California Cancer Reporting System Standards Volume I: Abstracting and Coding Procedures
This field refers to surgical procedures that are performed on the Primary Site. See Appendix Q.1 or Q.2 for Site-Specific Surgery Codes.
Generally, cancer-directed surgery includes most procedures that involve removal of a structure (those with the suffix "ectomy") and such procedures as:
Biopsy, excisional (which has microscopic residual disease or no residual disease)
Biopsy, NOS, that removes all tumor tissue
Chemosurgery (Moh’s technique)
Conization
Cryosurgery
Desiccation and Curettage for bladder and skin tumors
Electrocautery
Fulguration for bladder, skin, and rectal neoplasms
Laser therapy
Local excision with removal of cancer tissue (including excisional biopsy but excluding incisional biopsy)
Photocoagulation
Splenectomy for lymphoma or leukemia
Surgery removing metastatic malignant tissue
Transurethral resection (TUR) with removal of tumor tissue of bladder or prostatic tumors.
Enter the procedures in chronological order. If more than three surgical procedures are performed on a patient, the earliest surgery and the most definitive surgery must be included. For codes 00 through 79, the response positions are hierarchical.
Code 98 takes precedence over code 00.
Use codes 80 and 90 only if more precise information about the surgery is unavailable.
Surgery to remove regional tissue or organs is coded in this item only if the tissue/organs are removed in continuity with the primary site, except where noted in Appendix Q.1 or Q.2.
Do not code pre-surgical embolization of hypervascular tumors with particles, coils or alcohol. These pre-surgical embolizations are typically performed to make the resection of the primary tumor easier. Examples where pre-surgical embolization is used include meningiomas, hemangiomas, paragangliomas, and renal cell metastases in the brain.
Surgery of the Primary Site consists of three two-character fields which are to be used to record surgeries of the primary site only. If an en bloc resection is performed which removes regional tissue or organs with the primary site(s) part of a specific code definition, it should be coded. An en bloc resection is the removal of organs in one piece at one time.
Example:
Patient undergoes a modified radical mastectomy. The breast and auxiliary contents are removed in one piece (en bloc). Surgery would be coded 50 for modified radical mastectomy regardless of whether nodes were found by pathology in the specimen.
For non-en bloc resections, record the resection of a secondary or metastatic site in the Surgery of Other Regional Site(s), Distant Site(s) or Distant Lymph Node(s).
Refer to Appendix Q.1 or Q.2 for the site-specific surgery codes. They are hierarchical with less specific (NOS) terms followed by more specific terms. See the example.
Examples:
50 Gastrectomy, NOS WITH removal of a portion of esophagus.
51 Partial or subtotal gastrectomy.
52 Near total or total gastrectomy.
Codes 10-90 have priority over code 99.
Codes 10-84 have priority over codes 90 and 99.
Codes 10-79 have priority over codes 80, 90 and 99, where 80 is site-specific surgery, not otherwise specified.
If surgery removes the remaining portion of an organ, code the total removal of the organ.
Biopsies, NOS, that remove all gross tumor or leave only microscopic margins should be coded to surgery of the primary site. If there is no statement that the initial biopsy was excisional, yet no residual tumor was found at a later resection, assume that the biopsy was excisional.
Examples:
The patient had a resection of a stomach remnant and portion of the esophagus at the time of their second procedure.
The first procedure was a partial gastrectomy, NOS - code 30.
Excisional Biopsy:
Record an excisional biopsy as first surgical treatment, whether followed by further definitive surgery or not and whether or not residual tumor was found in a later resection.
NOTE: The CCR follows SEER guidelines and requires coding incisional biopsies without residual at re-excision to be coded as an excisional biopsy only in the Surgery of Primary Site data field. COC Facilities: Please make note in your user defined fields when standards between CoC and CCR differ.
Aborted Procedure:
Assign the surgery code(s) that actually represents the extent of the surgical procedure that was carried out when surgery is aborted. If the procedure was cancelled or discontinued before anything took place, assign code 00.
Extranodal Lymphomas:
When coding surgery for extranodal lymphomas, use the appropriate code for the extranodal site. For example, use a code for the stomach to code a lymphoma of the stomach.
Notes:
If the only information available is that the patient was referred to a surgeon, medical oncologist or radiation oncologist, with no confirmation that treatment was administered, code no treatment given.
Referral to a specialist is considered a recommendation. Registry personnel should follow-up on these cases to determine whether treatment was administered or not and code accordingly. This applies to cases diagnosed January 1, 2010 and forward.