First Course of Therapy--Heme & Lymphoid Neoplasms: How is first course of treatment coded for hematopoietic and lymphoid neoplasm (heme) cases who are put on surveillance for years while asymptomatic and then start chemotherapy or other treatment years later once they become symptomatic? See Discussion.
Patient was diagnosed with smoldering myeloma in October 2021 and put on surveillance. In May 2024, the patient became symptomatic and started chemotherapy.
Is the date of diagnosis in 2021, with date of first treatment with chemotherapy in 2024? Or is active surveillance first course and treatment with chemotherapy as second course in 2024?
Code the first course of treatment as active surveillance. Chemotherapy is second course of treatment based on this scenario due to progression.
We will add clarification about this type of scenario to the Heme Manual for the 2027 update.
Reportability/Ambiguous Terminology--Heme & Lymphoid Neoplasms: Should "consistent with" be included in the ambiguous terminology for reportability list in the updated Heme Manual? See Discussion.
In the Heme Manual, published October 2025, the ambiguous terminology used to determine reportability for heme and lymphoid neoplasms (Case Reportability Instructions) was updated and "consistent with" was removed. However, this is an ambiguous term that is used to describe reportability (and not just histology). The term "consistent with" was previously included as a reportable ambiguous term used to report cases prior to this update.
The updated Heme Manual is clear regarding "consistent with" now being a definitive diagnosis for the purpose of coding histology. However, the Note under instruction 4 states, "Do not apply these changes to casefinding, reportability, or staging." Is "consistent with" an exception to this Note? Or should it be re-added to the ambiguous terms related to reportability?
The 2027 version of the Hematopoietic Manual (release October 2026) will include the following in the Case Reportability Instructions, pg. 40:
4. “Consistent with” for reportability and casefinding is now a definitive diagnosis and is no longer ambiguous terminology. This is for hematopoietic neoplasms ONLY.
a. “Consistent with” has become a very common way for pathologists to document diagnoses for Hematopoietic neoplasms. In order to ensure that hematopoietic cases are being reported, “consistent with” has now become definitive terminology for casefinding and reportability (see Histology Coding Instructions for assigning histology).
b. Do not apply this instruction to casefinding and reportability for Solid Tumors.
5. Report the case when the diagnosis of a hematopoietic neoplasm is preceded by one or more of the ambiguous terms listed below:
a. This instruction pertains to reportability and case finding only. See the Histology Coding Instructions, #3-5 for instructions on assigning histology with ambiguous terminology (note that “consistent with” has been removed. See Note #4) .
Reportability/Histology--Breast: 2026: Is lobular neoplasia (atypical lobular hyperplasia) reportable? There is no mention of grade and or conclusive lobular carcinoma in situ (LCIS) statement given.
Do not report a case of atypical lobular hyperplasia of the breast until/unless it is definitively diagnosed as LCIS or another reportable neoplasm. WHO defines this as a non-invasive lobular neoplasia. Atypical lobular hyperplasia does not have an ICD-O code and is not equivalent to in situ.
First Course of Therapy/Hormone Therapy--Thyroid: Is Thyrogen (thyrotropin alpha) coded as hormone therapy when a patient is given Thyrogen as part of planned 2-day Thyrogen Stimulated I-131 treatment for a papillary or follicular cancer? See Discussion.
SEER*Rx categorizes Thyrogen as Hormones and hormonal mechanisms/Thyroid stimulating hormone. Probably not cancer directed–verify with attending MD.
Do not code Thyrogen as hormone therapy when given as a stimulating agent in I-131 therapy. The therapeutic agent is I-131.
The Thyrogen/thyroid stimulating hormone (TSH) is sensitizing the gland to absorb more I-131. Thyrogen/TSH is a trophic hormone so it can cause growth of cancer cells. Thyroid hormones are given in follicular and papillary thyroid cancers to suppress TSH. Although Thyrogen can promote cancer growth its use in Thyrogen stimulated I-131radioactive therapy is justified (benefits exceed the risk), since the use is short (2 days) and the high amount of I-131 would kill cancer cells in addition to majority of thyroid tissue.
We will update the Thyrogen entry in SEER*Rx and clarify in the next release of the SEER manual, Appendix C Coding Guidelines for Thyroid.
Primary Site--Colon: How is primary site assigned when the only documented term is “colorectal cancer?” See Discussion.
Patient is diagnosed with adenocarcinoma documented by the physician as “colorectal cancer.” The medical record does not specify colon, rectosigmoid, rectum, or any specific segment of the large intestine. There is also no imaging, operative, endoscopic, or pathology documentation identifying a more precise site of origin.
Specifically, should the registrar assign:
· C18.9 — Colon NOS - (excludes rectum, NOS C20.9 and rectosigmoid junction C19.9)
· C19.9 — Rectosigmoid junction
· C20.9 — Rectum NOS
· C26.0 — Intestinal tract, NOS
· C26.9 — Gastrointestinal tract, NOS
· or another site
Assign primary site as colon, NOS (C18.9) when the only information about the diagnosis you have is "colorectal cancer."
We consulted with a subject matter expert who believes that colon, NOS is closest to being correct and that rectosigmoid is not appropriate.
If further information becomes available through further workup and/or treatment, update the primary site as appropriate.
We will add clarification to the 2027 SEER Manual, Appendix C, Colon Coding Guidelines.
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