Report | Question ID | Question | Discussion | Answer | Year |
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20230043 | Solid Tumor Rules/Histology--Lung: What is the histology code for a lung tumor diagnosed as “Minimally invasive adenocarcinoma, mixed mucinous and non-mucinous, grade 1, lepidic-predominant”? See Discussion. |
The resection pathology report final diagnosis indicates this is both mixed mucinous and non-mucinous with a lepidic predominant component. The pathologist notes this is “Lepidic: 75%. Acinar: 25%.” The percentage of the mucinous component is not documented. Rule H1, Note 1, states “When mucinous carcinoma is mixed with another histology, such as adenocarcinoma and mucinous carcinoma, code mucinous ONLY when mucinous is documented to be greater than 50% of the tumor.” While mixed invasive mucinous and non-mucinous carcinoma is included in Table 2 (Combination/Mixed Histology Codes) without a required percentage, it is unclear whether one should move past Rule H7 and use Rule H8 to code this combination histology code. Rule H7 would instruct one to code the histology to lepidic adenocarcinoma (adenocarcinoma, lepidic predominant) based on the percentage of the lepidic component in the tumor. However, this does not address the mixed mucinous and non-mucinous diagnosis. Which H Rule and histology apply to this case? |
Assign histology code 8254/3 (mixed invasive mucinous and non-mucinous adenocarcinoma) to this lung tumor using Lung Solid Tumor Rules, Rule H4. This is a new code/term approved by IARC/WHO for ICD-O. Rule H4 instructs one to code the histology when only one histology is present. In this case, the pathologist indicates the tumor is mixed mucinous and non-mucinous histologies. The non-mucinous carcinoma that is seen in this mixed histology may be identified as: Adenocarcinoma in situ, minimally invasive adenocarcinoma, or lepidic predominant adenocarcinoma. In this case it is lepidic predominant adenocarcinoma. Lepidic is a recognized histology in lung. It is not unusual for the pathologist to indicate mixed non-muncinous and mucinous adenocarcinoma AND also list the non-mucinous subytpe. It is important to capture both mucinous and non-mucinous histologies which drives treatment, etc. |
2023 |
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20230057 | EOD (2018)/EOD Regional Nodes--Thyroid: How is Extent of Disease (EOD) Regional Nodes coded for thyroid primary with cervical lymph nodes containing psammomatous calcifications (psammoma bodies) but negative for metastatic tumor cells? See Discussion. |
The AJCC 8th edition confirms that the identification of psammomatous calcifications within a cervical lymph node is metastatic disease. Example: Patient had a thyroid lobectomy and level VI neck node excision in August 2022. The final diagnosis is multifocal papillary carcinoma of the thyroid, as well as rare psammomatous calcifications only in the resected node. The pathologist notes that “psammoma bodies only” in lymph nodes is not well defined, and while indolent, they do indicate capacity for lymphatic spread and are pN1a. Should thyroid primaries with cervical node psammomatous calcifications get captured in EOD Regional Nodes category as it is in the AJCC pN staging? |
Assign EOD Regional Nodes code 300 for Psammoma bodies within a cervical lymph node that are microscopically confirmed. A clarifying note for the Thyroid Schema will be included in the 2025 EOD updates. |
2023 |
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20230072 | Solid Tumor Rules/Multiple Primaries--Bladder: How many primaries and what M Rule applies to a diagnosis of non-invasive urothelial carcinoma of the bladder in 1996, followed by multifocal non-invasive papillary urothelial carcinoma involving bladder, prostatic urethra, and left ureter in 2022? See Discussion. |
An argument could be made to apply Rule M10 (timing rule which may result in reporting the case as an additional primary) because the 2022 primary included multiple non-invasive urothelial carcinoma tumors in both the bladder and other urinary sites (coded to site C689, not C679) following a long disease-free interval. While Rule M10 excludes multiple bladder tumors, does that also apply when new, multifocal urothelial tumors arise in both bladder and other urinary sites? Does the presence of any subsequent bladder tumor rule out the use of M10 and one must use M11 that indicates reporting this disease process is a single primary? |
Abstract as a new primary per rule M10, as the subsequent tumors are not limited to the bladder. Code the primary site to C689, per Instructions for Coding Primary Site, #4: "Code Urinary System NOS C689 when there are multiple non-contiguous tumors in multiple organs within the urinary system", and following Note: "The physician subject matter experts (SME) discussed the issue of coding primary site for multifocal/multicentric urinary tract carcinoma. Although the SMEs understood and acknowledged the importance of coding a specific primary site, there is no literature or criteria for determining the organ of origin for multiple tumors involving multiple urinary sites". |
2023 |
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20230030 | Primary site: Is there a physician priority list for coding primary site? For example, the surgeon states during a pancreatectomy that the primary is in body while the pathologist states in their synopitc report that primary is neck; neither is in agreement, or neither is available for confirmation. |
As a general rule, the surgeon is usually in a better position to determine the site of origin compared to the pathologist. The surgeon sees the tumor in its anatomic location, while the pathologist is often using information given to him/her by the surgeon and looking at a specimen removed from the anatomic landmarks. However, when a pathologist is looking at an entire organ, such as the pancreas, he/she may be able to pinpoint the site of origin within that organ. In the case of pancreas body vs. neck, the neck is a thin section of the pancreas located between the head and the body. It may be a matter of opinion whether a tumor is located in the "body" vs. the "neck." In the situation you describe, we would give preference to the surgeon and assign the code for body of pancreas, C251. |
2023 | |
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20230009 | Solid Tumor Rules/Multiple Primaries--Vulva: How many primaries are accessioned when a 2023 diagnosis of keratinizing squamous cell carcinoma (SCC) (8071/3) of the vulva follows a previous diagnosis of nonkeratinizing SCC (8072/3) of the vulva and the timing rule (M12) does not apply? See Discussion. |
Table 19: Vulva Histologies of the Other Sites Solid Tumor Rules does not include entries for either keratinizing or nonkeratinizing squamous cell carcinoma in the “Squamous cell carcinoma, NOS” row. However, these are two distinctly different histologies per the ICD-O-3.2. All other Solid Tumor Rules schemas include an M Rule instructing one to abstract multiple primaries when separate/non-contiguous tumors are two or more different subtypes/variants in Column 3 of the Specific Histologies, NOS, and Subtype/Variants Table for the schema (e.g., Rule M6 for Lung). The timing of these tumors is stated to be irrelevant. The Notes confirm the tumors may be subtypes/variants of the same or different NOS histologies and tumors in column 3 are all distinctly different histologies (even if they are in the same row). However, the 2023 Other Sites schema appears to be missing this rule. Should these distinctly different histologies be accessioned as separate primaries? Is an M Rule missing from the Other Sites schema to address distinctly different histologies? |
Table 19 is based on WHO 5th Ed Tumors of vulva and squamous cell variants, keratinizing and non-keratinizing, are no longer recommended and are excluded from the 5th Ed. HPV related terminology is now preferred for these neoplasms. Per consultation with our GYN expert pathologist, based on the information provided, this is likely a single tumor that was not completely excised in the original biopsy. A new tumor in the same site would not appear within 8 months. If you cannot confirm two separate/non-contiguous tumors were present, abstract a single primary per M1. As for histology, the tumor showed both keratinizing and non-keratinizing features and HPV status is unclear. Per our expert, code to SCC 8070/3—keratinization or lack of does not change treatment or prognosis. Even If there is proof of separate/non-contiguous tumors, our expert still feels this is a single primary coded to SCC 8070/3. Treatment does not differ by keratinization or HPV status. Coding two primaries would be incorrect and inflate incidence rates. Per our expert, this is an unusual occurrence. The rules cover 85% of cases but there will always be situations that do not fit a rule. This case is an example of that. A new GYN specific Solid Tumor Rules module is under development and a rule to address this situation could be included. |
2023 |
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20230008 | SEER Manual/Surgery of Primary Site 2023--Breast: What instructions should be followed when the 2023 SEER Manual Appendix C 2023 Breast Surgery Codes advise to code 1 in Surgical Procedure of Other Site for a simple bilateral mastectomy but the 2023 STORE Manual does not. See Discussion. |
The 2023 SEER Manual, Appendix C 2023 Breast Surgery Codes, note reads: SEER Note: Assign code A760 for a more extensive bilateral mastectomy. Assign code 0 in Surgical Procedure of Other Site (NAACCR #1294). For a simple bilateral mastectomy, assign code A410 with code 1 in Surgical Procedure of Other Site (NAACCR #1294). In the 2023 STORE Manual, these notes are not mentioned and we are instructed not to code surgery to other site. Other education related to 2023 breast coding provided by NAACCR states to not code surgery to other site. |
Assign code 1 in Surgical Procedure of Other Site (NAACCR #1294) when a simple bilateral mastectomy is performed for a single tumor involving both breasts. This statement was inadvertently omitted from the STORE manual and will be added back in: For single primaries only, code removal of contralateral breast under the data item Surgical Procedure/Other Site (NAACCR Item #1294) or Surgical Procedure/Other Site at This Facility (NAACCR Item #674). The information presented by NAACCR was intended to be consistent with what is in the SEER manual. It may have been misuderstood. |
2023 |
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20230069 | First Course Treatment/Immunotherapy--Colon: Is infliximab cancer directed treatment? See Discussion. |
While SEER*Rx does indicate infliximab should be coded as biological response modifier (BRM)/Immunotherapy, the manufacturer website for this medication indicates it is given for: Crohn’s disease, ulcerative colitis, rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and plaque psoriasis. In addition, SEER*Rx does not indicate which primary sites this treatment may be given for. If it is indeed cancer directed treatment, can the typical primary sites be added for clarity? Case example: Patient is diagnosed with colorectal cancer and also has an existing diagnosis of Crohn’s disease; received surgery and FOLFOX6, as well as infliximab. There was no statement of what disease the infliximab was given to treat. |
infliximab is not cancer-directed treatment. This drug was last updated by the FDA 2/22/2023 with additional information on its approval to treat non-malignant neoplasms. To date, the FDA has not approved it for use in colon cancer. This drug was intially developed to treat colon cancer; however, found to be ineffective treating cancer. |
2023 |
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20230014 | Reportability--Thyroid: Is a case with thyroid fine needle aspirate (FNA) cytology with nodule 1 Bethesda category 5 and nodule 2 Bethesda 6, reportable in 2021? Does the Bethesda category 5 or 6 have any bearing on reportability? |
In the absence of information to the contrary, thyroid FNAs designated as Bethesda classification category VI are reportable. Thyroid FNAs designated as Bethesda classification category V are not reportable unless there is additional information confirming a reportable diagnosis. For both Bethesda V and VI, NCCN Guidelines recommend total thyroidectomy or lobectomy (depending on tumor size and nodal involvement) for the purposes of definitive diagnosis/treatment, so additional information should be available. We will add this to the next version of the SEER manual. In your example, nodule 1 Bethesda V is not reportable. Nodule 2 Bethesda VI is reportable. |
2023 | |
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20230047 | Reportability/Histology--Head & Neck: Is a 2023 mandibular biopsy showing “severe squamous dysplasia with microscopic focus suspicious for superficial invasion” reportable? See Discussion. |
Patient had a mandibular mucosal lesion resected in June of 2023, with a diagnosis of “atypical squamous proliferation” and case was forwarded to an expert in oral pathology for best classification. Subsequent slide review final diagnosis was “moderate to severe squamous dysplasia.” That slide review diagnosis goes on to state “microscopic focus suspicious for superficial invasion.” Currently there is no ICD-O code for severe squamous dysplasia, however it is unclear if this terminology is equivalent to high grade squamous dysplasia (histology code 8077/2). |
Report as squamous cell carcinoma (8070/3) on the basis of “microscopic focus suspicious for superficial invasion.” "Severe dysplasia" is equivalent to "high grade dysplasia" in the Head and neck. As such, "severe squamous dysplasia" would be coded to 8077/2. However, in combination with the statement of "with microscopic focus suspicious for superficial invasion,” report as squamous cell carcinoma (8070/3) based on “microscopic focus suspicious for superficial invasion.” The 2023 SEER Manual instructs us to code the behavior as malignant (/3) if any portion of the primary tumor is invasive no matter how limited, i.e., microinvasion. Use text fields to record the details. |
2023 |
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20230049 | Update to Current Manual/Surgery of Primary Site 2023--Skin: Regarding the 2023 skin surgery codes for punch biopsy NOS (B220) and shave biopsy NOS (B230), how is Date of First Surgical Procedure coded for cutaneous lymphoma and Kaposi sarcoma when the punch or shave biopsy is not excisional? See Discussion. |
Now that there are specific surgery codes for shave and punch biopsies, are these biopsies always the Date of First Surgical Procedure (NAACCR Item #1200)? Or should we still be applying the Surgery of Primary Site 2023 instruction in the SEER Manual that states shave or punch biopsies are most often diagnostic; code as a surgical procedure only when the entire tumor is removed and margins are free/gross disease is removed? We are aware of the instruction for melanoma cases outlined in SINQ 20230034; however, it is unclear if this should also apply to cutaneous lymphomas and Kaposi sarcomas, or if the intent of the procedure is used for these specific types of skin cases that typically present with multifocal involvement. Example 1: Patient is diagnosed March 2023 with primary cutaneous T-cell lymphoma presenting as pink, tan patches on the trunk. Punch biopsy diagnosed CTCL and treatment was given via narrow band UVB phototherapy. Example 2: Patient is diagnosed February 2023 with Kaposi sarcoma presenting as widespread violaceous macules, papules, plaques on the torso, bilateral extremities, and abdomen. Punch biopsy diagnosed Kaposi sarcoma. |
Code the Date of First Surgical Procedure (NAACCR Item #1200) as the date the shave, punch, or elliptical biopsy was performed. This instruction applies to cutaneous lymphoma and Kaposi sarcoma as well. Beginning with cases diagnosed 2023 and after, shave, punch, or elliptical biopsies are coded as a surgical procedure regardless of margin status. The instruction in the 2023 SEER Manual that states "shave or punch biopsies are most often diagnostic; code as a surgical procedure only when the entire tumor is removed and margins are free/gross disease is removed" has been deleted from the 2024 SEER Manual. Refer also to the Appendix C Coding Guidelines for Kaposi Sarcoma of All Sites and Lymphoma for coding primary site. |
2023 |