ICD-10 Tips and Resources: Lung Adenocarcinoma
Description: Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient’s identification and “Right upper lobe lung”.
CLINICAL HISTORY: Probable right upper lobe lung adenocarcinoma.
SPECIMEN: Lung, right upper lobe resection.
GROSS DESCRIPTION: Specimen is received fresh for frozen section, labeled with the patient’s identification and “Right upper lobe lung”. It consists of one lobectomy specimen measuring 16.1 x 10.6 x 4.5.cm. The specimen is covered by a smooth, pink-tan and gray pleural surface which is largely unremarkable. Sectioning reveals a round, ill-defined, firm, tan-gray mucoid mass. This mass measures 3.6 x 3.3 x 2.7 cm and is located 3.7 cm from the closest surgical margin and 3.9 cm from the hilum. There is no necrosis or hemorrhage evident. The tumor grossly appears to abut, but not invade through, the visceral pleura, and the overlying pleura is puckered.
FINAL DIAGNOSIS: Right lung, upper lobe, lobectomy: Bronchioloalveolar carcinoma, mucinous type
COMMENT: Right upper lobe lobectomy.
Tumor type: Bronchioloalveolar carcinoma, mucinous type.
Histologic grade: Well differentiated.
Tumor size (greatest diameter): 3.6 cm.
Blood/lymphatic vessel invasion: Absent.
Perineural invasion: Absent.
Bronchial margin: Negative.
Vascular margin: Negative.
Inked surgical margin: Negative.
Visceral pleura: Not involved.
In situ carcinoma: Absent.
Non-neoplastic lung: Emphysema.
Hilar lymph nodes: Number of positive lymph nodes: 0; Total number of lymph nodes: 1.
P53 immunohistochemical stain is negative in the tumor.
ICD-10-CM Code(s): C34.11 Malignant neoplasm of upper lobe, right bronchus or lung
Rationale: The pathology report indicates the patient has bronchioloalveolar carcinoma. According to the ICD-10-CM official draft guidelines (I.C.2), when a histologic term is given it should be referenced first. When the main term Carcinoma, with the subterm bronchioloalveolar, is referenced in the Alphabetic Index, there is a listing for specified site. It states to see Neoplasm, malignant, by site. The codes for neoplasms of the lungs are broken down by type (malignant primary), laterality (right), and specific location (upper lobe).