SEER Study Guide

Published On July 15, 2016 | By admin | Featured

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).
  2. 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).
  3. C) Right external iliac lymph nodes, dissection: 3 lymph nodes, negative for carcinoma (0/3).
  4. D) Right pelvic lymph nodes, dissection: Fibroadipose tissue, no lymph nodes, no carcinoma identified.
  5. E) Right obturator lymph nodes, dissection: Positive for carcinoma, present in 1 of 2 lymph nodes, 0.8 cm in greatest dimension (1/2).
  6. 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.
  9. B) Left breast, 3:00 posterior, excisional biopsy:
  10. Usual ductal hyperplasia.
  11. No atypical hyperplasia, in situ or invasive carcinoma identified.
  12. 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.
  2. 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 cannt 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 Histor

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.
  2. E) Ventral tongue floor of mouth, composite resection: Invasive squamous cell carcinoma, moderately to poorly differentiated, with the following features:
  3. 2.0 cm in maximum dimension.
  4. 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.
  5. Perineural invasion present.
  6. No angiolymphatic invasion identified.
  7. 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)

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