Chapter 2 of the ICD-9-CM contains the codes for most benign and all malignant neoplasms. Certain benign neoplasms, such as prostatic adenomas, may be found in the specific body system chapters. To properly code a neoplasm it is necessary to determine from the record if the neoplasm is benign, in-situ, malignant, or of uncertain histologic behavior. If malignant, any secondary (metastatic) sites should also be determined.

The neoplasm table in the Alphabetic Index should be referenced first. However, if the histological term is documented, that term should be referenced first, rather than going immediately to the Neoplasm Table, in order to determine which column in the Neoplasm Table is appropriate. For example, if the documentation indicates “adenoma,” refer to the term in the Alphabetic Index to review the entries under this term and the instructional note to “see also neoplasm, by site, benign.” The table provides the proper code based on the type of neoplasm and the site. It is important to select the proper column in the table that corresponds to the type of neoplasm. The tabular should then be referenced to verify that the correct code has been selected from the table and that a more specific site code does not exist. See Section I. C. 18.d.4. for information regarding V codes for genetic susceptibility to cancer.

a. Treatment directed at the malignancy

If the treatment is directed at the malignancy, designate the malignancy as the principal diagnosis.

The only exception to this guideline is if a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or radiation therapy, assign the appropriate V58.x code as the first-listed or principal diagnosis, and the diagnosis or problem for which the service is being performed as a secondary diagnosis.

Example

The patient had a prostatectomy and a bilateral pelvic lymphadenectomy for prostate acinar adenocarcinoma. Treatment is directed to the primary cancer of the prostate, 185, 60.5, 40.3 (C61, 0VT00ZZ, 07BC0ZZ).

b. Treatment of secondary site

When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary site only, the secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present.

Example

Three months ago, the patient was given a diagnosis of small cell lung carcinoma with metastasis to the liver. The patient’s primary neoplasm is lung carcinoma; the secondary neoplasm is located in the liver. The patient underwent wedge resection for liver metastasis, 197.7, 162.9, 50.22 (C78.7 C34.90, 0FB00ZZ).

c. Coding and sequencing of complications

Coding and sequencing of complications associated with the malignancies or with the therapy thereof are subject to the following guidelines:

1) Anemia associated with malignancy

When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate anemia code (such as code 285.22, Anemia in neoplastic disease) is designated as the principal diagnosis and is followed by the appropriate code(s) for the malignancy.

Code 285.22 may also be used as a secondary code if the patient suffers from anemia and is being treated for the malignancy.

Code 285.22, Anemia in neoplastic disease, and code 285.3, Antineoplastic chemotherapy induced anemia, may both be assigned if anemia in neoplastic disease and anemia due to antineoplastic chemotherapy are both documented.

If anemia in neoplastic disease and anemia due to antineoplastic chemotherapy are both documented, assign codes for both conditions.

Example

Anemia due to metastatic bone cancer. The patient has a history of primary breast cancer, which was treated with mastectomy 4 years ago. The patient was admitted for transfusion of packed red blood cells (percutaneous peripheral vein), 285.22, 198.5, V10.3, V45.71, 99.04 (C79.51, D63.0, Z85.3, Z90.10, 30233N1. ICD-10-CM instructs to code neoplasm first when anemia is due to neoplasm).

2) Anemia associated with chemotherapy, immunotherapy and radiation therapy

When the admission/encounter is for management of an anemia associated with chemotherapy, immunotherapy or radiotherapy and the only treatment is for the anemia, the anemia is sequenced first followed by code E933.1. The appropriate neoplasm code should be assigned as an additional code.

Example

Aplastic anemia due to radiation. The patient is being treated for cancer of the brain. The patient was transfused with 2 units of packed red blood cells (percutaneous peripheral vein), 284.89, 191.9, V15.3, E879.2, 99.04 (D61.2, C71.9, Y84.2, 30233N1).

3) Management of dehydration due to the malignancy

When the admission/encounter is for management of dehydration due to the malignancy or the therapy, or a combination of both, and only the dehydration is being treated (intravenous rehydration), the dehydration is sequenced first, followed by the code(s) for the malignancy.

Example

The patient underwent chemotherapy treatment a few days ago, and since that time has become severely dehydrated. The patient is receiving chemo for treatment of cancer of the colon, 276.51, 153.9 (E86.0, C18.9).

4) Treatment of a complication resulting from a surgical procedure

When the admission/encounter is for treatment of a complication resulting from a surgical procedure, designate the complication as the principal or first-listed diagnosis if treatment is directed at resolving the complication.

Example

Hernia of colostomy with repair of parastomal hernia. The colostomy was performed 1 year ago during colon cancer resection. The patient is no longer receiving treatment, and the cancer was completely resected, 569.69, V10.05, 46.42 (K43.5, Z85.038, 0WQFXZZ).

d. Primary malignancy previously excised

When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category V10, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal or first-listed with the V10 code used as a secondary code.

Example

The patient had a melanoma removed from his back 4 years ago. The patient is currently being treated for metastatic melanoma of the lung, 197.0, V10.82 (C78.00, Z85.820).

e. Admissions/Encounters involving chemotherapy, immunotherapy and radiation therapy

1) Episode of care involves surgical removal of neoplasm.

When an episode of care involves the surgical removal of a neoplasm, primary or secondary site, followed by adjunct chemotherapy or radiation treatment during the same episode of care, the neoplasm code should be assigned as principal or first-listed diagnosis, using codes in the 140-198 series or where appropriate in the 200-203 series.

Example

The patient had a modified radical mastectomy for malignant neoplasm of the right (upper outer quadrant) breast with metastasis to lymph nodes with adjunct chemotherapy (percutaneous central vein), 174.4, 85.43, 99.25 (C50.411, C77.3, 0HTT0ZZ, O7B5OZZ, 3E04305).

2) Patient admission/encounter solely for administration of chemotherapy, immunotherapy and radiation therapy

If a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or radiation therapy assign code V58.0, Encounter for radiation therapy, or V58.11, Encounter for antineoplastic chemotherapy, or V58.12, Encounter for antineoplastic immunotherapy as the first-listed or principal diagnosis. If a patient receives more than one of these therapies during the same admission more than one of these codes may be assigned, in any sequence.

Example

The patient was admitted for chemotherapy (percutaneous central vein) treatment of acute lymphocytic leukemia (ALL), V58.11, 204.00, 99.25 (Z51.11, C91.00, 3E04305).

3) Patient admitted for radiotherapy/chemotherapy and immunotherapy and develops complications

When a patient is admitted for the purpose of radiotherapy, immunotherapy or chemotherapy and develops complications such as uncontrolled nausea and vomiting or dehydration, the principal or first-listed diagnosis is V58.0, Encounter for radiotherapy, or V58.11, Encounter for antineoplastic chemotherapy, or V58.12, Encounter for antineoplastic immunotherapy followed by any codes for the complications.

Example

The patient was admitted for chemotherapy (percutaneous peripheral artery) for lymphoma. Because of nausea and severe vomiting due to the chemotherapy, the patient was also treated for dehydration with IV fluids, V58.11, 202.80, 276.51, 787.01, 99.25 (Z51.11, C85.90, E86.0, T45.1x5A, R11.2, 3E05305).

f. Admission/encounter to determine extent of malignancy

When the reason for admission/encounter is to determine the extent of the malignancy, or for a procedure such as paracentesis or thoracentesis, the primary malignancy or appropriate metastatic site is designated as the principal or first-listed diagnosis, even though chemotherapy or radiotherapy is administered.

Example

Patient has known carcinoma of the left kidney and left pleural effusion. Patient is admitted to determine if the renal cancer has spread and a thoracentesis is done, which confirms metastasis to the pleura, 197.2, 511.81, 189.0, 34.91 (C78.2, J91.0, C64.2, 0W9B3ZX).

g. Symptoms, signs, and ill-defined conditions listed in Chapter 16 associated with neoplasms

Symptoms, signs, and ill-defined conditions listed in Chapter 16 characteristic of, or associated with, an existing primary or secondary site malignancy cannot be used to replace the malignancy as principal or first-listed diagnosis, regardless of the number of admissions or encounters for treatment and care of the neoplasm.

See section I.C.18.d.14, Encounter for prophylactic organ removal.

Example

The patient was admitted with a first-time seizure due to brain cancer. The code 780.39 for seizure can be found in Chapter 16, so the brain cancer code would be sequenced as the principal diagnosis, 191.9, 780.39 (C71.9, R56.9). Not all patients with brain cancer develop seizures, so it is appropriate to code the seizure code as a secondary diagnosis.

h. Admission/encounter for pain control/management

See Section I.C.6.a.5 for information on coding admission/encounter for pain control/management.

i. Malignant neoplasm associated with transplanted organ

A malignant neoplasm of a transplanted organ should be coded as a transplant complication. Assign first the appropriate code from subcategory 996.8, Complications of transplanted organ, followed by code 199.2, Malignant neoplasm associated with transplanted organ. Use an additional code for the specific malignancy.

Example

Patient was diagnosed with hepatocellular carcinoma. Patient had a liver transplant 2 years ago, 996.82, 199.2, 155.0, E878.0 (T86.49, C80.2, C22.0, Y83.0).

6. Chapter 6: Diseases of Nervous System and Sense Organs (320-389)

a. Pain—Category 338

5) Neoplasm Related Pain

Code 338.3 is assigned to pain documented as being related, associated or due to cancer, primary or secondary malignancy, or tumor. This code is assigned regardless of whether the pain is acute or chronic.

This code may be assigned as the principal or first-listed code when the stated reason for the admission/encounter is documented as pain control/pain management. The underlying neoplasm should be reported as an additional diagnosis.

When the reason for the admission/encounter is management of the neoplasm and the pain associated with the neoplasm is also documented, code 338.3 may be assigned as an additional diagnosis.

See Section I.C.2 for instructions on the sequencing of neoplasms for all other stated reasons for the admission/encounter (except for pain control/pain management).

Example

Patient is admitted for pain control due to metastatic bone cancer. Patient has a past history of primary breast cancer, 338.3, 198.5, V10.3 (G89.3, C79.51, Z85.3).

Apply the General Coding Guidelines as found in Chapter 5 and the Procedural Guidelines as found in Chapter 6.

ICD-10-CM Official Guidelines for Coding and Reporting

Please refer to the companion Evolve website for the most current guidelines.

2. Chapter 2: Neoplasms (C00-D49)

General guidelines

Chapter 2 of the ICD-10-CM contains the codes for most benign and all malignant neoplasms. Certain benign neoplasms, such as prostatic adenomas, may be found in the specific body system chapters. To properly code a neoplasm it is necessary to determine from the record if the neoplasm is benign, in-situ, malignant, or of uncertain histologic behavior. If malignant, any secondary (metastatic) sites should also be determined.

Primary malignant neoplasms overlapping site boundaries

A primary malignant neoplasm that overlaps two or more contiguous (next to each other) sites should be classified to the subcategory/code .8 (‘overlapping lesion’), unless the combination is specifically indexed elsewhere. For multiple neoplasms of the same site that are not contiguous such as tumors in different quadrants of the same breast, codes for each site should be assigned.

Malignant neoplasm of ectopic tissue

Malignant neoplasms of ectopic tissue are to be coded to the site mentioned, e.g., ectopic pancreatic malignant neoplasms are coded to pancreas, unspecified (C25.9).

The neoplasm table in the Alphabetic Index should be referenced first. However, if the histological term is documented, that term should be referenced first, rather than going immediately to the Neoplasm Table, in order to determine which column in the Neoplasm Table is appropriate. For example, if the documentation indicates “adenoma,” refer to the term in the Alphabetic Index to review the entries under this term and the instructional note to “see also neoplasm, by site, benign.” The table provides the proper code based on the type of neoplasm and the site. It is important to select the proper column in the table that corresponds to the type of neoplasm. The Tabular List should then be referenced to verify that the correct code has been selected from the table and that a more specific site code does not exist.

See Section I.C.21. Factors influencing health status and contact with health services, Status, for information regarding Z15.0, codes for genetic susceptibility to cancer.

a. Treatment directed at the malignancy

If the treatment is directed at the malignancy, designate the malignancy as the principal diagnosis.

The only exception to this guideline is if a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or radiation therapy, assign the appropriate Z51.– code as the first-listed or principal diagnosis, and the diagnosis or problem for which the service is being performed as a secondary diagnosis.

b. Treatment of secondary site

c. Coding and sequencing of complications

Coding and sequencing of complications associated with the malignancies or with the therapy thereof are subject to the following guidelines:

1) Anemia associated with malignancy

When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by the appropriate code for the anemia (such as code D63.0, Anemia in neoplastic disease).

2) Anemia associated with chemotherapy, immunotherapy and radiation therapy

When the admission/encounter is for management of an anemia associated with an adverse effect of the administration of chemotherapy or immunotherapy and the only treatment is for the anemia, the anemia code is sequenced first followed by the appropriate codes for the neoplasm and the adverse effect (T45.1X5, Adverse effect of antineoplastic and immunosuppressive drugs).

When the admission/encounter is for management of an anemia associated with an adverse effect of radiotherapy, the anemia code should be sequenced first, followed by the appropriate neoplasm code and code Y84.2, Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure.

3) Management of dehydration due to the malignancy

When the admission/encounter is for management of dehydration due to the malignancy and only the dehydration is being treated (intravenous rehydration), the dehydration is sequenced first, followed by the code(s) for the malignancy.

4) Treatment of a complication resulting from a surgical procedure

d. Primary malignancy previously excised

When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal or first-listed with the Z85 code used as a secondary code.

e. Admissions/Encounters involving chemotherapy, immunotherapy and radiation therapy

1) Episode of care involves surgical removal of neoplasm

When an episode of care involves the surgical removal of a neoplasm, primary or secondary site, followed by adjunct chemotherapy or radiation treatment during the same episode of care, the code for the neoplasm should be assigned as principal or first-listed diagnosis.

2) Patient admission/encounter solely for administration of chemotherapy, immunotherapy and radiation therapy

If a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or radiation therapy assign code Z51.0, Encounter for antineoplastic radiation therapy, or Z51.11, Encounter for antineoplastic chemotherapy, or Z51.12, Encounter for antineoplastic immunotherapy as the first-listed or principal diagnosis. If a patient receives more than one of these therapies during the same admission more than one of these codes may be assigned, in any sequence.

The malignancy for which the therapy is being administered should be assigned as a secondary diagnosis.

3) Patient admitted for radiation therapy, chemotherapy or immunotherapy and develops complications

When a patient is admitted for the purpose of radiotherapy, immunotherapy or chemotherapy and develops complications such as uncontrolled nausea and vomiting or dehydration, the principal or first-listed diagnosis is Z51.0, Encounter for antineoplastic radiation therapy, or Z51.11, Encounter for antineoplastic chemotherapy, or Z51.12, Encounter for antineoplastic immunotherapy followed by any codes for the complications.

f. Admission/encounter to determine extent of malignancy

g. Symptoms, signs, and abnormal findings listed in Chapter 18 associated with neoplasms

Symptoms, signs, and ill-defined conditions listed in Chapter 18 characteristic of, or associated with, an existing primary or secondary site malignancy cannot be used to replace the malignancy as principal or first-listed diagnosis, regardless of the number of admissions or encounters for treatment and care of the neoplasm.

See section I.C.21. Factors influencing health status and contact with health services, Encounter for prophylactic organ removal.

h. Admission/encounter for pain control/management

See Section I.C.6. for information on coding admission/encounter for pain control/management.

i. Malignancy in two or more noncontiguous sites

A patient may have more than one malignant tumor in the same organ. These tumors may represent different primaries or metastatic disease, depending on the site. Should the documentation be unclear, the provider should be queried as to the status of each tumor so that the correct codes can be assigned.

j. Disseminated malignant neoplasm, unspecified

Code C80.0, Disseminated malignant neoplasm, unspecified, is for use only in those cases where the patient has advanced metastatic disease and no known primary or secondary sites are specified. It should not be used in place of assigning codes for the primary site and all known secondary sites.

k. Malignant neoplasm without specification of site

Code C80.1, Malignant (primary) neoplasm, unspecified, equates to Cancer, unspecified. This code should only be used when no determination can be made as to the primary site of a malignancy. This code should rarely be used in the inpatient setting.

l. Sequencing of neoplasm codes

1) Encounter for treatment of primary malignancy

If the reason for the encounter is for treatment of a primary malignancy, assign the malignancy as the principal/first-listed diagnosis. The primary site is to be sequenced first, followed by any metastatic sites.

2) Encounter for treatment of secondary malignancy

When an encounter is for a primary malignancy with metastasis and treatment is directed toward the metastatic (secondary) site(s) only, the metastatic site(s) is designated as the principal/first listed diagnosis. The primary malignancy is coded as an additional code.

3) Malignant neoplasm in a pregnant patient

When a pregnant woman has a malignant neoplasm, a code from subcategory O9A.1-, Malignant neoplasm complicating pregnancy, childbirth, and the puerperium, should be sequenced first, followed by the appropriate code from Chapter 2 to indicate the type of neoplasm.

4) Encounter for complication associated with a neoplasm

When an encounter is for management of a complication associated with a neoplasm, such as dehydration, and the treatment is only for the complication, the complication is coded first, followed by the appropriate code(s) for the neoplasm.

The exception to this guideline is anemia. When the admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by code D63.0, Anemia in neoplastic disease.

5) Complication from surgical procedure for treatment of a neoplasm

When an encounter is for treatment of a complication resulting from a surgical procedure performed for the treatment of the neoplasm, designate the complication as the principal/first-listed diagnosis. See guideline regarding the coding of a current malignancy versus personal history to determine if the code for the neoplasm should also be assigned.

6) Pathologic fracture due to a neoplasm

When an encounter is for a pathological fracture due to a neoplasm, and the focus of treatment is the fracture, a code from subcategory M84.5, Pathological fracture in neoplastic disease, should be sequenced first, followed by the code for the neoplasm.

If the focus of treatment is the neoplasm with an associated pathological fracture, the neoplasm code should be sequenced first, followed by a code from M84.5 for the pathological fracture.

m. Current malignancy versus personal history of malignancy

When a primary malignancy has been excised but further treatment, such as an additional surgery for the malignancy, radiation therapy or chemotherapy is directed to that site, the primary malignancy code should be used until treatment is completed.

When a primary malignancy has been previously excised or eradicated from its site, there is no further treatment (of the malignancy) directed to that site, and there is no evidence of any existing primary malignancy, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.

See Section I.C.21. Factors influencing health status and contact with health services, History (of)

n. Leukemia, Multiple Myeloma, and Malignant Plasma Cell Neoplasms in remission versus personal history

The categories for leukemia, and category C90, Multiple myeloma and malignant plasma cell neoplasms, have codes indicating whether or not the leukemia has achieved remission. There are also codes Z85.6, Personal history of leukemia, and Z85.79, Personal history of other malignant neoplasms of lymphoid, hematopoietic and related tissues. If the documentation is unclear, as to whether the leukemia has achieved remission, the provider should be queried.

See Section I.C.21. Factors influencing health status and contact with health services, History (of)

o. Aftercare following surgery for neoplasm

See Section I.C.21. Factors influencing health status and contact with health services, Aftercare

p. Follow-up care for completed treatment of a malignancy

See Section I.C.21. Factors influencing health status and contact with health services, Follow-up

q. Prophylactic organ removal for prevention of malignancy

See Section I.C. 21, Factors influencing health status and contact with health services, Prophylactic organ removal

r. Malignant neoplasm associated with transplanted organ

A malignant neoplasm of a transplanted organ should be coded as a transplant complication. Assign first the appropriate code from category T86.-, Complications of transplanted organs and tissue, followed by code C80.2, Malignant neoplasm associated with transplanted organ. Use an additional code for the specific malignancy.

Apply the General Coding Guidelines as found in Chapter 5 and the Procedural Guidelines as found in Chapter 7.

Guideline Differences between ICD-9-CM and ICD-10-CM

There are additional ICD-10-CM guidelines that address the following:

Malignancy in two or more noncontiguous sites

Unspecified disseminated malignant neoplasm

Malignant neoplasm without specification of site

Current malignancy versus personal history of malignancy

Leukemia in remission versus personal history of leukemia

Sequencing of neoplasm codes when the encounter is for treatment of:

• Primary malignancy

• Secondary malignancy

• Malignant neoplasm in a pregnant patient

• Complication associated with a neoplasm

• Complication from surgical procedure for treatment of a neoplasm

• Pathologic fracture due to a neoplasm

Major Differences between ICD-9-CM AND ICD-10-CM

In ICD-10-CM, when an encounter is for the management of anemia associated with malignancy, the malignancy is sequenced as the principal or first-listed diagnosis because of an instructional note, and there is a guideline that addresses this situation.

There is a change in terminology for neoplasm codes that could be identified with regard to remission status. The terminology in ICD-9-CM is “without mention of remission,” but in ICD-10-CM, “not in remission” is used.

Anatomy and Physiology

Neoplasms can affect any of the body systems. The anatomy and physiology of these body systems are outlined in their respective chapters. It is important to understand some of the terminology that is specific to neoplasms and their behavior. According to the National Cancer Institute, the most common cancers in the United States include the following:

Non-Hodgkin’s lymphoma

A neoplasm is an abnormal tissue that grows by cellular proliferation more rapidly than normal tissue. Neoplasms show partial or complete lack of structural organization and functional coordination with normal tissue, and they usually form a distinct mass of tissue that may be benign (benign tumor) or malignant (cancer) (Figure 10-1). Both benign and malignant neoplasms are classified according to the type of tissue in which they are found. Benign neoplasms are tumors that are not malignant. Malignancy is a neoplasm that has the ability to invade adjacent structures and spread to distant sites. Fibromas are benign neoplasms of fibrous connective tissue, and melanomas are malignant changes of melanin cells. Malignant tumors originating from epithelial tissue (e.g., skin, bronchi, stomach) are called carcinomas (Table 10-1). Malignancies of epithelial glandular tissue such as those found in the breast, prostate, and colon are known as adenocarcinomas. Malignant growths of connective tissue (e.g., muscle, cartilage, bone) are called sarcomas (Table 10-2). Lymphomas form in lymphatic tissue, and leukemias are malignancies that arise from white blood cells. A myeloma originates within the bone marrow.

TABLE 10-1

CARCINOMA AND THE EPITHELIAL TISSUES FROM WHICH THEY DERIVE ¹

Types of Epithelial Tissue	Malignant Tumor (Carcinoma)
Gastrointestinal Tract
Colon	Adenocarcinoma of the colon
Esophagus	Esophageal carcinoma
Liver	Hepatocellular carcinoma (hepatoma)
Stomach	Gastric adenocarcinoma
Glandular Tissue
Adrenal glands	Carcinoma of the adrenals
Breast	Carcinoma of the breast
Pancreas	Carcinoma of the pancreas (pancreatic adenocarcinoma)
Prostate	Carcinoma of the prostate
Thyroid	Carcinoma of the thyroid
Kidney and Bladder
	Renal cell carcinoma (hypernephroma)
	Transitional cell carcinoma of the bladder
Lung
	Adenocarcinoma (bronchioloalveolar)
	Large cell carcinoma
	Small (oat) cell carcinoma
	Squamous cell (epidermoid)
Reproductive Organs
	Adenocarcinoma of the uterus
	Carcinoma of the penis
	Choriocarcinoma of the uterus or testes
	Cystadenocarcinoma (mucinous or serous) of the ovaries
	Seminoma and embryonal cell carcinoma (testes)
	Squamous cell (epidermoid) carcinoma of the vagina or cervix
Skin
Basal cell layer	Basal cell carcinoma
Melanocyte	Malignant melanoma
Squamous cell layer	Squamous cell carcinoma

TABLE 10-2

SARCOMAS AND THE CONNECTIVE TISSUES FROM WHICH THEY DERIVE ²

Types of Connective Tissue	Malignant Tumor
Bone
	Osteosarcoma (osteogenic sarcoma)
	Ewing’s sarcoma
Muscle
Smooth (visceral) muscle	Leiomyosarcoma
Striated (skeletal) muscle	Rhabdomyosarcoma
Cartilage
	Chondrosarcoma
Fat
	Liposarcoma
Fibrous Tissue
	Fibrosarcoma
Blood Vessel Tissue
	Angiosarcoma
Blood-Forming Tissue
All leukocytes	Leukemias
Lymphocytes	Hodgkin’s disease
Plasma cells	Non-Hodgkin’s lymphoma
	Burkitt’s lymphoma
	Multiple myeloma
Nerve Tissue
Embryonic nerve tissue	Neuroblastoma
Glial tissue	Astrocytoma (tumors of glial cells, called “astrocytes”)
	Glioblastoma multiforme

Figure 10-1 Differences between benign and malignant neoplasms.

The primary site is the location at which the neoplasm begins, or originates. It is important for the treating physician to identify the site of origin so that the best treatment course and prognosis can be determined. Metastasis is the spread of cancer from one part of the body to another, as is seen when neoplasms occur in parts of the body separate from the site of the primary tumor. Metastasis occurs through dissemination of tumor cells by the lymphatics or blood vessels, or by direct extension through serous cavities or other spaces.

Grading involves pathologic examination of tumor cells. The degree of abnormality of cells determines the grade of cancer (Table 10-3). When the level of cell abnormality is greater, the cancer is of higher grade. Cells that are well-differentiated closely resemble mature, specialized cells. Tumor cells that are undifferentiated are highly abnormal (i.e., immature and primitive).

TABLE 10-3

GRADES OF NEOPLASMS

Grade 1	Cells slightly abnormal and well-differentiated
Grade 2	Cells more abnormal and moderately differentiated
Grade 3	Cells very abnormal and poorly differentiated
Grade 4	Cells immature and undifferentiated

Cancerous tissue is classified according to degree of malignancy, from grade 1—barely malignant—to grade 4—highly malignant. In practice, it is not always possible for the pathologist to determine the degree of malignancy, and sometimes it may be difficult even to determine whether a particular tumor tissue is benign or malignant.

Staging, a means of categorizing a particular cancer, helps the clinician to determine a particular patient’s treatment plan and the need for further therapy. Each type of cancer is staged according to specific characteristics:

In situ cancers have been diagnosed at the earliest possible stage.

Stage I or “local” cancers have been diagnosed early and have not spread.

Stage II has spread into surrounding tissues but not beyond the location of origin.

Stage III or “regional” cancer has spread to nearby lymph nodes.

Stage IV or “distant” cancers have spread to other parts of the body and are the most difficult to treat.

See Table 10-4 for an example of how the TNM (tumor-node-metastasis) staging system would be used to classify a lung cancer.

TABLE 10-4

INTERNATIONAL TNM STAGING SYSTEMS FOR LUNG CANCER ³

Stage	TNM Description	5-Year Survival, %
I	T1-T2, N0, M0	60-80
II	T1-T2, N1, M0	25-50
IIIA	T3, N0-N1, M0	25-40
IIIB	T1-T3, N2, M0	10-30
IV	Any T4 or N3, M0	<5
	Any M1	<5
Primary Tumor (T)
T1	Tumor >3 cm in diameter
T2	Tumor <3 cm in diameter or with associated atelectasis–obstructive pneumonitis extending to the hilar region
T3	Tumor with direct extension into the chest wall, diaphragm, mediastinum, pleura, or pericardium
T4	Tumor invades the mediastinum, or presence of a malignant pleural effusion
Regional Lymph Nodes (N)
N0	No node involvement
N1	Metastasis to lymph nodes in the peribronchial and ipsilateral (same side as the primary tumor) hilar regions
N2	Metastasis to ipsilateral hilar and subcarinal (under the bifurcation of the trachea into the lungs) lymph nodes
N3	Metastasis to contralateral mediastinal or hilar nodes or any nodes new to the clavicular (collar) bone
Distance Metastasis (M)
M0	No known metastasis
M1	Distant metastasis present with site specified (e.g., brain, tumor)

Neoplasm Table

The coding of most neoplasms requires an extra step, which involves use of the Neoplasm Table (Figure 10-2). The main term for the type of neoplasm is located in the Alphabetic Index. All subterms must be reviewed to facilitate assignment of proper codes, including M codes if required. One must follow all instructions, such as see Neoplasm, by site, benign, or see also Neoplasm, by site, malignant. It is important to follow all steps to ensure correct code assignment. The temptation to go directly to the Neoplasm Table should be avoided.