Document Number:

OCAS-TIB- 0012

 

Office of Compensation Analysis and Support 

Effective Date: 

Technical Information Bulletin 02/10/2006 

Revision No. 1 

Selection for internal and external dosimetry target organs 

for lymphatic/hematopoietic cancers Page 1 of 15 

Approval: Signature on File 

Supersedes: 

 J.W. Neton, Associate Director for Science 

Date: 

 2/10/2006 Rev. 0 

ISSUE 

AUTHORIZATION 

DATE 

EFFECTIVE

DATE 

REV. 

NO. DESCRIPTION 

8/15/2005 8/15/2005 0 New document to re-evaluate target 

organ selection for lymphatic/ 

hematopoietic cancers. 

2/10/2006 2/10/2006 1 Modifications to internal target organ 

selection. 

1.0 Description

Questions have been raised regarding the selection of target organs for internal and 

external dosimetry in cases of lymphatic/hematopoietic cancers, especially various forms 

of lymphoma. OCAS has undertaken a comprehensive review of the state of scientific 

knowledge regarding the etiology and diagnosis of the various lymphomas, leukemias, 

and multiple myeloma. This review specifically focused on possible sites of original 

radiation injury leading to subsequent development of disease, and the implications for 

target organ selection. 

2.0 Evaluation

The current guidelines for target organ selection used in EEOICPA dose reconstruction 

are set out in OTIB-00051

. These guidelines generally rely on medical review for 

selection of internal target organ, and the “remainder” category is typically applied as the 

external target organ for the various lymphomas, and the bone marrow is selected as 

both internal and external target organs for the various leukemias and multiple myeloma. 

As a result of the current investigation, which involved extensive consultation with a 

board-certified hematologist2

, the following target organ selections are recommended for 
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Page 2 of 15 

radionuclide uptakes via ingestion and inhalation. Radionuclide intakes via wounds 

require special consideration, and the target organ selections recommended in this TIB 

should be explicitly evaluated to ensure appropriateness in such cases. 

Table 1: ICD 200 – 200.18

ICD Cancer code explanation 

Internal Target 

Organ External Target Organ 

200 LYMPHOSARC/RETICULOSARC LN(TH) Thyroid 

200.0 RETICULOSARCOMA LN(TH) Thyroid 

200.00 RETCLSRC UNSPEC EXT ORG LN(TH) Thyroid 

200.01 RETICULOSARCOMA HEAD LN(ET) Thyroid 

200.02 RETICULOSARCOMA THORAX LN(TH) Lung 

200.03 RETICULOSARCOMA ABDOM HNMO Stomach 

200.04 RETICULOSARCOMA AXILLA LN(TH) Lung 

200.05 RETICULOSARCOMA INGUIN HNMO Bladder 

200.06 RETICULOSARCOMA PELVIC HNMO Bladder 

200.07 RETICULOSARCOMA SPLEEN Spleen Stomach 

200.08 RETICULOSARCOMA MULT LN(TH) Thyroid 

200.1 LYMPHOSARCOMA LN(TH) Thyroid 

200.10 LYMPHSRC UNSPEC EXT ORG LN(TH) Thyroid 

200.11 LYMPHOSARCOMA HEAD LN(ET) Thyroid 

200.12 LYMPHOSARCOMA THORAX LN(TH) Lung 

200.13 LYMPHOSARCOMA ABDOM HNMO Stomach 

200.14 LYMPHOSARCOMA AXILLA LN(TH) Lung 

200.15 LYMPHOSARCOMA INGUIN HNMO Bladder 

200.16 LYMPHOSARCOMA PELVIC HNMO Bladder 

200.17 LYMPHOSARCOMA SPLEEN Spleen Stomach 

200.18 LYMPHOSARCOMA MULT LN(TH) Thyroid 

LN(TH) = lymph nodes, thoracic LN(ET) = lymph nodes, extrathoracic 

HNMO = highest nonmetabolic organ 

These cancers involve the cells that make up the lymph nodes themselves. The site of 

occurrence is the most likely site of the original radiation injury. 

Therefore, for internal target organ, the highest non-metabolic organ (HNMO) is the most 

plausible choice. There are three exceptions: cancers occurring in the thorax, head, and 

spleen. Lymph nodes in the thorax and head are specifically modeled [LN(TH) and 

LN(ET), respectively]. The spleen is a specifically modeled organ, and should therefore 

be selected for cancers in this group occurring there. 

For external target organ, specifically modeled surrogate organs are selected for 

cancers occurring in particular regions of the body. The most appropriate surrogate is 

chosen based primarily on anatomical location. When location alone is not sufficient to 

select a target (i.e. when more than one possible surrogate is available based on 

location), the surrogate with the highest dose conversion factor was chosen. The 

possible surrogate organs included in each region of the body are (most appropriate 

surrogate organ listed in bold): (1) head [eye, thymus, thyroid] (2) thorax [breast, 

esophagus, lung] (3) abdomen [colon, liver, stomach] (4) axilla [lung] (5) inguinal 

[bladder, testes] (6) pelvic [bladder, ovaries, uterus] (7) spleen [liver, stomach]. For 
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cancers where no specific site is identified, the thyroid was chosen as the most claimantfavorable target organ. 

Table 2: ICD 200.2 – 200.28

ICD Cancer code explanation 

Internal Target 

Organ External Target Organ 

200.2 BURKITT'S TUMOR/LYMPHOMA LN(TH) Lung 

200.20 

BURKITT'S TUMOR UNSPEC EXT 

ORG LN(TH) Lung 

200.21 BURKITT'S TUMOR HEAD LN(TH) Lung 

200.22 BURKITT'S TUMOR THORAX LN(TH) Lung 

200.23 BURKITT'S TUMOR ABDOM LN(TH) Lung 

200.24 BURKITT'S TUMOR AXILLA LN(TH) Lung 

200.25 BURKITT'S TUMOR INGUIN LN(TH) Lung 

200.26 BURKITT'S TUMOR PELVIC LN(TH) Lung 

200.27 BURKITT'S TUMOR SPLEEN LN(TH) Lung 

200.28 BURKITT'S TUMOR MULT LN(TH) Lung 

These are B-cell lymphomas. As such, the site of occurrence is not necessarily the site 

of original radiation injury. Furthermore, the site listed may not actually be the site of 

occurrence. Rather, it is common to list the site of the biopsy, which is selected based 

on convenience and ease of access, rather than the site of primary involvement. 

The main reason for selecting thoracic lymph nodes as the target organ for internal 

exposures and lung as the target for external exposures is that due to the insoluble 

nature of many of the radionuclides energy employees could inhale, the dose to thoracic 

lymph nodes is typically higher than the dose to other organs, and this represents a 

plausible target organ choice. 

Table 3: ICD 200.8 – 200.88

ICD Cancer code explanation 

Internal Target 

Organ External Target Organ 

200.8 MIXED LYMPHOSARCOMA LN(TH) Thyroid 

200.80 OTHER VARN UNSPEC EXT ORG LN(TH) Thyroid

200.81 MIXED LYMPHOSARC HEAD LN(ET) Thyroid

200.82 MIXED LYMPHOSARC THORAX LN(TH) Lung

200.83 MIXED LYMPHOSARC ABDOM HNMO Stomach

200.84 MIXED LYMPHOSARC AXILLA LN(TH) Lung

200.85 MIXED LYMPHOSARC INGUIN HNMO Bladder

200.86 MIXED LYMPHOSARC PELVIC HNMO Bladder

200.87 MIXED LYMPHOSARC SPLEEN Spleen Stomach

200.88 MIXED LYMPHOSARC MULT LN(TH) Thyroid

These cancers involve the cells that make up the lymph nodes themselves. The site of 

occurrence is the most likely site of the original radiation injury. 

Therefore, for internal target organ, the highest non-metabolic organ (HNMO) is the most 

plausible choice. There are three exceptions: cancers occurring in the thorax, head, and 
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spleen. Lymph nodes in the thorax and head are specifically modeled [LN(TH) and 

LN(ET), respectively]. The spleen is a specifically modeled organ, and should therefore 

be selected for cancers in this group occurring there. 

For external target organ, specifically modeled surrogate organs are selected for 

cancers occurring in particular regions of the body. The most appropriate surrogate is 

chosen based primarily on anatomical location. When location alone is not sufficient to 

select a target (i.e. when more than one possible surrogate is available based on 

location), the surrogate with the highest dose conversion factor was chosen. The 

possible surrogate organs included in each region of the body are (most appropriate 

surrogate organ listed in bold): (1) head [eye, thymus, thyroid] (2) thorax [breast, 

esophagus, lung] (3) abdomen [colon, liver, stomach] (4) axilla [lung] (5) inguinal 

[bladder, testes] (6) pelvic [bladder, ovaries, uterus] (7) spleen [liver, stomach]. For 

cancers where no specific site is identified, the thyroid was chosen as the most claimantfavorable target organ. 

Table 4: ICD 201 – 201.98

ICD Cancer code explanation 

Internal Target 

Organ External Target Organ 

201 HODGKIN'S DISEASE LN(TH) Thyroid

201.0 HODGKIN'S PARAGRANULOMA LN(TH) Thyroid

201.00 

HODGKINS PARAGRANULOMA 

UNSPEC EXT ORG 

LN(TH) Thyroid

201.01 HODGKINS PARAGRAN HEAD LN(ET) Thyroid

201.02 HODGKINS PARAGRAN THORAX LN(TH) Lung

201.03 HODGKINS PARAGRAN ABDOM HNMO Stomach

201.04 HODGKINS PARAGRAN AXILLA LN(TH) Lung

201.05 HODGKINS PARAGRAN INGUIN HNMO Bladder

201.06 HODGKINS PARAGRAN PELVIC HNMO Bladder

201.07 HODGKINS PARAGRAN SPLEEN Spleen Stomach

201.08 HODGKINS PARAGRAN MULT LN(TH) Thyroid

201.1 HODGKIN'S GRANULOMA LN(TH) Thyroid

201.10 

HODGKINS GRANULOM UNSPEC 

EXT ORG 

LN(TH) Thyroid

201.11 HODGKINS GRANULOM HEAD LN(ET) Thyroid

201.12 HODGKINS GRANULOM THORAX LN(TH) Lung

201.13 HODGKINS GRANULOM ABDOM HNMO Stomach

201.14 HODGKINS GRANULOM AXILLA LN(TH) Lung

201.15 HODGKINS GRANULOM INGUIN HNMO Bladder

201.16 HODGKINS GRANULOM PELVIC HNMO Bladder

201.17 HODGKINS GRANULOM SPLEEN Spleen Stomach

201.18 HODGKINS GRANULOM MULT LN(TH) Thyroid

201.2 HODGKIN'S SARCOMA LN(TH) Thyroid

201.20 

HODGKINS SRC UNSPEC EXT 

ORG 

LN(TH) Thyroid

201.21 HODGKINS SARCOMA HEAD LN(ET) Thyroid

201.22 HODGKINS SARCOMA THORAX LN(TH) Lung

201.23 HODGKINS SARCOMA ABDOM HNMO Stomach

201.24 HODGKINS SARCOMA AXILLA LN(TH) Lung
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201.25 HODGKINS SARCOMA INGUIN HNMO Bladder

201.26 HODGKINS SARCOMA PELVIC HNMO Bladder

201.27 HODGKINS SARCOMA SPLEEN Spleen Stomach

201.28 HODGKINS SARCOMA MULT LN(TH) Thyroid

201.4 HODGKINS LYMPH-HISTIOCYT LN(TH) Thyroid

201.40 LYM-HST UNSPEC EXT ORGN LN(TH) Thyroid

201.41 HODGKINS LYMPH-HISTIO HEAD LN(ET) Thyroid

201.42 

HODGKINS LYMPH-HISTIO 

THORAX 

LN(TH) Lung

201.43 

HODGKINS LYMPH-HISTIO 

ABDOM 

HNMO Stomach

201.44 

HODGKINS LYMPH-HISTIO 

AXILLA 

LN(TH) Lung

201.45 

HODGKINS LYMPH-HISTIO 

INGUIN 

HNMO Bladder

201.46 

HODGKINS LYMPH-HISTIO 

PELVIC 

HNMO Bladder

201.47 

HODGKINS LYMPH-HISTIO 

SPLEEN 

Spleen Stomach

201.48 HODGKINS LYMPH-HISTIO MULT LN(TH) Thyroid

201.5 HODGKINS NODULAR SCLEROS LN(TH) Thyroid

201.50 

NODULAR SCLEROS UNSPEC 

EXT ORG 

LN(TH) Thyroid

201.51 

HODGKINS NODUL SCLERO 

HEAD 

LN(ET) Thyroid

201.52 

HODGKINS NODUL SCLERO 

THORAX 

LN(TH) Lung

201.53 

HODGKINS NODUL SCLERO 

ABDOM 

HNMO Stomach

201.54 

HODGKINS NODUL SCLERO 

AXILLA 

LN(TH) Lung

201.55 

HODGKINS NODUL SCLERO 

INGUIN 

HNMO Bladder

201.56 

HODGKINS NODUL SCLERO 

PELVIC 

HNMO Bladder

201.57 

HODGKINS NODUL SCLERO 

SPLEEN 

Spleen Stomach

201.58 

HODGKINS NODUL SCLERO 

MULT 

LN(TH) Thyroid

201.6 HODGKINS MIX CELLULARITY LN(TH) Thyroid

201.60 MXD CELR UNSPEC EXT ORG LN(TH) Thyroid

201.61 HODGKINS MIX CELL HEAD LN(ET) Thyroid

201.62 HODGKINS MIX CELL THORAX LN(TH) Lung

201.63 HODGKINS MIX CELL ABDOM HNMO Stomach

201.64 HODGKINS MIX CELL AXILLA LN(TH) Lung

201.65 HODGKINS MIX CELL INGUIN HNMO Bladder

201.66 HODGKINS MIX CELL PELVIC HNMO Bladder

201.67 HODGKINS MIX CELL SPLEEN Spleen Stomach

201.68 HODGKINS MIX CELL MULT LN(TH) Thyroid

201.7 HODG LYMPHOCYTIC DEPLET HNMO Thyroid

201.70 LYM DPLT UNSPEC EXT ORG LN(TH) Thyroid

201.71 HODGKINS LYMPH DEPLET HEAD LN(ET) Thyroid
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201.72 

HODGKINS LYMPH DEPLET 

THORAX 

LN(TH) Lung

201.73 

HODGKINS LYMPH DEPLET 

ABDOM 

HNMO Stomach

201.74 

HODGKINS LYMPH DEPLET 

AXILLA 

LN(TH) Lung

201.75 

HODGKINS LYMPH DEPLET 

INGUIN 

HNMO Bladder

201.76 

HODGKINS LYMPH DEPLET 

PELVIC 

HNMO Bladder

201.77 

HODGKINS LYMPH DEPLET 

SPLEEN 

Spleen Stomach

201.78 HODGKINS LYMPH DEPLET MULT LN(TH) Thyroid

201.9 HODGKINS DISEASE NOS LN(TH) Thyroid

201.90 

HDGK DISEASE UNSPEC EXT 

ORG 

LN(TH) Thyroid

201.91 HODGKINS DISEASE NOS HEAD LN(ET) Thyroid

201.92 

HODGKINS DISEASE NOS 

THORAX 

LN(TH) Lung

201.93 HODGKINS DISEASE NOS ABDOM HNMO Stomach

201.94 HODGKINS DISEASE NOS AXILLA LN(TH) Lung

201.95 HODGKINS DISEASE NOS INGUIN HNMO Bladder

201.96 HODGKINS DISEASE NOS PELVIC HNMO Bladder

201.97 

HODGKINS DISEASE NOS 

SPLEEN 

Spleen Stomach

201.98 HODGKINS DISEASE NOS MULT LN(TH) Thyroid

Hodgkin’s disease is lymphoma that is thought to originate in a particular lymph node, 

then spreads to adjacent lymph nodes. The site of occurrence is the most likely site of 

the original radiation injury. 

Therefore, for internal target organ, the highest non-metabolic organ (HNMO) is the most 

plausible choice. There are three exceptions: cancers occurring in the thorax, head, and 

spleen. Lymph nodes in the thorax and head are specifically modeled [LN(TH) and 

LN(ET), respectively]. The spleen is a specifically modeled organ, and should therefore 

be selected for cancers in this group occurring there. 

For external target organ, specifically modeled surrogate organs are selected for 

cancers occurring in particular regions of the body. The most appropriate surrogate is 

chosen based primarily on anatomical location. When location alone is not sufficient to 

select a target (i.e. when more than one possible surrogate is available based on 

location), the surrogate with the highest dose conversion factor was chosen. The 

possible surrogate organs included in each region of the body are (most appropriate 

surrogate organ listed in bold): (1) head [eye, thymus, thyroid] (2) thorax [breast, 

esophagus, lung] (3) abdomen [colon, liver, stomach] (4) axilla [lung] (5) inguinal 

[bladder, testes] (6) pelvic [bladder, ovaries, uterus] (7) spleen [liver, stomach]. For 

cancers where no specific site is identified, the thyroid was chosen as the most claimantfavorable target organ. 

Table 5: ICD 202 – 202.08
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ICD Cancer code explanation 

Internal Target 

Organ External Target Organ 

202 

OTHER MALIG NEO 

LYMPH/HISTIO 

LN(TH) Thymus/Lung*

202.0 NODULAR LYMPHOMA LN(TH) Thymus/Lung*

202.00 

NODULAR LYM UNSPEC EXT 

ORG 

LN(TH) Thymus/Lung*

202.01 NODULAR LYMPHOMA HEAD LN(TH) Thymus/Lung*

202.02 NODULAR LYMPHOMA THORAX LN(TH) Thymus/Lung*

202.03 NODULAR LYMPHOMA ABDOM LN(TH) Thymus/Lung*

202.04 NODULAR LYMPHOMA AXILLA LN(TH) Thymus/Lung*

202.05 NODULAR LYMPHOMA INGUIN LN(TH) Thymus/Lung*

202.06 NODULAR LYMPHOMA PELVIC LN(TH) Thymus/Lung*

202.07 NODULAR LYMPHOMA SPLEEN LN(TH) Thymus/Lung*

202.08 NODULAR LYMPHOMA MULT LN(TH) Thymus/Lung*

* The external target organ should be lung if the lymphoma is known to be a B-cell variety, or 

thymus if the lymphoma is known to be a T-cell variety or if the variety is unknown. 

These are B-cell or T-cell lymphomas. As such, the site of occurrence is not necessarily 

the site of original radiation injury. Furthermore, the site listed may not actually be the 

site of initial or most clinically relevant occurrence. Rather, it is common to list the site of 

the biopsy, which is selected based on convenience and ease of access, rather than the 

site of primary involvement. 

The main reason for selecting thoracic lymph nodes as the target organ for internal 

exposures and lung as the target for external exposures is that due to the insoluble 

nature of many of the radionuclides energy employees could inhale, the dose to thoracic 

lymph nodes is typically higher than the dose to other organs, and this represents a 

plausible target organ choice. 

The thymus is selected as the target organ for external exposures. The main 

justification for this selection is that the thymus is a plausible site of original radiation 

injury for T-cell lymphomas. If the cancer is known to be a B-cell lymphoma, the lung is 

a more plausible choice. However, in the absence of this determination, the thymus is 

more claimant-favorable (i.e. the dose conversion factor, and therefore resultant organ 

dose, is higher for the thymus than for the lung). 

Table 6: ICD 202.1 – 202.18

ICD Cancer code explanation 

Internal Target 

Organ External Target Organ 

202.1 MYCOSIS FUNGOIDES Skin Skin 

202.10 MYCS FNG UNSPEC EXT ORG Skin Skin 

202.11 MYCOSIS FUNGOIDES HEAD Skin Skin 

202.12 MYCOSIS FUNGOIDES THORAX Skin Skin 

202.13 MYCOSIS FUNGOIDES ABDOM Skin Skin 

202.14 MYCOSIS FUNGOIDES AXILLA Skin Skin 

202.15 MYCOSIS FUNGOIDES INGUIN Skin Skin 

202.16 MYCOSIS FUNGOIDES PELVIC Skin Skin 
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202.17 MYCOSIS FUNGOIDES SPLEEN Skin Skin 

202.18 MYCOSIS FUNGOIDES MULT Skin Skin 

Mycosis fungoides is a T-cell lymphoma that arises in the skin. Therefore, the choices of 

HNMO for internal target organ and skin for external target organ are both reasonable 

and claimant-favorable. 

Table 7: ICD 202.2 – 202.28

ICD Cancer code explanation 

Internal Target 

Organ External Target Organ 

202.2 SEZARY'S DISEASE Skin Skin 

202.20 

SZRY DISEASE UNSPEC EXT 

ORG Skin Skin 

202.21 SEZARY'S DISEASE HEAD Skin Skin 

202.22 SEZARY'S DISEASE THORAX Skin Skin 

202.23 SEZARY'S DISEASE ABDOM Skin Skin 

202.24 SEZARY'S DISEASE AXILLA Skin Skin 

202.25 SEZARY'S DISEASE INGUIN Skin Skin 

202.26 SEZARY'S DISEASE PELVIC Skin Skin 

202.27 SEZARY'S DISEASE SPLEEN Skin Skin 

202.28 SEZARY'S DISEASE MULT Skin Skin 

Sezary’s disease is the leukemic phase of mycosis fungoides. As such, the precursor to 

this disease is mycosis fungoides, therefore the target organs appropriate for this 

condition are those of mycosis fungoides. 

Table 8: ICD 202.3 – 202.38

ICD Cancer code explanation 

Internal Target 

Organ External Target Organ 

202.3 MALIG HISTIOCYTOSIS LN(TH) Thyroid 

202.30 MLG HIST UNSPEC EXT ORG LN(TH) Thyroid

202.31 MALIG HISTIOCYTOSIS HEAD LN(ET) Thyroid

202.32 MALIG HISTIOCYTOSIS THORAX LN(TH) Lung

202.33 MALIG HISTIOCYTOSIS ABDOM HNMO Stomach

202.34 MALIG HISTIOCYTOSIS AXILLA LN(TH) Lung

202.35 MALIG HISTIOCYTOSIS INGUIN HNMO Bladder

202.36 MALIG HISTIOCYTOSIS PELVIC HNMO Bladder

202.37 MALIG HISTIOCYTOSIS SPLEEN Spleen Stomach

202.38 MALIG HISTIOCYTOSIS MULT LN(TH) Thyroid

These cancers involve immobile macrophages found in connective tissue. The site of 

occurrence is the most likely site of the original radiation injury. 

 

Therefore, for internal target organ, the highest non-metabolic organ (HNMO) is the most 

plausible choice. There are two exceptions: cancers occurring in the thorax and cancers 

occurring in the spleen. For cancers of the thorax, there is possible lung involvement. 

Due to the insoluble nature of many of the radionuclides energy employees could inhale, 
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the dose to the thoracic lymph nodes is typically higher than the dose to HNMO. The 

spleen is a specifically modeled organ, and should therefore be selected for cancers in 

this group occurring there. 

For external target organ, specifically modeled surrogate organs are selected for 

cancers occurring in particular regions of the body. The most appropriate surrogate is 

chosen based primarily on anatomical location. When location alone is not sufficient to 

select a target (i.e. when more than one possible surrogate is available based on 

location), the surrogate with the highest dose conversion factor was chosen. The 

possible surrogate organs included in each region of the body are (most appropriate 

surrogate organ listed in bold): (1) head [eye, thymus, thyroid] (2) thorax [breast, 

esophagus, lung] (3) abdomen [colon, liver, stomach] (4) axilla [lung] (5) inguinal 

[bladder, testes] (6) pelvic [bladder, ovaries, uterus] (7) spleen [liver, stomach]. For 

cancers where no specific site is identified, the thyroid was chosen as the most claimantfavorable target organ. 

Table 9: ICD 202.4 – 202.48

ICD Cancer code explanation 

Internal Target 

Organ External Target Organ 

202.4 LEUKEM RETICULOENDOTHEL Bone marrow Bone marrow 

202.40 LK RTCTL UNSPEC EXT ORG Bone marrow Bone marrow 

202.41 HAIRY-CELL LEUKEM HEAD Bone marrow Bone marrow 

202.42 HAIRY-CELL LEUKEM THORAX Bone marrow Bone marrow 

202.43 HAIRY-CELL LEUKEM ABDOM Bone marrow Bone marrow 

202.44 HAIRY-CELL LEUKEM AXILLA Bone marrow Bone marrow 

202.45 HAIRY-CELL LEUKEM INGUIN Bone marrow Bone marrow 

202.46 HAIRY-CELL LEUKEM PELVIC Bone marrow Bone marrow 

202.47 HAIRY-CELL LEUKEM SPLEEN Bone marrow Bone marrow 

202.48 HAIRY-CELL LEUKEM MULT Bone marrow Bone marrow 

Leukemia is a disease process that in originates in the bone marrow. Therefore the most 

plausible site of original radiation injury is the bone marrow. 

Table 10: ICD 202.5 – 202.58

ICD Cancer code explanation 

Internal Target 

Organ External Target Organ 

202.5 LETTERER-SIWE DISEASE LN(TH) Skin 

202.50 LTR-SIWE UNSPEC EXT ORG LN(TH) Skin 

202.51 LETTERER-SIWE DISEASE HEAD LN(TH) Skin 

202.52 

LETTERER-SIWE DISEASE 

THORAX LN(TH) Skin 

202.53 

LETTERER-SIWE DISEASE 

ABDOM LN(TH) Skin 

202.54 

LETTERER-SIWE DISEASE 

AXILLA LN(TH) Skin 

202.55 

LETTERER-SIWE DISEASE 

INGUIN LN(TH) Skin 

202.56 LETTERER-SIWE DISEASE LN(TH) Skin 
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PELVIC 

202.57 

LETTERER-SIWE DISEASE 

SPLEEN LN(TH) Skin 

202.58 LETTERER-SIWE DISEASE MULT LN(TH) Skin 

Letterer-Siwe disease is an acute form of Langerhans cell (dendritic cells of the 

interstitial spaces of the epidermis) histiocytosis, occurring most often in children 

younger than three years old. The site of occurrence is most likely the site of original 

radiation injury, however the evidence on this is far from conclusive. It is possible that 

this condition is a T-cell lymphoma variant, in which case, the site of occurrence would 

not necessarily be the site of original radiation injury. In light of this uncertainty, the 

claimant-favorable assumptions in this case are thoracic lymph nodes for internal target 

organ, and skin for external target organ. 

Table 11: ICD 202.6 – 202.68

ICD Cancer code explanation 

Internal Target 

Organ External Target Organ 

202.6 MALIG MAST CELL TUMORS LN(TH) Thyroid

202.60 MALIG MAST UNSPEC EXT ORG LN(TH) Thyroid

202.61 MALIG MASTOCYTOSIS HEAD LN(ET) Thyroid

202.62 MALIG MASTOCYTOSIS THORAX LN(TH) Lung

202.63 MALIG MASTOCYTOSIS ABDOM HNMO Stomach

202.64 MALIG MASTOCYTOSIS AXILLA LN(TH) Lung

202.65 MALIG MASTOCYTOSIS INGUIN HNMO Bladder

202.66 MALIG MASTOCYTOSIS PELVIC HNMO Bladder

202.67 MALIG MASTOCYTOSIS SPLEEN Spleen Stomach

202.68 MALIG MASTOCYTOSIS MULT LN(TH) Thyroid

These cancers involve the cells that make up the lymph nodes themselves. The site of 

occurrence is the most likely site of the original radiation injury. 

Therefore, for internal target organ, the highest non-metabolic organ (HNMO) is the most 

plausible choice. There are three exceptions: cancers occurring in the thorax, head, and 

spleen. Lymph nodes in the thorax and spleen are specifically modeled [LN(TH) and 

LN(ET), respectively]. The spleen is a specifically modeled organ, and should therefore 

be selected for cancers in this group occurring there. 

For external target organ, specifically modeled surrogate organs are selected for 

cancers occurring in particular regions of the body. The most appropriate surrogate is 

chosen based primarily on anatomical location. When location alone is not sufficient to 

select a target (i.e. when more than one possible surrogate is available based on 

location), the surrogate with the highest dose conversion factor was chosen. The 

possible surrogate organs included in each region of the body are (most appropriate 

surrogate organ listed in bold): (1) head [eye, thymus, thyroid] (2) thorax [breast, 

esophagus, lung] (3) abdomen [colon, liver, stomach] (4) axilla [lung] (5) inguinal 

[bladder, testes] (6) pelvic [bladder, ovaries, uterus] (7) spleen [liver, stomach]. For 

cancers where no specific site is identified, the thyroid was chosen as the most claimantfavorable target organ.
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Table 12: ICD 202.8 – 202.98

ICD Cancer code explanation 

Internal Target 

Organ External Target Organ 

202.8 LYMPHOMAS NEC LN(TH) Thymus/Lung* 

202.80 OTHER LYMP UNSPEC EXT ORG LN(TH) Thymus/Lung* 

202.81 LYMPHOMAS NEC HEAD LN(TH) Thymus/Lung* 

202.82 LYMPHOMAS NEC THORAX LN(TH) Thymus/Lung* 

202.83 LYMPHOMAS NEC ABDOM LN(TH) Thymus/Lung* 

202.84 LYMPHOMAS NEC AXILLA LN(TH) Thymus/Lung* 

202.85 LYMPHOMAS NEC INGUIN LN(TH) Thymus/Lung* 

202.86 LYMPHOMAS NEC PELVIC LN(TH) Thymus/Lung* 

202.87 LYMPHOMAS NEC SPLEEN LN(TH) Thymus/Lung* 

202.88 LYMPHOMAS NEC MULT LN(TH) Thymus/Lung* 

202.9 MALIG NEO LYM/HIST TIS NEC LN(TH) Thymus/Lung* 

202.90 UNSPEC LYM UNSPEC EXT ORG LN(TH) Thymus/Lung* 

202.91 LYMPHOID MALIG NEC HEAD LN(TH) Thymus/Lung* 

202.92 LYMPHOID MALIG NEC THORAX LN(TH) Thymus/Lung* 

202.93 LYMPHOID MALIG NEC ABDOM LN(TH) Thymus/Lung* 

202.94 LYMPHOID MALIG NEC AXILLA LN(TH) Thymus/Lung* 

202.95 LYMPHOID MALIG NEC INGUIN LN(TH) Thymus/Lung* 

202.96 LYMPHOID MALIG NEC PELVIC LN(TH) Thymus/Lung* 

202.97 LYMPHOID MALIG NEC SPLEEN LN(TH) Thymus/Lung* 

202.98 LYMPHOID MALIG NEC MULT LN(TH) Thymus/Lung* 

* The external target organ should be lung if the lymphoma is known to be a B-cell variety, or 

thymus if the lymphoma is known to be a T-cell variety or if the variety is unknown. 

These are B-cell or T-cell lymphomas. As such, the site of occurrence is not necessarily 

the site of original radiation injury. Furthermore, the site listed may not actually be the 

site of occurrence. Rather, it is common to list the site of the biopsy, which is selected 

based on convenience and ease of access, rather than the site of primary involvement. 

The main reason for selecting thoracic lymph nodes as the target organ for internal 

exposures and lung as the target for external exposures is that due to the insoluble 

nature of many of the radionuclides energy employees could inhale, the dose to thoracic 

lymph nodes is typically higher than the dose to other organs, and this represents a 

plausible target organ choice. 

The thymus is selected as the target organ for external exposures. The main 

justification for this selection is that the thymus is a plausible site of original radiation 

injury for T-cell lymphomas. If the cancer is known to be a B-cell lymphoma, the lung is 

a more plausible choice. However, in the absence of this determination, the thymus is 

more claimant-favorable (i.e. the dose conversion factor, and therefore resultant organ 

dose is higher for the thymus than for the lung). 

Table 13: ICD 203 – 203.01

ICD Cancer code explanation Internal Target External Target Organ 
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Organ 

203 MULTIPLE MYELOMA ET AL Bone marrow Bone marrow 

203.0 MULTIPLE MYELOMA Bone marrow Bone marrow 

203.00 MULT MYELM W/O REMISSION Bone marrow Bone marrow 

203.01 MULT MYELM W/REMISSION Bone marrow Bone marrow 

Multiple myeloma is a disease process that in the vast majority of cases is confined to 

the bone marrow. Therefore the most plausible site of original radiation injury is the 

bone marrow. 
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Table 14: ICD 203.1 – 208.91

ICD Cancer code explanation 

Internal Target 

Organ External Target Organ 

203.1 PLASMA CELL LEUKEMIA Bone marrow Bone marrow 

203.10 PLSM CELL LEUK W/O REMISSON Bone marrow Bone marrow 

203.11 PLSM CELL LEUK W/REMISS Bone marrow Bone marrow 

203.8 

IMMUNOPROLIFERAT NEOPLASM 

NEC Bone marrow Bone marrow 

203.80 

OTHER IMNPRFL NPL W/O 

REMISS Bone marrow Bone marrow 

203.81 OTHER IMNPRFL NPL W/REMISS 

204 LYMPHOID LEUKEMIA Bone marrow Bone marrow 

204.0 ACUTE LYMPHOID LEUKEMIA Bone marrow Bone marrow 

204.00 ACT LYM LEUK W/O REMISS Bone marrow Bone marrow 

204.01 ACT LYM LEUK W/REMISS Bone marrow Bone marrow 

204.1 CHRONIC LYMPHOID LEUKEMIA Bone marrow Bone marrow 

204.10 

CHRONIC LYM LEUK W/O 

REMISSION Bone marrow Bone marrow 

204.11 

CHRONIC LYM LEUK 

W/REMISSION Bone marrow Bone marrow 

204.2 SUBACUTE LYMPHOID LEUKEMIA Bone marrow Bone marrow 

204.20 SBAC LYM LEUK W/O REMISS Bone marrow Bone marrow 

204.21 SBAC LYM LEUK W/REMISS Bone marrow Bone marrow 

204.8 LYMPHOID LEUKEMIA NEC Bone marrow Bone marrow 

204.80 OTHER LYM LEUK W/O REMISS Bone marrow Bone marrow 

204.81 OTHER LYM LEUK W/REMISS Bone marrow Bone marrow 

204.9 LYMPHOID LEUKEMIA NOS Bone marrow Bone marrow 

204.90 UNS LYM LEUK W/O REMISS Bone marrow Bone marrow 

204.91 UNS LYM LEUK W/REMISS Bone marrow Bone marrow 

205 MYELOID LEUKEMIA Bone marrow Bone marrow 

205.0 ACUTE MYELOID LEUKEMIA Bone marrow Bone marrow 

205.00 ACT MYL LEUK W/O REMISS Bone marrow Bone marrow 

205.01 ACT MYL LEUK W/REMISS Bone marrow Bone marrow 

205.1 CHRONIC MYELOID LEUKEMIA Bone marrow Bone marrow 

205.10 CHRONIC MYL LEUK W/O REMISS Bone marrow Bone marrow 

205.11 CHRONIC MYL LEUK W/REMISS Bone marrow Bone marrow 

205.2 SUBACUT MYELOID LEUKEMIA Bone marrow Bone marrow 

205.20 SBAC MYL LEUK W/O REMISS Bone marrow Bone marrow 

205.21 SBAC MYL LEUK W/REMISS Bone marrow Bone marrow 

205.3 MYELOID SARCOMA Bone marrow Bone marrow 

205.30 MYL SRCOMA W/O REMISS Bone marrow Bone marrow 

205.31 MYL SRCOMA W/REMISS Bone marrow Bone marrow 

205.8 MYELOID LEUKEMIA NEC Bone marrow Bone marrow 

205.80 OTHER MYL LEUK W/O REMISS Bone marrow Bone marrow 

205.81 OTHER MYL LEUK W/REMISS Bone marrow Bone marrow 

205.9 MYELOID LEUKEMIA NOS Bone marrow Bone marrow 

205.90 UNS MYL LEUK W/O REMISS Bone marrow Bone marrow 

205.91 UNS MYL LEUK W/REMISS Bone marrow Bone marrow 

206 MONOCYTIC LEUKEMIA 

206.0 ACUTE MONOCYTIC LEUKEMIA Bone marrow Bone marrow 

206.00 ACT MONO LEUK W/O REMISS Bone marrow Bone marrow 
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206.01 ACT MONO LEUK W/REMISS Bone marrow Bone marrow 

206.1 

CHRONIC MONOCYTIC 

LEUKEMIA Bone marrow Bone marrow 

206.10 

CHRONIC MONO LEUK W/O 

REMISS Bone marrow Bone marrow 

206.11 CHRONIC MONO LEUK W/REMISS Bone marrow Bone marrow 

206.2 SUBAC MONOCYTIC LEUKEMIA Bone marrow Bone marrow 

206.20 

SUBACUTE MONO LEUK W/O 

REMISS Bone marrow Bone marrow 

206.21 

SUBACUTE MONO LEUK 

W/REMISS Bone marrow Bone marrow 

206.8 MONOCYTIC LEUKEMIA NEC Bone marrow Bone marrow 

206.80 OTHER MONO LEUK W/O REMISS Bone marrow Bone marrow 

206.81 OTHER MONO LEUK W/REMISS Bone marrow Bone marrow 

206.9 MONOCYTIC LEUKEMIA NOS Bone marrow Bone marrow 

206.90 UNS MONO LEUK W/O REMISS Bone marrow Bone marrow 

206.91 UNS MONO LEUK W/REMISS Bone marrow Bone marrow 

207 OTHER SPECIFIED LEUKEMIA Bone marrow Bone marrow 

207.0 ACUTE ERYTHREMIA Bone marrow Bone marrow 

207.00 ACT ERTH/ERYLK W/O REMISS Bone marrow Bone marrow 

207.01 ACT ERTH/ERYLK W/REMISS Bone marrow Bone marrow 

207.1 CHRONIC ERYTHREMIA Bone marrow Bone marrow 

207.10 

CHRONIC ERYTHRM W/O 

REMISION Bone marrow Bone marrow 

207.11 CHRONIC ERYTHRM W/REMISION Bone marrow Bone marrow 

207.2 MEGAKARYOCYTIC LEUKEMIA Bone marrow Bone marrow 

207.20 MGKRYCYT LEUK W/O REMISS Bone marrow Bone marrow 

207.21 MGKRYCYT LEUK W/REMISS Bone marrow Bone marrow 

207.8 SPECIFIED LEUKEMIA NEC Bone marrow Bone marrow 

207.80 OTHER SPF LEUK W/O REMISS Bone marrow Bone marrow 

207.81 OTHER SPF LEUK W/REMSION Bone marrow Bone marrow 

 LEUKEMIA-UNSPECIF CELL Bone marrow Bone marrow 

208.0 ACT LEUK UNS CL W/O REMISS Bone marrow Bone marrow 

208.00 ACT LEUK UNS CL W/O REMISS Bone marrow Bone marrow 

208.01 ACT LEUK UNS CL W/REMISS Bone marrow Bone marrow 

208.1 CHRONIC LEUKEMIA NOS Bone marrow Bone marrow 

208.10 

CHRONIC LEUK UNS CL W/O 

REMISS Bone marrow Bone marrow 

208.11 

CHRONIC LEUK UNS CL 

W/REMISS Bone marrow Bone marrow 

208.2 SUBACUTE LEUKEMIA NOS Bone marrow Bone marrow 

208.21 

SUBACUTE LEUKEMIA UNS CL 

W/REMISSION Bone marrow Bone marrow 

208.8 LEUKEMIA-UNSPEC CELL NEC Bone marrow Bone marrow 

208.80 

OTHER LEUK UNS CL W/O 

REMISSION Bone marrow Bone marrow 

208.81 

OTHER LEUK UNS CL 

W/REMISSION Bone marrow Bone marrow 

208.9 LEUKEMIA-UNSPEC CELL NOS Bone marrow Bone marrow 

208.90 

OTHER LEUK NOS W/O 

REMISSION Bone marrow Bone marrow 

208.91 OTHER LEUK NOS W/REMISSION Bone marrow Bone marrow 
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All of the conditions in this group involve either immature lymphocytes, myelocytes or 

other cells normally confined to the bone marrow. Therefore the most plausible site of 

original radiation injury is the bone marrow. 

3.0 Resolution/Corrective Action

OTIB-0005 will require revision to harmonize target organ selection with this document. 

Completed lymphoma dose reconstructions with probabilities of causation <50% will 

require reevaluation. 

4.0 Summary

Extensive changes to target organ selection for various forms of lymphoma are 

recommended. Past selection entailed a review of medical records for individual claims, 

and used ICD-9 codes to infer anatomical location of primary involvement. Such an 

inference is inappropriate for lymphoma, as ICD-9 code assignment often relies on the 

site of biopsy, rather than site of primary involvement. Furthermore, for non-Hodgkin’s 

lymphoma, the site of occurrence is not necessarily the site of original radiation injury. 

Current recommendations are based on an investigation of the etiology and progression 

of the various forms of lymphoma. Target organ selection for various forms of leukemia 

and multiple myeloma were also reviewed, with no changes recommended. 

5.0 References

1) ORAU Team, Technical Information Bulletin: IMBA organ, external dosimetry 

organ, and IREP model selection by ICD-9 code, ORAUT-OTIB-0005, Rev 01 

PC-3 (10/29/2004). 

2) Crowther, M.A. MD, MSc, FRCPC. Personal communication. 11/2004 – 7/2005.