Q&A Session
Collecting Cancer Data: Stomach and Esophagus
Thursday, October 04, 2012
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Q: if you have radiographic/endoscopic designation of primary site of esophagus (ex: lower third) in medical record and a surgical designation (ex: lower thoracic), what is the preferred ICD-O-3 topography code? Is there documentation of priority coding of primary site for esophagus?
A: The coding guidelines for esophagus in the site-specific coding module of the 2012 SEER Program Coding and Staging Manual say: “Assign the ICD-O-3 topography code that describes the primary site documented in the medical record.” There is no priority for coding primary site for esophagus if the sub-site is described using both systems that divide the esophagus into sub-sites. However, tumor location for esophagus is coded in CS SSF2. In your example, the lower thoracic (050) would take precedenceover lower third (090) following the coding instructions for esophagus schema CS SSF2. But, again, that is for SSF2.
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Q: If the lesion were in the distal esophagus, wouldn't the cell type be adenocarcinoma?
A: Not always. The squamous epithelium extends into the distal esophagus.
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Q: If there are multiple locations of esophageal tumors all with the same extension code, is there a priority for which tumor is represented in the SSF's; i.e., largest tumor; most proximal/distal?
A: If multiple esophageal tumors are 1 primary and they all have the same extension code (same level of invasion), I would code tumor location SSFs using largest tumor.
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Q: Does CSExtension code 300 apply to implants to any part of the stomach, including any layer? What about serosal implants?
A: If the primary is in the stomach and the implants are in the stomach, assign code 300.My thought is that serosal implants are outside of the stomach and would not be coded in CS Extension.
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Q: If extension and/or node involvement is determined on EUS, is the eval code 0 or 1? Although there is a scope in use, isn't it actually the ultrasound that determines the extension/lymph node involvement? I know this was an issue on the last reliability study and I was wondering if there is an official response. Thanks!
A: Yes; the ultrasound determines the lymph node involvement so eval code should be 0.
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Q: How is Ivor-Lewis procedure coded? Does this refer only to the approach, or also does it indicate total/partial resections of the esophagus and or stomach?
A: Probably a 53. If they remove the entire stomach, then 54.
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Q: For case scenario 2, how do you know it's worse after neoadjuvant treatment? CS Part I Section1 states, in general, to code extension prior to treatment when there is neoadjuvant treatment (page 34) and on page 35 states to code CS Extension 999 and eval 5 if extension is unknown prior to treatment.
A: I felt there was enough information in the clinical description of the disease to consider disease extension localized NOS. The disease after neoadjuvant treatment is worse than localized. However, if I did consider the extension unknown, there is no statement in the scenario stating that there was a response to the neoadjuvant treatment. So, I would assume no response to treatment and code extension from the surgical path report and eval code 6.
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Q: SSF2 in v2.04 is said to be "not required" by any standard setter. If it is needed for AJCC, why is it not a required SSFactor?
A: The location of the primary tumor for esophagus is anAJCC staging element for squamous cell carcinoma of the esophagus, but the ICD-O-3 primary site code is being used as location information, not SSF2. This is shown in the table, AJCC TNM 7 Stage Squamous, in the esophagus CS schema.
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Q: From Pop Quiz: are you sure that "adenopathy" is good enough to say that you have cN1? (I thought you could only use adenopathy for coding nodes positive for lung cancer and lymphomas?)
A: The EUS only documented adenopathy, but the physician interpreted that as clinical N1 and documented it as such on the staging form. That information can be used to code SSF1.
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Q: If the EUS does not document the diameter but says the tumor extends from 30 cm to 38 cm, can you say the tumor size was at least 8cm?
A: Yes.
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Q: What is site code for adenocarcinoma in Barrett's esophagus?
A: Barrett’s could be present in the EJG or in the lower esophagus. Code thetopography code on how the physician describes the location of the Barrett's.
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Q: On question #3 from quiz 2, the extension is described in the endoscopy.Why wasn't code 1, endoscopy, the correct code for CS Tumor Size/Ext Eval?
A: Even though the procedure is endoscopic ultrasound (EUS) information is from the ultrasound, an imaging technique. I believe 0 is the best code.
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Q: For quiz 2, question 3, why is the answer not B if there was a biopsy of both tumors?
A: The biopsy did not give any information about the extension. That information came from the ultrasound, code 0.
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Q: Quiz 2 question 10, for SSF3 (number of regional nodes with extracapsular tumor) since there was only FNA (which would be clinical staging) why wouldn't you code 998 (no histopathologic exam of regional nodes)?
A: It was FNA biopsy, not cytology, so there was histopathologic exam of tissue. However, in referring with authors of the schema, we found out that the outside of the lymph node needs to be examined to determine if there is extracapsular extension. Because only biopsy was performed, 998 is a better code in this situation.
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Q: In case scenario 1 for lymph nodes, would it be better to use code 305 so you are at least getting the proper Summary Staging for the mediastinal nodes?
A: That is what makes CS so complex sometimes. To get the hilar nodes you use code 500 but then you lose the distant summary stage for mediastinal nodes.
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Q: Would you please explain in case scenario 1 why CS SSF1 (clinical assessment of regional nodes) was assigned code 200 (metastasis in 3-6 nodes determined clinically; stated as clinical N2) when the only clinical statement was in the PET scan and it only stated multiple enlarged nodes, NO statement of malignancy?
A: The PET scan did only say enlarged nodes, but the physician interpreted that as clinical N2 and documented N2 in the radiation therapy report.
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Q: i believe that FORDS says that if you resect something (e.g. liver nodule) which comes back negative, then you do NOT code distant surgery. So distant surgery should be 0 not 4.
A: On page 20 of FORDS 2012, surgical data items, including surgical procedure/other site, are listed and described. Right after the description the following is documented: “If surgery of the respective type was performed, the code that best describes the surgical procedure is recorded whether or not any cancer is found in the resected portion.” In case scenario 2 the correct code for surgical procedure/other site is 4 (non-primary surgical procedure to distant site).
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