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Instruction number 1 under the Coding Multiple Histologies instructions states to code histology when the histology is described as subtype, type or variant. The general rules do indicate we can code the histology identified as type, but when applying the H Rules, it seems an argument could be made for either H1 or H3. H1 applies if you ignore the diagnosis of carcinoma and only code the histologic type: urothelial carcinoma. However, the rules do seem to imply that you take all histologies into account (e.g., code the subtype/variant when there is a not otherwise specified (NOS) and single subtype/variant). Following this logic, Rule H3 seems to be the only rule that fits, and one would code the subtype/variant urothelial carcinoma when the diagnosis is carcinoma NOS, histologic type: urothelial carcinoma.

The problem is that urothelial carcinoma is not a subtype/variant of carcinoma (NOS) per Table 2. The entry for Carcinoma NOS in Table 2 states, Subtypes of carcinoma NOS include adenocarcinoma and all subtypes/variants of adenocarcinoma. To some, urothelial carcinoma is a more specific type of carcinoma; however, urothelial carcinoma is not also listed as a subtype of carcinoma or of adenocarcinoma; only adenocarcinoma is categorized as a subtype of carcinoma. Consistently applying the rules becomes an issue when rules are interpreted in different ways. Should this Table be amended to include urothelial carcinoma as a subtype/variant of carcinoma NOS with the same caveat given to adenocarcinoma in Table 2?

Pathology--Right breast, lumpectomy with needle localization: Encapsulated papillary carcinoma of the breast. A separate focus of ductal carcinoma in situ is present. Sentinel lymph node, right breast, biopsy: One lymph node, negative for malignancy. No metastatic carcinoma is seen on slides stained with immunostain for cytokeratin (AE1/AE3). Specimen laterality: Right. Tumor size: 1.2 cm. Histologic type: Encapsulated papillary carcinoma. Nuclear grade: Grade 1 (low). Mitotic rate: Score 1. Ductal carcinoma in situ (DCIS): DCIS is present. Estimated size (extent) of DCIS: 3 mm. Architectural patterns: Cribriform and papillary. Nuclear grade: grade 1 (low). Necrosis: Not identified. Margins: Margins uninvolved by encapsulated papillary carcinoma. Distance from closest margin: 8 mm, superior Margins uninvolved by DCIS. Distance from closest margin: 11 mm, superior Lymph nodes: Total number of lymph nodes examined (sentinel and nonsentinel): 1. Number of sentinel lymph nodes examined: 1. Number of lymph nodes with tumor cells: 0. Pathologic staging: Primary tumor: See comment. Regional lymph nodes: pN0(i-). Comment: In the WHO Classification of Tumours of the Breast (2012), it is stated that "there is no universal agreement on how to stage encapsulated papillary carcinomas. In the absence of conventional invasive carcinoma, the consensus of the WHO Working Group was that such lesions should be staged and managed as Tis disease."

There is a group of patients diagnosed within the past few years with ovarian cancers who are now enrolled in a clinical trial and are being screened as potential patients for a particular protocol. The screening for these particular cases is being done by a pathologist who has a particular interest in GYN pathology. As the pathologist is screening the cases, there are some which the pathologist is reclassifying as being fallopian tube primaries rather than ovarian primaries. This is apparently due to newly emerging findings and literature. The problem for me is that these cases have been entered into the registry as ovarian primaries, which was correct as of the time of the initial diagnosis. Should the abstracts remain as they were initially coded, since the diagnosis was ovarian cancer at the time they were diagnosed, or should these cases be updated to reflect the current pathologist's interpretation that these are fallopian tube primaries?

10/27/2017 partial nephrectomy final path diagnosis: renal oncocytic neoplasm, favor hybrid oncocytic tumor. Comment:

We noticed this term was added to the most recent version of the Heme Database (DB) as an alternate name for chronic lymphocytic leukemia/small lymphocytic lymphoma; however we do not recall being notified that this was a new reportable term for code 9823 and the term was not included in the 2018 ICD-O-3 Histology updates. The Definition in the Heme DB for Chronic lymphocytic leukemia/small lymphocytic leukemia (CLL/SLL) includes information that the term was added in the 2016 WHO revision, thus would be reportable back to 2016, is that correct? In addition, the Definition seems to be describing it as a precursor condition to CLL and may never actually evolve into CLL, so it is unclear if this term should really be reportable.

Example: 09/08/2016 Onc Note: A/P: monoclonal B-cell lymphocytosis of undetermined significance (MBL): I reviewed with him the results of the bone marrow biopsy. Interestingly, there is no evidence of abnormal plasma cell population by flow cytometry and immunohistochemistry. Nevertheless, flow cytometry does demonstrate a very small population of abnormal and monoclonal B-cell lymphocyte population with immunophenotype consistent with CLL/SLL. Given the very low number of the abnormal B cells, this can be categorized as monoclonal B-cell lymphocytosis (MBL). I recommend surveillance visit in one year.

9/12/2017 Onc note: A/P: Monoclonal B-cell lymphocytosis of undetermined significance (MBL) and IgM MGUS. No symptoms concerning for active disease or progression. Explained that MBL is a very indolent process. Patients with CLL-phenotype MBL progress to CLL at a rate of ~1-2 percent per year. Follow-up in 1 year. Is this case reportable?

Examples

Example #1: CAP histology type: Adenocarcinoma, solid predominant, Final diagnosis states that Adenocarcinoma, poorly differentiated, solid predominant (80%) and cribriform (20%) subtype (see lung carcinoma synoptic report)

Example #2: CAP histology type : Invasive adenocarcinoma, solid predominant, Other Subtypes Present (specify subtype(s), may also include percentages): acinar (45%) and micropapillary (5%) Final diagnosis : adenocarcinoma of the lung, please see Synoptic Report

Example #3: CAP histology type: Adenocarcinoma, acinar predominant , Adenocarcinoma, solid predominant Final diagnosis: Adenocarcinoma, poorly differentiated, solid predominant (60%), papillary (30%) and acinar (10%) subtype (see lung carcinoma synoptic report)

It appears an argument could be made for both NLPHL (9659/3) and THRLBCL (9688/3). We favor coding NLPHL (9659/3) because the pathologist did specifically call this a Hodgkin lymphoma, and also specified that it only has a T-cell/histiocyte-rich large B-cell lymphoma-like pattern.

The SEER Manual states that Marriage is self-reported for the instruction in code 2, but it does not indicate if all other marital statuses are self-reported.

Examples: How is Marital Status reported for the following situations?

1. Patient with multiple tumors in the database, for the first tumor marital status is reported as married (code 2), for the subsequent tumor, marital status is reported as single (code 1).

2. Patient self- reports as single, but also has children.

3. Patient states they are in common law marriage, but our state is not a common law marriage state.