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SEER Training Modules

Breast Practice Case

  1. Read the following practice case. (This is all the information you have.)

    Breast Practice Case
    Surgical Pathology Report #1

    Surgical Pathology Report
    February 14, 2007

    Final Diagnosis:
    Left breast mass, biopsy: Infiltrating moderately differentiated lobular carcinoma, modified Bloom-Richardson grade 2, biopsy.

    Breast Practice Case
    Surgical Pathology Report #2

    Surgical Pathology Report
    March 29, 2007

    Final Diagnosis:

    1. Right breast, random biopsies: Scattered foci of lobular carcinoma in situ.
    2. Left breast lumpectomy: Infiltrating duct carcinoma, moderately differentiated grade 2 by Bloom Richardson. Duct carcinoma in situ comedo and non-comedo types, high nuclear grade. Tumor size: 2.3 cm. The infiltrating component is less than 0.1 cm from medial margin, less than 0.1 cm from posterior margin, 0.2 cm from superior and inferior margins, 0.5 cm from anterior margin, and greater than 1 cm from the lateral margin.
    3. Sentinel node #1 left breast: One lymph node with metastatic carcinoma
    4. Sentinel node #2 left breast: One lymph node with metastatic carcinoma
    5. Sentinel node #3 left breast: One lymph node with metastatic carcinoma
    6. Left axillary contents: Eleven (11) lymph nodes with metastatic carcinoma
    7. New anterior needle margin left breast: Infiltrating ductal carcinoma. Lobular carcinoma in situ with extension into ducts. The infiltrating component is present at the anterior margin and 5 mm from the inferior margin.

    Comment: The tumor is strongly positive for estrogen and progresterone receptors (100%). It is negative for Her-2/neu.

    Ask yourself the following questions (answers in italics)

    1. How many procedures?
      Two
    2. What are the dates?
      The second procedure was about 6 weeks after the first in 2007
    3. Are the pathology specimens similar?
      Yes, the first procedure biopsied the left breast, the second procedure included a left side lumpectomy and right breast biopsy.
    4. What is the primary site?
      Breast
    5. What site-specific set of rules should I use?
      Breast
    6. How many separate malignant, non-metastatic tumors are there?
      Multiple: "scattered foci" of lobular carcinoma in right breast (C50.9), both invasive lobular and invasive ductal and intraductal carcinoma in left breast (C50.9).
  2. Open the 2007 MPH document to the Equivalent Terms and Definitions for breast and read through them.
    1. Are there any important points to note?
      Breast is a site with laterality; there are several tables that list subtypes of ductal and intraductal carcinoma, as well as a table of combination codes for breast cancers.
  3. Turn to the breast multiple primaries rules in your preferred format.
    1. We know from scanning the documentation that there are tumors in both breasts, so the "Unknown if single or multiple tumors" module does not apply, and the "Single Tumor" module does not apply because this case has multiple tumors and is not inflammatory carcinoma.
    2. Start reading the "Multiple Tumors" rules beginning with M4.

      M4. Tumors in sites different at 2nd or 3rd character of ICD-O-3...
      Both breasts are coded to C50.9. Rule M4 does not apply. Keep reading.
      M5. Tumors diagnosed more than 5 years apart...
      Tumors were diagnosed 6 weeks apart. Rule M5 does not apply. Keep reading.
      M6. Inflammatory carcinoma...
      This case does not have a diagnosis of inflammatory carcinoma. Rule M6 does not apply. Keep reading.
      M7. Tumors on both sides (right and left) are multiple primaries.
      There are separate tumors in the right and left breasts. Rule M7 applies.

    3. STOP. You have found a multiple primaries rule that applies to the case. Look no further.
  4. Pick one of the two tumors and start an abstract.
    There are separate rules in the FORDS and SEER manuals about sequencing cancers diagnosed at the same time. Based on the fact that the right breast is in situ cancer only and the left breast is invasive, the left breast should be sequence 01.
  5. Turn to the breast histology coding rules in your preferred format.
    1. We are now working only with the left breast tumor, which is a single mass with elements of invasive and in situ tumor. Note that there are three subsections of the "Single Tumor" rules for breast: in situ only, invasive and in situ, and invasive only. Start reading the histology coding rules for "Single Tumor: Invasive and In situ Carcinoma" starting with rule H9.

      H9. Code the invasive histology when both invasive and in situ components are present.
      Note 1 says to ignore the in situ terms. But there is still invasive lobular from the biopsy and invasive ductal from the lumpectomy. Read further in the "Single Tumor: Invasive Carcinoma Only" section starting with rule H10.
      H10. If there's no pathology/cytology report...
      We have a pathology report. Rule H10 does not apply. Keep reading.
      H11. Code histology from a metastatic site...
      We have tissue from the primary site. Rule H11 does not apply. Keep reading.
      H12. Code the most specific histologic term...
      There are two specific invasive histologic terms, ductal and lobular. Rule H12 does not apply. Keep reading.
      H13. Inflammatory carcinoma...
      This case does not have a diagnosis of inflammatory carcinoma. Rule H13 does not apply. Keep reading.
      H14. Code the histology when only one histologic type is specified.
      There are two specified histologic types in this tumor. Rule H14 does not apply. Keep reading.
      H15. Code 8522 when there is a combination of duct and lobular carcinoma.
      This tumor has invasive duct and lobular carcinoma. Rule H15 applies.

    2. STOP. Look no further. Code the histology for this abstract (sequence 01) to 8522, duct and lobular carcinoma.
    3. Finish this abstract.
    4. Set up the second abstract for this case (sequence 02). We are now working only with right breast tumor. The pathology report says "scattered foci of lobular carcinoma in situ" so there are multiple tumors. Start reading the histology coding rules for "Multiple Tumors abstracted as a single primary" starting with rule H20.

      H20. If there's no pathology/cytology report...
      We have a pathology report. Rule H20 does not apply.
      H21. Code histology from a metastatic site...
      We have tissue from the primary site. Rule H21 does not apply.
      H22. Inflammatory carcinoma...
      This case does not have a diagnosis of inflammatory carcinoma. Rule H22 does not apply. Keep reading.
      H23. Code the histology when only one histologic type is specified.
      There is only one histologic type for all the scattered foci. Rule H23 applies.

    5. STOP. Look no further. Code the histology for this abstract (sequence 02) to 8520, lobular carcinoma (in situ—behavior code /2).
    6. Finish the abstract.
  6. This case had two primaries, one in the left breast and one in the right breast. Sequence 01, the more advanced (invasive) tumor in the left breast, was coded as a combination of duct andlobular carcinoma. Sequence 02, the right breast tumor, was coded as lobular carcinoma in situ.

Note: The histology code on sequence 02 may have to be revised at a later date if the patient returns for another procedure and more carcinoma is found in the right breast.