# Presentation: 490588

## Head and Neck

## Equivalent Terms, Definitions, Charts, Tables and Illustrations

- Primary site
- Do not code biopsy site

**Notes:**
Head and neck tumors often overlap/extend to contiguous sites. Do not assume that the biopsy site is the primary site. 
There may be one large tumor involving several sites with multiple biopsies in different sites.
Surgeons often do multiple surgeries on H&N sites to assess margins and see if involved.  Extensive resection done in many cases, adding to the difficulty of determining the primary site. 

## Priority Order Code Primary Site

- Tumor Board
- a. Specialty
- b. General

**Notes:**
Since it is often difficult to assign a primary site to head and neck tumors, these rules give a priority for using documentation to assign a primary site.

Discussions at tumor boards are the most reliable information on which primary site to code.

## Priority Order Code Primary Site

- Staging physician’s site assignment
- a. AJCC staging form
- b. TNM statement in medical record
- If neither 1 or 2 available, based on whether tumor was resected

**Notes:**
Second priority is the site assigned by the physician who documents the AJCC TNM stage.

If neither tumor board nor AJCC staging are available, the 3rd and 4th priorities are assigned based on whether the primary tumor was resected.

## Priority Order Code Primary Site

- Total resection of primary tumor (margins may be microscopically positive)
- a. Operative report – surgeon’s statement
- b. Final diagnosis on pathology report

**Notes:**
Note that the criteria is total resection of the primary tumor, not the site of origin – in other words, if the patient has a tumor on the base of the tongue, the entire tongue does not have to be resected. The tumor must have been totally resected – there cannot be any gross tumor at the margins. 

## Priority Order Code Primary Site

- No resection (may have biopsy)
- a. Endoscopy
- b. Radiation oncologist
- c. Diagnosing physician
- d. Primary care physician
- Continued on next slide

**Notes:**
If the margins of resection are grossly positive or if there is only a biopsy, use these sources given in priority order.

## Priority Order Code Primary Site

- e. Other physician
- f.  Diagnostic imaging
- g. Physician statement based on clinical examination

## Default Site Codes

- Point of origin cannot be determined
- C02.8 Overlapping lesion of tongue
- C08.8 Overlapping lesion of major salivary glands
- C14.8 Overlapping lesion of lip, oral cavity, and pharynx.

**Notes:**
Use default codes only when it is impossible to determine the point or organ of origin.

## Table 1 – Paired Sites

| Column 1: 
Paired Sites  | Column 2:
Code |
| --- | --- |
| Parotid Glands | C079 |
| Major Salivary Glands  | C080; C081 |
| Tonsils | C090; C091; C098; C099 |
| Nasal Cavity  | C300  |
| Accessory Sinuses | C310; C312 |
| Middle Ear  | C301 |

**Notes:**
It is important to identify those sites that are paired for use with the multiple primary rules. There are two organs on opposite sides of the body (right and left).

## Chart 1 – H&N Histology Groups and Specific Types

- Use this chart with the histology rules to code the most specific histologic term.  The tree is arranged in descending order. Each branch is a histology group, starting with the NOS or group terms and descending into the specific types for that group. As you follow the branch down, the terms become more specific

## Slide 11

**Notes:**
Follow one of the branches explaining that the histologies become more specific as the branch descends.

## Multiple Primary Rules

## Unknown if Single or Multiple Tumors

**Notes:**
Use this module when:

Central registry gets a pathology report of a biopsy followed by a hospital report of a resection. Central registry is not sure if there was a single tumor or multiple tumors

Hospital registry has an H&P documenting a biopsy in the physician’s office. Patient has another biopsy or resection. Registrar cannot confirm whether the patient had a single tumor or multiple tumors.

## Slide 14

**Notes:**
This is a default so everyone will handle the cases in a standardized manner. 

The note is a warning not to default to a single tumor until all sources of information have been exhausted.

## Single Tumor

## Slide 16

**Notes:**
Single tumors are always a single primary no matter how large they become or how many regional sites they may involve.

## Multiple Tumors

## Slide 18

**Notes:**
Table 1 lists all of the paired sites for H&N. 

Record as multiple primaries even if the doctor says it is “bilateral” (remind audience that the word bilateral is not used to determine multiple primaries). The only exception is if the physician says that one side is metastatic from the other.

## Slide 19

**Notes:**
This rule is NOT referring to a contiguous tumor that spreads from the upper to lower lip – the rule is for separate tumors on the upper and lower lip.  This is new. Upper lip and lower lip have the same first three digits in the ICD-O-3 topography code.  However they are separate primaries when there are separate tumors on upper and on lower lip.

## Slide 20

**Notes:**
Similar to the previous rule -- This rule is NOT referring to a contiguous tumor that spreads from the upper to lower gum – the rule is for separate tumors on the upper and lower gum.

## Slide 21

**Notes:**
Previously, separate tumors in the nasal cavity C300 and middle ear C301 would have been abstracted as a single primary because the first three characters of the topography codes are the same.  This new rule makes them multiple primaries when there are separate tumors in the nasal cavity and middle ear.  The old 3-digit topography rule does not work for these two sites.

## Slide 22

**Notes:**
See Table 2 for sites that would have been coded as a single primary in previous years.

## Slide 23

**Notes:**
First explain that if an invasive occurs less than 60 days after an in situ you would abstract as a single primary and code the invasive tumor.

This is new for everyone except SEER registries. Explain the rule thoroughly.

Note 1 means that the incidence counts are for invasive cases only with a few exceptions. 

Explain that we do not want survival graphs showing people dying of in situ disease. We also don’t want the survival time affected by the time between an in situ and an invasive tumor

Note 2: IMPORTANT. You may have to explain to your physicians the reason behind the rule. The CoC physicians were all supportive when the rule and rationale were presented to them. 

## Slide 24

**Notes:**
Data supports using a five year rule for new primaries. This rule will also prevent over-counting the recurrent in situ tumors that are prevalent in several head and neck sites.

## Slide 25

**Notes:**
Same as previous NOS rule with specific histologies given.

## Slide 26

**Notes:**
Same as previous three-digit histology rule.

## Slide 27

**Notes:**
This is a default rule. We do not have to write multiple rules saying that these conditions are single primaries. If the case did not meet the criteria for any of the previous rules, it is a single primary.

Use the rules to determine multiple primaries NOT the examples.

## Histology Rules

## Single Tumor

## Slide 30

**Notes:**
Used when there was no pathology or cytology specimen and when the abstractor does not have access to the pathology or cytology report.
Note 1 gives a priority for using documentation to code histology.
--If the medical record references a pathology or cytology report. Example: Patient had a biopsy of the tonsil prior to arrival that was positive for squamous cell carcinoma.
--Use the physician’s documentation in the medical record giving the histology. Example: H&P with a diagnosis of squamous cell carcinoma of the tonsil.
--Reference to histologic type in CT, PET, or MRI scans.
Note 2: If any of the documentation sources mentions a specific histology, code as documented.
Note 3: If the only mention is that the patient has “carcinoma” of the lung, code 8010. If the only mention is that the patient has cancer of the lung code 8000.

## Slide 31

**Notes:**
If there is no pathology or cytology specimen from the primary site, code the histology from a biopsy of a metastatic site. Example: Patient has biopsy of a cervical node that was positive for squamous cell carcinoma. CT scan confirms a primary malignancy of the tongue.  Code squamous cell carcinoma of the tongue.

## Slide 32

**Notes:**
Used when diagnosis is simply adenocarcinoma or squamous cell carcinoma.

## Slide 33

**Notes:**
This is a change from the previous rules. Be sure to emphasize.

The invasive histology is the one that will affect survival and govern treatment. By coding the invasive type, the case will be placed in the correct analysis group.

Even if the in situ portion is more specific, it will not be the histology that impacts survival and treatment. 

## Slide 34

**Notes:**
H5: Same as previous NOS rule with specific instructions.

H6: This is a default rule for any cases did not meet the criteria of the first 5 rules

## Multiple Tumors Abstracted as a Single Primary

## Slide 36

**Notes:**
Same as H1

## Slide 37

**Notes:**
Same as H2

## Slide 38

**Notes:**
Same as H3

## Slide 39

**Notes:**
Similar to H4.  H10 is for multiple tumors.

## Slide 40

**Notes:**
H11 is the same as H5

H12 is the same as H6

## MP/H Task Force