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Report Produced: 12/07/2025 05:59 AM

Report Question ID Question Discussion Answer Year
20200043

Histology/Behavior--Bladder: Is the behavior of a bladder tumor with low-grade papillary urothelial carcinoma /2 or /3? See Discussion.

Transurethral resection: Microscopic Diagnosis: Bladder, transurethral resection: Low-grade papillary urothelial carcinoma Gross Description: Received in formalin labeled with the patient's name and bladder tumor is a 3.0 x 2.0 1.0 cm aggregate of friable tan tissue biopsies. The specimen is submitted in toto, cassettes

This is all the information there is on this path report. Extent of Disease (EOD) instructions state inferred description of noninvasive: No statement of invasion (microscopic description present) SEER 2018 Appendix C Bladder Coding Guidelines state code behavior 3 if the only surgery performed is a transurethral resection of the bladder (TURB) documenting that depth of invasion cannot be measured because there is no muscle in the specimen OR the pathology report does not mention whether the submucosa is free of tumor or has been invaded by tumor.

For cases diagnosed 2021 or later

Code the behavior as in situ (/2) when the diagnosis is low grade urothelial carcinoma and there is no information regarding invasion. The SEER Manual Appendix C Bladder Coding Guidelines revision reflects this change. No changes have been made to EOD at this time.

The guidelines have been updated as follows.

Low grade urothelial carcinoma with no other information: Code to /2.

High grade urothelial carcinoma with no other information: Code to /3.

For cases diagnosed prior to 2021

Code the behavior as malignant (/3) for a bladder tumor with low-grade papillary urothelial carcinoma.

 2020
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
20230067

First Course Treatment/Scope of Regional Lymph Node Surgery--Breast:  How is Scope of Regional Lymph Node Surgery coded when initially there is a sentinel lymph node biopsy (SLNBx) and an intramammary node removed followed a month later by an axillary dissection for a right breast primary? See Discussion.

Patient has a diagnosis of invasive carcinoma of the right breast from a core biopsy on 04/2023.

Subsequent bilateral mastectomy and sentinel node biopsy proves one positive sentinel node and one negative intramammary node.

One month later there is a completion axillary node dissection with 15 nodes negative for malignancy.

Per previous SINQ 20190074, the initial mastectomy and sentinel node excision with intramammary node removal should be coded as Scope of Regional Lymph Node Surgery 6. It is unclear how the resulting axillary dissection should be recorded in Scope of Regional Lymph Node Surgery. There is no code for sentinel node biopsy and 3, 4, or 5 at same time (code 6) PLUS an additional subsequent axillary dissection.

Please provide coding instructions for Sentinel Lymph Nodes Positive, Sentinel Lymph Nodes Examined, and Scope of Regional Lymph Node Surgery in this scenario.

Scope of Regional Lymph Node Surgery:  Assign code 7, Sentinel node biopsy and code 3, 4, or 5 at different times. In this case, the SLNBx (code 2) preceded the regional node dissection (code 5: 4 or more regional lymph nodes removed), i.e., procedures performed in separate surgical events.

Sentinel Lymph Nodes Examined:  Assign code 98, Sentinel lymph nodes were biopsied, but the number is unknown. In this case, only the results were provided.

Sentinel Lymph Nodes Positive:  Assign code 01, Sentinel nodes are positive (code exact number of nodes positive). In this case, there was one positive sentinel node.

 2023
20140070

Reportability--Pancreas: Is this reportable? Is this benign? If reportable, what histology code and behavior code should be used? A final pathology diagnosis reads: "Cystic pancreatic endocrine neoplasm (CPEN)".

"Cystic pancreatic endocrine neoplasm (CPEN)" is reportable. Assign 8150/3 based on the information provided. We consulted our expert pathologist and he states "Since metastases have been reported in a few, and all the rest of the pancreatic endocrine tumors are now designated malignant, …we are safe considering them /3 until proven otherwise. Since most of them are non-functioning, [assign code] 8150/3 unless specified as to G1 (8240/3) or G2 (8249/3)."

2014
20150014

Reportability--Brain and CNS:  Is "Lhermitte-Duclos disease" is reportable? See discussion.

The MRI states "Lhermitte-Duclos disease" but does not include "dysplastic gangliocytoma of cerebellum"; is this the same as "Lhermitte-Duclos dysplastic gangliocytoma of cerebellum (C716)"?

"Lhermitte-Duclos disease" alone can be interpreted as "Lhermitte-Duclos dysplastic gangliocytoma of cerebellum (C716)" and reportable. The WHO classification for CNS tumors lists this entity as "Dysplastic gangliocytoma of the cerebellum (Lhermitte-Duclos disease)" signifying that the terms are used synonymously.

2015
20051079

Reportability/AmbiguousTerminology: Because there is a caveat in the SEER PCM, 3rd edition to ignore adverbs such as "strongly" when assessing reportability, should a term such as "likely" cancerous be reportable given than the expression "most likely" cancerous is reportable?

"Likely cancerous" is NOT reportable.

The CoC, NPCR and SEER have agreed to a strict interpretation of the ambiguous terms list. Terms that do not appear on the list are not diagnostic of cancer.

 2005
20081033 Ambiguous terminology: Is the phrase "malignancy is highly considered" reportable given that the phrase "considered to be malignant" is reportable per SINQ 20061094?

"Malignancy is highly considered" is not a reportable ambiguous term.

Diagnoses qualified by the phrase "considered to be malignant" are reportable because this phrase is interpreted as "This diagnosis is malignant."

 2008
20150001

Reportability/Histology: Would a histology reading "Well-differentiated neuroendocrine neoplasm" of the appendix be reportable? Since the word "tumor NOS" and "neoplasm NOS" both code to 8000, I would assume they would be interchangeable but just wanted to verify.

According to SINQ 20130027 & 20140002 a "Well-differentiated neuroendocrine tumor" of the appendix IS reportable.

"Well-differentiated neuroendocrine neoplasm" of the appendix is reportable. According to the WHO classification of Digestive System Tumors, "Well-differentiated neuroendocrine neoplasm" of the appendix is synonymous with NET. WHO states on page 13 "The term 'neuroendocrine neoplasm' can be used synonymously with 'neuroendocrine tumor.'"

Neuroendocrine "tumor," or NET G1, is listed in the WHO classification as one of the malignant neoplasms of the appendix.

 2015
20240043

Reportability/Histology--Digestive Sites: Is a diagnosis of “tubulovillous adenoma with high grade dysplasia” in the duodenum equivalent to a diagnosis of “tubulovillous adenoma, high grade” and, therefore, non-reportable, or is this a reportable non-colorectal high grade dysplasia? See Discussion.

The 2022 ICD-O-3.2 Implementation Guidelines indicate “Tubulovillous adenoma, high grade” is 8263/2 and is not SEER reportable. However, the 2024 SEER Manual and clarification from recent SINQs (20240021 and 20240025) confirm high grade dysplasia in the esophagus, stomach, and small intestine is reportable (8148/2).

Which reportability reference applies to a diagnosis of a tubulovillous adenoma with high grade dysplasia in non-colorectal sites?

A diagnosis of “tubulovillous adenoma with high grade dysplasia” in the duodenum is not equivalent to a diagnosis of “tubulovillous adenoma, high grade.”

Tubulovillous adenoma, high grade (8263/2) is not reportable as of 2022.

High grade dysplasia (glandular intraepithelial neoplasia, grade III) is reportable in the esophagus, stomach, and small intestine (8148/2).

 2024
20100052 Reportability/Primary Site: What is the reportability status and primary site for a papillary carcinoma of thyroid tissue arising in an otherwise benign mature monodermal cystic teratoma (struma ovarii)? See Discussion. Final diagnosis on the pathology report states, "One ovary showing mature monodermal cystic teratoma composed of thyroid tissue (struma ovarii)." The pathology COMMENT section states, "There is a 0.1 cm focus of thyroid tissue within the struma ovarii showing cytologic features of papillary carcinoma. This finding is likely of no clinical consequence."

A papillary carcinoma of thyroid tissue in benign struma ovarii (mature cystic teratoma) is reportable.

These ovarian tumors contain a diversity of tissues including hair, teeth, bone, thyroid, etc. This reportable malignancy arose in thyroid tissue within the ovarian tumor. Code the primary site to ovary. Code to the actual organ in which the cancer arose. This will keep the case in the appropriate category for surgery coding, regional nodes, staging, etc.

2010