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Code treatment with Iressa as chemotherapy.

Iressa is an epidermal growth factor inhibitor. While it doesn't kill cells directly, it damages the cell reproduction process. We classify it as a chemotherapy agent.

Code tomotherapy as 1 [Beam radiation].

Tomotherapy is external beam radiation therapy. It is a type of IMRT. Intensity-modulated radiation therapy (IMRT) is an advanced mode of high-precision radiotherapy that utilizes computer-controlled x-ray accelerators to deliver radiation. Tomotherapy is a CT image guided IMRT.

Code to the appropriate code (1, 2 or 3) under Other Therapy, depending on whether the drug was given as part of a clinical trial. If not part of a clinical trial, assign code 1 [Other cancer-directed therapy].

Thalidomide is not FDA approved for treating cancer. It is under investigation for anti-angiogenesis effects in different cancers.

Code to poorly differentiated thyroid carcinoma, 8337/3.

In this case the tumor is comrpised of two difffernat thyroid histologies: poorly differentiated carcinoma 8337/3 and papillary thyroid carcinoma 8260/3. WHO does not have a code for this combination. Per our endocrine pathology expert, the poorly differentiated carcinoma is the more agressive histology and will determine treatment and progrnosis.

Code to pleura, C384.

Per the Hematopoietic database, Diffuse Large B-Cell Lymphoma can originate in the pleural cavity.

Code to papillary carcinoma, encapsulated (C73.9) (8343/3) using Solid Tumor Rules, Other Sites, Rule H11, code the histology when only one histologic type is identified.  The usage of features is describing the cellular architecture of the encapsulated papillary carcinoma and does not necessarily indicate a specific histologic type. We consulted with our endocrine specialist pathologist who agrees and indicated terminology used in thryoid neoplasms is inconsistent.

Code to mucinous (8480) since that is the only clearly invasive component of this diagnosis.

According to our pathologist consultant, "Encysted papillary carcinoma is the same thing as intracystic papillry carcinoma, which I think of as an intraductal papillary carcinoma which has greatly expanded the duct to form a cyst-like structure. It generally behaves in an in-situ rather than an invasive fashion. The only clearly invasive component is the mucinous carcinoma, which is what I would code."

Code to metaplastic carcinoma, 8575/3. According to our expert pathologist consultant, "The term 'metaplastic stroma' implies that at least a portion of the carcinoma has undergone a 'metaplastic' change from epithelial in appearance to 'stromal' in appearance. I assume this is what CAP means by 'Invasive mammary carcinoma with matrix production,' which the WHO equates to metaplastic carcinoma."

Code to invasive adenocarcinoma, solid predominant (8230/3), based on the example, using Lung Solid Tumor Rules Coding Multiple Histologies instruction #1 that says to code the specific histology where the most specific histology may be described as component, majority/majority of, or predominantly, in this case, 75%. Apply Rule M2 as this appears to be a single tumor with multiple histologies based on the information provided.

The rules will be updated to add a new H rule and to reviseTable 2 when two or more histologies described as predominant are present.

Code to 8041, small cell carcinoma, because the medical opinon confirms that this was the correct histology from the begining.

"Possible" is not an ambiguous term used to code histology. The MP/H rules do not include coding phenotype. That leaves non-small cell (8046/3) at time of diagnosis. Chemotherapy does not alter cell type so its likely the tumor was small cell all along only now proven with additional testing.

Page 14 of the SEER Coding Manual gives examples of when to change the abstract's original codes and here is one example: When better information is available later. Example 1: Consults from specialty labs, pathology report addendums or comments or other information have been added to the chart. Reports done during the diagnostic workup and placed on the chart after the registrar abstracted the information may contain valuable information. Whenever these later reports give better information about the histology, grade of tumor, primary site, etc., change the codes to reflect the better information.