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We have a case of metastatic keratinizing squamous cell ca. The work-up shows small densities in the lung that may represent inflammatory or chronic changes. No other imaging that shows origin. Physical exam states 2 months of left axillary mass. H/O SCCA of the skin involving chest wall.

Path reads: Metastatic w/d keratinizing SCCA. This lesion almost undoubtedly represents mets. The most likely site of origin is lung followed by esophageal primary or head & neck. The final discharge states, "Metastatic SCCA to Left Axilla".

We are starting to see more specific histologies with neuroendocrine differentiation. How are we to deal with these histologies and will this be addressed in the revised MP/H rules?

We are seeing the term "incidentaloma" on magnetic resonance imaging (MR) reports of head and also with physician statements. For example, this MR of the head: Impression--Suboptimal study due to motion degradation. Heterogeneously enhancing pituitary gland without evidence of acute abnormality. A 3 mm focus of relative hypoenhancement in the left gland is favored to represent an incidentaloma. Advise correlation with clinical findings.

Also, there are cases where the scans show meningioma and then at a later date it is stated to be an incidentaloma in physician notes.

Is the term "incidentaloma" alone reportable, if the term "tumor" for CNS cases is never stated? When I googled the term, it is stated to mean "tumor."

We are seeing multiple head and neck cases with unclear or multiple grade assignments. Another example is alveolar mucosa SCC with histologic grade stated as: Moderately differentiated (G2 of 3). Grade Coding for Solid Tumor instruction 5.b. is not clear regarding this situation. Does a statement of differentiation take priority? Should we disregard the differentiation statement and code using the 3-grade systems?

We are seeing more use of PI-RAD categories on scans. The final impression on the scan will be PI-RADS Category 5, with no specific statement of malignancy. The scans include a blanket statement with the definitions of the PI-RADS categories as below.

PI-RADS (v2) categories:

PI-RADS 1 - Very low (clinically significant cancer is highly unlikely to be present)

PI-RADS 2 - Low (clinically significant cancer is unlikely to be present)

PI-RADS 3 - Intermediate (the presence of clinically significant cancer is equivocal)

PI-RADS 4 - High (clinically significant cancer is likely to be present)

PI-RADS 5 - Very high (clinically significant cancer is highly likely to be present)

A previous SINQ 20010094 indicates that we cannot use BI-RADS categories for breast cancer diagnosis, and SINQ 20160008 indicates we can use LI-RADS for HCC diagnosis, but those definitions are slightly different. Most often there will be a subsequent biopsy diagnosis of carcinoma, so the question is also in reference to Diagnosis Date. Can we use the date of the scans impression, which states PI-RADS category 5, as the Diagnosis Date?

We are seeing more use of LI-RAD categories on scans. The final impression on the scan will be LI-RADS Category 5 or LI-RADS Category 4, with no specific statement of HCC. The scans include a blanket statement with the definitions of the LI-RADS categories as below.

LIRADS (v2014) categories

M - Possible non-HCC malignancy

1 - Definitely Benign

2 - Probably Benign

3 - Intermediate Probability for HCC

4 - Probably HCC

5 - Definitely HCC (concordant with OPTN 5)

A previous SINQ, 20010094, indicates that we cannot use BI-RADS categories for breast cancer diagnosis, but those BI-RADS definitions are slightly different. Most often there will be a subsequent clinical statement of HCC, so the question is also in reference to Diagnosis Date. Can we use the date of the scan's impression, which states LI-RADS category 4 or 5, as the Diagnosis Date?

We are seeing many I-125 seed implants for breast cancer. Many of my associates are coding them as brachytherapy. I think they are the newest of the localization technique like wire localization but with greater accuracy. Most are done the same day as the surgery so brachytherapy does not make sense. Which is correct?

We are seeing increasing use of PET scans as diagnostic tools for cancer. PET scans use different terminology than the ambiguous terms listed in the EOD manual. Could we please have guidelines for interpreting PET scans?

Example: Patient with right lung cancer. PET scan showed intense uptake in the mediastinum and in the hilum. Can we code "intense uptake" as involvement of mediastinal and hilar lymph nodes?

We are preparing to send our hospitals a reminder that the behavior changes from 2 to 3 at the bottom of the basement membrane, and the T category changes from Tis to T1 at the bottom of the mucosa for colon and rectum carcinomas. We are confused by the wording of the Exception.

Distinguishing In Situ and Localized Tumors for the Digestive System

1.b. If the tumor has penetrated the basement membrane to invade the lamina propria, in which case it is localized and assigned Summary Stage 1 (localized) and for invasion of the lamina propria

Exception: Code 0 (behavior code 2) includes cancer cells confined within the glandular basement membrane (intraepithelial); includes in situ plus intramucosal carcinoma (involvement of the lamina propria and may involve but not penetrate through the muscularis mucosa) (penetration through the muscularis mucosa is behavior code 3.)

The text following (intraepithelial) is unclear. The question is: Does the text include in situ plus intramucosal carcinoma (involvement of the lamina propria and may involve but not penetrate through the muscularis mucosa) (penetration through the muscularis mucosa is behavior code 3.) mean the following:

Code 0 (behavior code 2) includes in situ plus intramucosal carcinoma. In situ plus intramucosal carcinoma is involvement of the lamina propria, which may involve (but not penetrate through) the muscularis mucosae. Penetration through the muscularis mucosa is behavior 3. If that is what the text above means, then it seems that the 2018 SEER Summary Stage Manual is saying colorectal tumors reported as: adenocarcinoma in situ, at least intramucosal adenocarcinoma in situ, high grade dysplasia/intramucosal adenocarcinoma in situ, focally intramucosal at the margin are to be coded behavior 2 and SEER Summary stage In situ (0) like the intraepithelial carcinoma tumors. However, it conflicts with the EOD Data for Colon and Rectum, Note 2, and SINQ 20210006. The text for both EOD Data for Colon and Rectum and SINQ 20210006 is clear. According to them, the above bulleted adenocarcarcinoma examples are coded SEER Summary Stage localized (1) and behavior 3. SINQ 20210006 states that: For purposes of Summary Stage, intramucosal carcinoma is a localized lesion So, intramucosal carcinoma is coded SEER Summary Stage 1 (localized) and (behavior code 3).

According to the text for EOD Primary Tumor, Colon and Rectum, Note 2 below, intramucosal, NOS involvement is invasive.

Note 2: Code 050 (behavior code 3) includes the following:

Intramucosal, NOS

Lamina propria

Mucosa, NOS

Confined to, but not through the muscularis mucosa

Thank you for your help clarifying the 2018 SEER Summary Manual Exception text above.

We are having difficulty determining whether the primary site is lip, NOS (C009) or skin of lip (C440). Usually we look for a statement of “skin” or “mucosa” in the microscopic description if the specimen label is only lip, NOS as instructed by the previous SINQ 20051049. Is a statement of "epidermis" or "dermis" in the microscopic description enough to indicate carcinoma is arising in the skin of the lip (C440) and thus not reportable?