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Diagnosis: Fragmented appendix with: Goblet cell carcinoid tumor (typical goblet cell carcinoid): WELL DIFFERENTIATED neuroendocrine tumor; INTERMEDIATE GRADE (GRADE 2 NET). Size 3.5 cm according to surgical pathology report. Tumor infiltrates through appendiceal wall to subserosa. Tumor is present in what appears to be the wall of the appendix near the perforation site or in hemorrhagic tissue on the surface of the appendix. MAXIMUM MITOTIC RATE IS TWO (2) FIGURES PER 10 HIGH POWER fields (2/10hpf). (4/10 hpf according to report).

WD indicates a 3- grade system (code 1 for WD) Intermediate grade indicates a 3- grade system (code grade 3 for intermediate grade), Grade 2 indicates a 2- grade system (code 2 for grade 2). Please advise.

At the central registry, we have accessioned this scenario as three primaries per Multiple Primaries/Histology (MP/H) Rule M10 (diagnosed more than 1 year apart), as the patient was stated to be disease free between each occurrence. However, the diagnosing/treating facility is not reporting these cases due to clinical statements of recurrent disease.

This is an example of a case type identified on casefinding audits conducted by our central registry in which we have learned SEER's expectation of MP/H rule application does not match hospital reporting. Can the 2018 version of the MP/H rules more clearly address how this type of clinically recurrent (multiple times) case should be handled?

Discussion: Example: Shave biopsy with superficial spreading melanoma, Breslow 0.25 mm, Clark level II. Excision with no residual melanoma and gross description of specimen size is 4.0 x 1.6 cm skin ellipse excised to a depth of 1.8 cm.

We have differing opinions in our registry.

Opinion 1: We can assume margins are greater than 1 cm based on the excision specimen size when there is no residual tumor on excision and all dimensions of the excision specimen are more than 1 cm. Surgery would be coded in 40s range.

Opinion 2: We should assume the melanoma defect was in the middle of the excision specimen, so for a skin ellipse that is 4.0 x 1.6 cm, there would be a 2 cm and 0.8 cm margin (respectively) from the middle of the specimen, thus margins are not > 1 cm. Surgery would be coded in 30s range.

Patient had radical resection of pelvic giant cell tumor of bone in August 2012. Final diagnosis clarified that no features to suggest a frankly malignant giant cell tumor were identified.

July 2013 left upper lobe nodules were removed and found to be consistent with multifocal metastatic lung involvement with a previous pelvic giant cell tumor of bone. However, the pathology report comment specifies there are no histological high-grade features to suggest a malignancy:

While SINQ 20091087 may apply, these metastases clearly arrived in the lung by hematogenous spread. The previous SINQ note refers to a case where the implants/metastases can seed the surrounding pelvic and abdominal structures by rupture of the tumor or intraoperative tumor spillage. That type of spread is not quite the same as the current case showing tumor cells leaving the primary tumor/site and travelling through the blood to implant in the lungs.

Sarcomotoid (8318) is listed as a specific renal cell subtype in the MP/H manual, but it is not listed as a renal cell subtype in the most recent WHO blue book for Urinary Organs. We are wondering if sarcomatoid features, as listed in the CAP protocol format in the following example, should be ignored when coding histology?

Left kidney, radical nephrectomy:

Clear cell renal cell carcinoma, with the following features:

Tumor size: 8.5 X 6 cm.

Tumor focality: Unifocal.

Macroscopic extent of tumor: Tumor limited to kidney.

Sarcomatoid features: Present (<20% of tumor shows sarcomatoid features).

Histologic grade: G4.

Microscopic tumor extension: Tumor limited to kidney.

Margins: All margins negative for invasive carcinoma.

Lymph-vascular invasion: Not identified.

8/1/2016 Left Abdomen biopsy: Early melanoma in situ (C445-2, 8720/2).

9/2/2016 Upper back: Superficially invasive malignant melanoma (C445-9, 8720/3).

Does rule M4 apply and multiple primaries should be reported or does rule M8 apply and a single primary should be reported?

5/27/02 Transurethral resection of bladder tumor (TURBT)--papillary transitional cell carcinoma, +lamina propria, no muscle invasion. All urine cytologies in 2011 and 2012 (only follow up received) show no malignancy. 3/11/15 Lung fine needle aspirate--poorly differentiated carcinoma consistent with urothelial carcinoma. 4/30/15 Renal pelvis biopsy--low grade papillary urothelial carcinoma, no lamina propria invasion, no muscularis propria invasion.

We are seeing more use of PI-RAD categories on scans. The final impression on the scan will be PI-RADS Category 5, with no specific statement of malignancy. The scans include a blanket statement with the definitions of the PI-RADS categories as below.

PI-RADS (v2) categories:

PI-RADS 1 - Very low (clinically significant cancer is highly unlikely to be present)

PI-RADS 2 - Low (clinically significant cancer is unlikely to be present)

PI-RADS 3 - Intermediate (the presence of clinically significant cancer is equivocal)

PI-RADS 4 - High (clinically significant cancer is likely to be present)

PI-RADS 5 - Very high (clinically significant cancer is highly likely to be present)

A previous SINQ 20010094 indicates that we cannot use BI-RADS categories for breast cancer diagnosis, and SINQ 20160008 indicates we can use LI-RADS for HCC diagnosis, but those definitions are slightly different. Most often there will be a subsequent biopsy diagnosis of carcinoma, so the question is also in reference to Diagnosis Date. Can we use the date of the scans impression, which states PI-RADS category 5, as the Diagnosis Date?