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The diagnosis date is 2/24/14.  The pathology report of the pancreas shows: Well-differentiated neuroendocrine tumor (NET), low grade (WHO G1 of 3). Addendum: Ki-67 confirms low grade of pancreatic endocrine tumor (less than 2% Ki-67/MIB-1 index). Chromogranin confirms the endocrine nature of the tumor. The Pre and Post Op Diagnosis is pancreatic neuroendocrine tumor consistent with insulinoma. AJCC Stage as noted on path report: pT1, pNX, pM.

The physician states: The patient has a well-documented insulinoma. Biochemistries confirmed the disease and it is localized in the tail of the pancreas.

The issue with NETs is that pathology report reflects what is seen or what is quantified under the microscope; often, there is a specimen without the accompanying medical history and clinical signs. Many of these NETs are specified on the basis of the hormone, as usually measured in the blood, that is overproduced, something not seen microscopically. All of the islet cell tumors are NETs. The insulinoma in the example above is a well-differentiated NET that is causing insulin to be over-produced. Thus, the diagnoses are not discordant; insulinoma is a more specific NET.

According to College of American Pathologists (CAP), lobular neoplasia is also known as lobular carcinoma in situ. In a previous SEER question 20041089, it was stated that they were not the same and should not be reported unless it was a Grade 3. I assume this has changed and we are to report lobular neoplasia as lobular carcinoma in situ, is this correct?

The patient was diagnosed with a carcinoid tumor of the small intestine. The pre-surgical work-up also identified a lung nodule that showed no octreotide uptake, but was indeterminate on biopsy. The imaging differential diagnosis included carcinoid, hamartoma, or a non-calcified granuloma. The patient underwent a resection of the primary small bowel tumor, and the physician noted the lung nodule was of unclear diagnosis. The physician stated a solitary lung metastasis would be atypical, but that lung metastatic involvement could not be ruled out. The physician recommended resection of the lung nodule to ensure that the patient was disease free. The lung wedge resection proved a pulmonary hamartoma.

The rules for coding Surgical Procedure of Other Site are not entirely clear. The definitions for First Course of Therapy in the SEER Manual do state that treatment includes, "Procedures that destroy or modify primary (primary site) or secondary (metastatic) cancer tissue." This would seem to exclude the lung resection as it did not destroy, modify or remove metastatic cancer tissue. However, the instructions for coding Surgical Procedure of Other Site do not address removal of distant sites that are not incidental. The lung resection was not incidental; the physician recommended it to ensure the lung was not involved, but it also disproved metastatic involvement. Should the Surgical Procedure of Other Site field be coded 0 (none) or 4 (non-primary surgical procedure to distant site) in this case?

Pathologists rarely diagnose a GIST as a malignant tumor. Per the AJCC, GISTs encompass a continuum in terms of biologic potential, with larger more mitotically active tumors landing on the "histologically sarcomatous" or malignant end of the spectrum. Because the pathologists generally do not categorize these tumors as benign or malignant, the judgement is typically made by the clinician in light of all the clinical and pathologic findings. Unless there are obvious distant metastases, the clinician usually decides whether a GIST is malignant and treats the patient as such.

In the case above, the patient underwent a gastric biopsy on 04/10/2014 that showed GIST. The subsequent resection on 04/12/2014 showed a 4.5 cm GIST, spindle cell type with 6 mitoses/5 square mm. The resection pathology report does not indicate the GIST is malignant, but does identify a large tumor with mitotic activity. After reviewing the evidence in this case, the clinician calls this a malignant GIST on 04/29/2014 and starts the patient on Gleevec.

Although neither the biopsy nor the resection call this a malignant tumor, should the date the GIST was first diagnosed (biopsy on 04/10/2014) be used to code the diagnosis date, since this is the date the tumor (ultimately felt to be malignant) was diagnosed? If the diagnosis date is coded as the date malignant GIST was first mentioned (04/29/2014), this would exclude surgery as treatment for this tumor.

Would this be a histologic diagnosis because the tumor was histologically confirmed to be GIST? Or must this be a clinical diagnosis because the diagnosis of malignancy was only made clinically (by the clinician's review of the clinical and pathologic findings)?

Please confirm correct coding for grade for papillary urothelial carcinoma of the bladder/renal pelvis and urothelial carcinoma of the bladder/renal pelvis. SEER Manual 2014 and 2015 state: "Do not use these tables to code grade for any other groups including WHO (CNS tumors), WHO/ISUP (bladder, renal pelvis), or FIGO (female gynecologic sites) grades." They also state "In transitional cell carcinoma for bladder, the terminology high grade TCC and low grade TCC are coded in the two-grade system" in the Grade section. These statements are not included in SEER Manuals prior to 2014.

Multilocular clear cell renal cell carcinoma is a specifc histologic type listed in the CAP cancer protocol for kidney, but not in the ICD-O-3 and it is not on the list of specific types of renal cell carcinomas in Table 1 of the kidney equivalent terms and definitions in the MP/H manual. There is a malignant multilocular cystic nephroma 8959 in Table 1, but I can't tell if this the same histology as what is stated in this path report.

LARYNGOSCOPY - ENDOLARYNGEAL EXAM WAS GROSSLY UNREMARKABLE EXCEPT THAT SHE APPEARS TO HAVE A T1A SQUAMOUS CELL CARCINOMA OF THE RIGHT TRUE VOCAL FOLD. IT EXTENDS FROM ALMOST THE ANTERIOR COMMISSURE ALL THE WAY BACK TO THE VOCAL PROCESS AND IS EXOPHYTIC IN NATURE. IT DOES NOT EXTEND INTO THE VENTRICLE OR ONTO THE FALSE VOCAL FOLD. NO SUBGLOTTIC EXTENSION IS SEEN. A. RIGHT POSTERIOR FALSE VOCAL CORD FOLD, BIOPSY:  SQUAMOUS CELL CARCINOMA IN SITU. B. RIGHT POSTERIOR TRUE VOCAL CORD FOLD, BIOPSY:  SQUAMOUS CELL CARCINOMA, SUSPICIOUS FOR INVASION. C. RIGHT MID TRUE VOCAL CORD, BIOPSY:  SQUAMOUS CELL CARCINOMA, SUSPICIOUS FOR INVASION. D. RIGHT ANTERIOR TRUE VOCAL FOLD, BIOPSY:  INVASIVE AND IN SITU SQUAMOUS CELL CARCINOMA, MODERATELY DIFFERENTIATED.

The pathology report states "Right mediastinal mass: poorly differentiated non-small cell carcinoma with neuroendocrine differentiation." This is the only histologic confirmation of this lung primary that is collected.