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Report Produced: 05/23/2026 12:33 PM

Report Question ID Question Discussion Answer Year
20230018

SEER Manual/First Course Treatment--Chemotherapy:  Does the First Course of Treatment end when subcategories change for treatments such as hormone therapy or immunotherapy or is that instruction specific to chemotherapy?  See Discussion.

Treatment for estrogen receptor positive (ER+) breast cancer started with tamoxifen (non-steroidal estrogen subcategory) and switched to letrozole (non-steroidal aromatase inhibitor subcategory). Patient being treated with immunotherapy, Avastin (cytostatic agent-antiangiogenesis agent subcategory), and then changed to Atezolizumab (monoclonal antibody subcategory).

Is Atezolizumab a new course of therapy because it is a different subcategory?

Answer updated April 2025

A change in the subcategory for a hormone drug does not indicate the end of First Course of Treatment because different hormone therapies generally achieve the same result. For example, some forms of breast cancer are estrogen-dependent and the various subcategories of hormone drugs used to treat them, such as gonadotropin-releasing factor agonists, aromatase inhibitors and estrogen antagonists, all achieve the same result - to block estradiol effects in these tumors.

Similarly, a change in immunotherapy is not a new course of treatment.

However, if a change to hormone therapy or immunotherapy is due to a change in the patient's ER, PR, or Her2 status, this could signify a new course of treatment.

The instruction in the SEER Manual is specific to chemotherapy. Chemotherapy is the only systemic treatment for which a change in the subcategory of a drug indicates the end of First Course of Treatment, due to the fact that different chemical agents damage cancer cells in different ways and at different phases in the cell cycle.

 2023
20230054

Reportability/Histology--Pancreas:  According to SINQ 20140058, solid pseudopapillary neoplasm of the pancreas is reportable (as of 2014). However, per ICD-O-3.2, this histology is not reportable until 2021+.  Please clarify which is correct and clearly state the timeframe that it was reportable or not reportable.

Solid pseudopapillary neoplasm of the pancreas is reportable for cases diagnosed in 2014 and later. Report solid pseudopapillary neoplasm of the pancreas (8452/3) as the guidance in SINQ 20140058 is still in effect.

The 4th and 5th editions of the WHO Classification of Tumors of the digestive system define solid pseudopapillary neoplasm of the pancreas as a low-grade malignant pancreatic tumor.

 2023
20230042

First Course Treatment/Surgery of Primary Site--Rectum:  What surgery code should be used for laparoscopic C/T open low anterior resection with colorectal anastomosis, loop ileostomy in diagnosis year 2020, code 30 or 40?  See Discussion.

Can you provide clarification on Rectum primary surgical code 40 Pull through WITH sphincter preservation (colo-anal anastomosis)? Would this be code 30 or 40 due to the colorectal anastomosis? 

Assign code 40, Pull through WITH sphincter preservation (colo-anal anastomosis).  The National Cancer Institute Dictionary of Cancer Terms defines coloanal anastomosis as a surgical procedure in which the colon is attached to the anus after the rectum has been removed. It is also called coloanal pull-through.

 2023
20230073

First Course Treatment/Surgery of Primary Site--Liver/Intrahepatic Bile Ducts: For a liver/intrahepatic bile duct primary, is an alcohol embolization the same thing as a percutaneous ethanol injection (PEI)?  See Discussion.

For C220-C221 primaries, Surgery of Primary Site includes code A150 for Alcohol tumor destruction (percutaneous ethanol injection/intratumoral injection of alcohol/alcohol ablation). The SEER and STORE manuals also indicate that alcohol embolization should be coded as Other Therapy, code 1. We are trying to determine whether alcohol embolization should be coded under Surgery of Primary Site or Other Therapy.

Code alcohol ablation under Surgery of Primary Site 2023. Code alcohol embolization as Other Therapy when tumor embolization is performed using alcohol as the embolizing agent.

Alcohol ablation, also known as an ultrasound-guided percutaneous ethanol injection (PEI); is treatment that involves injecting concentrated alcohol directly into the tumor. Embolization uses special techniques to close off blood flow by introducing special medications or using other techniques designed to block blood vessels. Types of embolization are arterial embolization as with alcohol (ethanol), chemoembolization, and radioembolization. Refer to the current SEER Program Coding and Staging Manual when assigning surgery and embolization procedures.

 2023
20230075

EOD/Summary Stage--Eye: How is stage coded for a patient with extranodal non-Hodgkin lymphoma involving bilateral choroids (single focus, both sites) and no lymph node involvement? Since the eyes are a paired site, is this two separate extranodal sites? If so, there are no Summary Stage or EOD tumor codes that best fit this scenario.

Assign as Stage IV as recommended by our expert hematological oncologist. This is a rare occurrence and this type of presentation does not fit the definition of intraocular extension. Stage IV is probably the best stage for this type of presentation, since there are two extranodal organs involved, even though they involve a bilateral site.

EOD Primary Tumor: 700

SS: 7 (Distant)

 2023
20230063

EOD 2018/EOD Regional Nodes--Melanoma: Can central cancer registries code Extent of Disease (EOD) Regional Nodes as 000 based on Breslow’s depth and/or Clark’s Level (per EOD and/or Summary Stage) from a melanoma pathology only report with a localized tumor and no information on regional lymph nodes or mets. See Discussion.

Based on the EOD General instructions for accessible sites, the following three requirements must be met

a. There is no mention of regional lymph node involvement in the physical examination, pre-treatment diagnostic testing, or surgical exploration;

b. The patient has localized disease;

c. The patient receives what would be the standard treatment to the primary site (treatment appropriate to the stage of disease as determined by the physician), or patient is offered usual treatment but refuses it.

As a central registry, we receive a lot of melanoma path reports but never receive an abstract since the patients are seen at a dermatology office that does not report to the central registry. In these scenarios, we have both the diagnosis and wide excision or Mohs surgery from which we create a consolidated record. It is not often that lymph nodes are removed which indicates there were no palpable nodes.

Since the Breslow’s and Clark’s level allow for summary staging, is it possible to have central registry guidelines that allow for coding lymph nodes other than 999? The path reports meet two of the three criteria. Is there any new literature that supports coding lymph nodes 000 based on a Clark’s level or Breslow measure providing the patient has a wide excision?

Assign 000 for EOD Regional Nodes when you have a pathology only report with a localized tumor based on Breslow’s depth and/or Clark’s Level (per EOD and/or Summary Stage) and no information on regional lymph nodes or mets. When the tumor is noted to be regional or distant based on Breslow’s Depth and/or Clark’s based on the definitions in EOD and/or Summary Stage, do not assume that the nodes are negative and assign 999. Clarification will be added to the EOD manual.

 2023
20230045

Reportability/Histology--Thyroid:  Is a diagnosis of “angioinvasive oncocytic thyroid neoplasm with features worrisome for a poorly differentiated oncocytic carcinoma” reportable if the diagnosis comment states, additional immunostains were performed which demonstrate the carcinoma cells are positive for thyroglobulin and negative for calcitonin?  See Discussion.

Patient had a right thyroid lobectomy on 12/2022, with initial diagnosis of “thyroid carcinoma pending expert consultation for definitive classification.”  The slide review documented in the addendum shows a final diagnosis of “Angioinvasive oncocytic thyroid neoplasm, see comment.”  The subsequent comment states, “I would classify this lesion as an angioinvasive oncocytic thyroid neoplasm with features worrisome for a poorly differentiated oncocytic carcinoma.”  The comment goes on to state, “Additional immunostains were performed which demonstrate the carcinoma cells are positive for thyroglobulin and negative for calcitonin. The diagnosis remains unchanged.”

Do not report angioinvasive oncocytic thyroid neoplasm with features worrisome for a poorly differentiated oncocytic carcinoma based on the final, unchanged diagnosis.  Worrisome is not a reportable ambiguous terminology.

 2023
20230055

Reportability/Histology--Heme and Lymphoid Neoplasms: Is "the differential diagnoses include, but not limited to, mantle cell lymphoma, atypical chronic lymphocytic leukemia/small lymphocytic lymphoma and a variant of marginal zone lymphoma" reportable? In the Heme manual, they use differential diagnosis that include reportable conditions as reportable. This can be found under Code 1: positive histology in the Diagnostic Confirmation Coding Instruction section page 18. The phrase "include, but not limited to" makes this not clear.

This is reportable as 9591/3, B-cell lymphoma, NOS.All diagnoses in the differential are all B-cell lymphomas. The pathologist knows it a B-cell lymphoma but has not determined the subtype. If at a later time a specific lymphoma is determined, update the histology code accordingly.

2023
20230059

Histology--Heme and Lymphoid Neoplasms: How is histology coded for a diagnosis stated as MDS/AML (myelodysplastic syndrome/acute myeloid leukemia) per the international consensus classification (ICC)?  See Discussion.

The final diagnosis on bone marrow biopsy was high grade myeloid stem cell neoplasm, 17% blasts by differential count.  The pathologist further states that this could be classified as “MDS with increased blasts (MDS-IB2) per the WHO 5th edition classification, or MDS/AML per the international consensus classification (ICC).”  FISH and cytogenetics revealed a loss of 7q, but no other AML-related genetic abnormalities. The physician confirms the patient has MDS/AML.

Updated Answer July 2024

Code histology as myelodysplastic neoplasm with increased blasts (9983/3) based on the WHO Classification of Hematolymphoid Tumors, 5th edition, Beta version 2.  WHO lists MDS with increased blasts-2 (MDS-IB2) as a subtype of 9983/3.

Terms coded to 9983/3 include

  • Myelodysplastic neoplasm with increased blasts
  • Myelodysplastic neoplasm with increased blasts-1
  • Myelodysplastic neoplasm with increased blasts-2
  • Myelodysplastic neoplasm with increased blasts and fibrosis
  • Subtypes: MDS with increased blasts-1 (MDS-IB1); MDS with increased blasts-2 (MDS-IB2); MDS with increased blasts and fibrosis (MDS-F)

When differences exist between WHO and ICC, assign the histology based on the WHO Classification.

 2023
20230044

First Course Treatment/Neoadjuvant Therapy--Breast: What pathology report descriptions are permissible to use in coding the Neoadjuvant Therapy Treatment Effect data item?  See Discussion.

1) In the SEER Manual's code definitions for Neoadjuvant Therapy - Treatment Effect, some sites specify the percentage of viable tumor. Pathology reports often list this along with the percentage of necrosis (e.g., 10% necrosis and 90% viable tumor). If only the percent necrosis is stated, is it acceptable to infer the percent viable tumor? For example, pathology report states only "treatment effect: present, necrosis extent: 30%" - could we then deduce that the percent viable tumor in this case would be 70%?

2) Can statements of Residual Cancer Burden (RCB) Class be used?  For example, pathology report states Treatment Effect: Residual Cancer Burden Class II, with no further description of partial vs. complete response. It appears that RCB Class II is a "moderate burden" of residual tumor after neoadjuvant therapy; could this be interpreted as a partial response in the Neoadjuvant Therapy--Treatment Effect code definitions?

1) Do not infer the percent of viable tumor if only percent of necrosis is provided. For the example, assign code 6 when Neoadjuvant therapy was completed and the treatment effect in the breast is stated only as “Present".

2) Do not use the residual cancer burden (RCB) score from the pathology report to code the Neoadjuvant Therapy--Treatment Effect field for breast cancer. We do not have a crosswalk from RCB to neoadjuvant Therapy--Treatment Effect.

RCB index is an accurate and reliable tool to assess patient prognosis. RCB is estimated from routine pathologic sections of the primary breast tumor site and the regional lymph nodes after the completion of neoadjuvant therapy. The data item Neoadjuvant Therapy--Treatment Effect records information on the primary tumor only.

Document information in a text field in both examples.

 2023