Q&A Session Collecting Cancer Data: Hematopoietic and Lymphoid Neoplasms Thursday, November 6, 2014

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1 Q&A Session Collecting Cancer Data: Hematopoietic and Lymphoid Neoplasms Thursday, November 6, 2014 Q: If polycythemia ruba vera (PRV) or essential thrombocythemia (ET) is diagnosed by peripheral smear, would these be coded as 2-positive cytology for Diagnostic Confirmation? We see this quite a bit with these 2 diagnoses, and sometimes JAK2 is done on the peripheral blood confirming the dx. A: According to Dr. Platz, a peripheral blood smear would be a 1 code 3 would be assigned if a JAK2 was also performed. Q: If we print the Hematopoietic and Lymphoid Neoplasm Coding Manual (PDF), will we be notified when there are updates to it? A: Updates to the manual are done annually (January). Notices will be sent through: SEER, CoC, NPCR, NAACCR, and NCRA. If a change is done at any other time during the year, everyone will be notified through the same channels. If you choose to print out the manual after a new one is posted in January, assume that will be the manual for the entire year unless you hear otherwise. Q: Please explain Rule M11 especially the example regarding plasmacytoma and multiple myeloma. Can you explain why this is two primaries versus further diagnostic workup? A: For the current rules, this is an acute and chronic process. There is some discussion about changing the rules and factoring in the diagnostic workup; however, that is not planned for For now, follow the rules and code as two primaries according to the instructions. Q: If a patient is diagnosed with acute leukemia, most likely acute myeloid leukemia (AML), and the Clinic Notes always refer to the patient being treated as AML, is this case coded as acute leukemia, NOS or acute myeloid leukemia? A: This case would be coded as AML. Per the primary site and histology coding instructions and rules, if you have ambiguous terminology used with a specific histology and then the physician states that they are treating for the specific disease, then you can assign the specific histology. (See #5 Example 2 in Primary Site and Histology Coding Instructions and Rules page 26). For this question, the physician is treating this as AML, so the specific histology (9861/3 for AML) may be used. Q: In Shannon s EXAMPLE 5, how did you get to the point where you are told to use Module 9? A: Module 9 is not commonly used. There is no module listed on the database for the disease in example 5. Shannon listed PH30 because you use the info from the DB. Q: I often see the abstractor code the lymph node regions where the biopsy was taken but the CT reveals lymphadenopathy above and below the diaphragm. Could you stress that this should be coded to C77.8?

2 A: Per Module 6 and 7: Do not simply code the site of a biopsy; use the information available from scans to determine the correct primary site. Use the PH rules in Module 6 and Module 7 to help you to determine the primary site. Q: In example 6 would you not use PH18? A: No. Para-spinal mass is describing a mass around the spine. There are no lymph nodes in the spine. Q: Would multiple areas of skin involvement be considered multiple organ involvement per PH27? What about bilateral breast involvement? A: This would depend on the histology. Generally, skin is one organ. Per Rule M2, bilateral involvement of lymph nodes and/or organs with a single histology is a single primary. Q: When determining regional lymph nodes for an organ, do we use regional lymph nodes defined by TNM or SEER Summary Stage 2000? A: You can use both and CS, which has the best description for regional lymph nodes. Q: What is the site code when both bone marrow and lymph nodes are involved? A: This is dependent on the histology. If you are looking at CLL (9823/3), this would be primary site C421. If you are looking at one of the other lymphoma/leukemias, you would code primary site to lymph nodes or an organ (if applicable). Q: Also, on PH18, only described as a mass, is it only masses in the four areas for the listed examples? A: The listed examples are the most common types of mass. We will add additional masses if needed. Be careful in assigning primary sites based on a mass. You may be in an area of the body that has no lymph nodes. Q: Under Rule G3 in the manual, follicular lymphoma grade 3 has the wrong morph listed. Is 9970/3, hairy cell leukemia a new addition or added in error? Were 9836/3 & 9940/3 removed on purpose or in error, and does 9831/3 belong in G9? A: We know, this has been fixed. 9831/3 can have 3 grades depending on the terminology used (5, 8, 9). The grade is coded based on the terminology used. Q: What would the date of diagnosis be if ambiguous terminology is used but the doctor treats it as cancer? A: For this question, rules for ambiguous terminology/case reportability are being mixed with the rules for ambiguous terminology/histology. The date of diagnosis would be based on the case reportability.

3 Q: Appendix C in Heme Manual has great lymph node table. A: Yes; it is a very useful table. Q: In the revised 2015 manual, will alternative names for histologies that are obsolete be updated to the new preferred histology/code? A: Unfortunately, there will not be time to do that for Q: Does it have to say polymorphic to assign it to post-transplant lymphoproliferative disorder (PTLD)? PTLD NOS is/1 in ICD-03. A: Do not use ICD-O-3 to assign histology code for hematopoietic neoplasms. The diagnosis does not have to state polymorphic to assign PTLD. If you have PTLD by itself (no accompanying lymphoma or myeloma), then you can assign 9971/3. Q: Please clarify primary site coding for extra-nodal lymphoma. For example, if a biopsy of the gastric antrum is positive for lymphoma, what is the correct code to use, C163 or C169? A: PH24 documents to code primary site to the organ when lymphoma is only present in an organ. If biopsy proved lymphoma of gastric antrum and there was no lymphoma anywhere else, site would be C163. Q: Pathology Report states "classical Hodgkin lymphoma". The pathology comments state, "path consistent with nodular sclerosis subtype. Would we have to code to "classical Hodgkin lymphoma" 9650/3? A: Since ambiguous terminology is used, per the histology coding instructions, the more specific classical Hodgkin lymphoma cannot be assigned. Assign histology 9650/3. If the physician documents somewhere in the record that they are treating the nodular sclerosis subtype, then the more specific histology can be assigned. Q: We are now testing minimum residual disease (MRD) for our leukemia patients regularly and often find that patients are in clinical remission but have positive MRD. How do we answer the follow-up question evidence of disease or not? A: If there is MRD, that means there is evidence of disease, so that s how it should be coded. Q: Where is the guideline that says we can take a size as involvement of lymph node on imaging? A: See first paragraph of page 609 of the AJCC Cancer Staging Manual 7 th Ed.

4 Q: Are immunohistochemistry (IHC) and immunophenotyping the same thing? Follicular Lymphoma has IHC listed under Definitive Diagnostic Methods. So is this different than what is listed under Immunophenotyping? A: This has been fixed for the 2015 release; only immunophenotyping is listed. Q: If the spleen is the only organ involved and the patient has a splenectomy, would it be considered pathological staging? A: Only if staging laparotomy was performed. Splenectomy alone does not necessarily mean staging laparotomy, because splenectomy is only part of the pathologic staging. Q: Do we generally exclude spleen as an organ in the PH rules unless specifically stated to be the primary? Example; if bone marrow, multiple nodes in different regions and spleen are involved, would this be coded to C778? A: It depends on the histology. Q: Why wouldn't primary site of case scenario 1 be C77.8? Spleen is considered a lymphatic structure, so you have lymphomas involving multiple lymph node regions. A: It doesn t really matter which code is used. Spleen would not make a difference, multiple lymph node regions are already involved. Q: In regards to Quiz 2 question # 4, please recheck and explain why the answer is A (100: single lymph node region) and not B (110: Single extralymphatic organ/site) as we do not agree. A: Thymus is a lymphatic site, not extralymphatic; involvement of a single lymphatic site is considered Stage I and assigned CS Extension code 100. Unfortunately, the description for CS Extension code 100 is not well written. Code 100 is involvement of a single lymphatic site. Lymphatic sites include lymph nodes, spleen, thymus gland, lingual tonsil, palatine tonsil, Waldeyer's ring, Peyer s patches, and lymphoid nodules of the appendix. Q: Please explain the difference between extralymphatic and extranodal. A: Extranodal is outside of a lymph node. Extralymphatic is outside of lymphatic tissue. So, thymus is extranodal but it is NOT extralymphatic because it is defined as a lymphatic site. Q: Why would splenectomy not be coded in Surgical Procedure/Other Sites for case scenario 2 since splenectomy had positive tissue? A: Since the spleen was not removed for treatment purposes, I would not be included in any of the surgery data items.

5 Q: What do we code if the pathology report is using ambiguous terms and the hematologist calls it that? A: First, remember that ambiguous terms can be used to determine reportability. If there is a less specific histology that is not modified by ambiguous terms, use the less specific term to code the histology. If there is not a less specific reportable term, you can use the term that is being modified by the ambiguous term. Q: Should we consider DLBCL (9680/3) to be an NOS histology for rule M7? Alternate names for DLBCL has a long list of histologies that appear to be fairly specific. A: No; this is a specific non-hodgkin lymphoma. The most common NOS code for NHL would be non- Hodgkin lymphoma, NOS (9591). Q: When you have a parotid lymphoma, should the site be C77.0 (lymph nodes of head, face, or neck) or C07.9 (parotid gland)? A: With this description, it sounds like this is a lymphoma of the parotid gland. Primary site code would be C07.9. Q: If the patient has a para-spinal mass and biopsy is positive for lymphoma, would you assume this is arising in lymphatic tissue and code the site to lymph node or is this coded to unknown primary? A: It is highly likely that this is arising in lymphatic tissue, but don't assume. Review all information available. If no further information is found, then apply Rule PH27 and code to unknown primary site. Q: Should we use PTLD NOS when diagnosis is monomorphic post-transplant lymphoproliferative disorder? A: According to the abstractor notes for PTLD, monomorphic PTLD has an accompanying B-cell lymphoma, T-cell lymphoma, classical Hodgkin lymphoma, or a plasmacytoma. The accompanying histology should be coded. Q: Is splenomegaly considered to be spleen involvement? The patient had splenomegaly on an x-ray; it was not palpable on physical. A: See page 609 of the AJCC Cancer Staging Manual 7 th Ed. It looks to me like it has to be palpable. Imaging can confirm, but it has to be unequivocally palpable per the AJCC manual. Q: On one of the slides, it lists the thymus gland as an extranodal lymphatic site. Should the sites listed just be called "lymphatic sites" rather than extranodal? A: Lymphatic sites include the sites listed on the slide plus lymph nodes. The slide title was extranodal lymphatic sites because the sites are not lymph nodes, but they are lymphatic.

6 Q: Case 2 states the histology is follicular lymphoma, WHO grade1. Would the histology be coded to 9690/3? A: The grade in follicular lymphoma grade 1 (9695/3) is established by WHO. So, it would be appropriate to assign histology code 9695/3 as opposed to 9690/3 (follicular lymphoma NOS).