Report | Question ID | Question | Discussion | Answer | Year |
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20240074 | Solid Tumor Rules/Histology--Head & Neck: How is histology coded for nasopharyngeal non-keratinizing squamous cell carcinoma, undifferentiated type? See Discussion. |
Example: Patient had a 2023 nasopharyngeal mass biopsy showing “Nasopharyngeal non-keratinizing squamous cell carcinoma, undifferentiated type.” The Head and Neck Solid Tumor Rules (STRs) do not include an H Rule that instructs us how to code histology when there are two subtypes/variants present for a head and neck primary, nor does the STR define undifferentiated carcinoma as a subtype/variant for 8072. The WHO Classification of Head and Neck Tumors states non-keratinizing nasopharyngeal carcinoma (non-keratinizing squamous cell carcinoma (SCC) is the most common subtype for nasopharyngeal ca, but that non-keratinizing can be subdivided into undifferentiated and differentiated subtypes. Should histology be 8020 (undifferentiated carcinoma) or 8072 (non-keratinizing SCC)? |
Assign histology as 8072 for non-keratinizing SCC, undifferentiated subtype. WHO Classification of Head and Neck Tumors, 5th edition assigns 8072/3 to squamous cell carcinoma, non-keratinizing, NOS in the nasopharynx. As the tumor exhibits a variety of architectural patterns and appearances histologically, they can be further classified as undifferentiated or differentiated subtypes. These subtypes do not change the histology code. |
2024 |
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20240044 | First Course Treatment/Neoadjuvant Therapy--Esophagus: Should the Neoadjuvant Therapy data item be coded as 1 or 2 when the patient completes all but one cycle of the planned neoadjuvant therapy and the managing physician notes the patient completed the neoadjuvant therapy? See Discussion. |
The patient had neoadjuvant chemotherapy (Carboplatin and Paclitaxel) concurrent with radiation per the managing physician. The physician stated the patient completed the neoadjuvant therapy; however, it was also noted that patient completed five cycles of chemotherapy, but the sixth cycle was held due to neutropenia. The SEER Manual does not address how to code Neoadjuvant Therapy when the patient completed almost all the planned neoadjuvant therapy. It seems inappropriate to code Neoadjuvant Therapy as 2 (Started but not completed) simply because the patient did not have one cycle of chemotherapy but is otherwise felt to have completed neoadjuvant therapy per the managing physician. Does the managing physician’s statement of “completion” impact how this scenario is coded? |
Assign code 2, Neoadjuvant therapy started, but not completed OR unknown if completed, for the 2024 SEER Manual data item Neoadjuvant Therapy. Assign code 2 when neoadjuvant therapy was begun and the patient did not complete the full course of neoadjuvant therapy. See Coding Instruction #3 on page 230. The fact that the patient completed five cycles of the planned chemotherapy, but the sixth cycle was held due to neutropenia is important information and should be abstracted correctly and documented via text data items. |
2024 |
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20240038 | Solid Tumor Rules/Multiple Primaries--Brain and CNS: How many primaries are accessioned, and what M Rule applies to a 2023 diagnosis of pituitary macroadenoma followed by a 2024 diagnosis of pituitary neuroendocrine tumor (PitNET) when the patient did not undergo surgery, but did undergo hormone therapy with Cabergoline? See Discussion. |
Malignant Central Nervous System (CNS) Rule M5 instructs us to abstract a single primary (as malignant) when a single tumor is originally diagnosed as non-malignant, the “First course treatment was active surveillance (no tumor resection),” and the subsequent resection pathology is malignant. This patient’s first course of treatment was not active surveillance. While the patient did not have first course tumor resection, the tumor was treated with Cabergoline. Should Rule M5 apply because there was no tumor resection? If so, should Rule M5 clearly state no tumor resection is the criteria (not active surveillance)? SINQ 20230023 does indicate a PitNET diagnosis following a diagnosis of pituitary adenoma does not fall into standard rules, but in the previous SINQ the first course treatment was a partial resection. It is unclear whether other types of treatment could result in a new malignant PitNET, following a previously treated non-malignant pituitary tumor. |
Abstract a single primary as 8272/3 (pituitary adenoma/PitNET) using the Malignant CNS and Peripheral Nerves Solid Tumor Rules, Rule M2, a single tumor is always a single tumor. Change the histology of the 2023 diagnosis to 8272/3. This scenario does not meet the criteria in the current rules for M5 in that it requires a resection as part of the criteria. Since the patient did not undergo resection for either diagnosis, the 2024 diagnosis may indicate recurrence or progression. A diagnosis of pituitary adenoma only is still coded 8272/0 (this code is still valid). A diagnosis of pituitary adenoma/PitNET, PitNET, or pituitary neuroendorine tumor is coded 8272/3. Cabergoline is used to treat prolactinoma or high levels of prolactin but does not impact the PitNET. |
2024 |
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20240062 | Reportability--Brain and CNS: Is an MRI finding of “statistically meningioma” reportable? See Discussion. |
Example: Patient has a 2023 brain MRI described as having a “new dural based nodule, statistically meningioma, along the left distal tentorial incisura.” All subsequent chart information is related to patient’s unrelated diagnosis of multiple sclerosis only. Is the terminology “statistically” reportable ambiguous terminology in this context? |
If you cannot clarify this with the involved physicians, do not report this case of meningioma based on information provided. There is no indication that the patient was treated or further evaluated for meningioma. |
2024 |
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20240030 | Reportability/Primary Site--Skin: Is squamous cell carcinoma (SCC) that overlaps skin and the vermillion border reportable when the percent of overlap is unknown? See Discussion. |
SINQ 20031110 addresses an overlapping lip lesion between skin and the vermillion border. We were instructed to go with area of greatest involvement. Case would be reportable if >50% of tumor was on the vermillion border and site would be coded to vermillion border (C00._). Often times percentage of involvement is not stated and all that is known is that the lesion overlaps skin and mucosa. |
Determine whether the lesion is on the mucosa or skin based on the pathology report, history and physical, and operative notes when available. The gross description of the pathology report should include information to help in determining whether the site of origin is epithelium (skin) or mucosa (lip). Do not report the case when the site of origin cannot be determined between a reportable site and non-reportable site for this histology. This includes situations where the site of origin or the site with the greatest involvement is undetermined. In this case, you cannot confirm reportability. |
2024 |
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20240033 | Solid Tumor Rules/Multiple Primaries--Stomach: Is a carcinoid tumor of the stomach diagnosed on 01/01/2023, on a patient who was followed up by Gastrointestinal (GI) and was found to have another stomach carcinoid on 02/01/2024, one primary or two? See Discussion. |
Based on the Solid Tumor Rules, we would make this two since it is over one year. According to a previous SINQ question 20110046, we are to code this as one primary. We see patients come back with multiple carcinoid tumors over the years and would like clarification. |
Stop at the first rule that applies which is M12. Per note 3: When it is unknown/not documented whether the patient had a recurrence, use date of diagnosis to compute the time interval. This means there are two primaries. There is a genetic syndrome that causes multiple carcinoid tumors in the GI tract, per our GI expert, and they should be treated as new primaries per M12. SINQ 20110046 describes a unique situation whereby the subject matter expert felt that the occurrence of multiple tumors was due to an unknown underlying condition driving the proliferation of neuroendocrine cells. |
2024 |
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20240054 | EOD 2018/Primary Tumor--Breast: We are having difficulty deciding when we can or cannot use physician-assigned TNM staging to code EOD data items if the medical record or hospital abstract documentation is unclear. As a central registry, we are unable to query physicians for clarification. Please advise what is a “discrepancy” in the EOD General Instructions to “Use the medical record documentation to assign EOD when there is a discrepancy between the T, N, M information and the documentation in the medical record.” See Discussion. |
We know that physician TNM staging is not always accurate, and we also know that doctors sometimes use information in assigning their TNM which may not be available to registrars. Is it a discrepancy when the documentation in the chart is unclear or not definitive, yet the physician assigns a TNM that seems to incorporate that documentation? Or is a discrepancy an obvious conflict between chart documentation and the doctor’s staging – such as a mis-assignment of TNM category that doesn’t at all match with clear and complete medical record documentation, or the physician’s use of criteria that should be excluded from the TNM assignment per AJCC guidelines? A real case example is a patient with breast carcinoma, imaging states 12 cm tumor with thickening of dermis, and thickening of morphologically suspicious internal mammary and level 1-2 axillary lymph nodes. Medical oncologist states locally advanced breast cancer with extensive changes involving skin thickening associated with the mass, at least stage IIIC based on imaging and exam findings, cT4 N3b. Only axillary nodes were sampled and found to be positive. Post-neoadjuvant therapy resection showed only focal DCIS. Per EOD guidelines, would the oncologist’s staging be a discrepancy with the chart documentation and therefore ignored, with EOD-Primary Tumor coded 200 for skin thickening, and EOD-Lymph Nodes 200 for involvement of axillary nodes only? Or would the doctor’s TNM be a clarification/confirmation of documentation terms that we otherwise would not code, with EOD-PT coded 400 for extensive skin involvement and EOD-LNs 600 for internal mammary + axillary nodes? |
Use all information available in the medical record. EOD is a combination of the most precise clinical and pathological documentation of the extent of disease as instructed in the EOD 2018 General Instructions, Extent of Disease section. EOD 2018 General Instructions, General Coding Instructions section advises to use the medical record documentation to assign EOD when there is a discrepancy between the T, N, M information and the documentation in the medical record. When there is doubt that the documentation in the medical record is complete, code the EOD corresponding to the physician staging. A discrepancy can exist within the medical record when the information in the chart is unclear, incomplete, or conflicting, for example, the TNM staging from pathology differs from the medical oncologist’s TNM staging. In the scenario provided, use the medical oncologist stage information that takes into account imaging and exam findings. Based on the stage cT4 N3b, assign EOD Primary Tumor: 400 Extensive skin involvement WITHOUT a stated diagnosis of inflammatory carcinoma WITH or WITHOUT dermal lymphatic filtration EOD Regional Nodes: 600 Internal mammary node(s), ipsilateral, clinically apparent (On imaging or clinical exam) WITH axillary (level I, II, or III) lymph node(s), ipsilateral including infraclavicular |
2024 |
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20240031 | Reportability/Histology: Is a diagnosis of non-lung neuroendocrine tumorlet reportable? See Discussion. |
Patient was diagnosed March 2023 with a neuroendocrine tumorlet of the rectum measuring 0.8 mm via excisional biopsy during colonoscopy. Prior SINQ 20160011 (stomach specific) indicates microcarcinoid and carcinoid tumors are reportable. Microcarcinoid is a designation for neuroendocrine tumors of the stomach when they are less than 0.5 cm. in size. Is the current rectal tumor a reportable gastrointestinal neuroendocrine tumor if it is less than 5 mm (i.e., is a neuroendocrine tumorlet equivalent to a microcarcinoid)? |
Do not report neuroendocrine tumorlet of lung and non-lung sites. Microcarcinoid and carcinoid tumors are reportable. Tumorlet is a tumor of neuroendocrine differentiation, defined by size < 5 mm in diameter, mitotic count < 2 mitoses/2 mm², and absence of necrosis. Microcarcinoid is a designation for neuroendocrine tumors when they are less than 0.5 cm. in size. The term "tumorlet" is used in a number of other settings, referring to small tumors (usually < 0.5 cm), and does not necessarily mean carcinoid tumor. The term microcarcinoid tumor is not equivalent to neuroendocrine tumorlet. |
2024 |
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20240036 | Update to Current Manual/Race: How is Race coded when stated as Hispanic and there is no other information? See Discussion. |
There appears to be discrepant information in the 2024 (and prior) SEER manual regarding race coding when the patient is described only as Hispanic/Latina. Page 78 tells us to Code as 01 (White) when: b. There is a statement that the patient is Hispanic or Latino(a) and no further information is available
However, in Appendix D, under "Other Race descriptions", there is a statement that "If no further information is available, code as 99 Unknown." The list includes "Hispanic." |
Assign code 01 (White) for Hispanic when there is no additional information. It is listed in the 2024 SEER Manual, Race Coding Instruction 6.b.i. and in Appendix D for code 01. We will remove Hispanic from the list in Appendix D under code 99 in the next version of the manual. |
2024 |
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20240047 | Reportability/Histology--Endometrium: Is “high grade serous intraepithelial neoplasm” of the endometrium reportable? See Discussion. |
The patient had a 2023 endometrial polypectomy and curettage with final diagnosis of “at least serous intraepithelial neoplasia arising in association with an endometrial polyp.” Diagnosis comment states, “There are multiple tissue fragments with highly atypical glandular lining consistent with a high-grade serous neoplasm. There are focal areas which are suspicious, but not conclusive, for stromal invasion.” Subsequent hysterectomy and BSO showed no residual carcinoma. According to previous SINQ 20210043, serous tubal intraepithelial neoplasm (STIN) is reportable when stated to be high grade. Does the same logic apply to a similar neoplasm in the endometrium and/or endometrial polyp? |
Report high grade serous intraepithelial neoplasm of the endometrium. |
2024 |