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20130021 | Histology--Heme & Lymphoid Neoplasms: When will the follicular lymphoma, grade 1 code [9695/3] ever be used? See Discussion. | The Abstractor Notes currently do not explain the histologic classification of follicular lymphoma [FL]. Frequently, FL grade 1 and 2 are not being separated and are described as "low grade" or "grade 1-2" in the pathology final diagnosis. The correct histology code would be 9691/3 [FL, grade 2] for these cases. Apparently, per the 2008 WHO Classification, grade 1 and grade 2 are being grouped together as grade 1-2 due to the minimal difference in patient outcome. If these histologies are grouped together, will histology code 9695/3 [FL, grade 1] ever be used? Should the Heme Database explain the classifications of follicular lymphoma grade 1, 2, and 3? | When the latest WHO classification for heme neoplasms was written in 2008, there was a lot of controversy about whether or not the FL grading system was useful or not. A number of papers have been written stating that grades 1 and 2 do not have a statistically different survival or transformation rate. Given that the controversy had not been settled by those in the clinical world, the WHO recommended analyzing grades 1 and 2 together. They did not, however, remove either grade 1 or 2 from their classification. When the WHO intend to change their classification (have both grades classified under one histology number), they omit one code from their book (make it obsolete) and change the definition for the other code. The 2008 WHO book did not make either ICD-O-3 code obsolete. Therefore, we continue to collect the cases as designated by the pathologist. If the controversy is settled before the next WHO classification, you may see changes in the codes.
Additionally, since the 2008 WHO book was written, there have been some clinical papers challenging the designation of grade 3. They contend that grade 3 can be mistaken for low-grade.
The grades for follicular lymphoma are based on the number of centroblasts per high powered field (HPF). The number of centroblasts for grade 1 is 0-5; for grade 2 is 6-15, for grade 3a and 3b is >15 centroblasts. 3a has centrocytes and 3b has no centrocytes. |
2013 |
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20210025 | Primary site--Ovary: What information takes precedence for coding the primary site in cases with high grade serous carcinoma that are clinically called ovarian but on pathology, the pathologist calls the primary site fallopian tube and the gynecology oncology/managing phsyician continues to call the cases ovarian. Both the ovary and tube are involved. Sometimes also referred to as "tubo-ovarian." |
When the choice is between ovary, fallopian tube, or primary peritoneal, any indication of fallopian tube involvement indicates the primary tumor is a tubal primary. Fallopian tube primary carcinomas can be confirmed by reviewing the fallopian tube sections as described on the pathology report to document the presence of either serous tubal intraepithelial carcinoma (STIC) and/or tubal mucosal invasive serous carcinoma. If there is no information about the fallopian tubes, refer to the histology and look at the treatment plans for the patient. If all else fails, you may have to assign C579 as a last resort. Use text fields to document the details. For additional information, see the CAP GYN protocol, Table 1: Criteria for assignment of primary site in tubo-ovarian serous carcinomas. |
2021 | |
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20240049 | First Course Treatment/Neoadjuvant Therapy--Breast: When are pre-operative therapies given as part of a clinical trial coded as neoadjuvant treatment versus limited systemic exposure in the Neoadjuvant Therapy data item? See Discussion. |
The SEER Manual seems to give somewhat conflicting instructions for clinical trial therapies under the Neoadjuvant Therapy data item. One section states that limited systemic therapy may occur in clinical trials to impact the biology of a cancer, but is not a full course of neoadjuvant therapy with the intent to impact extent of surgical resection or other outcomes (organ preservation, function or quality of life); do not code as neoadjuvant therapy for the purposes of this data item. Then another section states for purposes of this data item, the criteria for neoadjuvant therapy include that treatment must follow recommended guidelines for the type and duration of treatment for that particular cancer site and/or histology, and that neoadjuvant therapy may be given as part of a clinical trial. For example, a patient was diagnosed with invasive ductal carcinoma of the breast, 6 cm in size; treatment planning conference recommended neoadjuvant chemotherapy. The patient elected to participate in a clinical trial and was assigned to a group given the antibody drug conjugate datopotamab deruxtecan (Dato-DXd) plus durvalumab for 12 weeks. There was no physician documentation of intent or expected outcomes, nor yC staging or statement of clinical response. Post-therapy imaging showed no residual mass, and post-therapy mastectomy path report showed only residual ductal carcinoma in situ, stating "Treatment Effect (after neoadjuvant): Residual Cancer Burden - pCR, In the breast - complete response." The medical oncologist stated post-therapy stage was ypTis ypN0 cM0. The trial drugs this patient were given do not appear to be approved or standard neoadjuvant/pre-operative drugs in SEER*Rx or NCCN guidelines for this type of cancer; however, the duration of treatment was fairly substantial, and although we don't have clear documentation from physicians as recommended in the SEER manual (which is usually not stated, in our experience), it seems like they may be considering it as neoadjuvant therapy. How should the Neoadjuvant Therapy data item be coded for cases like this? What is the best way to differentiate between clinical trial therapies that are "limited systemic exposure" (code 3) versus true neoadjuvant therapy (code 1)? |
When pre-operative therapies are given as part of a clinical trial, code as neoadjuvant treatment in the Neoadjuvant Therapy data item when the intent is neoadjuvant and/or when surgical resection follows the clinical trial therapies. In the example, neoadjuvant chemotherapy was recommended in the treatment planning and the patient had the planned resection after neoadjuvant treatment. The treatment effect outcome is based on imaging that reported no mass and as documented by the physician, pathologist in this case as complete response to the neoadjuvant therapy based on the resection. Use code 3 (limited systemic exposure) when treatment does not meet the definition of neoadjuvant therapy in the data item, Neoadjuvant Therapy. Limited exposure occurs when the patient receives some therapy prior to surgical resection, but the treatment is not enough to qualify for a full course of neoadjuvant therapy with the intent to impact extent of surgical resection or other outcomes. While this type of treatment may given as part of a clinical trial, it mostly refers to short term treatments such as hormone therapy. When neoadjuvant therapy is given prior to surgical resection that is planned (intended) or performed to improve outcomes, use Code 1 or 2. Because a clinical trial is a type of research study that tests new methods of screening, prevention, diagnosis, or treatment of a disease, the treatment regimens likely will not be incorporated in recommended guidelines until all phases of the trial are completed and approved by the U.S. Food and Drug Administration. ClinicalTrials.gov is available to learn more about clinical studies around the world. |
2024 |
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20200077 | Solid Tumor Rules (2018)/Histology--Kidney: What is the histology code for succinate dehydrogenase-deficient renal cell carcinoma (SDHD)? See Discussion. |
Table 1 of the 2018 Kidney Solid Tumor Rules (STR) lists succinate dehydrogenase-deficient renal cell carcinoma as histology code 8312, but in the ICD-O-3.2 Coding Table it is listed as histology code 8311. No changes were made in the Kidney STR. As a result, the histology change described in the ICD-O-3.2 Coding Table conflicts with Table 1. Succinate dehydrogenase-deficient renal cell carcinoma (SDHD) is listed in Table 1 as a synonym for renal cell carcinoma, NOS (8312). However, the ICD-O-3.2 Coding Table lists this as a related term for histology code 8311/3. This related term was not discussed in the Implementation Guidelines, and no change was noted in the STR. While it seems we should continue to follow the STR, without clarification as to why this histology change was not implemented in STR, achieving consistency will be problematic if registrars jump straight to the ICD-O-3.2 Coding Table to code histology for cases diagnosed 2021 and later. If this code cannot be used for cases diagnosed prior to 2021, should that clarification be included in the STR? This question was prompted from preparing SEER*Educate coding exercises. We will use the answer as a reference in the rationales. |
When creating table 1, our GU SME's stated Succinate dehydrogenase-deficient renal cell carcinoma (SDHD) is a rare neoplasm and is coded to RCC, NOS until such time a new code is proposed in the 5th Ed BB. ICD-O-3.2 added this term to 8311 as a related term BUT there is no documentation that these neoplasms are different and should be on separate lines in table 1 making them separate primaries. Its likely IARC made the decision to group these rare genetic histologies into one code. SEER is waiting for confirmation from GU experts. If it's valid, the RCC row will be updated in columns 2 and 3 with applicable dates each histology is valid. |
2020 |
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20061095 | First Course Treatment: If an "aromatase inhibitor" used as a complement to Tamoxifen is treatment, how should it be coded? |
When an aromatase inhibitor is part of the planned first course of therapy, code it under hormone treatment. When a change of drug is PLANNED, it is part of the same course even if subcategories change. This is the usual situation with Tamoxifen and aromatase inhibitor (for example: Femara). The switch to Femara is planned, so it is not a new course. When a drug change happens that is not planned, it is still the same course if both drugs are in the same category and subcategory. An unplanned drug change to a different subcategory would be a new course. |
2006 | |
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20081119 | Reportability/Date of diagnosis--Liver: Does the final diagnosis of a scan have higher priority than the findings in the discussion in the body of the report? See Discussion. |
A patient with liver cancer becomes transplant eligible when the tumor is 2 cm in size. Frequently, liver tumors will be watched (no biopsy) for months until they meet the 2 cm size criteria. In the meantime, multiple scans will describe the tumor using variations of ambiguous terms that drift in and out of reportablility. One day the tumor is labeled "presumed hepatocellular carcinoma." Weeks later it is back to "worrisome for hepatoma." A single scan will use different terms in different sections of the report. Example case: Abdominal CT reveals a 1 cm liver lesion. Per the discussion portion of the scan, the lesion is consistent with hepatocellular carcinoma. Per final diagnosis: 1 cm liver lesion, possibly hepatocellular carcinoma. Is this report diagnostic of cancer? Would the date of this report be the date of diagnosis? (Patient did receive a liver transplant for hepatocellular carcinoma months later.) |
When a reportable ambiguous term is used in one part of a report or the medical record and a non-reportable ambiguous term is used in another part of the report or the medical record, accept the reportable term and accession the case. The example above is reportable. "Consistent with" is a reportable ambiguous term. Accept "consistent with" over the non-reportable term "possibly." The date of this report would be the date of diagnosis if this is the earliest report using reportable terminology. |
2008 |
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20220048 | First Course Treatment/Immunotherapy--Other Therapy: Should all therapies given as part of a clinical trial be coded as Other Therapy (NAACCR #1420), or only those that cannot be classified in one of the other treatment categories (systemic therapy, surgery, radiation) or as ancillary treatments? Does it matter what is listed in SEER*Rx under Primary Sites or Remarks regarding FDA approvals? See Discussion. |
The SEER Manual states that the Other Therapy data item identifies treatments given that cannot be classified as surgery, radiation, systemic therapy, or ancillary treatment; and the instructions for code 2, Other-Experimental, say to assign this for any experimental or newly developed treatment, such as a clinical trial, that differs greatly from proven types of cancer therapy. Does this mean that only unclassifiable treatments should be coded in Other Therapy, even if given as part of a clinical trial? For example, if a patient is given a drug as part of a trial that is categorized in SEER*Rx as immunotherapy, should it be assigned both Immunotherapy (NAACCR #1410) code 1 and Other Therapy code 2, or only coded in Immunotherapy since it is classified as such? How should a clinical trial drug be coded if it has a treatment classification in SEER*Rx, but the type of cancer being treated is not listed under the Primary Site or Remarks sections as being FDA approved? A real case scenario is atezolizumab given for colon cancer as part of a trial; this drug's category is Immunotherapy in SEER*Rx but colon is not listed under Primary Sites or in the Remarks detailing FDA approvals. |
When a drug is being administered as part of a clinical trial and it is not yet approved as treatment for the cancer site for which it is being administered, code in Other Therapy. Do not code it as Immunotherapy (for the example provided). While a drug may be approved to treat one type of malignancy, it may be in clinical trials to determine its value in treating other malignancies. Coding as immunotherapy is misinformation in this case since there are other types of approved immunotheraputic agents. |
2022 |
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20170036 | Grade--Prostate: How are the prostate-related fields completed when documentation in pathology reports only includes one of the new grade groups? See Discussion. |
Our pathologists have starting to use a new prostate cancer grading system that was adopted by WHO in 2016. The new grading scheme correlates with the prior Gleason grading scheme as follows: Grade Group 1 = Gleason score 6 or less Grade Group 2 = Gleason score 3+4=7 Grade Group 3 = Gleason score 4+3 = 7 Grade Group 4 = Gleason score 8 Grade Group 5 = Gleason score 9-10 Our pathologists are no longer dictating the Gleason Primary and Secondary Pattern values nor the Gleason's Score. Reverse correlation from the new grade groups to the required patterns and score are difficult with Grade Groups 2 and 3 needing to be distinguished from one another and Grade Group 5 including two unique scores. The prostate-related fields include: Collaborative Site Specific Factor 7: Gleason's Primary Pattern and Secondary Pattern Values on Needle Core Biopsy/TURP Collaborative Site Specific Factor 8: Gleason's Score On Needle Core Biopsy/TURP Collaborative Site Specific Factor 9: Gleason's Primary Pattern and Secondary Pattern Values on Prostatectomy/Autopsy Collaborative Site Specific Factor 10: Gleason's Score on Prostatectomy/Autopsy |
When all you have is the grade group, you may use the following table to convert the Prostate Grade Groups to the appropriate code for the indicated fields. Grade Group Gleason Score Gleason Pattern SSF7 SSF8 SSF9 SSF10 Grade/diff Grade Group 1 6 or less <=3+3 099 999 099 999 1 Grade Group 2 7 3+4 034 007 034 007 2 Grade Group 3 7 4+3 043 007 043 007 2 Grade Group 4 8 4+4, 3+5, 5+3 999 999 999 999 3 Grade Group 5 9-10 4+5, 5+4, 5+5 099 999 099 999 3 |
2017 |
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20130027 | Reportability--Are well-differentiated neuroendocrine tumors and grade 1 neuroendocrine tumors of the appendix now reportable? See Discussion. |
The terminology for carcinoid tumors has changed. The current terminology used is "neuroendocrine tumor." Are well-differentiated neuroendocrine tumors of the appendix non-reportable because carcinoid, NOS of the appendix has a borderline behavior code [8240/1]? When the histology/behavior codes for the term "well-differentiated neuroendocrine tumor" became 8240/3, did SEER intend this change to also apply to appendix primaries? If so, for which diagnosis year did this change go into effect? |
Well-differentiated neuroendocrine tumors and grade 1 neuroendocrine tumors of the appendix are reportable because these tumors have a morphology code 8240/3 per the WHO Classification of Tumors of the Digestive System. However, per the ICD-O-3, carcinoid tumors of the appendix have a behavior code of /1 [borderline]. The terminology of neuroendocrine tumors is evolving and current thinking at the international level is that carcinoid/WD NET of appendix is reportable. However, reportability in the United States is based on ICD-O-3. The histology code for "Carcinoid of appendix" is 8240/1; the histology code for a carcinoids of all other primary sites is 8240/3. Until the United States adopts the proposed changes for ICD-O-3, reportability of appendix cases is as follows:
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2013 |
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20140002 | Reportability--Appendix: Is a pathologic final diagnosis of an appendix with "well-differentiated neuroendocrine tumor (carcinoid)" reportable? See discussion. | SINQ 20130027 states that "well-differentiated neuroendocrine tumor" of the appendix is reportable (8240/3) while "carcinoid" tumors of the appendix are not reportable (8240/1). Please explain the difference between "well-differentiated neuroendocrine tumor" of the appendix and a "carcinoid" of the appendix. | Well-differentiated neuroendocrine tumor of the appendix is reportable. The difference is terminology. "Carcinoid" is listed in ICD-O-3 as a /1 for appendix making it non-reportable.
When both terms are used, ask for clarification from the pathologist. Failing that, accept the reportable terminology and report the case. |
2014 |
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