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Report Produced: 07/27/2025 11:19 AM

Report Question ID Question Discussion Answer Year
20130216

Primary site--Heme & Lymphoid Neoplasms: Need help determining primary site for Diffuse Large B-Cell Lymphoma 9680/3 confirmed pathologically in right ovary and soft tissue left adnexa. No lymph nodes examined pathologically. Patient treated outside and no access to notes. See discussion.

CT A/P massively enlarged uterus with no distention between the vagina, cervix or proximal to mid uterus identified. Highly concerning for malignancy though distinct etiology not clear. Ovarian not favored though not excluded given lack of clearly defined fat planes between uterus and either ovary. Extensive bilateral iliac chain and periaortic/pericaval lymphadenopathy.

Trying to work through Module 7 in the Hem DB. According to the ovary site, regional lymph nodes include the iliac and the para-aortic lymph nodes. This makes me think I should use Rule PH35 (organ and regional nodes). However, using Appendix C in the Hem DB, the iliac lymph nodes are part of the pelvic C775 while the para-aortic (periaortic) are intra-abdominal C772. This makes me wonder if I should go with rule PH36 present in organ and nodes that are not regional.

Use Rule PH25 and code primary site to C569.

First determine if the iliac and para-aortic lymph nodes are regional for Ovary. Use AJCC TNM or Collaborative Stage. Per AJCC 7th edition, regional lymph nodes for ovary include iliac and para-aortic (pg. 419). Therefore, this case involves an organ and its regional lymph nodes. Use appendix C to determine how to code a lymph node primary. It should not be used to determine whether lymph nodes are regional for a specific organ.

2013
20200059

Reportability--Kidney: Is Bosniak 4 cystic lesion of right kidney reportable, and would the first CT date be the date of diagnosis? See Discussion.

CT a/p read by radiologist shows: "Bosniak 4 cystic lesion of right kidney." Follow-up MRI a month later reads "right kidney cystic lesion with enhancing mural nodule concerning for cystic renal cell carcinoma (RCC)." Urologist consult used the same wording of "Bosniak 4 cystic lesion" and "concerning for renal cell carcinoma." Treatment discussed but due to patient health status recommended repeat imaging. Repeat CT few months later reads: "cystic right renal lesion with enhancing nodule similar to most recent prior and suspicious for cystic RCC."

Though "suspicious for cystic RCC" per latest imaging is reportable, Bosniak 4 is "clearly malignancy, ~100% malignant" by definition, so is the case actually reportable with the first CT a/p date as date of diagnosis?

2023

Bosniak 4 is defined as  "clearly malignant cystic mass." The case is reportable as of the first date it is diagnosed as a Bosniak 4 lesion unless further workup (especially biopsy or resection) disproves the CT findings.

https://radiopaedia.org/articles/bosniak-classification-system-of-renal-cystic-masses?lang=us

 2020
20180035

Solid Tumor Rules (2018)/Multiple Primaries--Lung: How many primaries should be abstracted in this 2018 lung case? See Discussion.

CT chest findings: 1. There is a dominant 1 cm. nodule in the left mid lung. 2. In addition, there is a new rather dominant bilobed nodule in the left lung base. 3. Distant metastases are not identified. Four months later, a doctor's note says routine follow-up visit status post Cyber Knife stereotactic body radiation therapy for synchronous early stage non-small cell carcinomas of the left upper and left lower lobes, both Stage IA. He is medically inoperable. This situation is described as a second primary tumor in AJCC8 page 438. However, by the 2018 Lung Solid Tumor rules, this would be a single primary, per rule M7. Is that correct?

Abstract one primary per Rule M7. Follow the Lung Solid Tumor Rules to determine the number of primaries. The AJCC TNM manual is used for staging. Do not apply AJCC instructions to determine the number of primaries.

 2018
20031039

EOD-Clinical Extension--Liver: How do the segments of the liver described by AJCC Manual correspond to the lobes of the liver described by the SEER EOD Manual? See Description.

CT described hepatocellular ca involvement of the liver with nodules identified in segments 5 and 7. Would EOD-extension be coded to 30 [multiple tumors (one lobe)]?

Segments 2, 3, and 4 correspond to the left lobe of the liver. Segments 5, 6, 7 and 8 correspond to the right lobe of the liver. Segment 1 is the caudate lobe, which has completely different drainage and vascularization, is separate from the larger right and left lobes.

For cases diagnosed 1998-2003: Since segments 5 and 7 are both in the right lobe, assign EOD-extension code 30 for the case above, unless there is mention of vascular invasion. Be sure to record the size of the largest primary tumor.

Tumor size and vascular invasion are the most important factors for AJCC 6th edition staging.

 2003
20041091 Primary Site/Summary Stage 2000/EOD-Extension--Lymphoma: How are these fields coded when a CT Impression states: Large retroperitoneal/abdominal mass resulting in extra-hepatic biliary obstruction & bilateral urinary tract obstruction & encasement of major vessels most c/w lymphoma? See Discussion.

CT findings state: Very lg sft tiss mass encasing pancreatic head & portion of body, splenic & portal veins, celiac axis, sup mesenteric artery & bilateral renal veins. Two components to this mass: 1) retroperitoneal mass encasing great vessels and 2) peritoneal component 10.8cm size, displaces bowel & other structures & encases vessels.

If the physician stated "this is bulky disease" would that change the EOD?

For tumors diagnosed 1998-2003:

Based on the information provided:

The topography code for this lymphoma is C772 [Intra-abdominal lymph nodes].

Code SEER Summary Stage 2000 to 5 [Regional NOS].

Code EOD Extension to 20. More than one lymph node region below the diaphragm is involved (retroperitoneal and peritoneal). The organs mentioned are not involved by the lymphoma. The bulk of the masses is causing obstruction by displacing and/or encasing organs.

A physician description of "bulky disease" would not change the EOD for this case.

 2004
20120042 Histology--Heme & Lymphoid Neoplasms: How is the histology coded if a pelvic mass biopsy is positive for B-cell non-Hodgkin lymphoma and a mediastinal lymph node biopsy is positive for follicular lymphoma, grade 1? See Discussion.

CT guided core biopsy of pelvic mass is positive for B-cell non-Hodgkin lymphoma. Bone marrow biopsy is negative. Mediastinoscopy with mediastinal and pretracheal nodes biopsy is positive for follicular lymphoma grade 1 of 2. The patient has a PET demonstrating positive extensive metastatic disease with nodes in neck, chest, abdomen/pelvis and bone involvement. Should the histology be coded 9591/3 [NHL, NOS] or 9695/3 [FL, grade 1]? Which rule applies?

The table of contents for the Hematopoietic Manual indicates Module 8 for these histologies, however, Module 8 rules do not seem to apply. Continuing on to Module 9, the first rule that applies is PH30. PH30 states use the Heme DB to determine primary site/histology. The Heme DB indicates these are separate primaries, but both histologies are B-cell lymphomas.

For cases diagnosed 2010 and forward, access the Hematopoietic Database at http://seer.cancer.gov/seertools/hemelymph.

Code the histology to 9695/3 [follicular lymphoma, grade 1] per PH29.

Under the Alternate Names section of the Heme DB, B-cell non-Hodgkin lymphoma is synonym for non-Hodgkin lymphoma, NOS and B-cell lymphoma, NOS.

Per PH29, one codes the histology when there is one non-specific histology (NHL, NOS) and one specific histology (FL, grade 1). You are also required to confirm the specific and the non-specific (NOS) histology represent the same primary using the Multiple Primaries Calculator. The calculator indicates these are the same primary.

SEER*Educate provides training on how to use the Heme Manual and DB. If you are unsure how to arrive at the answer in this SINQ question, refer to SEER*Educate to practice coding hematopoietic and lymphoid neoplasms. Review the step-by-step instructions provided for each case scenario to learn how to use the application and manual to arrive at the answer provided. https://educate.fhcrc.org/LandingPage.aspx.

 2012
20100049

Multiple primaries--Heme & Lymphoid Neoplasms: How many primaries are to be abstracted when a lymph node biopsy reveals "malignant lymphoma, peripheral T-cell type, with some features of angioimmunoblastic T-cell lymphoma and follicular T-cell lymphoma," the bone marrow biopsy was negative for involvement, and the oncologist states this patient has "peripheral T-cell lymphoma"? See Discussion.

CT scan showed retroperitoneal and inguinal adenopathy. Right inguinal lymph node biopsy revealed "malignant lymphoma, peripheral T-cell type, with some features of angioimmunoblastic t-cell lymphoma and follicular t-cell lymphoma." Flow cytometry studies showed no evidence of B-cell lymphoma and atypical CD3+/CD10+/CD7-/CD4+/CD56+ T cells are detected (19%). The bone marrow biopsy was negative for involvement. Patient was staged as Stage II Peripheral T-Cell lymphoma by the oncologist and started chemotherapy.

For cases diagnosed 2010 and forward, access the Hematopoietic Database at http://seer.cancer.gov/seertools/hemelymph.

Code the oncologist's clinical diagnosis of peripheral T-cell lymphoma.

The definition for this neoplasm is "A large group of lymphomas which we collectively refer to as peripheral T-cell lymphomas with the optional addition of "unspecified" to emphasize that these cases do not belong to any better defined entities. Attempts to distinguish between them on morphological basis have met with poor reproducibility."

Per the Abstractor Notes in the Heme DB: Patients present with peripheral LN involvement. The diagnosis of PTCL, NOS is made ONLY when other specific entities have been explored.

This fits your case; attempts to find a more specific disease (flow cytometry; BM biopsy) were negative and gave no further information that could be used to assign a more specific classification.

SEER*Educate provides training on how to use the Heme Manual and DB. If you are unsure how to arrive at the answer in this SINQ question, refer to SEER*Educate to practice coding hematopoietic and lymphoid neoplasms. Review the step-by-step instructions provided for each case scenario to learn how to use the application and manual to arrive at the answer provided. https://educate.fhcrc.org/LandingPage.aspx.

2010
20061136

Primary Site: What site code best reflects the final diagnosis of a metastatic "pancreatobiliary" adenocarcinoma to the liver? See Discussion.

CT showed multiple masses in the liver and lymphadenopathy in areas of gastrohepatic ligament, celiac axis, superior mesenteric and left periaortic regions. No mention of a mass in pancreas or common duct. When the term "pancreatobiliary" primary is stated in the final diagnosis, what site code should be used?

Contact the physician for clarification of the term "pancreatobiliary." If no further information can be obtained for this case, assign code C249 [Biliary tract, NOS] based on the CT findings for the specific case in this question.

When the primary is described as "pancreatobiliary" with NO FURTHER INFORMATION, assign C269.

 2006
20170060

MP/H Rules/Histology/Grade--Unknown & ill-defined sites: What is the correct histology and grade of a liver biopsy with metastatic neuroendocrine carcinoma low to intermediate grade if primary site is unknown? See Discussion.

CT-guided liver biopsy, diagnosis: Metastatic neuroendocrine carcinoma. Diagnosis Comment: Cytology of the tumor appears to be low to intermediate grade.

Would this case be coded as an atypical carcinoid tumor (8249/3) based on SINQ 20170033 and the statement of intermediate grade; or should this be 8240/3 (neuroendocrine tumor) per SINQ 20160023 because it is a metastatic site? More clarification is needed on when to code 8249/3 or 8240/3 for a neuroendocrine carcinoma or neoplasm seen in a metastatic specimen only when there is specified grade.

Assign histology code 8246/3 and assign code 9 for grade.

Since the primary is unknown and the type of NEC is not definitively stated, code neuroendocrine carcinoma, NOS based on the diagnosis.

Code grade from primary tumor only. Assign grade code 9 when the primary site is unknown. See instruction 2.b. in the Grade Coding Instructions for 2014+.

SINQ 20170033 and SINQ 20160023 provide instructions for coding the grade/differentiation field. Using these SINQ questions to code histology could lead to errors.

 2017
20020062 Histology (Pre-2007): Can the histology code 8582/3, "thymoma, mixed type, malignant" only be used when you have a thymoma with both type A and type B features? See discussion.

Can this same histology be used when you have two type B features in the thymoma specimen? What code is used to represent the histology?

Example 1: Thymoma, spindle cell and epithelial type

Example 2: Thymoma, mixed lymphocytic and epithelioid type

For tumors diagnosed prior to 2007:

For example 1, code histology to 8582 [Thymoma, type AB]. This code is only applicable to "Type AB thymoma [mixed]" in the WHO classification. Use 8582 only for thymomas with type A and type B features. Spindle cell is a type A feature and epithelial is a type B3 feature.

For example 2, code histology to 8585 [Thymoma, type B3]. Lymphocytic is a B1 feature (8583) and epithelial is a B3 feature (8585). There is no type A component. Code the histology based on ICD-O-3 rule K on page 34.

For tumors diagnosed 2007 or later, refer to the MP/H rules. If there are still questions about how this type of tumor should be coded, submit a new question to SINQ and include the difficulties you are encountering in applying the MP/H rules.

 2002