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Tumor Tip of the Week-Benign and Borderline Brain & CNS reminders

Tumor Tip Of The Week-Benign And Borderline Brain & CNS Reminders

Scenario:  05-01-2019 MRI Pituitary gland: IMPRESSION:  3.7 mm Microadenoma seen in the left pituitary gland

05-29-2019 Neurologist Typically microadenomas do not cause symptoms and not progressive, will continue to follow with serial imaging

05-15-2020 Neurologist: Microadenoma appears stable on CT

07-27-2020 ER visit-Broken arm

Data Field Answer Rationale
Date of Diagnosis 05/01/2019
Primary Site C75.1 pituitary gland
Histology 8272/0 Pituitary adenoma, NOS

 

*TIP:   if you just did a lookup in your registry software for the word adenoma, you might accidentally pick code 8140/0, review registry for these types of errors & correct
Diagnostic Confirmation 7

 

STORE Diagnostic Confirmation Radiography and other

imaging techniques without microscopic confirmation

Clinical Grade 1 WHO Grade I

 

Grade Coding Instructions and Tables Effective with Cases Diagnosed 1/1/2018 and Forward Published August 2019 Version 1.7

Note 4: CNS WHO classifications use a grading scheme that is a “malignancy scale” ranging across a wide variety of neoplasms rather than a strict histologic grading system that can be applied equally to all tumor types.

  • Code the WHO grading system for selected tumors of the CNS as noted in the AJCC 8th edition Table 72.2 where WHO grade is not documented in the record
Pathological Grade 9 Grade cannot be assessed; Unknown

 

Grade Coding Instructions and Tables Effective with Cases Diagnosed 1/1/2018 and Forward Published August 2019 Version 1.7

Note 5: Code 9 when

  • No resection of the primary site
Lymphovascular Invasion 8 Not Applicable

 

STORE Lymphovascular Invasion: Code 8, Not Applicable for benign/borderline brain and CNS tumors.
Tumor Size Summary 004 STORE Tumor Size Summary Note: All measurements should be in millimeters (mm).

Rounding: Round the tumor size only if it is described in fractions of millimeters. If tumor size is greater than 1 millimeter, round tenths of millimeters in the 1-4 range down to the nearest whole millimeter, and round tenths of millimeters in the 5-9 range up to the nearest whole millimeter.

Example: Breast cancer described as 6.5 millimeters in size. Round up Tumor Size as 007

Date of First Course Treatment 05-29-2020 STORE Date of First Course of Treatment If active surveillance or watchful waiting is selected as the first course of treatment (RX Summ–Treatment Status [1285] = 2) record the date this decision is made.
Date Last Contact

 

07-27-2020 STORE Date of Last Contact Record the last date on which the patient was known to be alive or the date of death.
Date Last Tumor Status 05-15-2020 [ date of the last note stating the patient status] STORE Data Item Clarification: Cancer Status

Never disease-free

  • Cancer Status [1770] = 2 (cancer)
  • Date of First Recurrence [1860] = BLANK, as per existing STORE instructions because it records date of recurrence after disease-free period which in this scenario there never was a disease-free period)
  • Recurrence Date 1st Flag [1861] = code 11 “patient never disease free” (STORE code 11 presently combines disease free after treatment and never disease free)
  • Date of Last Cancer (tumor) Status [1772] = record date of the last note stating the patient status (not disease free). In cases when the only information is a diagnosis, use the date of diagnosis.

 

https://www.facs.org/quality-programs/cancer/news/ncdb-news-081519

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