Q&A Session for Collecting Cancer Data: Skin Malignancies
February 04, 2010
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Q: Patient presented with Merkel cell carcinoma located in the subcutaneous tissue of the buttocks; no epidermal tissue was involved. Is this unusual for no epidermal skin to be involved in what is usually considered a skin malignancy?
A: I've not heard of anything like that. What topography code did you use? I wonder if that was the primary or metastatic site.
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Q: For Merkel cell carcinoma, please further explain the difference between CS extension code 500 [subcutaneous tissue (through entire dermis)] and CS Mets at DX code 15 (metastasis to skin or subcutaneous tissue). How do we know if the involvement is an extension or a metastasis?
A: Code 500 is direct extension of the primary Merkel cell carcinoma into subcutaneous tissue. CS Mets at DX code 15 is used when there are separate metastatic lesions in the subcutaneous tissue or skin.
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Q: Per slide #29-31 for Merkel cell carcinoma, if biopsy of a node is positive for metastasis, what would code for CS Lymph Nodes be?
A: The code for CS Lymph Nodes would depend on the regional node(s) that was positive.
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Q: Since liver biopsy is positive for metastaticMerkel cell carcinoma, what would the code for CS Mets at DX be?
A: If liver is the only metastatic site in a primary Merkel cell carcinoma of the skin, code for CS Mets at DX is 45 (all other visceral sites; distant metastases except distant lymph nodes).
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Q: How and what are we to use as a guide for determining "clinical" extracapsular extension?
A: Regional lymph nodes described as fixed or matted are considered to have clinical extracapsular extension and coded as such per note 2 that precedes the codes for SSF17 in the Merkel cell carcinoma of the skin draft schema. If extracapsular extension of involved regional nodes is described in an imaging report, code as such in SSF17.
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Q: Shannon, will you please review the reasoning behind the answer for SSF 19. In this case the depth of invasion was 999. I'm not clear how the answer is 010 for SSF 19.
A: Yes, there was no measurement for depth of invasion. But the first path report did document that the lesion involved the deep margin. According to the note that precedes the codes for this data item, if deep margins are documented as involved, tumor base can be considered transected.
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Q: What if the patient has a history of CLL or other immunosuppressive condition (unknown if active) at the time of the Merkel cell diagnosis?
A: If the history of the condition is documented by the physician, I would code it in SSF22 for Merkel cell carcinoma.
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Q: Jim/Shannon: FYI, the Merkel Cell Skin case will actually produce a T1 tumor as the mapping is based on extension and size. SSF1 (depth) does not play into the T category.
A: That’s absolutely correct. I’ll forward that information to the developer of the CSv2 materials and suggest that rationale be removed from the exercise answer sheet.
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Q: I believe the AJCC manual states that melanoma is not graded. This was in the 6th Ed. in the front of the manual.
A: On page 336 of the AJCC 7th Ed. it is stated: “Histologic grading is not used in the staging of melanoma.” However, AJCC coding instructions do not apply to coding the grade data item. We will forward this for clarification.
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Q: Is CS Tumor Size the diameter or thickness?
A: Code the largest diameter of the primary tumor in CS Tumor Size for melanoma and Merkel cell carcinoma.The measured depth or thickness of the primary tumor is coded in SSF1 in both the MerkelCellSkin and MelanomaSkin schemas.
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Q: The definition for CS Extensioncode 999 for melanoma includes:‘Primary tumor cannot be assessed (e.g., shave biopsy or regressed melanoma)’. What if depth is given in the shave, should it be coded? Please see p. 337of the AJCC 7th ed., 1st paragraph under St. I and II mentions that depth should be recorded from a shave.
A: The measured thickness or depth of the primary melanoma is coded in SSF1. Record the actual measurement in hundredths of millimeters from the pathology report. As documented in the AJCC 7th Ed. the information may come from the shave biopsy. The extension of the primary tumor, not the measured thickness or depth, is coded in CS Extension for melanoma.
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Q: How are in-transit metastasis identified?
A: I believe they are usually clinically present.
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Q: SSF3 question: "lymphadenopathy" is not an acceptable diagnostic term to infer involvement per previous instructions in CS. Wouldn't the correct answer be 001, clinically occult (microscopic lymph node metastases only)
A: Lymphadeonpathy was not an acceptable diagnostic term for lymph node involvement to be coded in the CS Lymph Nodes data item. I don’t find the same instructions for melanoma SSF3. I believe that the lymphadeonpathy is considered clinically apparent because the nodes were also pathologically positive. If there had been adenopathy and the nodes had been negative, code 000 (no lymph node metastases) would have been assigned. However, we will refer to the CSv2 team for clarification.
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Q: Please define clinically occult lymph node metastases, code 001 in SSF3 for melanoma.
A: Clinically occult nodes means they looked but did not identify metastatic lymph nodes clinically (imaging, palpation, etc), but the pathology does show metastasis microscopically in the lymph nodes.
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Q: Our surgeon who specializes in melanoma often does not repeat LDH testing when the values are "slightly" above normal. I have explained to him that if the LDH is elevated the test MUST be repeated 24 hours later to insure that it is not a false positive.
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Q: For LDH what would you code for SSFs if you have only 1 lab done and it is elevated keeping in mind the AJCC note about false positives?
A: There is a difference in wordage used in notes that precede the codes for SSF4 and SSF5 for melanoma. We have referred this to CSv2 experts for clarification.
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Q: Wouldn't we use the LDH test from 5-12 because it's the closest test before the date of first surgical procedure?
A: The LDH value from the first test was coded based on the instructions in note 1 preceding the codes for SSF5 for melanoma. It states: “Code the LDH value prior to treatment or within 6 weeks of diagnosis. Give priority to the first test performed.”
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Q: If LDH is not done in the hospital and there is no record in the H&P, etc. should we assume it was not done & code 000 or code 999?
A: To uses code 000 you need to have something that makes you believe the test was not done. In the situation you described, I think you would have to code 999. This would be a great topic for your cancer committee!
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Q: What if you are a central registry...what would you code for LDH not being in the chart?
A: Unless you have something to make you believe the test was not done, code ass 999.
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Q: How come you don't use the second LDH value which is higher than the first value?
A: Note 1 in SSF5 states to give priority to 1st test performed. You want to use the same test for all 3 of the LDH data items.
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Q: So if you only 1 LDH level, do you not use.
A: I don't think that is true, but we will get this clarified by the experts.
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Q: The definition for code 999 in melanoma SSF8 includes "not stated". Please clarify code 000 as assigned in the exercise.
A: Good question. We will send to the CSv2 team for clarification.
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Q: To record regression in SSF8 for melanoma, can regression be stated in the content of the path report or must it be documented in the final diagnosis?
A: To assign code 001, regression present, in SSF8 for melanoma schema, regression may be documented anywhere in the path report. Documentation in the final path diagnosis is a coding instruction from the Multiple Primary and Histology Coding Rules for assigning histology code.
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Q: What is the difference between depth of invasion and vertical growth for melanoma?
A: Depth of invasion is a measurement. Vertical growth indicates that the tumor is growing vertically.
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Q: if on the path report it just has Clark’s level II, III etc. but nothing is stated about vertical growth, would you assign code 001, vertical growth present?
A: I'll have to look into that. We will forward this to the CSv2 team.
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Q: I am just curious about the vertical & horizontal growth of tumor, can you elaborate.
A: The horizontal or radial growth phase is when the tumor is growing along the epidermis. The vertical growth phase is when it invades down through the dermis.
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Q: Thank you very much for the informative webinar
A: Thank you for the great questions!