Report | Question ID | Question | Discussion | Answer | Year |
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20170023 | Reportability/Date of Diagnosis--Prostate: Is PI-RADS 5 diagnostic of prostate cancer, and if so, can we use the date of the impression on the scan that states PI-RADS category 5 as the diagnosis date? See Discussion. |
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? |
Updated answer PI-RADS categories 4 and 5 are reportable, unless there is other information to the contrary. 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) Use the date of the scan as the date of diagnosis. |
2017 |
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20170081 | Grade/Neuroblastoma: What grade is to be used when pathology states only differentiating retroperitoneal neuroblastoma? |
For cases diagnosed prior to 2018 Assign grade code 2 for "differentiating" retroperitoneal neuroblastoma. The rationale of our expert pathologist advisor is that "it leaves the grade 1 category open (since a "well differentiated neuroblastoma" is actually called ganglioneuroblastoma), and it also avoids putting "differentiating" into what is usually a well differentiated category." Additionally, assign grade code 3 to a poorly differentiated retroperitoneal neuroblastoma and grade code 4 to an undifferentiated retroperitoneal neuroblastoma. For cases diagnosed 2018 and later Follow the instructions for coding grade in SEER*RSA |
2017 | |
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20170011 | MP/H Rules/Multiple primaries--Breast: Can we accession two breast primaries when imaging is "suspicious for malignancy" on both breasts but only one biopsy is taken and is histologically confirmed, and assume bilateral complete response to neoadjuvant chemotherapy with bilateral mastectomies negative for residual cancer? See Discussion. |
The patient is diagnosed by bilateral mammograms suspicious for malignancy in both breasts. A biopsy is done on one breast and is positive. The physician states that he will not biopsy the contralateral breast, as the patient has consented to bilateral mastectomy. The patient receives neoadjuvant chemo, follow by bilateral mastectomies. Both breasts are negative for residual cancer, stated as a complete response. Based on "suspicious for malignancy" can we accession two primaries and assume bilateral complete response? |
Accession two breast primaries, one right and one left, rule M7. "Suspicious" is reportable ambiguous terminology. |
2017 |
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20170055 | First Course of Treatment/Surgery of Primary Site--Corpus uteri: Do you code total hysterectomy or radical hysterectomy when a specimen indicates the uterus, cervix, ovaries, fallopian tubes, and right and left parametrium were resected, but shows no portion of the vagina. See Discussion. |
AFS1-AFS2-frozen section control, endomyometrium; AFS3-frozen section control, subserosal intramural mass; A4-anterior cervix; A5-posterior cervix; A6-anterior cervical endometrial junction; A7-posterior cervical endometrial junction; A8-A10-anterior endomyometrium, including tumor; A11-A13-posterior endomyometrium, including tumor and adjacent mass; A14-random section subserosal mass; A15-left parametrium at margin of resection; A16-right parametrium at margin of resection; A17-A18-left ovary and fallopian tube; A19-A20-right ovary and fallopian tube. The final diagnosis includes Endometrial adenocarcinoma, favor serous carcinoma, with papillary and solid areas. Tumor involves: Cervix present, Right ovary, Left ovary, Right fallopian tube, Left fallopian tube, Right parametrium, Left parametrium. |
Assign code 50 for total hysterectomy. According to Appendix C Surgery Codes for Corpus Uteri of the 2016 SEER Coding and Staging Manual, total hysterectomy is surgery to remove the entire uterus, including the cervix; whereas, radical hysterectomy includes the vagina. |
2017 |
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20170006 | Diagnostic confirmation--Heme & Lymphoid Neoplasms (Lymphoma): To code "3" in Diagnostic Confirmation, does the genetic testing need to confirm a specific histology or is it enough that is simply rules out others? See Discussion. |
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. |
Both histologic plus immunophenotyping or genetic testing should be positive to assign code 3 for Diagnostic Confirmation. The Hematopoietic and Lymphoid Neoplasm Coding Manual Diagnostic Confirmation instructions state, assign 3 for Cases positive for neoplasm being abstracted (including acceptable ambiguous terminology and provisional diagnosis) AND Immunophenotyping, genetic testing, or JAK2 is listed in the Definitive Diagnosis in the Heme DB AND a.) Confirms the neoplasm OR b.) Identifies a more specific histology (not preceded by ambiguous terminology). Because the patient was diagnosed with DLBCL by histology, and flow cytometry was positive for CD antigens (immunophenotyping) 20, 22, and 30 for DLBCL, code 3 is appropriate. |
2017 |
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20160075 | MP/H Rules/Histology--Breast: What histology code(s) and MP/H rule applies for a breast resection final diagnosis of "undifferentiated sarcoma associated with a malignant phyllodes tumor and a tumor size of approximately 7 x 6.5 x 4 cm"? (The tumor is primarily sarcoma, with the phyllodes tumor measuring 2.8 cm)? See Discussion. |
Patient has a diagnosis of undifferentiated sarcoma with an associated malignant phyllodes tumor in a single mass. Should this be abstracted as two primaries, one for an undifferentiated sarcoma and the other for a malignant phyllodes tumor? Which MP/H rule applies? |
Abstract a single primary. Based on the information provided, this is a single tumor, and therefore a single primary, Rule M3. Code the histology to malignant phyllodes tumor. According to our expert pathologist consultant, "The presence of a phyllodes tumor component identifies the whole thing as such. Stromal overgrowth/sarcoma is the usual identifier of malignancy in a phyllodes tumor. (If there were no phyllodes component we would be left with undifferentiated sarcoma, but that is not the case here. The diagnosis of malignancy in phyllodes tumor may be difficult/problematic when there is no overt stromal/sarcoma overgrowth as in this case.) As an aside, the behaviors of pure sarcoma and a phyllodes tumor such as we have here are similar, but we would lose the primary diagnosis if we just called this sarcoma." |
2016 |
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20160054 | MP/H Rules/Multiple primaries--Melanoma: How many melanoma primaries should be abstracted if, during the workup for a metastatic melanoma of an unknown cutaneous site, an in situ melanoma is also discovered? See Discussion. |
Patient has diagnosis of melanoma with spindle cell features found in a right lower lobectomy specimen. Chart notes indicate this is metastatic from a cutaneous primary of unknown site. Further work up includes a biopsy of the tip of the nose, which is diagnostic for in situ melanoma. Should this be abstracted as two separate primaries, one for an invasive melanoma of unknown primary site and the other for an in situ melanoma of the skin on the tip of the nose? Which MP/H Rule would apply? |
Yes, abstract this as two separate primaries, an invasive melanoma of unknown primary site and an in situ melanoma of the skin on the tip of the nose. Rule M3 applies. |
2016 |
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20160071 | SEER Summary Stage 2000--Melanoma: Can Clark's level classification still used to Summary Stage melanoma? It was previously used by AJCC TNM, but was not included in the 7th edition. I see it is still listed in the CAP protocols for melanoma. |
Clark's level can be used to assign in situ, localized or regional summary stage.
If there is a discrepancy between the Clark’s level and the pathologic description of extent, use the higher Summary Stage code. |
2016 | |
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20160048 | Reportability--Kidney: Is renal cell neoplasm of oncocytosis reportable based on the pathology from a nephrectomy? See Discussion. |
The pathology diagnosis reads: Diagnosis Right Kidney, Laparoscopic Nephrectomy:
-Renal Cell Neoplasm of Oncocytosis (pT1a, pNX See Comment and Template).
-Surgical margins free of tumor.
Kidney, right, nephrectomy:
Tumor histologic type: Renal cell neoplasms of oncocytosis (see Note)
Sarcomatoid features (%) Not identified
Tumor size: 4 cm (greatest dimension largest tumor)
Other dimensions: 2.7 x 2.5 cm
Macroscopic extent of tumor: Limited to kidney
Focality: Multifocal
Number of tumors: 11 grossly visible, range 0.2 4 cm
Fuhrman grade: 2 of 4
Microscopic extent of tumor:
Perinephric fat invasion: Not identified
Renal sinus invasion: Not identified
Other: N/A
Renal vein involvement: Not identified
Adrenal gland present: No
Involved by tumor: N/A
Direct invasion or metastasis: N/A
Cancer at resection margin: Not identified
Location(s): N/A
Pathologic findings in nonneoplastic kidney: Multiple collections of oncocytic cells
Hilar lymph nodes present: No
Number of involved/number present: N/A
"Thank you for sending this fascinating case. In reviewing the H&E-stained slides, we recognize that multiple lesions of varying sizes are present within the specimen, some with features of oncocytoma, some with those of chromophobe RCC, and yet others with features of both. The immunohistochemical studies for CK7 performed at your institution serve to highlight this point with "mass #1" showing focal single cell staining typical of oncocytoma and "mass #2" showing a patchy and confluent staining pattern typical of chromophobe RCC. This second mass was also positive with special stain for Hales colloidal iron. As mentioned, the morphology varies somewhat in each tumor, however, every single mass is comprised of cells with eosinophilic (pink to bright red) cytopolasm. Some tumors show more tightly nested or sheet like growth, others are more tubular or microcystic. Another important feature, present on slides of renal cortex are microscopic tumorlets seemingly emanating from eosinophilic tubules. This finding, along with the presence of numerous oncocytic neoplasms is supportive of the above diagnosis. The absence of clinical features to suggest Birt-Hogg-Dube syndrome is noted. Although these tumors are not recognized in the current classification of renal tumors, we regard these neoplasms as being a distinct entity, unrelated to both oncocytoma and chromophobe renal cell carcinoma, and have applied the designation "renal tumor of oncocytosis" to such lesions (Gobbo S, et al. Renal cell neoplasms of oncocytosis have distinct morphologic, immunohistochemical, and cytogenetic profiles. Am J Surg Patholl 34:620-626, 2010). We concur that the expected behavior in these cases is one of indolence." |
Do not report Renal cell neoplasms of oncocytosis. According to our expert pathologist consultant, these neoplasms do not behave "in a malignant fashion." They are not currently classified as malignant and are not reportable to cancer registries. |
2016 |
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20160043 | MP/H Rules/Histology--Bladder: Should the term "dedifferentiation" be used to code sarcomatoid transitional cell carcinoma (8122/3)? Or is this typically referring to the grade, and not the histologic subtype? See Discussion. |
Pathology report Final Diagnosis: TURBT : Urothelial carcinoma, high grade. Type/grade comment: Extensive sarcomatoid dedifferentiation is present (40-50% of tumor volume). |
Assign 8122/3 for urothelial carcinoma, extensive sarcomatoid dedifferentiation. Sarcomatoid dedifferentiation refers to the histologic type. 8122/3 is also correct for the following diagnoses.
Urothelial carcinoma, sarcomatoid carcinoma or sarcomatoid variant 8122/3 Urothelial carcinoma with sarcomatoid features 8122/3
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2016 |