SEER Inquiry System - Search

Example 1: 8/23/2017 debulking path diagnosis of low-grade appendiceal mucinous neoplasm (LAMN) with involvement of intrapelvic mucin, left ovarian mass, uterine serosa and pelvic tumor, consistent with disseminated peritoneal adenomucinosis, that may also be called low-grade mucinous carcinoma peritonei. 8/8/2018 resection of sigmoid and rectum, path diagnosis of peri-colorectal fibroadipose issue with low-grade mucinous carcinoma compatible with the prior diagnosis of pseumomyxoma peritonei with low-grade mucinous carcinoma histology.

Example 2: Path diagnosis of low-grade appendiceal mucinous neoplasm in association with low grade mucinous carcinoma peritonei involving the serosa of the small intestine and mesentery. Also, there is involvement of serosal lined soft tissue of peritoneum, omentum, stomach, falciform ligament, gallbladder, diaphragm and spleen.

Some pathologists in our area are referring to DPAM as mucinous carcinoma peritonei, which is causing confusion because the term carcinoma is being used. One would assume that because the pseudomyxoma peritonei/underlying tumor itself is low-grade (LAMN), then the case is not reportable, but we would like clarification.

Example: Initial CT scan impression is large appendiceal mucocele with a moderate amount of right-sided abdominal ascites. Faint mural enhancement suggesting an underlying appendiceal neoplasm (mucinous adenoma or adenocarcinoma).

Appendectomy follows two days later with final diagnosis of high-grade appendiceal mucinous neoplasm, see comment. Histologic grade: Grade G2 of 4 (based on the CAP protocol) . . . Ascites fluid (ThinPrep(r) and cell block preparations): Mucin, fragments of debris, and macrophages. No diagnostic neoplastic cells are identified . . . Pathologic stage: pT4a, pNX, pM1a (AJCC 8th ed).

Diagnosis Comment states, We feel that there are areas of this tumor where the cytologic atypia is beyond what one would expect in low-grade appendiceal mucinous neoplasm. While mitotic figures are not strikingly increased, there are focal nuclear changes that would support classification of this tumor as high-grade appendiceal mucinous neoplasm.

Approximately two weeks later the patient has an Oncology assessment stating new diagnosis of T4a, NX, M1a, Stage IVA high-grade mucinous adenocarcinoma of the appendix with mucinous ascites. Patient has had an appendectomy but no further surgery so far. However, anecdotally, the best reported case series has been with surgical debulking followed by HIPEC chemotherapy In that instance I have recommended surgery with intraperitoneal chemotherapy.

Is this a reportable malignancy? If so, what is the best histology for the diagnosis?

Cytology is not listed in the Priority Order for Using Documentation to Identify Histology (Histology Coding Rules) in the Head and Neck schema. Other schemas do include cytology in the hierarchy below tissue from a biopsy or resection. Cytology is often less specific than histology, so one would expect cytology to be listed below tissue in this hierarchy. Was this an oversight? Or would cytology be equivalent to histology if it provided the most specific histology for the case?

From a number of definitions reviewed, it seems unclear if it's part of the appendix or the cecum of the colon. For example: The cecum is usually located in the right iliac fossa. In the pole of the cecum, there is often the appearance of fusion of the three teniae coli around the appendix, giving rise to the tri-radiate fold (Mercedes Benz sign), but the anatomy can be variable. The most reliable landmarks of the cecum are the appendiceal orifice and ileocecal valve. The appendiceal orifice is usually an unimpressive slit, often crescentic in shape. The ileocecal valve is made up of the superior and inferior lips (usually not seen en face) and is the gateway leading into the terminal ileum. It is located on the prominent ileocecal fold encircling the cecum, between 3 and 5 cm distal to the cecal pole. (https://www.sciencedirect.com/science/article/pii/S2212097113701730)

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)

Per Rule M8, this is a single primary as there are multiple urothelial tumors as outlined in Table 1 (papillary urothelial carcinoma [8130] and sarcomatoid urothelial carcinoma [8122]) simultaneously present in multiple urinary organs (bladder, ureter and renal pelvis). As Rule M8 indicates these are a single primary, despite the histologies differing at the third digit (8130 vs 8122), then Rule H14 (Code the histology of the most invasive tumor) seems to be the most applicable histology rule. Following Rule H14 (in the Text version of the MP/H Rules), the histology would be coded as 8122 (sarcomatoid urothelial carcinoma) since the renal pelvis tumor was the most invasive tumor present.

However, in both the Matrix and Flowchart versions of the MP/H Rules, Rule H14 contains a note (missing from the Text version) that states that this rule should only be used when the first three numbers of the histology codes are identical (This is a single primary). Rule M8 clearly tells us these are a single primary, despite the differences at the third digit of the histology. Further defaulting to Rule H15 (Code the numerically higher histology code) in this case would ignore the histology of the tumor with the worse prognosis (the most invasive tumor). Was this note included in the Matrix and Flowchart versions in error?

The clinical documentation clearly identifies residual tumor after the 2011 craniotomy. Scans demonstrated slow enlargement of the tumor over the years, which resulted in a repeat craniotomy. The pathologist noted in the diagnosis comment section of the pathology report that

Is this a single primary per MP/H Rule M3 (A single tumor is always a single primary), or an additional brain malignancy per MP/H Rule M8 (Tumors with ICD-O-3 histology codes on different branches in Chart 1 or Chart 2 are multiple primaries)?

The FORDS Manual (pg. 22) states: The first course of treatment includes all methods of treatment recorded in the treatment plan and administered to the patient before disease progression or recurrence. The instructions in the FORDS Manual and clarification from multiple CAnswer Forum posts indicates the planned first course treatment stops following disease progression, even when the first course treatment plan is not altered or changed.

SEER, on the other hand, instructs registrars to do the opposite. The SEER Manual instructs registrars to code all completed treatment given as part of the initial first course treatment plan, even after disease progression, provided the treatment plan is not changed or altered. (See 2016 SEER Manual, Section VII First Course of Therapy, Treatment Timing, Rule 1 and Example 1.)

For consistency in data collection, shouldnt the standard setters use the same guidelines to define first course treatment? Given that the majority of cases are reported to SEER by registrars in CoC facilities, who may not be abstracting treatment modalities that occur after progression, the SEER expectation is likely not able to be performed consistently. Wont this difference in standard setter data collection expectations negatively impact the treatment data reflected on our files?

For example, pathology states: Right axillary lymph node, excision: Diffuse large B-cell lymphoma (DLBCL) (see note). COMMENT: FISH studies were performed that were negative for BCL-6, c-Myc/IgH, CCND1/IgH and IgH/BCl-2 gene rearrangement, ruling out the most common forms of double-hit lymphoma. Flow cytometry studies demonstrated positivity for CD45, CD20, HLA-Dr, CD19, CD11c, CD22, CD30, CD38, CD79b, and FMC7. Low positivity was seen for CD5. No reactivity was seen for CD10, CD23, CD25, CD103 or CD123.

Our pathologists have starting to use a new prostate cancer grading system that was adopted by WHO in 2016. The new grading scheme correlates with the prior Gleason grading scheme as follows:

Grade Group 1 = Gleason score 6 or less

Grade Group 2 = Gleason score 3+4=7

Grade Group 3 = Gleason score 4+3 = 7

Grade Group 4 = Gleason score 8

Grade Group 5 = Gleason score 9-10

Our pathologists are no longer dictating the Gleason Primary and Secondary Pattern values nor the Gleason's Score. Reverse correlation from the new grade groups to the required patterns and score are difficult with Grade Groups 2 and 3 needing to be distinguished from one another and Grade Group 5 including two unique scores.

The prostate-related fields include:

Collaborative Site Specific Factor 7: Gleason's Primary Pattern and Secondary Pattern Values on Needle Core Biopsy/TURP

Collaborative Site Specific Factor 8: Gleason's Score On Needle Core Biopsy/TURP

Collaborative Site Specific Factor 9: Gleason's Primary Pattern and Secondary Pattern Values on Prostatectomy/Autopsy

Collaborative Site Specific Factor 10: Gleason's Score on Prostatectomy/Autopsy