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SEER Inquiry System - Report
Produced: 11/26/2024 1:13 PM
Question 20081119
Inquiry Details
References:
#1: 2007 SEER Manual, 4. 1.b.
#2: 2007 SEER Manual, 61
Question:
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.
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.)
Answer:
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.
