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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.

Example:  A prostate core biopsy showed intraductal carcinoma in 09/2022, which is an in situ tumor.  A core biopsy again showed intraductal carcinoma in 12/2022.  The subsequent radical prostatectomy in 04/2023, revealed multiple foci of invasive prostate adenocarcinoma with extensive intraductal carcinoma. 

Per Solid Tumor Rules, Other Sites, Rule M3, acinar adenocarcinoma of the prostate is always a single primary.  Note 4, this rule applies to subtype variants of acinar adenocarcinoma listed in Table 3, which has intraductal/ductal as a variant subtype of acinar adenocarcinoma. Does rule M3 apply to incidence cases (an invasive tumor following an in situ tumor)?

in March, the patient with stage cT1c, Gleason grade 7, prostate cancer elected active surveillance. In April, the patient consented to treatment with Lupron. There was no evidence of disease progression. According to the rules on page 161 of the 2023 SEER manual, we think the answer is yes, but the reporting hospital states that this is second course therapy.

The patient has adenopathy in multiple lymph node regions above and below the diaphragm and a lymph node biopsy pathology proved CLL/small lymphocytic lymphoma (SLL). Further work-up with peripheral blood proved an abnormal CD5-positive B-cell population comprising only a small percentage of the white blood cells (WBCs). The pathologist noted this neoplastic B-cell population comprises “3.5% of white blood cells and has an immunophenotype characteristic of CLL/SLL and is similar to the recent lymph node biopsy in this patient.” The managing physician indicated this was a Lugano Stage III SLL. The registrar coded the peripheral blood involvement in EOD Primary Tumor.

If this small percentage of WBCs with an abnormal B-cell population is included in EOD Primary Tumor as peripheral blood involvement, then this would indicate peripheral blood/bone marrow involvement and primary site would need to be coded to C421 per Rule PH5. Rules PH5 and PH6 confirm primary site must be coded C421 if peripheral blood or bone marrow are involved.

Is there a cutoff value for these abnormal B-cell populations in the peripheral blood? Or should these abnormal B-cell populations be ignored unless the pathologist states the abnormal B-cell population is consistent with CLL/SLL (not just immunophenotypically characteristic of CLL/SLL)?

The 2023 SEER Manual instructions contain a new note in Hematologic Transplant And Endocrine Procedure, Coding Instruction 6, regarding bilateral salpingo-oophorectomy (BSO) when performed for hormonal effect for breast, endometrial, vaginal, and other primary cancers. While we have observed BSO being performed for breast primaries, we do not recall ever seeing a statement for endometrial or vaginal primaries regarding a “BSO being done as hormonal manipulation” when scheduled either with or without a hysterectomy being performed simultaneously. As a result, we are not clear exactly when a BSO would be captured in the Hematologic Transplant And Endocrine Procedure field for these gynecologic primary sites.

Also, if these types of procedures are Hematologic Transplant And Endocrine Procedures, are they also captured and coded in the Surgery of Primary Site codes that directly relate to those same organs? Does timing have any effect on the coding of either field?

There was a 3.5 cm invasive adenocarcinoma tumor in the pancreatic head. There were four separate, sized pancreatic neuroendocrine tumors measuring 0.9, 0.7, 0.5 and 0.2 cm in the pancreatic body. There are multiple tumors with distinctly different histologies. However, Table 11 (Pancreas Histologies) does not include any entries for neuroendocrine tumors of the pancreas (e.g., pancreatic NET, WHO grade 1, histology 8240). While it would seem Rule M19 should apply as they’re distinctly different histologies, because PanNETs are not included in Table 11, it is not clear which M Rule applies to these multiple tumors.

If Rule M19 does not apply, we are left with Rule M21 (Abstract a single primary when there are multiple tumors that do not meet any of the above criteria). Are these separate tumors with distinctly different histologies really a single primary? Pancreatic neuroendocrine tumors are not an uncommon histology, is there a reason these were not included in Table 11?

Patient had a mandibular mucosal lesion resected in June of 2023, with a diagnosis of “atypical squamous proliferation” and case was forwarded to an expert in oral pathology for best classification. Subsequent slide review final diagnosis was “moderate to severe squamous dysplasia.” That slide review diagnosis goes on to state “microscopic focus suspicious for superficial invasion.”

Currently there is no ICD-O code for severe squamous dysplasia, however it is unclear if this terminology is equivalent to high grade squamous dysplasia (histology code 8077/2).

The WHO Blue Books do not include dedifferentiated carcinoma as a valid histology for the breast.  However, there is known to be progression of ductal carcinoma that is essentially dedifferentiation of an estrogen receptor, progesterone receptor, and HER2 breast carcinoma to a triple negative "dedifferentiated" carcinoma which it appears this patient has. Whether we should accession this as a separate 8020/3 primary per M14 is unclear and the Solid Tumor Manual does not address this scenario.

SINQ 20180104 indicates, in the absence of further info, the terms “almost certainly” and “until proven otherwise” are NOT reportable. There is no date range provided for this answer.

SINQ 20200027 indicates, in the absence of further info, the term “most certainly” IS reportable. There is no date range provided for this answer.

SEER Program Coding and Staging Manual 2022 indicates, in the absence of further info, the terms “until proven otherwise” and “most certainly” ARE reportable.

Essentially, we are hoping for an update of SINQ 20180104 due to 2022 reportability change. Clarification to the equivalence of “almost certainly” and “most certainly” would also be helpful.