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20190006 | MP/H Rules/Multiple primaries--Breast: Please confirm Multiple Primaries/Histology Breast Rule M8 applies in this 2017 case. The surgical resection is >60 days past the biopsy date but is it possible treatment plans for breast could span >60 days and this is one primary? See Discussion. |
7/25/17 Part A: Left breast at 8:00, 5 CFN: Specimen type: Stereotactic biopsy. Tumor type: Ductal carcinoma in situ (DCIS), cribriform type. Tumor size: The largest focus of DCIS measures 1 mm in greatest dimension as measured on the slide. Nuclear grade: 2 (Intermediate grade). Microcalcifications: Present. Other findings: Stromal fibrosis, microcalcification and fat necrosis. 11/1/17 A. Sentinel lymph node, left: One lymph node, negative for metastatic tumor on three levels of routine H\T\E and pan cytokeratin immunohistochemical stains. B. Left breast: Procedure: Total mastectomy with skin and nipple. Specimen Laterality: Left. Lymph Node Sampling: Yes, portion A. Specimen Integrity: Intact. Histologic Type: Extensive ductal carcinoma in situ and one focus of Invasive ductal carcinoma with mucinous features. Histologic Grade (Nottingham Histologic Score): Glandular Differentiation: Score 3 Nuclear Grade: Score 2. Mitotic Count: Score 1. Total Nottingham score 6 (grade 2, moderately differentiated). Tumor Size: 3.3 x 2 mm (0.33 x 0.2 cm) measured on slide (B3). Tumor Site: Lower inner quadrant of left breast. Tumor Focality: Unifocal. Ductal Carcinoma In Situ (DCIS): Present, cribriform, solid and micropapillary types with focal necrosis and calcifications. Size of DCIS: Number of blocks examined: Thirty (30). Number of blocks with DCIS: Thirteen (13). Lobular Carcinoma In Situ (LCIS): Not identified, Lymphovascular Invasion: Present. Perineural Invasion: Not identified. Other Findings: Changes consistent with previous biopsy site. Cysts, foci of atypical ductal hyperplasia, focal ductal hyperplasia, adenosis, stromal fibrosis and microcalcifications. Skin (epidermis): Uninvolved. Nipple: Uninvolved. Margins: 1 mm from DCIS to the closest deep margin (slide B12). At least 10 mm (1 cm) from invasive carcinoma to deep margin. Estrogen receptor (ER, clone 1D5) by immunohistochemistry performed on this material: Positive (invasive and in situ carcinoma), high intensity, in greater than 95% of carcinoma cells. Progesterone receptor (PR, clone 16) by immunohistochemistry performed on this material: Positive (invasive and in situ carcinoma), moderate intensity in about 80% of the carcinoma cells. Her 2 by FISH performed on this material: Pending, an addendum to follow. Pathologic staging: pT1aN0(sn)MX (AJCC 7th edition). Dictated by: (Pathologist), MD Intradepartmental review. |
Abstract a single breast primary. Apply MP/H Rule M3 as this is a single tumor identified in the biopsy at 8 o'clock and at the same location in the mastectomy specimen. Code the behavior as invasive according to rule H9. The first course of therapy ends when the documented treatment plan is completed, no matter how long, unless there is progression, recurrence, or treatment failure. |
2019 |
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20190041 | Reportability/Primary Site--Gastrointestinal (GI) Tract: Is a gastrointestinal stromal tumor (GIST) with a single nodule in the small intestine (C17_) and a nodule in the stomach (C16_) reportable per the 2018 SEER Coding Manual reporting instructions for GIST due to the multiple foci or do the multiple foci need to be in the same organ to be reportable? See Discussion. |
Example: Small intestine wedge resection with GIST, 1.8 cm in mid small intestine, single nodule. Stomach nodule biopsy: GIST, 0.3 cm. Pathology report comment section indicates the gastric GIST is not staged due to the small size and incidental nature. |
Report the GIST in the small intestine. The 2018 SEER Manual says to report GIST when there are multiple foci and to code the primary site to the site where the malignancy originated. Use text fields to record the details, including the stomach nodule. |
2019 |
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20190106 | Tumor Size--Esophagus: Can information from the endoscopy procedure that implies a size of 3 cm for Tumor Size--Clinical be used for Esophagus? See Discussion. |
1-28-2018 CT Scan: 2.4 cm mass 2-15-2018 Endoscopy: Mass was present 22 to 25 cm. Biopsies were taken with cold forceps for histology; biopsy positive. |
For the case you describe, we would record the clinical tumor size stated on the CT report. The priority order for clinical tumor size is as follows. 1. Biopsy or operative (surgical exploration) report 2. Imaging 3. Physical exam We do not recommend coding tumor size based on an inferred tumor size from a description such as "Mass was present 22 to 25 cm." Look for an actual measurement of the mass, or a stated tumor size. Use text fields to record details. |
2019 |
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20190049 | Lymph nodes/Melanoma: Is a single axillary lymph node regional or distant for a patient diagnosed in 2018 with metastatic melanoma to the brain found via imaging. The staging procedure was an single axillary lymph node excision that was positive for metastatic melanoma. The exact site of the primary was never determined; the primary site is coded to C449. See Discussion. |
The patient was diagnosed in 2018 with met melanoma to the brain found via imaging. The staging procedure was a single axillary lymph node excision which was positive for metastatic melanoma. The exact site of the primary was never determined and the site code is C449. Is the axillary lymph node regional or distant? This affects how I code regional lymph nodes positive, regional lymph nodes examined, and scope of regional lymph node surgery or surgical procedure other site. Similar question was asked in the past (question # 20091101) but I have not found this question restated since the 2018 changes and just want to verify this is still what we are to do. |
Lymph node mets from a melanoma of unknown primary site are presumed to be regional if the lymph node mets are confined to one area, as they are in this case. We are assuming there are no previous melanoma diagnoses for this patient. The workup should include examination of the skin areas that drain to the axillary area. |
2019 |
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20190096 | Solid Tumor Rules (2018)/Multiple primaries--Colon: Is a colorectal anastomotic site recurrence reportable, that is, a second primary, per Rule M7, third bullet, if there is no mention of mucosa but the tumor is seen on colonoscopy? See Discussion. |
Colon, Rectosigmoid, and Rectum Multiple Primary Rule M7 states, Abstract multiple primaries when a subsequent tumor arises at the anastomotic site AND the subsequent tumor arises in the mucosa. We identified tumors at the anastomotic site of previous colon primaries with no mention of mucosa in any of the available documentation. Are there any other indicators that would imply a tumor arising in the mucosa, or do we need this specific statement to apply rule M7? Example: Patient has a history of invasive ascending colon adenocarcinoma diagnosed in October 2017 status post hemicolectomy followed by adjuvant chemo. There is no documentation of disease until August 2019 colonoscopy which shows a mass in the ileocolic anastomosis. Biopsy of the anastomotic site is positive for adenocarcinoma consistent with recurrence of the patient's colonic adenocarcinoma. There is no mention of mucosa found on the pathology report. |
Abstract a single primary using 2018 Colon Solid Tumor Rule M8 in the example provided as there is a subsequent tumor occurring less than 24 months in the anastomotic site, with the same histology and no mention of mucosa. The new tumor would be a new primary when it meets any one of the criteria noted in M7. The tumor does not have to be stated to have arisen in the mucosa. M8 also has three options to determine if a single primary is present. |
2019 |
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20190080 | Update to current manual/Surgery of Primary Site/Surgery codes--Melanoma: Can the operative report be used to assess margins if there is no residual melanoma on the wide excision and no margins stated, or if distance is not stated on the pathology report when there is residual melanoma? See Discussion. |
1) Is the operative report only used for margins when the wide excision states no residual disease and no margins are stated on path report? Or do you use the operative report too for margins when the wide excision has residual melanoma and margins are negative but distance is not stated on path report? Does it matter if there was residual melanoma on the wide excision or not as far as using the operative report for margins? 2) Do these rules only apply to melanoma cases or do they also apply to Merkel cell? 3) Did CoC and SEER both agree on this? Are they going to send out an update because this is not how I interpret what is in the STORE manual/SEER manual under the surgery codes. It might be good to send out an official update to the surgical coding rules if this is how we are to code now. |
1. You may take margin information from the operative report if it is missing from the pathology report when assigning the surgery codes for skin.
2. The rule applies to any skin malignancy for which the skin surgery codes apply. 3. SEER, CoC, NPCR, NCRA, NAACCR, and the Canadian registries participated in this decision. SEER is publishing this SINQ question for reference. |
2019 |
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20190089 | Solid Tumor Rules (2018)/Histology--Lung: Rule H3 of the Solid Tumor Rules was added to capture non-small cell carcinoma modified by ambiguous terminology when the physician confirms the ambiguous term as the histologic diagnosis, also included in Coding Histology instruction 3.B. If differentiation and features are not included in the histology term, does instruction 2 takes precedence? See Discussion. |
For example, pathologic diagnosis is non-small cell carcinoma with squamous features. The medical oncologist describes this as squamous cell carcinoma and begins treatment regimen. As I interpret the rules, we would use code 8046, non-small cell carcinoma, because of instruction 2 and the fact that features is not included in the list of ambiguous terminology. |
Code 8046 using Coding Instruction 2 that says to: Code the histology described as differentiation or features/features of ONLY when there is a specific ICD-O code for the "NOS with ____ features" or "NOS with ____ differentiation." Note: Do not code differentiation or features when there is no specific ICD-O code. In the example, no ambiguous terminology is used. If ambiguous terminology is used indicating a more specific term, you would code to the specific histology. |
2019 |
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20200054 | Solid Tumor Rules (2018)/Multiple primaries--Liver: When does a hepatocellular carcinoma (HCC) recurrence in the same area of the liver get accessioned as a new tumor following TACE/Y90/RFA? If there is a new HCC in the same area as previously treated but it is stated to be recurrent and/or progressive disease, is that evidence of a disease-free interval? If the tumor area is stated to be LR-TR and non-viable, but then a new HCC in that area is diagnosed, does that count as a disease-free interval? See Discussion. |
Example 1: 5/2013 diagnosis of HCC in segment 4B (single tumor), treated with microwave ablation in 7/2013. CT scan in 11/2017 with new 23mm hypodensity in liver segment 4 suspicious for recurrent disease. Clinical assessment in 1/2018: New enlarging lesion in liver most consistent with progression of HCC. Treated with RFA in 2/2018. Is the 2018 occurrence a new primary as imaging stated this was a new lesion? Example 2: 7/2017 diagnosis of HCC in right liver; 2.5 cm lesion in segment 5/6 with a couple of satellites and 12mm lesion in segment 6, treated with Y90 radioembolization. Follow-up note in 11/2017: complete response of treated cluster of lesions in segment 5/6 and lesion in segment 6, increase in size of caudate lesion not amenable for treatment (this lesion was stated to be indeterminate on 7/2017 imaging). Caudate lesion finally stated as LI-RADS5 on 3/2018 imaging and was treated with chemoembolization 6/2018. 7/2018 and 10/2018 Follow-up imaging states LR-TR nonviable lesion in caudate lobe. 8/2019 CT shows caudate lobe with arterial enhancement, new compared to prior imaging, LR-TR viable. MD note states patient has small local HCC recurrence in segment 1 (caudate lobe) with plan to repeat TACE. Is this 8/2019 HCC a new primary as the patient was disease free for greater than 1 year, or is it the same tumor and a single primary? |
Both examples are multiple primaries. Example 1: The 2018 lesion is a new tumor. Abstract multiple primaries based on 2018 Other Sites Solid Tumor Rules, Rule M10, when tumors are diagnosed more than one year apart. Example 2: 2017 diagnosis showed complete response to treatment. 2019 lesion is a new primary based on timing. The General Instructions of the Solid Tumor Rules instruct: Do not use a physician's statement to decide whether the patient has a recurrence of a previous cancer or a new primary. Each scenario should be evaluated separately using the rules as a guide. |
2020 |
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20200076 | Reportability/Solid Tumor Rules (2018)--Kidney: Should clarification (Notes) be added to Table 1 of the 2018 Kidney Solid Tumor Rules regarding the use of clear cell papillary renal cell carcinoma (8323) and sarcomatoid renal cell carcinoma (8312) as these histologies conflict with the ICD-O-3.2? See Discussion. |
First, reportability of clear cell papillary renal cell carcinoma changed from 8323/3 to 8323/1. Although it does not appear the standard-setters implemented this change, note of the conflict between the ICD-O-3.2 and the Solid Tumor Rules (STR) is not included in the Implementation Guidelines or STR. The current Note for clear cell papillary renal cell carcinoma (8323) was left in Table 1, so this presumably is still reportable. It would be helpful if the conflict with ICD-O-3.2 was addressed, especially since the existing Note refers to changes made back in 2016 (not 2018 or 2021). Second, is the term sarcomatoid renal cell carcinoma still coded as a synonym for renal cell carcinoma (8312) because sarcomatoid is referring to a pattern of differentiation or 8318 (renal cell carcinoma, sarcomatoid)? The STR, Table 1, lists sarcomatoid renal cell carcinoma as 8312, but the ICD-O-3.2 lists this as 8318. The Note in Table 1 still indicates WHO/IARC and College of American Pathologists agree that sarcomatoid carcinoma is a pattern of differentiation, not a specific subtype, of renal cell carcinoma. This appears to conflict with WHO/IARC ICD-O-3.2 Coding Table as it provides a different, specific histology code for this malignancy. How can WHO/IARC classify this both a pattern of renal cell carcinoma and a separate, specific histology? This question was prompted from preparing SEER*Educate coding exercises. We will use the answer as a reference in the rationales. |
For cases diagnosed 2021 or later, use ICD-O-3.2 to determine reportability. Use the Solid Tumor Rules to determine the number of primaries to report and the histology to code for tumors that are reportable. Do not use the Solid Tumor Rules to determine reportability. ICD-O-3.2 was implemented by the North American standard setters as of 1/1/2021 and it is the basis for reportability for cases diagnosed as of 1/1/21. See 1.a on page 6 in the 2021 SEER manual, https://seer.cancer.gov/manuals/2021/SPCSM_2021_MainDoc.pdf WHO 4th edition Tumors of the Urinary System has proposed ICD-O code 8323/1 for clear cell papillary renal cell carcinoma. This has not been approved for implementation by the standard setters. Continue assigning 8323/3 for clear cell papillary renal cell carcinoma. Sarcomatoid RCC is listed as a synonym for RCC 8312/3. This is correct per WHO and our SME. Do NOT code sarcomatoid RCC to 8318/3. |
2020 |
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20200017 | Histology--Head & Neck: Why is 8070 not listed as a valid histology for ill-defined sites as squamous cell carcinoma arises in the head and neck sites. See Discussion. |
Per the site validation list: https://seer.cancer.gov/icd-o-3/sitetype.icdo3.20190618.pdf#search=site%20validation, ill-defined sites (ILL-DEFINED C760-C768) does not include 8070- Squamous cell carcinoma as a valid histology. Therefore when a Cervical Lymph Node and Unknown Primary Tumor of the Head and Neck is submitted with a C760 and 8070/3, it requires an override be set. |
Histology code 8070 has been added to C760 on the site validation list. It will be updated for 2021. Continue to override this combination for now. |
2020 |
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