SEER Inquiry System - Search

Example: Diagnosis is made on liver core biopsy path showing Metastatic carcinoma, poorly-differentiated, consistent with lung primary. Diagnosis Comment notes: Carcinoma cells are positive for CK7 and TTF-1, negative for CK20.

Subsequent immunohistochemistry report for PD-L1 testing states Liver: Metastatic adenocarcinoma consistent with lung primary. Interpretation: no PD-L1 expression.

IHC/Biomarker testing is often performed to determine treatment type, but it seems like some of the biomarkers for treatment planning are also histology specific. The Solid Tumor Rules do not address the use of biomarkers reports in the histology coding instructions.

Lung Rule M14 appears to be the first rule that applies to this case and instructs the user to abstract a single primary. However, we were hoping for confirmation that a cancer (NOS) or malignancy (NOS) would not be a distinctly different histology that may qualify for Lung Rule M8. Currently, these histologic terms are not included in the Table 3 options or mentioned in the preceding notes.

Insulinoma, NOS is reportable for cases diagnosed 2021 and later. However, the diagnosis of insulinoma is most frequently made with clinical correlation of the patient's clinical syndrome and serum hormone levels. Despite a pathological diagnosis of NET, this will clinically be stated as insulinoma based on the functional type of tumor. At the largest facility in our area, all pathology reports with a diagnosis of insulinoma over the last year only provide a pathological Final Diagnosis of NET (either G1 or G2), but elsewhere specify, Functional Type: Pancreatic neuroendocrine tumor, functional. Correlation with Clinical Syndrome and Elevated Serum Levels of Hormone Product: Insulin-producing (Insulinoma).

For 2021 and later, it seems this should be accessioned as insulinoma (8151/3), but one cannot arrive at that histology using the current Other Sites (MP/H) H Rules. Following the existing rules, one would code the histology to NET, G1 or NET, G2 (8240 or 8249) per Rule H6. There are technically two specific histologies to consider: NET (either 8240 or 8249) and insulinoma, NOS (8151). Following the H Rules, Rule H6 instructs one to code the histology with the numerically higher ICD-O-3 code (8240 or 8249).

Coding this histology to NET (8240 or 8249) does not seem to reflect the most accurate classification of this tumor, but applying the current rules, this is the only histology that can be coded. There is no current guideline in the Other Sites schema or the ICD-O-3.2 Implementation Guidelines instructing us to ignore the pathological diagnosis of a NET for these tumors (even though insulinomas are NETs). The only SINQ that currently exists (SINQ 20150019) states the histology can be coded as either a NET or an insulinoma in these cases. How are registrars to consistently code histology for these tumors without a rule clarification?

This question was prompted from preparing SEER*Educate coding exercises. We will use the answer as a reference in the rationales.

Per the 2018 Solid Tumor Rules instructions, Final Diagnosis and Staging Summary (synoptic report) have equal coding priority. However, it is unclear which takes priority, or if this should be a combination of components, when the histologies are two different specific histologic types per Table 3 of the Breast Solid Tumor Rules Manual.

The Extent of Disease (EOD) Manual states: Neoadjuvant (preoperative) therapy: If the patient receives neoadjuvant (preoperative) systemic therapy (chemotherapy, immunotherapy) or radiation therapy, code the clinical information if that is the farthest extension documented. If the post-neoadjuvant surgery shows more extensive disease, code the extension based on the post-neoadjuvant information.

Table 3 (Specific Histologies, NOS, and Subtypes/Variants) lists Ewing sarcoma as a synonym for Peripheral primitive neuroectodermal tumor 9364. Presumably, this is to be used for the reportable malignant peripheral nerve tumors when diagnosed as pPNET or Ewing sarcoma. However, this patient has a type of central (or CNS) primitive neuroectodermal tumor (histology 9473). Table 3 does not list central primitive neuroectodermal tumor (PNET or CPNET) as a valid histology for CNS tumors.

While Table 3 does not list all the possible histologies for the CNS, it currently is not clear how one would arrive at the histology code for a CNS Ewing sarcoma family tumor with CIC alteration, as this is recognized as a new entity for primitive neuroectodermal tumors of the CNS (i.e., PNET, histology 9473) per multiple journal articles. Ewing sarcoma family tumors include both peripheral PNET and central PNET tumors, but to code this histology as a peripheral PNET (9364) in this case seems incorrect when the primary tumor is stated to be of central nervous system origin, not peripheral nervous system origin.

11/01/2018, lung, left upper lobe, wedge resection: Invasive moderately differentiated adenocarcinoma, predominantly papillary subtype, with minor acinar and lepidic subtypes. Would this be 8260/3 since the acinar and lepidic subtypes are described as minor or would this be 8255/3 because there is papillary plus two other subtypes/variants described as subtypes?

There is a discrepancy between Notes 3 and 6 in the schemas Fallopian Tube, Ovary, and Primary Peritoneal Carcinoma for EOD Primary Tumor. Note 3 describes extension/discontinuous metastasis to the pelvic sites (code 450) and includes the sigmoid colon, rectosigmoid and rectum since these are all pelvic sites. However, Note 6 also includes rectosigmoid and sigmoid colon.

Note 6 is describing extension/discontinuous metastasis to the abdominal sites (600-750), so it should include rectosigmoid or sigmoid colon (since those are pelvic sites). Note 6 indicates, Intestine, large (except rectum). In the previous Collaborative Stage, the corresponding note used to also include: except sigmoid colon, rectosigmoid and rectum.

Did sigmoid colon and rectosigmoid get removed from the list here? That is, should Note 6 read, Intestine, large (except sigmoid colon, rectosigmoid, rectum)? Involvement of the sigmoid, rectosigmoid, or rectum via peritoneal seeding/metastasis is consistent with T2b disease and would correlate with code 450 (pelvic sites), not codes 600-750 (abdominal sites). Those codes only correlate with T3 and greater disease (i.e., peritoneal seeding/metastasis of the abdomen).

Example: Bone marrow biopsy diagnosis is chronic myelogenous leukemia, chronic phase, and the RT-PCR test result proved, BCR-ABL1 p210 (Major Breakpoint) - Detected, 3.3659%.

Even though the p210 fusion transcript was less than 5%, it was detected. The presence of BCR-ABL1 does define whether or not patients are treated with tyrosine kinase therapies. Therefore, it seems likely that the presence of any BCR-ABL1 would be captured using the more specific histology code 9875/3, instead of the non-specific CML, NOS histology code 9863/3.

Are there minimum threshold requirements for these quantitative studies in order to code the histology to the more specific type of CML?