lymphoma was identified. However, a low-grade stem cell disorder could not be entirely excluded and clinical, cytogenetic, and morphologic correlation is required.

06/12/2014 – Path Report #2

Clinical Diagnosis/History:

History of productive cough and chronic intermittent night sweats, presents with mediastinal adenopathy, right upper lobe lung lesion, and large bilateral pleural effusions.

Cytologic Impression:

A-B)  Anterior mediastinum and right upper lobe lung mass, needle core biopsies: Classical Hodgkin lymphoma.  See comment.

Comment:

Pathology is called to Radiology to assist in the CT-guided needle core biopsies of an anterior mediastinal and right upper lobe lung masses.

  1. A) Anterior mediastinal mass, needle core biopsies:

Evaluation episodes (1):

1 (pass 1):  Inflammatory exudate;

2:  Atypical cells present.

  1. B) Right upper lobe lung needle core biopsies: Evaluation episodes 1-4 (passes 1-4):  Atypical cells present.

Part A consists of three alcohol-fixed touch preparation slides that are subsequently Papanicolaou stained, and one air-dried touch preparation slide that is stained with Wright stain.  A composite length of 0.3 cm cores are made into one cell block with hematoxylin and eosin-stained slides prepared.  Slides contain an atypical lymphoid infiltrate with dense sclerotic bands of fibrous tissue intervening, foci of necrosis, and clusters of large highly atypical cells. These large cells are positive for CD30, Pax-5 (weak) and CD45 (weak, variable), and negative for CD20, CD15, ALK, and CD3.  Background smaller lymphocytes are mixed CD3 and CD20 positive lymphocytes.   Concurrent flow cytometry results showed an abnormal CD30-positive hematopoietic cell population.  The findings are consistent with classical Hodgkin lymphoma.  Further subclassification is not possible given this limited biopsy.

Part B, from the right upper lobe lung mass, consists of eight alcohol-fixed touch preparation slides that are subsequently stained with Papanicolaou stain and a composite length of 0.5 cm cores that are made into one cell block with hematoxylin and eosin-stained slides prepared.  The slides contain highly atypical dispersed lymphoid elements in a background of mixed inflammatory components with an immunophenotype similar to part A.  Concurrent flow cytometry results  showed an abnormal CD30-positive hematopoietic cell population, and large atypical CD30-positive cells are observed with immunohistochemistry.  The findings are consistent with classical Hodgkin lymphoma.

Specimen Source:

Specimen A)  Needle aspirate (anterior mediastinum);

Specimen B)  Needle aspirate (RUL lung)

Specimen Description:

Specimen (A)  3 slides in etoh container, 1 air dry slide, 0.3 cm core in saline fluid;

Specimen (B)  8 slides in etoh container, 0.5 cm core in saline fluid in specimen cup

Cytopreparation:

Specimen (A)  4 smears, 1 cell block;

Specimen (B)  8 smears, 1 cell block

IHC Studies:

Specimen A1:  Population: Cells of interest

PAX5 Pax-5[24]                                (See comment)  Controls appropriately positive

AE1/AE3   Pan-Cytokeratin Cocktail [AE1/AE3]      Negative  Controls appropriately positive

ALK-1     ALK Protein [ALK1]       (See comment)  Controls appropriately positive

CD15 CD15 (Leu-M1) [80HD]        (See comment)  Controls appropriately positive

CD20 CD20 [L26]                            (See comment)  Controls appropriately positive

CD3  CD3 [LN10]                            (See comment)  Controls appropriately positive

CD30 CD30/Ki-1 [Ber-H2]              (See comment)  Controls appropriately positive

CD45 CD45 [2B11 + PD7/26/16]    (See comment)  Controls appropriately positive

Specimen B1:  Population: Cells of interest

AE1/AE3   Pan-Cytokeratin Cocktail [AE1/AE3]      Negative  Controls appropriately positive

ALK-1     ALK Protein [ALK1]       (See comment)  Controls appropriately positive

CD20 CD20 [L26]                            (See comment)  Controls appropriately positive

CD3  CD3 [LN10]                            (See comment)  Controls appropriately positive

CD30 CD30/Ki-1 [Ber-H2]           (See comment)  Controls appropriately positive

CD45 CD45 [2B11 + PD7/26/16]  (See comment)  Controls appropriately positive

TTF-1     Thyroid Transcription Factor 1 [8G7G3/1], TTF          Negative  Controls appropriately positive

IHC Interpretation:

Immunohistochemistry was medically necessary in addition to flow cytometry on both parts to evaluate immunophenotype and histologic correlations.

Data Item :

Diagnosis Date

Correct Answer :

05/03/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the 05/03/2014 CT scan that was c/w either stage IV primary lung carcinoma or lymphoma (both malignancies).

Ambiguous terminology may be used to accession a case when the ambiguous terminology is considered reportable. “C/w” or consistent with, is a reportable ambiguous term. The clinical diagnosis of malignancy was subsequently confirmed by biopsy.

Data Item :

Primary Site

Correct Answer :

C341

Rationale:

The CT scan documentation indicates there is a RUL lung mass, mediastinal, epicardial, bilateral hilar, supraclavicular and neck adenopathy and suspicious prominent retroperitoneal nodes. The PET scan also identified internal mammary uptake and uptake in bone marrow and spleen consistent with lymphoma.

Use the Heme Manual instructions to code primary site. First, check the Heme DB. The Abstractor Notes in the Heme DB entry for Hodgkin lymphoma indicates primary extranodal involvement is rare, but not impossible. Since the patient appears to have a primary extranodal tumor with regional lymph node involvement, the primary site(s) noted in the Heme DB do not apply; this appears to be a rare occurrence of extranodal Hodgkin lymphoma. Because the rare primary site was not given in the Heme DB, the rules in Module 7 must be applied. Module 7 is the correct module to use when coding primary site for lymphoma.

In this case, there is both organ and lymph node involvement. Rule PH25 is the first rule that applies to involvement of a single organ and the organ’s regional lymph nodes. PH25 states to code the primary site to the organ when a lymphoma is present in an organ (lung) and that organ’s regional lymph nodes (mediastinal, epicardial, bilateral hilar, and supraclavicular lymph nodes). Distant lymph node involvement (neck, internal mammary) and the splenic involvement should be ignored for coding primary site, this will be considered in the staging. Apply code C341 (Upper lobe lung).

Data Item :

Laterality

Correct Answer :

1

Rationale:

Per the scan information and the OP report information there was a right upper lobe lung mass. Apply code 1 (right).

Data Item :

Histology

Correct Answer :

9650

Rationale:

The 06/12/2014 anterior mediastinum and RUL biopsies (histologic confirmation) found Classical Hodgkin lymphoma. Module 9, Rule PH30 of the Heme Manual states to use the Heme DB to determine histology when rules PH1-PH29 do not apply. When Classical Hodgkin lymphoma is entered into the Heme DB, code 9650 is most applicable. The Heme Manual Primary Site and Histology Coding Instructions state to code the histology from the Definitive Diagnostic Method(s) identified in the Heme DB. FISH, histologic confirmation and immunophenotyping are listed as definitive diagnostic methods for Classical Hodgkin lymphoma. Apply code 9650 (Classical Hodgkin lymphoma).

Data Item :

Behavior

Correct Answer :

3

Rationale:

The Heme Manual Case Reportability Instructions designate that all cases with morphology codes 9590-9992 be reported with a behavior code of /3 (Instruction 2).

Data Item :

Grade

Correct Answer :

9

Rationale:

The Heme Manual Grade of Tumor Rules, Rule G9, states Grade should be coded to 9, if no cell type is specified. There was no mention of cell type on the pathology report or clinically. Apply code 9 (unknown, not stated).

Data Item :

Clin T

Correct Answer :

88

Rationale:

TNM classification is not applicable to classical Hodgkin lymphoma. Apply code 88 (Not applicable).

Data Item :

Clin N

Correct Answer :

88

Rationale:

TNM classification is not applicable to classical Hodgkin lymphoma. Apply code 88 (Not applicable).

Data Item :

Clin M

Correct Answer :

88

Rationale:

TNM classification is not applicable to classical Hodgkin lymphoma. Apply code 88 (Not applicable).

Data Item :

Clin Stg Grp

Correct Answer :

4B

Rationale:

The patient underwent multiple CT scans (both PTA and at this facility) that demonstrated a right upper lobe (RUL) lung mass, extensive mediastinal, bilateral hilar, supraclavicular, cardiophrenic and neck adenopathy. The scans also demonstrated both pleural and pericardial effusions. The 05/29/2014 PET scan showed uptake in the previously identified nodal regions, as well as uptake in the internal mammary nodes, bone marrow and spleen that was consistent with lymphoma.

The 05/21/2014 bone marrow biopsy was negative for lymphoma; however, the PET scan eight days later did show uptake consistent with bone marrow involvement. The 06/12/2014 mediastinal and right upper lobe mass biopsies were positive for Hodgkin lymphoma.

Any mention of mass, enlargement or adenopathy is considered nodal involvement for lymphomas. Although the scans identified pleural and pericardial effusions, neither were cytologically proven to be involved. Pleural or pericardial effusions with unknown cytology are not considered an E lesion, or involvement, per the AJCC Cancer Staging Manual.

Each stage should be classified as either A or B according to the absence or presence of defined constitutional symptoms. The 05/03/2014 physical exam noted a history of drenching night sweats and weight loss.

Despite the negative bone marrow biopsy preceding the PET scan, the physician staged this as Stage IV disease on 06/27/2014, presumably based on the PET scan involvement of the bone marrow.  While the physician only provided the Stage Group, the documentation in the record clearly identified B symptoms. Apply code 4B (Stage IVB).

Note: For the SEER*Educate TNM 7th Edition exercises, registrars are instructed to assign TNM independent of the physician’s documented stage. There are two exceptions when the registrar may use the physician’s documented stage in these exercises as the preferred answer. Exception 1: The physician’s stage is all that is available to the registrar. Exception 2: The staging documentation in the abstracted text and/or pathology report is unclear and/or incomplete.

In this instance, the physician’s documented stage will be used because the abstracted text or pathology report is unclear and/or incomplete.

Data Item :

Clin Desc

Correct Answer :

5

Rationale:

There was clinical involvement of an extranodal site (lung) and involvement of the spleen on imaging. Apply code 5 (E&S-Extranodal and spleen, lymphomas only).

Data Item :

Path T

Correct Answer :

88

Rationale:

TNM classification is not applicable to classical Hodgkin lymphoma. Apply code 88 (Not applicable).

Data Item :

Path N

Correct Answer :

88

Rationale:

TNM classification is not applicable to classical Hodgkin lymphoma. Apply code 88 (Not applicable).

Data Item :

Path M

Correct Answer :

88

Rationale:

TNM classification is not applicable to classical Hodgkin lymphoma. Apply code 88 (Not applicable).

Data Item :

Path Stg Grp

Correct Answer :

BLANK

Rationale:

There was no staging laparotomy performed. Pathologic staging for lymphomas is reserved for patients who undergo staging laparotomy with intent to assess the presence of abdominal disease. Staging laparotomy and pathologic staging have essentially been abandoned as useful procedures. Apply code BLANK.

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Data Item :

SS 2000

Correct Answer :

7

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has distant stage disease as the patient was diagnosed with Stage IV Hodgkin lymphoma, presumably due to bone marrow involvement identified on imaging. The physician staged this as Stage IV disease.

Stage IV disease is considered distant per the Summary Stage Manual. Apply code 7 (Distant)

Social History

Divorced, Canadian female born and raised in the Northwest. BP: Vancouver, BC. Ins: Medicaid

Physical Exam

03/12/2014 – cc: Pt w/ clinical T3b N0 M0 malignant melanoma on her Rt anterior leg. HPI: Has had lesion on Rt leg for 5 years, ~ 1 year ago it blistered, top of blister came of and has continued to bleed since that time. PCP felt it was pyogenic skin lesion and tx’d with liquid nitrogen, however it has continued to change. Had PTA bx 02/20/2014 which found invasive malignant melanoma, Breslow 3.1 mm, mitotic index of 6 per square mm, no ulceration, no regression. PE: On rt anterior leg ~ 1.8 x 1.8 cm raised lesion. Lymph: No supraclavicular, cervical or inguinal adenop. IMP: Melanoma Rt anterior leg. PLAN: Recommend WLE w/ 2 cm margins and SLN biopsy.

04/08/2014 – IMP: Pt s/p WLE for T4b N1a M0 nodular melanoma. PLAN: Discussed MSLT-II clinical trial, discussed referring to Med Onc for systemic options and additional surg w/ inguinal LN dissection. Pt inclined to join MSLT-II trial, but still considering options.

Scans

04/17/2014 – CT Chest/Abd/Pelvis: RML area of consolidation w/ ground glass opacity, suggestive of infection vs. inflammatory process. Two liver lesions c/w cysts. Indeterminate left adnexal mass, recommend ultrasound for further eval.

04/30/2014 – Abd/Pelvic U/S: Fatty infiltration in liver, lesion seen on CT not well visualized. Multiple uterine fibroids. Mass adj to left ovary seen on prior exam, not visualized on this exam

Labs

06/24/2014 – LDH: 174 U/L (80-190 U/L normal)

Operative Reports

03/25/2014 – Wide local excision, Rt leg skin lesion, Rt inguinal sentinel LN mapping and dissection: Found one hot Rt inguinal sentinel LN, no other palpable abnl nodes. Removed an additional 2 cm radial skin margins around the 2 x 2.5 cm Rt pretibial skin lesion.

Treatment Plan

06/25/2014 – Pt chose not to pursue lymphadenectomy or participation in the MSLT-II trial. She also declined receiving systemic interferon tx and is currently on surveillance.

02/20/2014 – Path Report #1

Clinical Diagnosis/History:

  1. A) BCC, friable 1.5 cm lesion with rolled edges, present x 1 year.
  1. B) Pyogenic granuloma, painful 1.5 cm lesion.

Final Diagnosis:

Outside Laboratory (02/20/2014)

  1. A) Skin, right leg, biopsy: Malignant melanoma, nodular type with the following features:
  2. Approximate Breslow thickness: 3.1 mm.
  3. Clark’s Level: IV.
  4. Ulceration: Not identified.
  5. Mitotic rate: 6/mm2.
  6. Lymphocapillary invasion: Not identified.
  7. Satellitosis: Not identified.
  8. Perineural invasion: Not identified.
  9. Lymphocytic infiltrate: Non-brisk.
  10. Regression: Not identified.
  11. Margins: The peripheral margins are involved, the deep margin is free.
  12. Melanoma in situ: Definitive in-situ component not identified, see comment.
  1. B) Skin, right hand, biopsy: Invasive, moderately-to-well differentiated squamous cell carcinoma, the deep and peripheral margins are involved.  Perineural invasion is not identified.

Diagnosis Comment:

The lack of definitive in-situ component raises the possibility of a metastatic melanoma, although it is unlikely based on the rather intimate association of the lesion with the epidermis.  Clinical correlation remains essential.

Gross Description:

Received include:

One H&E and six IHC slides also labeled “A1” including one negative IHC control, and One H&E slide also labeled “B1”.

Microscopic Description:

Specimen A:  The sections show a nodular proliferation of highly atypical melanocytes in the dermis.  There is no apparent pagetoid spread and epidermal nests of atypical melanocytes.  The cells in the melanocytic nodule are epithelioid with large hyperchromatic vesicular nuclei, prominent nucleoli and abundant cytoplasm without melanin pigments.  Dermal mitoses are readily identified.  There is no ulceration, lymphovascular invasion, satellitosis or perineural invasion.  The lymphocytic infiltrate is non-brisk.  There is no regression present.  There is no definitive melanoma in-situ component.  The overlying epidermis has focal area of vesicular changes covered by fibrin, blood cells and parakeratosis.  The immunohistochemical stains performed at outside institution show that the tumor is diffusely positive for S100 and melan-A, focally positive for HMB45, and negative for CD68 and pan keratin.  The inked peripheral margins are involved.  The inked deep margin is free in sections examined.

Specimen B:  The sections show an atypical keratinocyte proliferation infiltrating into the dermis.  There is paradoxical keratinization and focal areas of glassy cytoplasm. Perineural invasion is not identified.  This lesion involves the peripheral and deep margins.

03/25/2014 – Path Report #2

Clinical Diagnosis/History:

172.7.  Right leg melanoma.

Per electronic medical record:  Malignant melanoma, nodular type; no lymphocapillary invasion; peripheral margins are involved.

Final Diagnosis:

  1. A) Right inguinal sentinel lymph node, resection:

1 lymph node, positive for metastatic melanoma by H&E and immunohistochemistry (1/1):

Location:  subcapsular and within afferent vessels

Dimension:  0.1 X 0.1 mm

Extranodal extension: not identified

  1. B) Skin, right leg, excision: Malignant melanoma, nodular type, with the following features:
  2. Approximate Breslow thickness: 6.5 mm.
  3. Clark’s Level: V.
  4. Ulceration: Present.
  5. Mitotic rate: 15/mm2.
  6. Lymphocapillary invasion: Suspicious.
  7. Satellitosis: Not identified.
  8. Perineural invasion: Not identified.
  9. Lymphocytic infiltrate: Non-brisk.
  10. Regression: Not identified.
  11. Margins: The inked margins are free in the examined sections.
  12. Melanoma in situ: Not identified.
  13. AJCC stage: pT4b, pN1a.
  1. C) Skin, right hand, excision: Crateriform squamous neoplasm consistent with regressing/resolving keratoacanthomatous squamous cell carcinoma; the inked margins are free in the examined sections.
  1. D) Skin, new ulnar margin right hand, resection: Diffuse actinic changes, no carcinoma identified.
  1. E) Skin, new distal margin right hand, resection: Diffuse actinic changes, no carcinoma identified.

Immunohistochemistry Studies:

Specimen A1:  Population: Melanoma cells

S100 S-100 [DR96+BC96]  Positive Highlights subcapsular and intravascular melanoma nests

MELAN A Melan-A [A103]  Positive Highlights subcapsular and intravascular melanoma nests

IHC Interpretation:

The S100 and melan-A stains highlight subcapsular and intravascular melanoma nests, which are also visualized on the H&E sections.

Gross Description:

Specimen A:  Received in formalin labeled “right inguinal sentinel lymph node” is a 2.4 x 2.4 x 1.0 cm yellow, lobulated portion of fibrofatty tissue, bisected to show fatty, white, fibrous-appearing cut surfaces.  The specimen is entirely submitted in cassette A1.

Specimen B:  Received in formalin labeled “right leg skin lesion, short = superior, long = lateral” is a 5 x 5 x 1.2 cm tan-brown, ovoid skin ellipse.  There is a single suture attached to the 12:00 tip (designated as superior), and a long suture attached to the 9:00 tip (designated as lateral).  Centrally there is a 1.7 x 1.3 cm tan-brown, irregular raised nodule.  The lesion is widely free from all margins (1.7 cm from 12:00, 2 cm from 3:00, 1.7 cm from 6:00, and 1.7 cm from 9:00).  The specimen is inked as follows:  12-3- 6:00 = green, 6-9:00 = orange, 9-12:00 = blue, and deep margin = black.  The specimen is serially sectioned from 12:00 to 6:00, revealing a tan-white, irregular lesion as described above.  The depth of invasion is 0.5 cm.  Representative sections are submitted as follows:  B1 – 12:00 and 6:00 tips; B2 – grossly uninvolved section between 12:00 tip and the central lesion; B3 – grossly uninvolved section between the central lesion and 6:00 tip; B4-B5 – composite section of the lesion; B6-B10 – the remaining entire lesion.

Specimen C:  Received in formalin labeled “right hand skin lesion” is a 2.5 x 2.0 x 0.2 cm tan, irregular fragment of skin with a central 1.7 x 1.0 x 0.5 cm tan, crusted lesion.  There is a short suture attached to the proximal end of the specimen and a long suture attached to the ulnar side of the specimen.  The margins of resection are inked as follows:  proximal ulnar blue, distal ulnar orange, entire radial side black.  The specimen is sectioned.  The lesion has crusted cut surfaces which extend into the underlying dermis and approach the deep margin focally.  The specimen is entirely submitted labeled:  C1 – perpendicularly sectioned distal margin; C2 – perpendicularly sectioned proximal margin; C3 – remaining tissue.

Specimen D:  Received in formalin labeled “right hand new ulnar margin” is a non oriented 2.0 x 1.0 x 0.5 cm, tan, triangular-shaped fragment of skin.  The epidermis has been marked purple.  The margins are inked blue.  The specimen is sectioned and has fibrofatty cut surfaces and no masses are identified.  The specimen is entirely submitted in cassette D1.

Specimen E:  Received in formalin labeled “right hand new distal margin” is a 2 x 1.5 x 0.2 cm tan, triangular-shaped, nonoriented skin ellipse.  The margins are inked blue.  The specimen is sectioned and has grossly unremarkable cut surfaces.  The tissue is entirely submitted in cassette E1.

Data Item :

Diagnosis Date

Correct Answer :

02/20/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the 02/20/2014 skin biopsy .

Data Item :

Primary Site

Correct Answer :

C447

Rationale:

Per the abstract information and pathology report, the melanoma was located on the right leg. Apply code C447 (skin of leg).

Data Item :

Laterality

Correct Answer :

1

Rationale:

Code 1 (Right) when the primary site is a paired site and the primary tumor originated on the right.

Data Item :

Histology

Correct Answer :

8721

Rationale:

The MP/H Rules (general rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. The 03/25/2014 excision specimen was the most representative specimen and it showed malignant melanoma, nodular type.

Per the MP/H Rules, Melanoma, apply rule H9 and code the most specific histologic term when the diagnosis is melanoma with a single specific type. Nodular type of melanoma is a more specific histology. Code the histology as 8721.

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology report, this is a malignant tumor. Code the behavior as /3 (malignant) when the primary tumor, or any portion of the primary tumor, is invasive.

Data Item :

Grade

Correct Answer :

9

Rationale:

The grade of the melanoma is unknown. The final diagnosis on either pathology report does not give a grade for this melanoma. Melanomas usually are not graded. Code grade 9 when there is no grade specified on the pathology report prior to neoadjuvant treatment.

Data Item :

Clin T

Correct Answer :

3A

Rationale:

Clinical staging of melanoma is performed after the diagnostic biopsy (which may include a complete excision of the primary melanoma) and clinical/radiographic evaluation for metastases. The clinical T category is limited to the initial biopsy (punch, shave, excisional biopsy, etc.).

The PTA 02/20/2014 right leg biopsy showed nodular melanoma extending to a Breslow thickness of 3.1 mm with no ulceration, and a mitotic rate of 6/mm squared. Clinically, this patient was noted to have a residual 1.8 cm lesion. In this case, the initial PTA biopsy was a diagnostic biopsy only. The biopsy pathology findings will be used to assign the clinical T category. Apply code 3A (T3a, melanomas 2.01 – 4.0 mm, with no ulceration).

Although the 03/12/2014 physician’s clinical TNM indicates this was T3b disease, there was no evidence of ulceration on the review of slides pathology report. The AJCC Manual indicates melanoma ulceration is based on a histopathologic examination of the primary tumor. There was no histopathologic evidence of ulceration on the diagnostic biopsy.

Data Item :

Clin N

Correct Answer :

0

Rationale:

The lymph nodes were clinically negative per the physical exam on 03/12/2014 which noted no supraclavicular, cervical or inguinal adenopathy. There was also no indication of satellite involvement on exam. The physician clinically staged this patient as N0 per the 03/12/2014 physical exam note.

The patient underwent a sentinel lymph node biopsy at the time of complete tumor excision; however, a sentinel lymph node biopsy is considered pathologic staging for a melanoma primary, and not clinical or diagnostic work-up. Apply code 0 (N0, no detectable evidence of distant metastases).

Data Item :

Clin M

Correct Answer :

0

Rationale:

Per the AJCC Cancer Staging Manual, general instructions, a case with no symptoms or signs of metastasis is classified as clinically M0.

The 03/12/2014 physical exam noted no evidence of distant lymph node involvement and the physician clinically staged this patient as M0. Although the imaging was performed following definitive treatment, it confirmed the pre-treatment clinical findings of M0 disease. There were no symptoms or findings the physician felt clinically suspicious for metastasis at diagnosis. Apply code 0 (M0, no detectable evidence of distant metastases).

Data Item :

Clin Stg Grp

Correct Answer :

2A

Rationale:

Per the melanoma of the skin staging form, when the clinical TNM is cT3a cN0 cM0, apply code 2A (Stage IIA).

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

4B

Rationale:

Pathologic staging for melanoma combines the microstaging of the primary melanoma (initial biopsy, which may incidentally represent a complete excision of the primary tumor), with the definitive treatment specimen (wide excision or re-excision), and pathologic evaluation of regional lymph nodes, except for pathologic Stage 0 and Stage IA which do not require evaluation of the lymph nodes.

The wide excision showed nodular melanoma extending to a Breslow thickness of 6.5 mm with ulceration, and a mitotic rate of 15/mm squared. The physician pathologically staged this as T4b. Apply code 4B (T4b, melanomas more than 4.0 mm with ulceration).

Data Item :

Path N

Correct Answer :

1A

Rationale:

The 03/25/2014 wide excision with sentinel lymph node dissection included resection of one regional lymph node. The right inguinal sentinel lymph node was positive for micrometastatic melanoma measuring 0.1 mm in greatest dimension. There were no clinically detectable nodal metastases prior to surgery; therefore, the lymph node metastasis qualifies as a micrometastasis. The physician pathologically staged this as N1a. Apply code 1A (N1a, metastasis in 1 node, micrometastasis only).

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic examination of distant metastasis. Apply code BLANK (Not recorded).

Data Item :

Path Stg Grp

Correct Answer :

3B

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, for cases with known pT and pN categories, use the clinical M category to complete the pathologic stage group.

Per the melanoma of the skin staging form, when the pathologic TNM is pT4b pN1a cM0, apply code 3B (Stage IIIB).

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Data Item :

SS 2000

Correct Answer :

4

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has regional stage disease as the primary tumor pathologically extended to Clark’s level V (subcutaneous tissue) on the wide excision. Additionally, the patient had pathologic evidence of regional lymph node metastases. The sentinel lymph node biopsy was positive for metastatic melanoma involving a single right inguinal sentinel lymph node. There were no distant metastases. Apply code 4 (Regional, direct extension and regional lymph nodes).

Social History

Single Kenyan female. Born in Kenya. Not insured, charity care.

Physical Exam

05/28/2014 – cc: Newly dx’d Lt adnexal mass. HPI: Pt initially presented to outside hospital ER complaining of progressive pelvic pain on left, radiating to right. Had a CT scan done PTA on 05/17/2014 that revealed a left adnexal mass, 4.8 x 8.1 x 4.8 cm, with cystic and solid portions. PE: Pelvic: Exam notable for fullness in posterior and left sided exam. External genitalia WNL. Cervix and uterus surgically absent. Large left sided semi-movable mass. IMP: Lt adnexal mass. Plan: Surgery.

06/18/2014 – Stage IIIC pelvic node positive high-grade serous ovarian cancer s/p optimal debulking. Recommend: Chemo.

Labs

05/28/2014 – CA-125: 55 U/mL (0-35 U/mL normal)

Operative Reports

05/30/2014 – Robotic-assisted laparoscopic oophorectomy converted to open exploratory surgery, BSO, tumor debulking of extensive peritoneal implants in pelvis, incl resection argon beam ablation, left ureterolysis, complete ometectomy, bxs, destruction of tumor implants: On entering, upper abd looked nml, diaphragm nml. By camera, several adhesions in pelvis. Large left adnexal mass, bxs taken of miliary ds that appeared outside ovary. Rt tube/ovary slightly abnl. Multiple miliary implants throughout pelvis ranging from 1-4 mm in size. Omentum looked nml. No suspicious LNs. Pelvis was able to be completely rendered disease free with no gross residual.

Chemo Text

07/01/2014 – Started Taxol and Carboplatin.

05/30/2014 – Path Report #1

Clinical Diagnosis/History:

(789.30) Pelvic mass.

Final Diagnosis:

A-E and I)  Sigmoid nodule, right and left fallopian tube and ovary, sigmoid epiploica, left pelvic lymph nodes, sigmoid epiploica, biopsies and bilateral salpingo-oophorectomy:  High-grade serous carcinoma with the following features:

  1. Consistent with ovarian primary involving right and left ovary (2.5 cm right ovarian mass and 5.5 cm left ovarian mass), left fallopian tube (4 cm mass), and sigmoid epiploica.
  1. Detached pieces of carcinoma present in left pelvic lymph nodes specimen and 4 lymph nodes, no carcinoma identified. (See comment)
  1. Right and left fallopian tube, no intraepithelial neoplasia identified.

F-H, J-L)  Left periaortic, right pelvic, right periaortic lymph nodes, omentum, right and left hemidiaphragm, excision and biopsies:

  1. 2 left periaortic lymph nodes negative for carcinoma (0/2).
  2. 5 right pelvic lymph nodes negative for metastatic carcinoma (0/5).
  3. 1 right periaortic lymph node negative for metastatic carcinoma (0/1).
  4. Omentum, right and left hemidiaphragm negative for carcinoma.

Comment:

The detached pieces of carcinoma in the specimen designated left pelvic lymph nodes (specimen E) may represent an entirely replaced lymph node metastasis.

Intraoperative Consultation:

AFS)  Poorly differentiated carcinoma.

Gross Description:

Specimen A:  Received fresh in a container for frozen labeled “sigmoid nodule” is a 0.2 x 0.2 x 0.1 cm tan, irregular soft tissue, entirely submitted for frozen.  The frozen section residue is submitted in block AFS1.

Specimen B:  Received in formalin labeled “right tube and ovary” is a 24 g (post-fixation), 4 x 4 x 2.8 cm nodularly distorted, focally cystic, stated right ovary.  The serosa is tan-white, lobulated, and focally studded by tan-yellow nodules.  The ovary is sectioned, and there is a 2.5 x 2.0 x 1.2 cm tan-white, fleshy, solid area admixed with a 2.2 x 2.2 x 2.0 cm cystic space.  The cystic surface is tan-white, smooth, and glistening, and no obvious nodules or lesions are identified.  No normal ovarian parenchyma is identified.  Attached to the ovary is a 5 x 0.5 x 0.5 cm fallopian tube.  The serosa is tan-pink, smooth, and glistening.  The fallopian tube is serially sectioned, and there are tan, rubbery cut surfaces with a patent stellate lumen.  The attached mesosalpinx is sectioned and has fibrofatty, vascular, unremarkable cut surfaces.  Representative sections are submitted as follows:  B1, B2 – ovarian mass; B3 – entire fallopian tube.

Specimen C:  Received fresh labeled “left tube and ovary” is a 101 g (post-fixation), 9 x 6 x 3.5 cm nodularly distorted stated left ovary.  The serosa is tan-pink, focally hemorrhagic, and focally studded by tan-white, papilliferous, friable lesions.  The ovary is sectioned, revealing a 5.5 x 4.5 x 1 cm, tan-yellow, fleshy, solid mass.  There is also a 2.5 x 1.5 x 1.0 cm cystic space.  The cystic surface is tan-white, smooth, and glistening, and no obvious lesion is identified.  No normal ovarian parenchyma is identified.  Attached to the ovary is a 4 x 1.5 x 1.0 cm, tan-brown, focally hemorrhagic, fallopian tube candidate.  The serosa is tan-red, smooth, and focally hemorrhagic.  The fallopian tube is serially sectioned, and it has tan, rubbery cut surfaces.  Representative sections are submitted as follows:  C1, C2 – ovarian mass; C3-C7 – entire fallopian tube candidate.

Specimen D:  Received in a container of formalin labeled “sigmoid epiploica” is a 3.5 x 2.2 x 0.5 cm epiploic appendage.  The serosa is variegated, hemorrhagic, and studded by multiple white tumor nodules ranging in size from 0.2 cm to 0.5 cm.  One of these nodules is located at the margin of resection, which is marked with blue ink.  The nodules are sectioned and focally extend into the underlying adipose tissue and appear to be arising from the serosa.  Representative sections are submitted in cassette D1.

Specimen E:  Received in formalin labeled “left pelvic lymph nodes” are multiple yellow, lobulated fragments of adipose tissue measuring 4.5 x 4.5 x 1.0 cm in aggregate dimension.  Four lymph node candidates are identified on cut surfaces ranging in size from 1 cm to 3.5 cm.  Also noted on cut surfaces is a 3 x 3 x 0.5 cm hemorrhagic, soft, friable possible lesion.  Representative sections are submitted labeled:  E1 – 3 individual lymph node candidates; E2, E3 – 1 quadrisected lymph node candidate; E4 – 1/2 of possible friable intramural lesion.

Specimen F:  Received in formalin labeled “left periaortic lymph nodes” is a 2.5 x 1.0 x 0.5 cm fragment of adipose tissue.  Two lymph node candidates are identified on cut surfaces averaging 1.5 cm in greatest dimension, entirely submitted in cassette F1.

Specimen G:  Received in formalin labeled “right pelvic lymph nodes” are multiple yellow, lobulated fragments of adipose tissue measuring 6.0 x 5.0 x 1.0 cm in aggregate dimension.  Seven lymph node candidates are identified on cut surfaces ranging in size from 1 cm to 3 cm.  Representative sections are submitted labeled:  G1 – 3 individual lymph node candidates; G2 – 2 individual lymph node candidates; G3 – 1 bisected lymph node; G4 – 1 bisected lymph node.

Specimen H:  Received in formalin labeled “right periaortic lymph nodes” is a 2.5 x 1.5 x 0.5 cm yellow, lobulated portion of fibrofatty tissue, submitted in toto in cassette H1.

Specimen I:  Received in formalin labeled “sigmoid epiploica” are eight yellow, lobulated epiploic appendages measuring 9 x 5 x 1.5 cm in aggregate dimension.  The serosal surfaces are variegated, focally hemorrhagic, and diffusely studded by white apparent tumor nodules averaging 0.3 cm.  There are fatty cut surfaces and the tumor nodules appear to be confined to the serosa.  Representative sections of the serosal nodules are submitted in cassette I1.

Specimen J:  Received fresh labeled “omentum” is a 30 x 23 x 1.5 cm portion of greater omentum.  The serosa is tan-yellow, smooth, and glistening.  The omentum is serially sectioned and has fibrofatty cut surfaces.  No obvious nodules or masses are identified.  Representative sections submitted in J1-J2.

Specimen K:  Received in formalin labeled “right hemidiaphragm” is a 1 x 0.5 x 0.5 cm tan-brown, rubbery portion of tissue, bisected and entirely submitted in cassette K1.

Specimen L:  Received in formalin labeled “left hemidiaphragm” is a 0.5 x 0.5 cm tan, rubbery mass which is submitted in toto in cassette L1.

05/30/2014 – Path Report #2

Clinical Diagnosis/History:

Patient presented with acute abdominal pain, workup revealed a large 7 x 9 cm complex cystic and solid mass in the left adnexa with CA-125 was mildly elevated at 55, and presents now for surgical management.

Cytologic Impression:

  1. A) Upper Abdominal Washing: Positive for malignancy.  See comment.
  2. B) Peritoneal Washing: Positive for malignancy.  See comment.

Comment:

  1. A) 70 mls grossly hemorrhagic fluid is received from which two alcohol-fixed Papanicolaou stained smears and one hematoxylin and eosin stained cell block slide are prepared. Slides contain cohesive clusters of markedly atypical epithelial cells with nuclear enlargement, anisonucleosis, hyperchromasia, macronucleoli, and pale cytoplasm.  The findings are positive for malignancy suggestive of high-grade carcinoma.
  1. B) 60 mls hemorrhagic fluid is received from which two alcohol-fixed Papanicolaou stained smears and one hematoxylin and eosin stained cell block slide are prepared. Slides contain scattered cohesive clusters of markedly atypical epithelial cells with nuclear enlargement, anisonucleosis, hyperchromasia, macronucleoli, and pale cytoplasm.  The findings are positive for malignancy, suggestive of high-grade carcinoma.

Note:

Please refer to concurrent surgical pathology case for definitive diagnosis.

Specimen Source:

  1. A) Upper Abdominal Washing;
  2. B) Peritoneal wash

Specimen Description:

(A)  70 ml grossly hemorrhaigc fluid in specimen cup with “upper abdominal washing” written on label;

(B)  60 ml hemorrhagic fluid in specimen cup with “peritoneal wash” written on label

Cytopreparation:

(A)  2 smears, 1 cell block;

(B)  2 smears, 1 cell block

Data Item :

Diagnosis Date

Correct Answer :

05/30/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the 05/30/2014 resection pathology report that showed serous carcinoma.

Data Item :

Primary Site

Correct Answer :

C569

Rationale:

The pathology report indicated serous carcinoma consistent with an ovarian primary and the physician also clinically stated this was an ovarian primary. Apply code C569 (Ovary).

Data Item :

Laterality

Correct Answer :

4

Rationale:

The pathology report indicated that the serous carcinoma was involving the right and left ovary. Per the SEER Manual, ovary is a paired site. Apply code 4 when both ovaries are involved simultaneously and there is a single histology.

Data Item :

Histology

Correct Answer :

8441

Rationale:

The MP/H Rules (general rules) state the priority for coding histology is from the pathology report of the most representative specimen. In this case, the patient had a resection of the primary site/tumor and the pathology report showed serous carcinoma. Per the MP/H Rules, Other Sites, apply rule H23 and code the histology when only one histologic type is identified. Code the histology as 8441 (serous carcinoma, NOS).

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology report, this is a malignant tumor (serous carcinoma). Code the behavior as /3 (malignant) when the primary tumor, or any portion of the primary tumor, is invasive.

Data Item :

Grade

Correct Answer :

4

Rationale:

Code the highest grade given from the primary tumor. In this case, the pathology report stated “high-grade serous carcinoma, consistent with ovarian primary.” Use the grade conversion tables in the SEER Manual when there are no site-specific coding guidelines that apply. Per the Terminology Conversion table, high grade is coded as SEER code 4.

Data Item :

Clin T

Correct Answer :

BLANK

Rationale:

The PTA 05/17/2014 CT scan showed an 8.1 cm left adnexal mass with cystic and solid portions. The 05/28/2014 physical exam noted a large left-sided semi-movable mass. No further work-up or imaging was performed at this facility. The minimal documented PTA imaging findings do not indicate whether a malignant tumor was suspected prior to the resection.

The 05/28/2014 physical exam note indicates the impression was a left adnexal mass (NOS) and the plan was to proceed directly to surgery. An ovarian malignancy was not clinically suspected or diagnosed prior to the surgical resection on 05/30/2014. There was no clinical diagnosis of a reportable ovarian primary, and, therefore, a clinical stage cannot be assigned. Apply code BLANK.

Note: Assigning BLANK indicates clinical staging was not done.

Data Item :

Clin N

Correct Answer :

BLANK

Rationale:

The PTA 05/17/2014 CT scan showed an 8.1 cm left adnexal mass with cystic and solid portions. The 05/28/2014 physical exam noted a large left-sided semi-movable mass. No further work-up or imaging was performed at this facility. The minimal documented PTA imaging findings do not indicate whether a malignant tumor was suspected prior to the resection.

The 05/28/2014 physical exam note indicates the impression was a left adnexal mass (NOS) and the plan was to proceed directly to surgery. An ovarian malignancy was not clinically suspected or diagnosed prior to the surgical resection on 05/30/2014. There was no clinical diagnosis of a reportable ovarian primary, and, therefore, a clinical stage cannot be assigned. Apply code BLANK.

Note: Assigning BLANK indicates clinical staging was not done.

Data Item :

Clin M

Correct Answer :

0

Rationale:

Per the AJCC Cancer Staging Manual, general instructions, a case with no symptoms or signs of metastasis is classified as clinically M0.

The PTA 05/17/2014 CT scan showed an 8.1 cm left adnexal mass with cystic and solid portions. The 05/28/2014 physical exam noted a large left-sided semi-movable mass. No further work-up or imaging was performed at this facility. The minimal documented PTA imaging findings do not indicate whether a malignant tumor was suspected prior to the resection.

The 05/28/2014 physical exam note indicates the impression was a left adnexal mass (NOS) and the plan was to proceed directly to surgery. An ovarian malignancy was not clinically suspected or diagnosed prior to the surgical resection on 05/30/2014. However, imaging was performed prior to surgery and there appeared to be no definitive clinical evidence of distant metastasis.

In the absence of pathologic evidence of metastasis, the clinical M category is required to assign the pathologic stage group when applicable. As the patient meets the criteria for pathologic staging, the clinical M category cannot be left blank in the registry fields. Both the cM and pM categories cannot be left blank in the registry field. While the patient did not meet the criteria for clinical staging, the cM category cannot be blank in this case. The primary tumor was not identified or clinically staged, but the clinical absence of metastasis was documented. Per the CAnswer Forum, apply code 0 (M0, no distant metastasis).

Data Item :

Clin Stg Grp

Correct Answer :

99

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, a clinical Stage Group cannot be assigned when the T or N categories are assigned an X value. One exception: any combination of TX or NX with M1 is classified as Stage IV.

Per the ovary staging form, when the TNM is cT (BLANK) cN (BLANK) cM0, apply code 99 (Unknown).

Note: Code 99 (Unknown) is most appropriate in cases where clinical staging could not be done.  CoC requires a non-BLANK value for the Clinical Stage Group.

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

2C

Rationale:

The 05/30/2014 bilateral oophorectomy and tumor debulking operative report and pathology report showed an ovarian primary involving the bilateral ovaries, left fallopian tube, sigmoid epiploica, and extensive miliary implants throughout the pelvis. The omentum and upper abdomen were negative for tumor. The upper abdominal washing and peritoneal washing were both positive for malignancy.

The patient had involvement of pelvic tissues and positive peritoneal washings, which is considered T2c involvement. Although the AJCC definition of T3c disease includes regional lymph node metastasis, if the T category does not meet the extension definition, it would not be assigned as T3c. This patient’s pathologic T category only meets the definition for T2c disease. Apply code 2C (T2c, pelvic extension and/or implants (T2a or T2b) with malignant cells in ascites or peritoneal washings).

Data Item :

Path N

Correct Answer :

1

Rationale:

The 05/30/2014 bilateral oophorectomy and tumor debulking included resection of multiple regional lymph nodes (bilateral pelvic and periaortic nodes). The pathology report showed “detached pieces of carcinoma present in left pelvic lymph nodes specimen” as well as four negative pelvic nodes. The diagnosis comment indicates this may represent an entirely replaced lymph node metastasis. The rest of the resected nodes were negative. The patient had at least one pelvic node positive for metastatic carcinoma. Apply code 1 (N1, regional lymph node metastasis).

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic examination of distant metastasis. This patient had a clinical assessment only, clinically M0. Apply code BLANK.

Data Item :

Path Stg Grp

Correct Answer :

3C

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, for cases with known pT and pN categories, use the clinical M category to complete the pathologic stage group.

Per the ovary staging form, when the pathologic TNM is pT2c pN1 cM0, apply code 3C (Stage IIIC).

Data Item :

Path Desc

Correct Answer :

3

Rationale:

The 05/30/2014 debulking pathology report showed multiple tumors of the ovary, one in the left ovary and one in the right ovary. Apply code 3 (M-Multiple primary tumors in a single site).

Data Item :

SS 2000

Correct Answer :

4

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has regional stage disease as there were tumor implants in the pelvis only and positive pelvic and abdominal washings. Tumor implants limited to pelvic structures (sigmoid epiploica) with positive peritoneal washings are considered regional by direct extension only. Additionally, the patient had regional lymph node metastasis. Positive pelvic lymph nodes were identified on resection. There were no distant metastases. Apply code 4 (Regional, direct extension and regional lymph nodes).

Social History

Filipina here with husband and children. BP: Philippines. Insured.

Physical Exam

03/12/2014 – cc: Pelvic mass. HPI: Pt w/hx bilateral breast cancer in 2011, tx’d w/ bilat mastectomy, adjuvant chemo and radiation. Presented for reconstruction eval and pre-operative CT aortogram revealed a large pelvic mass, 12.4 x 13.5 x 13.9 cm in Rt adnexa. Her CA-125 is 10 U/mL (WNL). PE: Pelvic: No lesions in vagina. Bimanual exam limited by discomfort. Appears to be a large mass extending above the umbilicus. Not possible to distinguish between adnexa, uterus and mass. No nodularity in rectovaginal septum. IMP: Large pelvic mass, recommend surgical removal.

Scans

02/28/2014 – CT Aorta: 14 cm cystic/soft tissue Rt adnexal cystic and solid mass concerning for an ovarian cystic neoplasm.

Operative Reports

03/21/2014 – Expl lap, TAH/BSO: On entering abd, there was mass arising from Rt tube/ovary, not attached to any bowel or sidewall. No excresecences noted on outside. Removed without rupture. Upper abd, liver, diaphragm and uterus grossly nml. On gross inspection there was an endometrial polyp and leiomyomata. Left tube/ovary nml. Surgically absent appendix.

Treatment Plan

04/23/2014 – Chemotherapy not recommended given low grade of tumor and confined to one ovary. FU every 3 months.

Stage

04/23/2014 – Stage IA primarily borderline mucinous neoplasm of the ovary with a small focus of adenocarcinoma per MD.

03/21/2014 – Path Report #1

Clinical Diagnosis/History:

Right ovarian mass, breast cancer.  Surgery:  Total abdominal hysterectomy/bilateral salpingo-oophorectomy/tumor debulking.

Final Diagnosis:

  1. A) Right fallopian tube and ovary (1309 gm), unilateral salpingo-oophorectomy:
  2. Adenocarcinoma, microscopic foci, in a background of a mucinous cystic neoplasm with extensive in situ epithelial neoplasia, low-grade and high-grade, with associated necrosis. Please see Comment.
  3. Fallopian tube with no evidence of neoplasia.
  1. B) Uterus, left fallopian tube and ovary, hysterectomy and unilateral salpingo-oophorectomy:
  2. Uterus with weakly proliferative endometrium and benign endometrial polyp, negative for hyperplasia or carcinoma.
  3. Cervix and endocervix, negative for neoplasia.
  4. Ovary and fallopian tube, negative for neoplasia.
  5. Leiomyomata (1.8 cm) of myometrium.

IHC Interpretation:

Neoplastic cells lack expression of estrogen and progesterone receptors; background ovarian stroma is appropriately positive.  The above Final Diagnosis remains unaltered by this Addendum report.

Gross Description:

Specimen A:  Received fresh in a container labeled “right tube and ovary – frozen” for intraoperative consultation is a 1309 g, 16 x 15 x 10 cm round cystic mass with a smooth tan- pink surface.  Fallopian tube is present along one aspect of the specimen and measures up to 9 cm in width x up to 0.6 cm in maximum diameter.  The fimbriated end is free.  The specimen is opened to reveal clear thin liquid.  After the liquid is drained, the specimen weighs 264 gm.  Within the main cystic cavity are multiple other smaller cysts, the largest measuring up to 7.5 x 3 x 3 cm.  The larger cyst is incised to reveal tan, mucinous material.  At one aspect of the larger cyst is an area of firm tissue measuring up to 2 x 1 x 0.8 cm.  A representative section of the smaller firm piece of tissue and piece of the larger cystic mass are submitted for frozen section analysis.  The frozen section remnants are thawed in formalin and submitted entirely in cassette A1FS.  The area of hard white tissue is excised and serially sectioned to reveal a well circumscribed, tan-yellow tissue without gross invasion into the underlying capsule (0.1 cm thick).  The largest mucin filled cystic mass is serially sectioned to reveal numerous smaller cysts ranging in size from 0.4 up to 2 cm in maximum dimension.  The cysts are filled with gelatinous tan-yellow mucin without definitive papillary excrescences within the cyst wall.  The fallopian tube is removed and serially sectioned to reveal internal luminal diameter of 0.1 cm grossly.  No intraluminal masses are identified.  The remaining cyst is serially sectioned to reveal numerous smaller cysts underlying the main cyst wall.  The cysts range in size from 0.4 up to 1.5 cm.  The cysts are filled with gelatinous, tan-yellow mucin.  Small areas of more solid tan-yellow tissue are present distributed throughout the smaller cystic areas.  More solid areas are excised, photographed, and representative sections are submitted.

Cassette index:

A1FS – Frozen section remnants

A2-A3 – cross-sections of solid mass within large cyst;

A4-A5 – representative sections of largest cystic mass ampled at frozen section;

A6-A8 – fallopian tube serially sectioned and entirely submitted;

A9-A17 – representative sections of more solid and cystic areas underlying main cystic ovarian mass.

  1. B) Received fresh in a container labeled “uterus, cervix, left tube and ovary” is a 10.5 x 6.5 x 4 cm uterus with a smooth, tan serosal surface. There is a single attached fallopian tube and ovary.  The ovary measures 2.8 x 1.3 x 1.1 cm.  The attached fallopian tube measures up to 7 cm in length by 0.7 cm in maximum width.  The serosal surface is tan-deep brown with no masses on the surface.  The ovary is lobulated, tan-white without excrescences on the surface.  The cervix measures 4 x 3.9 cm with a centrally located os.  The anterior aspect of the specimen is inked blue, posterior is inked black.  The specimen is bivalved to reveal a cystic endometrial polyp arising at the right aspect of the uterus.  The endometrial polyp measures 3 x 2 x 0.5 cm maximally.  The endometrial thickness is 0.3 cm maximally.  The anterior posterior aspect of the uterus are sectioned to reveal unremarkable endomyometrium without gross lesions seen.  There is an intramural leiomyoma up to 1 cm in maximum dimension with an irregular, whorled, tan appearance.  Along the anterior left aspect of the specimen is subserosal leiomyoma up to 1.8 cm in maximum dimension.  The ovary and fallopian tube are amputated.  The fallopian tube is serially sectioned to reveal internal luminal diameter of 0.1 cm.  No gross masses or lesions are identified.  The ovary is trisected to reveal lobulated, tan parenchyma without masses or lesions.  A single corpus albicans is identified measuring up to 0.3 cm grossly.  The endometrium is further sectioned to reveal multiple other intramural leiomyomas ranging in size from 0.5 to 1.0 cm along the anterior and posterior aspects of the specimen.  Leiomyomas are serially sectioned in situ to reveal firm, white, whorled parenchyma without areas of necrosis or gross degeneration.

Cassette index:

B1 – representative sections of fallopian tube

B2 – 1/3 of ovary

B3 – anterior cervix and lower uterine segment

B4 – posterior cervix and lower uterine segment

B5 – full thickness anterior endomyometrium

B6 – full thickness posterior endomyometrium

B7 – posterior full thickness endomyometrium at site of polyp attachment

B8, B9 – bisected polyp entirely submitted (resection surface inked blue)

B10 – representative sections of multiple leiomyoma

Frozen Section Diagnosis:

AFS1)  Right ovary:  Mucinous cystadenoma with focal borderline changes involving <2% of the lesion.

B Gross)  Uterus: Endometrial polyp and leiomyomas.

Addendum:

Immunohistochemistry Studies:

Specimen A1:  Population: Neoplastic cells

ER Estrogen Receptor [SP1]               Negative     Controls appropriately positive

PR88 Progesterone Receptor [PR88]  Negative     Controls appropriately positive

Specimen A12:  Population: Neoplastic cells

ER Estrogen Receptor [SP1]               Negative     Controls appropriately positive

PR88 Progesterone Receptor [PR88]  Negative     Controls appropriately positive

Addendum Reason:

To report results of IHC for ER and PR

Diagnosis Comment:

  1. A) The ovary is markedly enlarged and cystic, and it is lined by mucinous epithelium, predominantly Mullerian type but also with areas of goblet cell differentiation, with micro-papillary architecture. Much of the neoplastic epithelium has low-grade cytoarchitectural features, but there are also areas of high-grade cytology, with complex micropapillae, high nuclear to cytoplasmic ratios, enlarged nuclear to cytoplasmic ratios, loss of nuclear polarity and nuclear stratification.  In addition, there is extensive necrosis, and there are focal areas with invasive adenocarcinoma (best seen on slide A12).  Although this may be a primary ovarian neoplasm, in which case the pathological stage is FIGO 1A, the histological features also raise consideration of a metastasis to the ovary, from a gastrointestinal or pancreatic source.  We recommend correlation with the clinical and radiological features.  Results of immunohistochemistry for estrogen and progesterone receptors will be reported as an Addendum.

The difference between the Final Diagnosis and the initial frozen section interpretation for part A reflects both sampling and the fact that the initial interpretation of “focal borderline changes” was based on gross examination.  Once fixed, there were more apparent velvety, papillary areas in the cystic neoplasm, which involves many of the blocks taken after fixation.  In addition, the foci of carcinoma were not seen in the frozen section block.

My colleague has also reviewed slide A12 and concurs with the diagnosis of focal adenocarcinoma in a background of a mucinous cystic neoplasm.

03/21/2014 – Path Report #2

Clinical Diagnosis/History:

Right ovarian mass.

Cytologic Impression:

Peritoneal wash:  No cytologically malignant cells are identified.  See comment.

Diagnosis Comment:

80 mls hemorrhagic fluid is received from which two Papanicolaou-stained concentrated smears are made.  Smears contain mesothelial cells in sheets with wash artifact.  No cytologically malignant cells are identified.  Please refer to the concurrent surgical case for more information.

Data Item :

Diagnosis Date

Correct Answer :

03/21/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the 03/21/2014 resection pathology report that showed a foci of adenocarcinoma arising in a mucinous cystic neoplasm.

Data Item :

Primary Site

Correct Answer :

C569

Rationale:

The patient’s 03/21/2014 pathology report identified a foci of adenocarcinoma in the ovarian cystic neoplasm, which was thought to be a primary ovarian neoplasm but also raised consideration of a metastasis to the ovary per the comment. Clinical correlation recommended. The 04/23/2014 treatment plan and staging indicated an ovarian primary. Apply code C569 (Ovary).

Data Item :

Laterality

Correct Answer :

1

Rationale:

The pathology report indicated that the adenocarcinoma involved the right ovary. Per the SEER Manual, ovary is a paired site. Apply code 1 when the right side of a paired site is involved.

Data Item :

Histology

Correct Answer :

8140

Rationale:

The MP/H Rules (general rules) state the priority for coding histology is from the pathology report of the most representative specimen. In this case, the patient had a resection of the primary site/tumor and the pathology report showed a microscopic foci of adenocarcinoma. Per the MP/H Rules, Other Sites, apply rule H11 and code the histology when only one histologic type is identified. Code the histology as 8140 (adenocarcinoma, NOS).

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology report, this is a malignant tumor (adenocarcinoma). Code the behavior as /3 (malignant) when the primary tumor, or any portion of the primary tumor, is invasive.

Data Item :

Grade

Correct Answer :

9

Rationale:

The grade is unknown. The resection pathology report did not give a grade for the primary tumor. The patient’s adenocarcinoma arose in a background of low to high grade neoplasia. The “low to high grade” is describing the neoplasia, not the adenocarcinoma. The grade cannot be coded when no grade is given on the pathology specimen or there is no clinical statement of the primary tumor’s grade specified in the medical record. Apply code 9 (unknown, not stated).

Data Item :

Clin T

Correct Answer :

BLANK

Rationale:

The 02/28/2014 CT scan showed a 14 cm cystic and solid right adnexal mass concerning for an ovarian cystic neoplasm. The 03/12/2014 physical exam note stated there was a large mass extending above the umbilicus and it was not possible to distinguish between adnexa, uterus and mass. No further work-up or imaging was performed at this facility. The minimal documented clinical findings do not indicate whether a malignant tumor was suspected prior to the resection.

The 03/12/2014 physical exam note indicates the impression was a large pelvic mass (NOS). The physician recommended a surgical removal of the pelvic mass and the plan was to proceed directly to surgery. An ovarian malignancy was not clinically suspected or diagnosed prior to the surgical resection on 03/21/2014. There was no clinical diagnosis of a reportable ovarian primary, and, therefore, a clinical stage cannot be assigned. Apply code BLANK.

Note: Assigning BLANK indicates clinical staging was not done.

Data Item :

Clin N

Correct Answer :

BLANK

Rationale:

The 02/28/2014 CT scan showed a 14 cm cystic and solid right adnexal mass concerning for an ovarian cystic neoplasm. The 03/12/2014 physical exam note stated there was a large mass extending above the umbilicus and it was not possible to distinguish between adnexa, uterus and mass. No further work-up or imaging was performed at this facility. The minimal documented clinical findings do not indicate whether a malignant tumor was suspected prior to the resection.

The 03/12/2014 physical exam note indicates the impression was a large pelvic mass (NOS). The physician recommended a surgical removal of the pelvic mass and the plan was to proceed directly to surgery. An ovarian malignancy was not clinically suspected or diagnosed prior to the surgical resection on 03/21/2014. There was no clinical diagnosis of a reportable ovarian primary, and, therefore, a clinical stage cannot be assigned. Apply code BLANK.

Note: Assigning BLANK indicates clinical staging was not done.

Data Item :

Clin M

Correct Answer :

0

Rationale:

Per the AJCC Cancer Staging Manual, general instructions, a case with no symptoms or signs of metastasis is classified as clinically M0.

The 02/28/2014 CT scan showed a 14 cm cystic and solid right adnexal mass concerning for an ovarian cystic neoplasm. The 03/12/2014 physical exam note stated there was a large mass extending above the umbilicus and it was not possible to distinguish between adnexa, uterus and mass. No further work-up or imaging was performed at this facility. The minimal documented clinical findings do not indicate whether a malignant tumor was suspected prior to the resection.

The 03/12/2014 physical exam note indicates the impression was a large pelvic mass (NOS). The physician recommended a surgical removal of the pelvic mass and the plan was to proceed directly to surgery. An ovarian malignancy was not clinically suspected or diagnosed prior to the surgical resection on 03/21/2014. However, imaging was performed prior to surgery and there appeared to be no definitive clinical evidence of distant metastasis.

In the absence of pathologic evidence of metastasis, the clinical M category is required to assign the pathologic stage group when applicable. As the patient meets the criteria for pathologic staging, the clinical M category cannot be left blank in the registry fields. Both the cM and pM categories cannot be left blank in the registry field. While the patient did not meet the criteria for clinical staging, the cM category cannot be blank in this case. The primary tumor was not identified or clinically staged, but the clinical absence of metastasis was documented. Per the CAnswer Forum, apply code 0 (M0, no distant metastasis).

Data Item :

Clin Stg Grp

Correct Answer :

99

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, a clinical Stage Group cannot be assigned when the T or N categories are assigned an X value. One exception: any combination of TX or NX with M1 is classified as Stage IV.

Per the ovary staging form, when the TNM is cT (BLANK) cN (BLANK) cM0, apply code 99 (Unknown).

Note: Code 99 (Unknown) is most appropriate in cases where clinical staging could not be done.  CoC requires a non-BLANK value for the Clinical Stage Group.

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

1A

Rationale:

The 03/21/2014 TAH/BSO and exploratory laparotomy operative report and pathology report showed an ovarian primary involving the right ovary only. The patient had a large mucinous cystic neoplasm with microscopic foci of adenocarcinoma confined to the ovary, without involvement of the ovarian surface. The operative report noted the mass was arising from the right tube/ovary, was not attached to bowel or sidewall, and had no excrescences on the outside of the ovary. The tumor was removed without rupture. The peritoneal wash was also negative for malignancy. The patient had involvement of one ovary only. Apply code 1A (T1a, tumor limited to one ovary; capsule intact, no tumor of ovarian surface. No malignant cells in ascites or peritoneal washings).

Data Item :

Path N

Correct Answer :

X

Rationale:

Per Table 1.6, N Classification Rules, a pathologic N value cannot be assigned in the absence of a surgical resection. Although Table 1.6 also states a biopsy confirming the highest N may be used, it is used only in appropriate circumstances where the pathologic staging criteria for the site has been met.

In order to assign the pN0 category, histologic examination of regional nodes is required. The surgical observation of nodes at the time of resection, without pathologic examination, is not recorded in the pathologic stage. The patient did not undergo a lymph node resection during the TAH/BSO and exploratory laparotomy; therefore, the regional lymph nodes cannot be assessed pathologically. Apply code X (NX, regional lymph nodes cannot be assessed).

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic examination of distant metastasis. This patient had a clinical assessment only, clinically M0. Apply code BLANK.

Data Item :

Path Stg Grp

Correct Answer :

99

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, a pathologic Stage Group cannot be assigned when the T or N categories are assigned an X value. One exception: any combination of TX or NX with M1 is classified as Stage IV.

Although the tumor was pathologically T1a (FIGO Stage IA) by resection, no pathologic examination of the regional lymph nodes was performed and the pathologic lymph node category cannot be assessed (pNX). Apply code 99 (Unknown).

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Data Item :

SS 2000

Correct Answer :

1

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has local stage disease as there was pathologic evidence of microscopic foci of adenocarcinoma involving the right ovary only. The patient has no regional lymph node or distant metastases. Apply code 1 (Localized only).

Social History

Social History: 68 y/o black female. BP: WA. Insurance: Medicare Advantage. Divorced.

Physical Exam

03/20/2014 – HPI: Recently diagnosed neoplasm of pancreatic tail. 35 lb weight loss, workup included CT showing a 4.4 cm mass in pancreatic tail. PE: HEENT: No thyromegaly or cervical adenopathy. Lungs: Clear. Abd: Flat, soft, nontender w/ no masses or organomegaly. IMP: Probable islet cell tumor of pancreatic tail.

04/05/2014 – HPI: 4.4 cm pancreatic tail mass, needle aspirate w/ IHC confirmed a neuroendocrine tumor. Pt had glucagon levels checked during workup, returned at 2,000 ng/mL, diagnostic for glucagonoma. IMP: Islet cell tumor of pancreatic tail, glucagonoma, in setting of new-onset diabetes, glucosuria and 35 lb weight loss.

Scans

03/11/2014 – CT Abd/Pelvis: 4.4 cm pancreatic tail mass abutting splenic vessels and spleen, suspicious for pancreatic cancer or islet cell tumor/neuroendocrine tumor. Multiple liver hypodensities, some cysts. 4.8 cm cystic lesion in Rt ovary, suspicious for ovarian malignancy. Re-eval on US or pelvic MRI.

03/14/2014 – Pelvic U/S: IMP: Tubular cystic mass in Rt adnexa likely a hydrosalpinx.

03/21/2014 – CT Chest/Abd: Enhancing pancreatic neoplasm c/w known neuroendocrine tumor (5.0 x 4.0 x 4.2 cm), displaces splenic vessels without splenic or splenic vessel invasion. No evidence of mets disease.

09/06/2014 – CT Abd/Pelvis: No signs of local recurrence. Multiple hepatic cysts are unchanged.

Scopes

03/14/2014 – Upper EUS: Pancreatic duct normal. Single, solid, bilobed mass off tail of pancreas. Solid, heterogenous, hypoechoic mass w/ no evidence of invasion of splenic vein. Mass bx’d. Pancreas otherwise normal. No celiac or peripancreatic LAD. IMP: Single solid mass of tail of pancreas extending to splenic hilum.

Labs

03/14/2014 – CA 19-9: 27 U/mL (0 – 54 U/mL normal)

03/14/2014 – Chomogranin A (CgA): 196 ng/mL (< 93 normal)

Operative Reports

04/08/2014 – Laparoscopic distal pancreatectomy w/ splenectomy: No sign of mets disease. Large firm mass in tail of pancreas, normal proximal pancreas.

Treatment Plan

03/22/2014 – Surgical Consult: Recommend surgical resection involving distal pancreatectomy w/ splenectomy for pancreatic neuroendocrine tumor, susp for glucagonoma.

Stage

04/19/2014 – Per MD note: p T3 N0 glucagonoma of pancreatic tail.

03/14/2014 – Path Report #1

Clinical Diagnosis/History:

Pancreatic mass.

Final Diagnosis:

  1. A) Abdominal mass, ultrasound-guided core needle biopsy: Positive for neoplastic cells, comprising well-differentiated neuroendocrine neoplasm.  Please see comment.

Diagnosis Comment:

The H&E-stained sections show predominantly blood with a few detached small fragments of epithelioid cells with eosinophilic cytoplasm and centrally-located small nuclei, with powdery chromatin.  No mitotic figures are identified.  No tissue necrosis is present.  Immunohistochemical studies demonstrate uniform chromogranin and synaptophysin immunoreactivity in the epithelioid cells.  The findings are diagnostic of a well-differentiated neuroendocrine neoplasm.  Please correlate with the concurrent cytological report.

Gross Description:

Specimen A:  Received in neutral buffered formalin and labeled with the patient’s name is a specimen designated “abdominal mass,” comprising multiple pieces of tan white tissue measuring 0.1 cm to 1.7 cm.  Submitted in total in 1 cassette.

Immunohistochemistry Studies:

Specimen A1:  Population: Neoplastic cells

PHE5/CG Chromogranin [Phe5/CG LK2H10]    (See comment)   Positive

SYNAPTO Synaptophysin [SY38]                      (See comment)   Positive

Addendum Reason:

To report additional studies, including heabs stain and IHC for KI-67.

IHC Interpretation:

Fewer than 1% of the neoplastic cells are reactive with the antibody recognizing Ki-67, consistent with neuroendocrine neoplasm.  The above Final Diagnosis remains unaltered by this Addendum report.

Addendum:

A HEABS stain assists in evaluation of the tissue architecture and is negative for cytoplasmic mucin.

03/14/2014 – Path Report #2

Clinical Diagnosis/History:

Patient with weight loss, abnormal glucose handling, and an abdominal mass in the splenic hilum, who presents for evaluation.

Cytologic Impression:

Abdominal Mass, Fine Needle Aspiration:

Positive for neoplasia, favor endocrine neoplasm.  See comment.

Diagnosis Comment:

Ten alcohol fixed direct smears are received and subsequently stained with Papanicolaou stain.  The slides contain a highly cellular sample composed of numerous singly dispersed cells and cells in loose, variably sized aggregates.  Cells appear atypical and have enlarged nuclei with stippled chromatin and frequent conspicuous nucleoli.  Some cells have a plasmacytoid appearance.  The findings are positive for neoplasia.  The morphologic features appear most compatible with an endocrine neoplasm.  In the absence of cell block material, a scrap preparation will be made from selected direct smears.  Ancillary studies will be performed and resulted separately in an addended report.

04/08/2014 – Path Report #3

********** This Is A Revised Or Corrected Report ***********

**** Please See End Of Report For Detail Of Corrections ****

********** This Is An Addendum Report **********

Revision #1 (See end of report for new text): More Material or Decals Examined

Revision #2 (See end of report for new text): Additional Histological Findings

Revision #3 (See end of report for new text): Additional Studies

Clinical Diagnosis/History:

Neuroendocrine tumor.

Surgery:  Distal pancreatectomy, possible splenectomy (laparoscopic).

Final Diagnosis:

  1. A) Pancreas and spleen, distal pancreatectomy and splenectomy: Well differentiated neuroendocrine tumor with the following features:
  2. Size: 5.5 cm in greatest dimension.
  3. Well circumscribed, but focally invading into spleen and peripancreatic fat.
  4. Pancreatic margin negative for neoplasm.
  5. Less than 1 mitotic figure per 10 HPF.
  6. Minimum pathologic stage: pT3 NX.

Comment:

Given the absence of lymph node metastases, the minimum pathologic stage is now pT3 N0.  The previous diagnoses are otherwise unchanged.  Per request of the patient’s family, a representative block of the tumor will be sent to Outside Laboratory (A3).

Gross Description:

  1. A) Received fresh labeled “distal pancreas and spleen ” is a 246 g spleen and portion of pancreas. The spleen measures 11.0 x 9.0 x 3.0 cm.  The attached pancreas and peripancreatic adipose tissue measures 6.0 x 5.0 x 5.0 cm.  There is a 3.8 cm staple line at the pancreas margin.  The staple line is 6.5 cm from the spleen.  The stapled margin is inked blue  The peripheral part of the pancreas and peripancreatic adipose tissue is inked black.  The specimen is serially-sectioned revealing a 5.5 x 4.5 x 4.0 cm irregular firm tan nodule, which appears to be adjacent to the spleen and pancreas.  No definitive invasion is seen.  Samples not needed for diagnostic purposes were taken for research.  The specimen is placed in formalin and allowed to fix overnight.  Following fixation, the specimen is further sectioned and no other masses or lesions are identified.  Representative sections are submitted as follows:  A1-A4 – composite section of mass and adjacent spleen, A5 – mass with adjacent pancreas, A6 – samples of perpendicular pancreatic stapled margin.

Addendum Reason:

This addendum is report additional potential prognostic information in response to physician’s query about the difference between the reported mitotic rate and MIB labeling index.

New slides were cut from the tumor and mitotic figures were counted from an additional 10 fields in each of 5 slides.  The overall mitotic rate is 0.4 mitoses/10 hpf, which is very low.

The MIB labeling index was repeated on the section of tumor taken from where it invaded the spleen.  Three different fields were counted in detail.  43 MIB-positive cells were identified amidst and estimated 2,152 cells for an overall labeling index of 2.00%.

There is no change to the previous diagnoses.

Addendum Reason:

This addendum is to summarize NextGen molecular sequencing results performed by Outside Laboratory.  They report a genomic alteration in the DAXX gene (E37*).  No abnormalities were identified among 235 other genes and 47 introns tested.  A complete copy of their report is on file in the Pathology Department.

Addendum Reason:

This addendum is issued to include additional diagnoses related to lymph nodes and tumor necrosis.

Addendum:

  1. A) Pancreas and spleen, distal pancreatomy and splenectomy:
  2. Twelve lymph nodes, all negative for metastatic neuroendocrine tumor (see comment).
  3. No tumor necrosis identified on review of histologic sections.

Addendum Gross Description:

Specimen A:  The specimen was re-examined specifically to identify lymph nodes.  There are 13 lymph node candidates identified ranging from 0.3 to 0.8 cm in greatest dimension.  The lymph node candidates are entirely submitted as follows:  A7 – five individual lymph node candidates, A8 – five individual lymph node candidates, A9 – three individual lymph node candidates.

Data Item :

Diagnosis Date

Correct Answer :

03/11/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the 03/11/2014 CT scan that identified a 4.4 cm mass in the pancreatic tail. The CT impression was suspicious for pancreatic cancer or islet cell tumor/neuroendocrine tumor.

Both terms given in the differential diagnosis are reportable. Islet cell tumor/neuroendocrine tumors of the pancreas are reportable. Pancreatic neuroendocrine tumors (NET) are malignant and reportable per the WHO Classification of Digestive System Tumors. An islet cell tumor is a pancreatic endocrine tumor; per WHO, pancreatic endocrine tumor is now the preferred name for an islet cell tumor. Both pancreatic neuroendocrine tumors and pancreatic endocrine tumors (PanNETs) are reportable per SEER. The clinical diagnosis of malignancy was subsequently confirmed by pathology.

Data Item :

Primary Site

Correct Answer :

C252

Rationale:

The upper EUS, CT scans, and operative report showed the primary tumor was in the tail of the pancreas. Apply code C252 (tail of pancreas).

Data Item :

Laterality

Correct Answer :

0

Rationale:

Code 0 (not a paired site) when the primary site is not considered a paired site per SEER.

Data Item :

Histology

Correct Answer :

8240

Rationale:

The MP/H Rules (general rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. The patient underwent a distal pancreatectomy with splenectomy. The surgical resection was the most representative specimen, and it showed well differentiated neuroendocrine tumor of the pancreas. Per the MP/H Rules, Other Sites, apply rule H11 and code the histology when only one histologic type is identified. Code the histology as 8240 (NET, G1, well differentiated neuroendocrine tumor).

While the abstracted information clinically refers to this as an islet cell tumor or glucagonoma, the pathology report final diagnosis has priority over a clinical diagnosis per the MP/H Rules. Per SINQ, well differentiated neuroendocrine tumors of the pancreas are reportable and the histology is coded to 8240/3.

Data Item :

Behavior

Correct Answer :

3

Rationale:

A carcinoid tumor (well differentiated neuroendocrine tumor) in the pancreas is a malignant tumor per the ICD-O-3. Code the behavior as /3 (malignant).

Data Item :

Grade

Correct Answer :

1

Rationale:

Code the highest grade given from the primary tumor prior to neoadjuvant treatment. The pancreatic mass biopsy on 03/14/2014 showed well differentiated neuroendocrine neoplasm. The surgical resection pathology final diagnosis also showed well differentiated neuroendocrine tumor.

Use the grade conversion tables in the SEER Manual when there are no site-specific coding guidelines that apply. Per the Terminology Conversion table, well differentiated is coded as SEER code 1.

Data Item :

Clin T

Correct Answer :

3

Rationale:

The 03/11/2014 CT scan showed a 4.4 cm pancreatic tail mass that abutted the splenic vessels and spleen. The repeat CT scan on 03/21/2014 also showed the known neuroendocrine tumor measuring 5 cm, without splenic or splenic vessel invasion. The tumor “abuts” adjacent sites, but there is no indication the tumor actually involves them. The 03/14/2014 endoscopic ultrasound (EUS) showed the pancreatic tail mass with no evidence of splenic vein invasion, but extension to the splenic hilum. The EUS proved involvement of the splenic hilum. The 03/14/2014 core biopsy confirmed a well differentiated neuroendocrine tumor.

The splenic hilum is located on the surface of the spleen, and extension to the splenic hilum implies imaging evidence of tumor extending beyond the pancreas. Although the CT scans were not definitive for splenic or splenic vessel involvement, the EUS confirmed a primary pancreatic neoplasm with at least extension beyond the pancreas. Apply code 3 (T3, tumor extends beyond the pancreas but without involvement of the celiac axis or the superior mesenteric artery).

Data Item :

Clin N

Correct Answer :

0

Rationale:

The 03/11/2014 CT scan made no mention of regional lymph nodes. The 03/14/2014 endoscopic ultrasound (EUS) identified no celiac or peripancreatic adenopathy. The 03/21/2014 CT scan stated there was no evidence of metastatic disease. The 03/20/2014 physical exam of the abdomen was negative. Apply code 0 (N0, no regional lymph node metastasis).

Data Item :

Clin M

Correct Answer :

0

Rationale:

Per the AJCC Cancer Staging Manual, general instructions, a case with no symptoms or signs of metastasis is classified as clinically M0.

The 03/11/2014 CT scan showed muliple liver hypodensities and an ovarian cystic lesion. The 03/14/2014 pelvic ultrasound proved the ovarian lesion to a be a hydrosalpinx. The repeat CT scan on 03/21/2014 showed no evidence of metastasis. The physical exam was negative. There were no symptoms or findings the physician felt clinically suspicious for metastasis. Apply code 0 (M0, no distant metastasis).

Data Item :

Clin Stg Grp

Correct Answer :

2A

Rationale:

Per the exocrine and endocrine pancreas staging form, when the clinical TNM is cT3 cN0 cM0, apply code 2A (Stage IIA).

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

3

Rationale:

The 04/08/2014 distal pancreatectomy with splenectomy resection pathology report showed a 5.5 cm well differentiated neuroendocrine tumor of the pancreas focally invading into the spleen and peripancreatic fat. The margins were negative and no further extension was identified microscopically or by surgical observation. The physician staged this as T3, which is consistent with the surgical findings. Apply code 3 (T3, tumor extends beyond the pancreas but without involvement of the celiac axis or the superior mesenteric artery).

Data Item :

Path N

Correct Answer :

0

Rationale:

The 04/08/2014 distal pancreatectomy with splenectomy included resection of multiple regional lymph nodes, NOS. The pathology report addendum diagnosis showed the resected nodes were negative for metastatic carcinoma. Apply code 0 (N0, no regional lymph node metastasis).

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic examination of distant metastasis. Apply code BLANK.

Data Item :

Path Stg Grp

Correct Answer :

2A

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, for cases with known pT and pN categories, use the clinical M category to complete the pathologic stage group.

Per the exocrine and endocrine pancreas staging form, when the pathologic TNM is pT3 pN0 cM0, apply code 2A (Stage IIA).

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Data Item :

SS 2000

Correct Answer :

2

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has regional stage disease as the primary tumor pathologically invaded the peripancreatic fat and spleen per the resection pathology report. Both extension to the peripancreatic fat and spleen for a pancreatic tail primary are considered regional by direct extension. There were no regional lymph nodes or distant metastases. Apply code 2 (Regional, direct extension only).

Social History

White/Chinese male lives with his wife currently and they do not have any children. Primary payer at dx: Medicaid. Birthplace: New York.

Physical Exam

03/01/2014 – cc: Elevated PSA. HPI: The patient’s PSA’s have always been in the normal range. Unfortunately, in 12/2013, his PSA was 4.3 and a repeat PSA in 01/2014 was found to be persistently elevated at just about 5. He denies any major lower urinary tract symptoms, but has had a history of kidney stones. PE: Abd: He has a benign-feeling abdomen. Rectal: He has somewhat of an asymmetric prostate with mild amount of firmness on the right side. There were no overt nodules. Plan: Biopsy.

05/24/2014 – Treatment options discussed, including external beam, brachytherapy, combo of both and radical prostatectomy. Pt originally leaning towards external beam rads, but now leaning more toward surgery.

Labs

12/12/2013 – PTA PSA: elevated at 4.26

01/16/2014 – PSA: 5.37 ng/mL (0-4 nml range)

Operative Reports

03/22/2014 – Transrectal US guided prostate needle bx: Seminal vesicles normal. No hypoechoic peripheral zones noted w/in the prostate.

Stage

04/12/2014 – Clinical T1c, Gleason 3 + 4 = 7, PSA 5 with low volume disease per MD.

03/22/2014 – Path Report #1

Clinical Diagnosis/History:

Elevated PSA.

Final Diagnosis:

Prostate needle core biopsies as designated:

Right base: Carcinoma       Cancer length: 0.6cm    Total length: 3.2cm

Pos. cores: 1 of 3

Right mid: Non-neoplastic prostate tissue

Right apex: Non-neoplastic prostate tissue

Left base: Carcinoma       Cancer length: 0.3cm    Total Length: 2.9cm    Pos. cores: 1 of 3

Left mid: Non-neoplastic prostate tissue

Left apex: Non-neoplastic prostate tissue

Histologic Type: Adenocarcinoma (conventional type), NOS (81403)

Gleason grade: Primary: 3  Secondary: 4  = Score: 7

Secondary pattern represents <10% of the cancer

Perineural invasion: Not identified

Gross Description:

The following needle biopsies are received in formalin:

Specimen A:  Designated “right base, medial inked,” one inked, three cores; ranging from 0.2 to 1.7 cm in length.

Specimen B:  Designated “right mid, medial inked,” one inked, three cores; ranging from 0.3 to 2.2 cm in length.

Specimen C:  Designated “right apex, medial inked,” two inked, six cores; ranging from 0.4 to 1.7 cm in length.

Specimen D:  Designated “left base, medial inked,” three inked, three cores; ranging from 0.4 to 1.8 cm in length.

Specimen E:  Designated “left mid, medial inked,” two inked, three cores; ranging from 1.1 to 1.7 cm in length.

Specimen D:  Designated “left apex, medial inked,” one inked, four cores; ranging from 0.3 to 2.1 cm in length.

All are stained with hematoxylin, wrapped and submitted in corresponding cassettes.

Data Item :

Diagnosis Date

Correct Answer :

03/22/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the 03/22/2014 transrectal US guided prostate needle biopsy.

Data Item :

Primary Site

Correct Answer :

C619

Rationale:

The transrectal US guided prostate needle biopsy showed the primary tumor was in the prostate. Apply code C619 (prostate).

Data Item :

Laterality

Correct Answer :

0

Rationale:

Code 0 (not a paired site) when the primary site is not considered a paired site per SEER.

Data Item :

Histology

Correct Answer :

8140

Rationale:

The MP/H Rules (general rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. The patient underwent a transrectal US guided prostate needle biopsy on 03/22/2014 showing adenocarcinoma, NOS. The biopsy is the only and most representative specimen.

Per the MP/H Rules, Other Sites, apply rule H11 and code the histology when only one histological type is identified. Code the histology as 8140 (adenocarcinoma, NOS).

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology report, this is a malignant tumor. Code the behavior as /3 (malignant) when the primary tumor, or any portion of the primary tumor, is invasive.

Data Item :

Grade

Correct Answer :

2

Rationale:

Code the highest grade given from the primary tumor prior to neoadjuvant treatment using the special grade systems for solid tumors when applicable. The Gleason score is the special grade system for the prostate. Record the highest Gleason score from the biopsy, TURP or prostatectomy. This patient underwent a core biopsy showing Gleason primary pattern 3, secondary pattern 4, and Gleason score 7. Apply grade code 2.

Data Item :

Clin T

Correct Answer :

1C

Rationale:

The patient was noted to have an elevated PSA PTA. The digital rectal exam (DRE) on 03/01/2014 noted an asymmetric prostate with mild firmness, but no overt nodules were palpated. The 03/22/2014 transrectal ultrasound (TRUS) showed the seminal vesicles to be normal with no evidence of hypoechoic zones within the prostate.

The physician clinically staged this as T1c. This is consistent with the physical exam and imaging findings of a clinically inapparent prostate tumor. Adenocarcinoma was confirmed by biopsy. Apply code 1C (T1c, tumor identified by needle biopsy (e.g., because of elevated PSA)).

Data Item :

Clin N

Correct Answer :

0

Rationale:

The lymph nodes can be considered clinically negative based on the inapparent prostate tumor, clinically low stage disease, PSA less than 20 ng/ml, and treatment plan indicating treatment options usually given for a clinically localized tumor. Per the AJCC, most patients diagnosed in an environment of ubiquitous PSA screening will be at a low risk of positive nodes or metastases. When Gleason score is less than 7 and the PSA is less than 20 ng/ml, imaging studies are not helpful and seldom recommended for these patients. There was no clinical suspicion for regional lymph node involvement. Apply code 0 (N0, no regional lymph node metastasis).

Data Item :

Clin M

Correct Answer :

0

Rationale:

Per the AJCC Cancer Staging Manual, general instructions, a case with no symptoms or signs of metastasis is classified as clinically M0.

The transrectal ultrasound did not reveal extensive disease. The physical exam was negative. There were no symptoms or findings the physician felt clinically suspicious for metastasis. Apply code 0 (M0, no clinical or radiographic evidence of distant metastases).

Data Item :

Clin Stg Grp

Correct Answer :

2A

Rationale:

Per the prostate staging form, when the clinical TNM is cT1c CN0 cM0 with a PSA less than 20 ng/ml, and a Gleason score of 7, apply code 2A (Stage IIA).

Note: This patient does not have Stage I disease. Gleason X indicates the Gleason score cannot be processed; it does not indicate any Gleason score value applies.

For prostate, prognostic factors are required to assign the clinical stage group. Use findings from the clinical assessment only (e.g., prostate biopsy). Findings from the pathologic assessment (e.g., prostatectomy) are excluded.

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

BLANK

Rationale:

Per the site-specific pathologic staging rules for prostate (Chapter 41), a pathologic T value cannot be assigned in the absence of a surgical resection, or a biopsy proving T3 or T4 disease for a prostate primary.

There was no resection of the primary tumor. The patient was leaning towards surgery, but it has not been performed yet. The primary tumor was not eligible for pathologic staging. Apply code BLANK.

Note: Click here to open “TNM_Document.pdf” which describes general rules for developing preferred answers in SEER*Educate.

Data Item :

Path N

Correct Answer :

BLANK

Rationale:

Per Table 1.6, N Classification Rules, a pathologic N value cannot be assigned in the absence of a surgical resection. Although Table 1.6 also states a biopsy confirming the highest N may be used, it is used only in appropriate circumstances where the pathologic staging criteria for the site has been met.

The patient did not undergo a lymph node resection. The patient was leaning towards surgery, but it has not been performed yet. The regional lymph nodes were not eligible for pathologic staging. Apply code BLANK.

Note: Click here to open “TNM_Document.pdf” which describes general rules for developing preferred answers in SEER*Educate.

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic examination of distant metastasis. Apply code BLANK (Not recorded).

Data Item :

Path Stg Grp

Correct Answer :

BLANK

Rationale:

There was no surgical resection of the primary tumor and/or regional lymph nodes. The patient was leaning towards surgery, but it has not been performed yet. Apply code BLANK.

Note: Click here to open “TNM_Document.pdf” which describes general rules for developing preferred answers in SEER*Educate.

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Note: Click here to open “TNM_Document.pdf” which describes general rules for developing preferred answers in SEER*Educate.

Data Item :

SS 2000

Correct Answer :

1

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has local stage disease as the primary tumor is a clinically inapparent tumor (T1c). The patient has no regional lymph node or distant metastases. Apply code 1 (Localized only).

Social History

22 y/o BM, single w/ no children. Pt is South African but lived in Europe prior to immigrating to the US. HMO patient.

Physical Exam

04/18/2014 – cc: New dx of nonseminomatous germ cell tumor here for consult and management of mets disease. HPI: Pt was in normal health until he presented PTA w/ long-standing left testicular mass. He felt the mass was due to a trauma to his testicle approximately 2 years ago. U/S of scrotum revealed a likely mass. PTA CT Abd 03/20/2014 w/ 2 masses inferior to Lt kidney and anterior to psoas, one 7.7 cm the other 5 cm. No other abnl. Tumor markers normal with AFP of 1.5 ng/mL, hCG less than 2 mIU/mL and LDH 179 U/L. PTA Lt-sided orchiectomy on 03/27/2014 was stage pT1. PTA Chest CT 04/16/2014 w/ NE malignant spread. PE: Abd: No clear palpable masses. Genitourinary: Normal remaining Rt testicle. Lt scrotal contents w/ palpable abnormality, probable hematoma. IMP: Nonseminoma with immature teratoma and apparent retroperitoneal spread of disease. Marker negative. PLAN: Consulted colleagues at Outside Hospital who agreed that induction chemo is warranted in this case.

Scans

04/18/2014 – Scrotal U/S: Lt side testis removed. There is a Lt scrotal complex mass w/ surrounding complex fluid. This could represent a hematoma w/ surrounding hematocele.

07/17/2014 – CT Abd/Pelvis: Two cystic metastases (4.5 X 3.2 cm and 5.3 X 5.1 cm) overlying the left psoas muscle, one is stable while the other has decreased in size.

Labs

08/17/2014 – LDH: 179 U/L (80-190 U/L normal)

08/17/2014 – AFP: <5.0 ng/mL (0.0-8.5 ng/mL normal)

08/17/2014 – HCG: <1 mIU/mL (0-5 mIU/mLnormal)

Operative Reports

08/29/2014 – Cystoscopy, Lt retrograde pyelogram, Lt ureteric stent placement, Lt ureterolysis and bilateral RPLND: Two large para-aortic masses. Lt ureter was densely adherent to both masses.

Treatment Plan

07/23/2014 – After much consultation, it was decided to proceed w/ BEP chemotherapy ending approximately 3 weeks ago PTA, which caused shrinkage of these masses. Next step should be removal of these retroperitoneal masses, begin surgical planning.

Chemo Text

05/01/2014 – PTA Started Bleomycin, Etoposide, Platinum.

03/27/2014 – Path Report #1

Clinical Diagnosis/History:

Slide review.  Testis cancer.

Final Diagnosis:

Outside Laboratory (03/27/2014)

Left testicle, radical orchiectomy:  Non-seminomatous germ cell tumor consisting only of immature teratoma with the following features:

  1. Size: 6.0 cm.
  2. Extent of invasion: Immature teratoma confined to testis.
  3. Intratubular germ cell neoplasia: Present.
  4. Spermatic cord margin: Negative.
  5. Angiolymphatic invasion: Not identified.
  6. Minimum pathologic stage: pT1NX (AJCC 7th Edition, 2010).

Materials Received:

Specimen A: Left testicle, radical orchiectomy

08/29/2014 – Path Report #2

Clinical Diagnosis/History:

Testicular cancer.

Final Diagnosis:

  1. A) Designated “tissue for disposal,” excision: Mature adipose tissue with no significant pathologic abnormalities.
  1. B) Designated “left abdominal mass,” excision: Mass (11.0 x 7.5 x 5.0 cm) with immature teratoma with histologic features consistent with treatment effect.
  1. C) Designated “psoas mass,” excision: Skeletal muscle with no germ cell tumor.
  1. D) Designated “aortocaval mass,” excision: Three lymph nodes with no germ cell tumor.
  1. E) Lymph nodes, paracaval and right iliac, lymphadenectomy: One lymph node with no germ cell tumor.
  1. F) Distal left spermatic cord, excision: Spermatic cord with no significant pathologic abnormalities.

Gross Description:

Specimen A:  Received fresh labeled “tissue for disposal” is an 11.0 x 6.5 x 2.0 cm irregular fragment of fibrofatty tissue partially covered by smooth white membranes.  No firms masses are identified upon palpation.  A representative section is submitted in cassette A1.

Specimen B:  Received fresh labeled “left abdominal mass” is a 201 g, 11.0 x 7.5 x 5.0 cm unoriented, boggy, fluctuant mass.  The surfaced is inked black.  Sectioning of the mass reveals multiple cystic areas lined by granular bright yellow material and solid, white, tessellated areas.  The white tessellated areas come to within 0.2 cm of the surgical margin.  The frozen section residue is transferred to cassette B1.  Cassette B2 – white tessellated area including closest margin, B3 – tumor, representative sections.

Specimen C:  Received fresh labeled “psoas mass” are two tan-pink nodules of tissue, one is 1.2 x 0.8 x 0.3 cm and the other is 1.6 x 1.1 x 0.6 cm.  The frozen section residue is transferred to cassette C1 and the remainder of the specimen is entirely submitted in cassette C2.

Specimen D:  Received fresh labeled “aortocaval mass” is a tan-pink irregular portion of soft tissue (4.0 x 3.2 x 1.5 cm).  The specimen is palpated and no firm masses are identified.  Serial-sectioning reveals fibrofatty cut surfaces and portions of skeletal muscle.  Representative sections are submitted in cassettes D1-D2.

Specimen E:  Received in formalin labeled “paracaval and right iliac” is a 7.0 x 1.5 x 0.7 cm tan-yellow fatty portion of tissue containing a small amount of lymph node tissue.  The specimen is sectioned and entirely submitted in cassettes E1-E2.

Specimen F:  Received in formalin labeled “distal left spermatic cord” is a tubular structure (8.0 cm in length, 0.2 cm to 0.4 cm in diameter) and attached adipose tissue.  There is a long suture attached to one end.  The margin with the long suture is inked blue and the other margin is inked black.  There is a small amount of attached adipose tissue.  Representative sections are submitted in cassette F1.

Frozen Section Diagnosis:

BFS)  Left abdominal mass:  Metastatic germ cell tumor with features of immature teratoma.

CFS)  Psoas mass:  Skeletal muscle with no neoplasm identified.

Data Item :

Diagnosis Date

Correct Answer :

03/27/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the PTA 03/27/2014 left orchiectomy. The PTA CT scan on 03/20/2014 did not give a reportable, clinical diagnosis.

Data Item :

Primary Site

Correct Answer :

C621

Rationale:

The PTA scrotal ultrasound and PTA surgical resection on 03/27/2014 showed the primary tumor was in the left testicle. While the physical exam information and pathology report do not specifically state the testicle was descended, this can be inferred from the physical exam information. The patient noted a long-standing history of a left testicular mass which was confirmed on scrotal ultrasound. A self-palpated mass in the testicle implies that this testicle is a descended testicle. An undescended testis (a testis absent from the normal scrotal position) would be non-palpable. Apply code C621 (descended testis, scrotal testis).

Data Item :

Laterality

Correct Answer :

2

Rationale:

Code 2 (Left) when the primary site is a paired site and the primary tumor originated on the left.

Data Item :

Histology

Correct Answer :

9080

Rationale:

The MP/H Rules (general rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. The PTA left orchiectomy is the most representative specimen in this case, and it showed a non-seminomatous germ cell tumor consisting only of immature teratoma.

The final diagnosis gives two reportable histologies. Non-seminomatous germ cell tumor (histology code 9065/3) and immature teratoma (histology code 9080/3). Both are types of germ cell neoplasms per the ICD-O-3. This is not a mixed tumor. The non-seminomatous germ cell tumor was further characterized as being entirely an immature teratoma. Per the MP/H Rules, Other Sites, apply rule H17 and code the histology with the numerically higher ICD-O-3 code. Code the histology as 9080 (immature teratoma, NOS).

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the orchiectomy pathology report, this is a malignant tumor. Code the behavior as /3 (malignant) when the primary tumor, or any portion of the primary tumor, is invasive.

Data Item :

Grade

Correct Answer :

9

Rationale:

The grade is unknown. The review of slide of the orchiectomy pathology did not give a grade for the immature teratoma. The grade cannot be coded when no grade is given on the pathology specimen or there is no clinical statement of the primary tumor’s grade specified in the medical record. No grade was given for this patient’s testicular primary. Apply code 9 (unknown, not stated).

Data Item :

Clin T

Correct Answer :

X

Rationale:

Per the AJCC Cancer Staging Manual and CAnswer Forum, the clinical TX category is assigned for most cases of testicular cancer. The extent of the primary tumor is usually classified after radical orchiectomy and only a pathologic stage is assigned. Although the patient underwent a PTA scrotal ultrasound showing a mass, the extent of the tumor within the testicle/scrotum is not assessed clinically. Apply code X (TX, primary tumor cannot be assessed).

Data Item :

Clin N

Correct Answer :

3

Rationale:

The PTA 03/20/2014 CT scan identified two masses inferior to the left kidney and anterior to the psoas muscle (in the retroperitoneal region) measuring 7.7 cm and 5 cm in size. The physician’s impression was that this patient had apparent retroperitoneal spread of disease per the 04/18/2014 physical exam note.

Although the masses were not specifically stated to represent involvement of retroperitoneal lymph nodes, in the absence of conflicting information, it can be assumed the retroperitoneal involvement was lymph node involvement. The patient’s presentation with retroperitoneal masses (retroperitoneal nodal involvement) is characteristic of the usual spread of testicular cancer, and the patient received chemotherapy for the retroperitoneal metastasis.

The patient has clinical evidence of at least one metastatic lymph node mass measuring more than 5 cm. The largest retroperitoneal mass measured 7.7 cm prior to chemotherapy. Apply code 3 (N3, metastasis with a lymph node mass more than 5 cm in greatest dimension).

Data Item :

Clin M

Correct Answer :

0

Rationale:

Per the AJCC Cancer Staging Manual, general instructions, a case with no symptoms or signs of metastasis is classified as clinically M0.

The PTA 03/20/2014 CT scan demonstrated the retroperitoneal masses, but no other abnormalities. The PTA 04/16/2014 chest CT scan showed no evidence of metastatic disease. The physical exam was negative. There were no symptoms or findings the physician felt clinically suspicious for metastasis. Apply code 0 (M0, no distant metastasis).

Data Item :

Clin Stg Grp

Correct Answer :

2C

Rationale:

Serum tumor markers are required to determine the Stage Group for testicular primaries. The serum tumor marker studies used to assign the stage must be the studies performed immediately after orchiectomy, taking into account the half-life of AFP and hCG (5-7 days and 1-3 days respectively). While pre-operative tumor markers are usually performed, they are not taken into account when assigning the Stage Group. An exception: when the pre-operative tumor markers are negative and no post-operative studies are performed, use the pre-operative studies for the purpose of assigning stage.

The patient’s pre-orchiectomy serum tumor markers were negative, consistent with S0 disease. Per the testis staging form, when the clinical TNM is cTX cN3 cM0 with Serum Tumor Markers S0, apply code 2C (Stage IIC).

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

1

Rationale:

The PTA 03/27/2014 left radical orchiectomy identified immature teratoma, 6 cm in size, that was confined to the testis. Intratubular germ cell neoplasia was present, but there was no lymphatic invasion and the margins were negative. The pathologist staged this as T1, which is consistent with the pathology findings. Apply code 1 (T1, tumor limited to the testis and epididymis without vascular/lymphatic invasion).

Data Item :

Path N

Correct Answer :

3

Rationale:

The patient has clinical and pathologic evidence of N3 disease. The patient clinically had retroperitoneal lymph node metastases and proceeded with chemotherapy following orchiectomy. The 08/29/2014 bilateral retroperitoneal lymph node dissection (RPLND) intraoperatively identified the two large para-aortic masses (the clinically identified retroperitoneal masses).

The 08/29/2014 pathology report showed treatment effect, but identified an 11.0 cm “left abdominal mass” that was positive for immature teratoma. In addition, a “psoas mass” was negative, three aortocaval lymph nodes were negative and a paracaval/right iliac lymph node was negative. The “left abdominal mass” is one of the para-aortic masses identified intraoperatively, and should be assumed to represent at least one positive lymph node.

Per the AJCC Cancer Staging Manual (Chapter 42, Testis), in post-treatment specimens it may be difficult to distinguish individual nodes from a mass. Since the pathology report does not clarify the number of positive nodes, this patient has at least one lymph node metastasis in the large 11.0 cm mass. Apply code 3 (N3, metastasis with a lymph node mass more than 5 cm in greatest dimension).

Although the left abdominal mass was not pathologically stated to represent an involved retroperitoneal lymph node, in the absence of conflicting information, it can be assumed this was retroperitoneal lymph node involvement. The patient’s presentation with retroperitoneal masses (retroperitoneal nodal involvement) is characteristic of the usual spread of testicular cancer.

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic examination of distant metastasis. Apply code BLANK (Not recorded).

Data Item :

Path Stg Grp

Correct Answer :

2C

Rationale:

Serum tumor markers are required to determine the Stage Group for testicular primaries. The serum tumor marker studies used to assign the stage must be the studies performed immediately after orchiectomy, taking into account the half-life of AFP and hCG (5-7 days and 1-3 days respectively). While pre-operative tumor markers are usually performed, they are not taken into account when assigning the Stage Group. An exception: when the pre-operative tumor markers are negative and no post-operative studies are performed, use the pre-operative studies for the purpose of assigning stage.

The patient’s pre-orchiectomy serum tumor markers were negative, consistent with S0 disease. Per the testis staging form, when the pathologic TNM is pT1 pN3 cM0 with Serum Tumor Markers S0, apply code 2C (Stage IIC).

Data Item :

Path Desc

Correct Answer :

0

Rationale:

Per Table 1.9, yp is used for pathologic postneoadjuvant systemic or radiation therapy followed by surgical resection.

There are no pathologic descriptors that apply to this case. To be considered neoadjuvant treatment, radiation or systemic treatment must be the first treatment.  In this case, the patient had primary site surgery first.  Apply code 0.

Data Item :

SS 2000

Correct Answer :

3

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has regional lymph node(s) involved only. The primary testis tumor was pathologically confined to the testis. The patient had clinical and pathologic evidence of metastatic disease involving the retroperitoneal lymph nodes. There were no distant metastases. Apply code 3 (Regional, regional lymph node(s) involved only).

Social History

Social History: 54 y/o female. BP: OK. Mother is Cherokee. Father, Caucasian. Presents today w/ partner. Insurance: IHS.

Physical Exam

02/14/2014 – HPI: Recently diagnosed adenocarcinoma of GE junction. Last several months noticed worsening reflux, treated w/ Prilosec w/ some improvement. PTA underwent EGD on 01/31/2014 which showed a 3 cm ulcerated, fungating mass in GE junction, bx positive for moderately differentiated adenocarcinoma. PTA PET scan revealed mets disease. PTA oncology consult recommended chemo. Here for 2nd opinion. IMP: GE junction adenocarcinoma w/ mets to liver and abd LNs.

04/23/2014 – Oncology consult: GE junction adenocarcinoma w/ mets to liver and gastrohepatic LNs. Good response radiographically to FOLFOX (completed 4 cycles). Decrease in sizes of primary tumor, hepatic mets and gastrohepatic LNs.

Scans

02/04/2014 – PTA PET: Staging PET scan showed primary tumor in gastric cardia/GE junction w/ multiple avid LNs in para-aortic and retroperitoneal regions, multiple mets throughout both lobes of liver.

02/20/2014 – CT Chest/Abd/Pelvis: Large GE junction mass extending along lesser and greater curvatures measures 4.0 x 3.7 cm (previously measured 4.2 x 3.6 cm on PTA scan). Enlarged gastrohepatic and para-aortic LNs, interval increase in size of multiple liver foci. No bone mets.

04/22/2014 – CT Chest/Abd/Pelvis: Decrease in size of primary tumor, hepatic metastases, and gastrohepatic LNs.

09/10/2014 – CT Chest/Abd/Pelvis: Stable appearance of primary GE junction tumor and liver mets. Stable gastrohepatic LN.

Treatment Plan

02/14/2014 – Plan: Disease is incurable, no surgery or radiation recommended, but pt is a good candidate for chemotherapy. Proceed w/ FOLFOX chemotherapy plus/minus Trastuzumab depending on HER2 status.

03/01/2014 – FISH negative for HER2, pt will not be treated with Trastuzumab.

Chemo Text

03/01/2014 – Started FOLFOX.

08/27/2014 – Started Capecitabine. Pt transitioned to single agent Capecitabine on 08/10/2014 following nine cycles of FOLFOX w/ good response but escalating toxicities.

02/13/2014 – Path Report #1

Clinical Diagnosis/History:

Slide review.

Final Diagnosis:

Outside Laboratory (1/31/2014)

Duodenum, second part, biopsy (part A):  Small bowel mucosa with no diagnostic alterations.

Stomach, antrum, biopsy (part B):  Antral mucosa with no diagnostic alterations, including no intestinal metaplasia or dysplasia.

Gastroesophageal junction, mass, biopsy (part C):  Invasive moderately differentiated adenocarcinoma undermining squamous mucosa and two fragments of gastric mucosa.

Microscopic Description:

A recut slide confirms residual invasive carcinoma in the block.

IHC Interpretation:

Moderate basolateral membranous reactivity by immunohistochemical stain, equivocal for over-expression.

Addendum Reason:

This addendum is issued to report the results of HER2/neu studies, as requested by the clinician.

Note:

By analogy to ASCO/CAP Guideline Recommendations for HER2/neu testing in breast cancer (Arch Pathol Lab Med 131: 18-43, 2007), ratios of less than 1.8 are interpreted as negative, ratios of more than 2.2 are interpreted as positive, and ratios between 1.8 and 2.2 are interpreted as equivocal for gene amplification.  Alternatively, cancers having > 6 signals of HER2 per nucleus are considered positive, < 4 signals per cell are negative and 4-6 signals/cell are equivocal.

Note:

The interpretation criteria for gastric cancer are those of Hofmann, et al with a HER2/CEP17 ratio of >= 2.0 being considered positive (Hofmann, et al. Histopathology 2008; 52:797-805.  Assessment of a HER2 Scoring System for Gastric Cancer: Results from a Validation Study).

Immunohistochemistry Studies:

Specimen A3:  Population: Carcinoma cells

HER2 (w/HEIR) C-erbB-2,  (w/ HIER)  Equivocal for over-expression (2+)

.

DNA Analysis:

Unstained sections are prepared and regions of invasive carcinoma are marked by comparison with H&E-stained sections from the same block.  Fluorescence in situ hybridization for the HER2/neu gene is then carried out using the FDA-approved Vysis Path Vysion HER2 DNA probe kit.  The prepared slides are then viewed under a fluorescent microscope with appropriate filters for the chromosome 17 probe (green), the HER2/neu probe (orange) and DNA (blue) to localize nuclei.  Signals are counted from up to 60 cells and the ratio of HER2/neu to chromosome 17 signals is computed.  Control slides from non-amplified and low-level amplified tumor cells are prepared simultaneously to ensure reproducibility between assays.  Results are listed in the table below:

Specimen A3:  Population: Carcinoma cells

FISH H2N/17 ICC FISH Chromosome 17 PROBE 2.3 signals/cell

FISH H2N/17 ICC FISH HER2Neu PROBE 3.7 signals/cell

Ratio: 1.6  Interpretation: Not amplified

Addendum – Final Diagnosis:

Outside Laboratory (01/31/2014)

Gastroesophageal junction, mass, biopsy (part C):  Invasive moderately differentiated adenocarcinoma NEGATIVE for gene amplification of HER2/neu by fluorescence in situ hybridization technique.

Data Item :

Diagnosis Date

Correct Answer :

01/31/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the PTA 01/31/2014 endoscopy with biopsy (EGD).

Data Item :

Primary Site

Correct Answer :

C160

Rationale:

The endoscopic biopsies, CT scans and PET scan showed the primary tumor was in the GE junction. Apply code C160 (gastroesophageal junction).

Data Item :

Laterality

Correct Answer :

0

Rationale:

Code 0 (not a paired site) when the primary site is not considered a paired site per SEER.

Data Item :

Histology

Correct Answer :

8140

Rationale:

The MP/H Rules (general rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue. In this case the patient underwent a biopsy of the GE junction mass only. The biopsy is the only and most representative specimen, and it showed invasive adenocarcinoma. Per the MP/H Rules, Other Sites, apply rule H11 and code the histology when only one histologic type is identified. Code the histology as 8140 (adenocarcinoma, NOS).

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology report, this is a malignant tumor. Code the behavior as /3 (malignant) when the primary tumor, or any portion of the primary tumor, is invasive.

Data Item :

Grade

Correct Answer :

2

Rationale:

Code the highest grade given from the primary tumor. Use the grade conversion tables in the SEER Manual when there are no site-specific coding guidelines that apply. Per the Terminology Conversion table, moderately differentiated is coded as SEER code 2.

Data Item :

Clin T

Correct Answer :

X

Rationale:

The PTA 01/31/2014 EGD (endoscopy) showed a 3 cm ulcerated, fungating mass in the GE junction that was biopsy positive for adenocarcinoma. The PTA 02/04/2014 PET scan showed a primary tumor in the gastric cardia/GE junction. The 02/20/2014 CT scan showed a 4.0 cm GE junction mass (previously measured 4.2 cm on PTA scan) extending along the lesser and greater curvatures of the stomach.

None of the scans documented the depth of the tumor invasion. The T category is assigned based on depth of invasion, not based on tumor size. The imaging only noted the location and the size.  Based on imaging, it is unclear if the primary tumor invaded surrounding tissues or organs or if the primary tumor was confined to the esophageal wall; therefore, the extent of the primary tumor is unknown.  Apply code X (TX, primary tumor cannot be assessed).

Data Item :

Clin N

Correct Answer :

1

Rationale:

The PTA 02/04/2014 PET scan identified avid lymph nodes in the para-aortic and retroperitoneal regions. Both para-aortic and retroperitoneal nodes are distant nodes for a GE junction primary. The 02/20/2014 CT scan showed enlarged gastrohepatic and para-aortic nodes.

The 02/14/2014 physical exam note indicates the physician’s impression was GE junction adenocarcinoma with metastases to the liver and abdominal lymph nodes. The 04/23/2014 oncology note indicates the patient has metastases to the liver and gastrohepatic lymph nodes. Based on the oncologist’s assessment, this patient has regional abdominal (gastrohepatic) lymph node metastases.

The number of involved gastrohepatic lymph nodes was not clinically noted, and there is no documentation that can be used to estimate the number of involved nodes. Per the AJCC Cancer Staging Manual, when the N category is unclear (e.g., N1 vs. N2), assign the lower N category. The patient has at least N1 disease; therefore, apply code 1 (N1, metastasis in 1-2 regional lymph nodes).

Data Item :

Clin M

Correct Answer :

1

Rationale:

The PTA 02/04/2014 PET scan showed multiple metastases throughout both lobes of the liver. The PET scan also showed avid para-aortic and retroperitoneal lymph nodes (distant nodes), but there was no definitive statement that these distant nodes were involved. The 04/23/2014 oncology note only indicated regional lymph node and liver metastases.

The 02/20/2014 CT scan again identified the liver metastases, but showed no bone metastases. Although the distant nodes were not clearly stated to be involved, the patient does have definitive evidence of liver metastases. Apply code 1 (M1, distant metastasis).

Data Item :

Clin Stg Grp

Correct Answer :

4

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, a clinical Stage Group cannot be assigned when the T or N categories are assigned an X value. One exception: any combination of TX or NX with M1 is classified as Stage IV.

Per the esophagus (adenocarcinoma) staging form, when the clinical TNM is cTX cN1 cM1 with any primary tumor grade, apply code 4 (Stage IV).

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

BLANK

Rationale:

Per Table 1.5, T classification rules, a pathologic T value cannot be assigned in the absence of a surgical resection. Although Table 1.5 also states a biopsy confirming the highest T may be used, it is used only in appropriate circumstances where the pathologic staging criteria for the site has been met.

The treatment plan did not include surgical resection of the primary tumor. The patient’s disease was incurable and surgery was not recommended. The primary tumor was not eligible for pathologic staging. Apply code BLANK.

Data Item :

Path N

Correct Answer :

BLANK

Rationale:

Per Table 1.6, N Classification Rules, a pathologic N value cannot be assigned in the absence of a surgical resection. Although Table 1.6 also states a biopsy confirming the highest N may be used, it is used only in appropriate circumstances where the pathologic staging criteria for the site has been met.

The patient did not undergo a lymph node resection. The patient’s disease was incurable and surgery was not recommended. There was no removal of regional lymph nodes; therefore, the lymph nodes were not eligible for pathologic staging. Apply code BLANK.

Data Item :

Path M

Correct Answer :

BLANK

Rationale:

Per Table 1.7, M classification rules, neither pathologic M0 nor MX are valid categories and they may not be assigned.

There was no pathologic examination of distant metastasis. Apply code BLANK (Not recorded).

Data Item :

Path Stg Grp

Correct Answer :

BLANK

Rationale:

There was no surgical resection of the primary tumor and/or regional lymph nodes. The patient’s disease was incurable and the treatment plan was for systemic treatment alone. Apply code BLANK.

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Data Item :

SS 2000

Correct Answer :

7

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has distant stage disease as the patient was diagnosed with metastases to the liver on imaging. The primary tumor extension could not be determined, but there was clinical evidence of regional lymph node involvement.

The presence of liver metastases alone is always coded as distant stage disease, regardless of the tumor involvement or whether regional lymph nodes were involved. Apply code 7 (Distant site(s)/lymph node(s) involved).

Social History

Social History: 36 y/o Jamaican male. BP: Jamaica. Pt recently divorced and moved here to live w/ his sister. Not currently insured (self-pay).

Physical Exam

03/01/2014 – HPI: Pre-op assessment for GE junction adenocarcinoma.

03/12/2014 – GI Oncology Note: Several month hx of epigastric pain and progressive dysphagia. EGD on 02/05/2014 showed a nearly obstructing mass in distal esophagus from 38 to 45 cm (Abstractor note: path negative). Endoscopy w/ bx on 02/13/2014 was positive for poorly differentiated adenocarcinoma. On 02/13/2014 EUS, lesion appeared to be at least T3. IMP: Metastatic adenocarcinoma of the GE junction. Plan: Discussed systemic therapy w/ FOLFOX and option of supportive care only. Pt is interested in systemic therapy. Pt will have a port-a-cath placed.

03/19/2014 – Palliative Care Consult: Pt had G-tube dysfunction on 03/14/2014 resulting in peritonitis. IMP: Currently not eligible for chemotherapy. Recommend discharge home w/ hospice.

Scans

02/07/2014 – CT Chest/Abd/Pelvis: Large eccentric mass (3.8 x 3.0 x 8.4 cm) centered around the GE junction extending superiorly into the distal esophagus and inferiorly into the gastric cardia, with necrosis. Mass abuts left gastric artery and extends to celiac axis, w/ no evidence of vascular invasion. No large paraesophageal LNs. Small amount free fluid in pelvis.

02/27/2014 – PET/CT Mid-body: Uptake in distal esophagus and gastric cardia c/w primary malignancy w/ mucosal spread. Hypermetabolic LNs in paraesophageal region, porta hepatis and posterior to Lt renal vein. Perihepatic ascites. Lungs and bones negative.

Scopes

02/13/2014 – EUS/EGD with biopsies: In distal esophagus, there was large mass, appeared to measure 2.1 x 3.7 cm, clearly involved the muscularis propria (T2) and in some areas concerning for T3 disease. No LNs that met EUS criteria for malignancy. Staging EUS c/w T3 N0 lesion, although it should be noted that this staging was incomplete because not able to pass scope through mass, nor were we able to examine for lymphadenopathy distal to mass.

Operative Reports

03/05/2014 – Diagnostic laparoscopy, aspiration of ascites, peritoneal bx, placement of feeding gastrostomy tube: 1 liter malignant green ascites removed. Evidence of peritoneal mets both in upper abd and pelvis. Representative area from left upper quadrant peritoneum biopsied and sent to pathology, clearly a metastasis.

Stage

03/05/2014 – Per MD note: Stage IV gastroesophageal junction adenocarcinoma w/ malignant ascites and peritoneal metastasis.

02/13/2014 – Path Report #1

Clinical Diagnosis/History:

Dysphagia.  Mass at GE junction.  Question adenocarcinoma.

Final Diagnosis:

Specimen A,B:  Esophageal mass, biopsies:  Adenocarcinoma, moderately-to-poorly differentiated, involving squamocolumnar junctional mucosa.  No definite goblet cell metaplasia identified by HEABS stain in each part.

Specimen C:  Gastric cardia, biopsy:  Adenocarcinoma, diffuse type with occasional signet ring cells, involving gastric cardiac-type mucosa.  No Helicobacter pylori organisms identified by Genta stain with an appropriately positive control.

Addendum Reason:

This addendum is issued to report FISH study for HER2 gene.

FISH Interpretation:

Specimen A:  Adenocarcinoma is positive for HER2 gene amplification by FISH study.

Note:

Per the ASCO/CAP Guideline Recommendations for HER2/neu testing in breast cancer (Arch Pathol Lab Med 131: 18-43, 2007), ratios of less than 1.8 are interpreted as negative, ratios of more than 2.2 are interpreted as positive, and ratios between 1.8 and 2.2 are interpreted as equivocal for gene amplification.  Alternatively, cancers having > 6 signals of HER2 per nucleus are considered positive, < 4 signals per cell are negative and 4-6 signals/cell are equivocal.

Gross Description:

Specimen A:  Received in neutral buffered formalin and labeled with the patient’s name is a specimen designated “esophageal mass,” comprising multiple pieces of tan white tissue measuring 0.1 cm to 0.5 cm.  Submitted in total in 1 cassette.

Specimen B:  Received in neutral buffered formalin and labeled with the patient’s name is a specimen designated “esophageal mass,” comprising multiple pieces of tan white tissue measuring 0.1 cm to 0.7 cm.  Submitted in total in 1 cassette.

Specimen C:  Received in neutral buffered formalin and labeled with the patient’s name is a specimen designated “gastric cardia,” comprising 4 pieces of tan white tissue measuring 0.2 cm to 0.6 cm.  Submitted in total in 1 cassette.

Microscopic Description:

A recut slide confirms residual invasive carcinoma in the block A1.

DNA Analysis:

Unstained sections are prepared and regions of invasive carcinoma are marked by comparison with H&E-stained sections from the same block.  Fluorescence in situ hybridization for the HER2/neu gene is then carried out using the FDA-approved Vysis Path Vysion HER2 DNA probe kit.  The prepared slides are then viewed under a fluorescent microscope with appropriate filters for the chromosome 17 probe (green), the HER2/neu probe (orange) and DNA (blue) to localize nuclei.  Signals are counted from up to 60 cells and the ratio of HER2/neu to chromosome 17 signals is computed.  Control slides from non-amplified and low-level amplified tumor cells are prepared simultaneously to ensure reproducibility between assays.  Results are listed in the table below:

Specimen A1:  Population: Neoplastic cells

FISH H2N/17 ICC FISH Chromosome 17 PROBE 1.4 signals/cell

FISH H2N/17 ICC FISH HER2Neu PROBE 3.6 signals/cell

Ratio: 2.57  Interpretation: Positive for HER2 gene amplification

03/05/2014 – Path Report #2

Clinical Diagnosis/History:

Esophageal cancer G-tube placement.  150.9.

Final Diagnosis:

Peritoneum, biopsy: Positive for poorly differentiated malignant neoplasm consistent with adenocarcinoma.

Diagnosis Comment:

Concurrent ascitic fluid is positive for malignancy, consistent with adenocarcinoma.

Gross Description:

Specimen A:  Received in a container of formalin labeled “peritoneum” is a 1.5 x 0.6 x 0.2 cm tan, rubbery portion of tissue.  The specimen is bisected and entirely submitted in cassette A1.

03/05/2014 – Path Report #3

Clinical Diagnosis/History:

Patient with recently diagnosed esophageal adenocarcinoma in Feb 2014, presents for surgical management.

Diagnosis Comment:

A total of 240 mls of orange fluid is received, from which two alcohol fixed, Papanicolaou stained smears and one H&E stained cell block slide are prepared.  Slides contain numerous markedly atypical epithelial cells, present singly and in small, loosely cohesive groups.  Atypical cells have nuclear enlargement, hyperchromasia, prominent macronucleoli, and pale, sometimes vacuolated cytoplasm.  The findings are positive for malignancy, most consistent with adenocarcinoma and compatible with this patient’s known history of gastroesophageal junction adenocarcinoma.  Please refer to concurrent surgical pathology case for additional details.

Cytologic Impression:

Fluid:  Positive for malignancy, consistent with adenocarcinoma.  See comment.

Data Item :

Diagnosis Date

Correct Answer :

02/13/2014

Rationale:

The date of diagnosis is the date the reportable disease was first diagnosed, clinically or microscopically, by a recognized medical practitioner. In this case, the first reportable statement of malignancy was on the 02/13/2014 endoscopy with biopsy (EGD). The CT scan on 02/07/2014 did not conclusively diagnose a malignancy.

Data Item :

Primary Site

Correct Answer :

C160

Rationale:

The endoscopic biopsies, CT and PET scans and Oncology Note indicates the primary tumor arose from the GE junction. While the biopsies showed both esophageal and gastric involvement, this tumor was centered at the GE junction and extended into the distal esophagus and gastric cardia per the scan information. Apply code C160 (gastroesophageal junction), the site the tumor originated in, even if it extends to an adjacent site.

Data Item :

Laterality

Correct Answer :

0

Rationale:

Code 0 (not a paired site) when the primary site is not considered a paired site per SEER.

Data Item :

Histology

Correct Answer :

8145

Rationale:

The MP/H Rules (general rules) state the priority order for coding histology is from the pathology report of the most representative specimen, the specimen that removed the most tumor tissue, from the primary tumor. This patient underwent biopsies of the overlapping GE junction tumor from the distal esophagus as well as the gastric cardia. The biopsy of the peritoneal metastasis is not used to code the histology because it is a metastatic site.

The distal esophagus biopsy showed adenocarcinoma (NOS). The gastric cardia biopsy showed adenocarcinoma, diffuse type. Per the MP/H Rules, Other Sites, apply rule H13 and code the most specific histologic term when the diagnosis is adenocarcinoma and a more specific type of adenocarcinoma. Adenocarcinoma, diffuse type is a more specific histology. Code the histology as 8145 (adenocarcinoma, diffuse type).

Note: The presence of occasional signet ring cells does not change the histology coding. The term “occasional” is not used to code a more specific histology per the MP/H Rules. The pathologist also did not state this tumor had “signet ring cells features,” or had “signet ring cell differentiation,” etc. The tumor did not meet the criteria for signet ring cell adenocarcinoma; the tumor was not predominantly composed of signet ring cells. The pathologist only identified occasional signet ring cells throughout the biopsy.

Data Item :

Behavior

Correct Answer :

3

Rationale:

Per the pathology report, this is a malignant tumor. Code the behavior as /3 (malignant) when the primary tumor, or any portion of the primary tumor, is invasive.

Data Item :

Grade

Correct Answer :

3

Rationale:

Code the highest grade given from the primary tumor. Use the grade conversion tables in the SEER Manual when there are no site-specific coding guidelines that apply. Per the Terminology Conversion table, moderately to poorly differentiated is coded as SEER code 3.

Data Item :

Clin T

Correct Answer :

3

Rationale:

The 02/07/2014 CT scan identified a large 8.4 cm mass centered in the GE junction that extended into the distal esophagus and gastric cardia. The mass was noted to abut the left gastric artery and extend to the celiac axis with no evidence of vascular invasion. The 02/13/2014 endoscopic ultrasound with esophagogastroduodenoscopy (EUS/EGD) identified a 3.7 cm mass in the distal esophagus involving the muscularis propria and in some areas concerning for T3 disease. The oncologist’s assessment was that the staging EUS was consistent with a T3 lesion. The 02/27/2014 PET scan noted mucosal spread only.

The celiac axis is located in the adjacent connective tissue and is in the same area as the left gastric artery. The tumor extended to the celiac axis, but did not invade the celiac artery. The tumor abutted the gastric artery only, there was no clear involvement of the gastric artery.

The staging work-up definitively proved involvement of the adventitia (adjacent connective tissue), but did not definitively identify involvement of adjacent structures (T4 disease). Apply code 3 (T3, tumor invades adventitia).

Data Item :

Clin N

Correct Answer :

X

Rationale:

The SEER*Educate panel was divided between X and 0. For the purpose of providing a single answer, X was selected.

The 02/07/2014 CT scan found no large paraesophageal lymph nodes. The 02/13/2014 endoscopic ultrasound (EUS) found no lymph nodes that met EUS criteria for malignancy (N0); however, it was also noted that the exam was incomplete and they were not able to examine for lymphadenopathy distal to the mass. The 02/27/2014 PET scan identified hypermetabolic lymph nodes in the paraesophageal region, porta hepatis and posterior to the left renal vein. No lymph nodes were noted during the diagnostic laparoscopy on 03/05/2014.

There was no further indication whether the “hypermetabolic” lymph nodes were felt to be involved, so it is unclear whether these represent lymph node metastases. The patient has extensive metastatic disease with no clear documentation whether the regional nodes are also involved. Apply code X (NX, regional lymph nodes cannot be assessed).

Note: The SEER*Educate panel was divided in their reconciliation of proposed answers. This issue has been forwarded to the standard setters as an area needing further clarification and training.

Data Item :

Clin M

Correct Answer :

BLANK

Rationale:

The 03/05/2014 peritoneum biopsy and paracentesis (performed at the time of the diagnostic laparoscopy) clinically and pathologically confirmed the presence of distant metastasis. The biopsy of a distant site was part of the clinical work-up, and is therefore included in the clinical M. The 03/05/2014 laparoscopy showed evidence of peritoneal metastases in both the upper abdomen and in the pelvis, though only one area of the upper peritoneum was biopsied. The physician’s assessment per the 03/12/2014 physical exam note confirmed metastatic adenocarcinoma of the GE junction.

The peritoneum biopsy and positive ascites are considered pM1 for both the clinical stage and the pathologic stage. A case with pM1 may grouped as clinical and pathologic when it was proven during the clinical work-up. The clinical evidence of metastasis is not recorded in both the clinical and pathologic M categories. Apply code BLANK for cM.

Data Item :

Clin Stg Grp

Correct Answer :

4

Rationale:

Per Table 1.8, anatomic stage/prognostic grouping rules, a clinical Stage Group cannot be assigned when the T or N categories are assigned an X value. One exception: any combination of TX or NX with M1 is classified as Stage IV.

Per the esophagus (adenocarcinoma) staging form, when the clinical TNM is cT3 cNX pM1 with any primary tumor grade, apply code 4 (Stage IV).

Data Item :

Clin Desc

Correct Answer :

0

Rationale:

There are no clinical descriptors that apply to this case. Apply code 0.

Data Item :

Path T

Correct Answer :

BLANK

Rationale:

Per Table 1.5, T classification rules, a pathologic T value cannot be assigned in the absence of a surgical resection. Although Table 1.5 also states a biopsy confirming the highest T may be used, it is used only in appropriate circumstances where the pathologic staging criteria for the site has been met.

The treatment plan did not include surgical resection of the primary tumor. The patient was not eligible treatment. The primary tumor was not eligible for pathologic staging. Apply code BLANK.

Data Item :

Path N

Correct Answer :

BLANK

Rationale:

Per Table 1.6, N Classification Rules, a pathologic N value cannot be assigned in the absence of a surgical resection. Although Table 1.6 also states a biopsy confirming the highest N may be used, it is used only in appropriate circumstances where the pathologic staging criteria for the site has been met.

The patient did not undergo a lymph node resection. The patient was not eligible for treatment. There was no removal of regional lymph nodes; therefore, the lymph nodes were not eligible for pathologic staging. Apply code BLANK.

Data Item :

Path M

Correct Answer :

1

Rationale:

The patient has pathologic evidence of distant metastasis. The patient underwent a peritoneal biopsy and paracentesis at the time of the diagnostic laparoscopy that were positive for malignancy, and were consistent with adenocarcinoma. In this case, the biopsy positive peritoneal metastasis and cytologically positive ascites qualify as both clinical and pathologic staging. Apply code 1 (M1, distant metastasis).

Data Item :

Path Stg Grp

Correct Answer :

4

Rationale:

Per the esophagus (adenocarcinoma) staging form, when the pathologic TNM is pT(Any) pN(Any) pM1 with any primary tumor grade, apply code 4 (Stage IV).

Although the T and N categories could not be assigned, not eligible for pathologic staging, any pathologic evidence of M1 disease allows the Stage Group to be determined.

Data Item :

Path Desc

Correct Answer :

0

Rationale:

There are no pathologic descriptors that apply to this case. Apply code 0.

Data Item :

SS 2000

Correct Answer :

7

Rationale:

The Summary Stage is based on documented tumor extension, regional lymph node involvement, and/or distant metastasis documented in the record. A direct correlation with the coded TNM categories is not always possible.

This patient has distant stage disease, as the patient was diagnosed with metastases to the peritoneum on diagnostic laparoscopy and biopsy. The primary tumor was regional stage, as the primary tumor extended into the adventitia (adjacent connective tissue) on imaging. Extension to the adjacent connective tissue is considered regional by direct extension. The status of the regional lymph nodes could not be determined.

The presence of peritoneal metastases alone is always coded as distant stage disease, regardless of the tumor involvement or whether regional lymph nodes were involved. Apply code 7 (Distant site(s)/lymph node(s) involved).

 

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