Report | Question ID | Question | Discussion | Answer | Year |
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20230001 | Solid Tumor Rules/Multiple Primaries--Lung: How many primaries should be reported when two separate squamous cell carcinoma (SCC) tumors, one in the left upper lobe (LUL) and one in the right lower lobe (RLL), are diagnosed? The tumors are separated by an interval occurring right hilar lymph node biopsy proving metastatic pulmonary adenocarcinoma without a clear description of a corresponding interval occurring lung tumor. See Discussion. |
The patient was diagnosed with a biopsy-proven 12/2020 LUL SCC treated with radiation only, followed by a right hilar lymph node biopsy in 07/2022, that proved “metastatic pulmonary adenocarcinoma” per pathology and treated with radiation, followed by a biopsy-proven 12/2022 RLL SCC to be treated with immunotherapy only. The imaging never definitively identified a lung tumor that can be assumed to be a primary adenocarcinoma tumor. In 06/2022, a PET scan only described a “strongly PET positive Rt inferior hilar LN vs infrahilar pulmonary mass,” as well as the subsequently biopsy-proven SCC in the RLL (12/2022 SCC primary). The biopsy path indicates this was a right hilar lymph node metastasis and does not indicate this is an infrahilar pulmonary mass. No other PET positive pulmonary lesions were seen at the time. The oncologist’s assessment indicates the right hilar node was the only positive finding on the biopsy, and it was unclear if this right hilar node metastasis was from the left lung or if the primary was “not detectable.” The oncologist summarized this as a LUL lung lesion radiated for SCC, a right hilar lesion radiated for adenocarcinoma, and a RLL lung lesion on pathology found to be SCC. Should the interval occurring metastatic adenocarcinoma be accessioned as a separate lung, NOS primary based on the histology difference? While the Solid Tumor Rules do not apply to metastasis, the oncologist did treat these three malignancies separately and does not indicate the hilar lymph node metastasis was felt to be from either SCC primary. |
Abstract three primaries based on this scenario. 1 – 2020, SCC LUL lung 2 – 2022, Adenocarcinoma lung, described as metastatic pulmonary, based on biopsy of right hilar node (Rule M8) 3 – 2022, SCC RLL lung (Rule M11) |
2023 |
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20230063 | EOD 2018/EOD Regional Nodes--Melanoma: Can central cancer registries code Extent of Disease (EOD) Regional Nodes as 000 based on Breslow’s depth and/or Clark’s Level (per EOD and/or Summary Stage) from a melanoma pathology only report with a localized tumor and no information on regional lymph nodes or mets. See Discussion. |
Based on the EOD General instructions for accessible sites, the following three requirements must be met a. There is no mention of regional lymph node involvement in the physical examination, pre-treatment diagnostic testing, or surgical exploration; b. The patient has localized disease; c. The patient receives what would be the standard treatment to the primary site (treatment appropriate to the stage of disease as determined by the physician), or patient is offered usual treatment but refuses it. As a central registry, we receive a lot of melanoma path reports but never receive an abstract since the patients are seen at a dermatology office that does not report to the central registry. In these scenarios, we have both the diagnosis and wide excision or Mohs surgery from which we create a consolidated record. It is not often that lymph nodes are removed which indicates there were no palpable nodes. Since the Breslow’s and Clark’s level allow for summary staging, is it possible to have central registry guidelines that allow for coding lymph nodes other than 999? The path reports meet two of the three criteria. Is there any new literature that supports coding lymph nodes 000 based on a Clark’s level or Breslow measure providing the patient has a wide excision? |
Assign 000 for EOD Regional Nodes when you have a pathology only report with a localized tumor based on Breslow’s depth and/or Clark’s Level (per EOD and/or Summary Stage) and no information on regional lymph nodes or mets. When the tumor is noted to be regional or distant based on Breslow’s Depth and/or Clark’s based on the definitions in EOD and/or Summary Stage, do not assume that the nodes are negative and assign 999. Clarification will be added to the EOD manual. |
2023 |
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20230009 | Solid Tumor Rules/Multiple Primaries--Vulva: How many primaries are accessioned when a 2023 diagnosis of keratinizing squamous cell carcinoma (SCC) (8071/3) of the vulva follows a previous diagnosis of nonkeratinizing SCC (8072/3) of the vulva and the timing rule (M12) does not apply? See Discussion. |
Table 19: Vulva Histologies of the Other Sites Solid Tumor Rules does not include entries for either keratinizing or nonkeratinizing squamous cell carcinoma in the “Squamous cell carcinoma, NOS” row. However, these are two distinctly different histologies per the ICD-O-3.2. All other Solid Tumor Rules schemas include an M Rule instructing one to abstract multiple primaries when separate/non-contiguous tumors are two or more different subtypes/variants in Column 3 of the Specific Histologies, NOS, and Subtype/Variants Table for the schema (e.g., Rule M6 for Lung). The timing of these tumors is stated to be irrelevant. The Notes confirm the tumors may be subtypes/variants of the same or different NOS histologies and tumors in column 3 are all distinctly different histologies (even if they are in the same row). However, the 2023 Other Sites schema appears to be missing this rule. Should these distinctly different histologies be accessioned as separate primaries? Is an M Rule missing from the Other Sites schema to address distinctly different histologies? |
Table 19 is based on WHO 5th Ed Tumors of vulva and squamous cell variants, keratinizing and non-keratinizing, are no longer recommended and are excluded from the 5th Ed. HPV related terminology is now preferred for these neoplasms. Per consultation with our GYN expert pathologist, based on the information provided, this is likely a single tumor that was not completely excised in the original biopsy. A new tumor in the same site would not appear within 8 months. If you cannot confirm two separate/non-contiguous tumors were present, abstract a single primary per M1. As for histology, the tumor showed both keratinizing and non-keratinizing features and HPV status is unclear. Per our expert, code to SCC 8070/3—keratinization or lack of does not change treatment or prognosis. Even If there is proof of separate/non-contiguous tumors, our expert still feels this is a single primary coded to SCC 8070/3. Treatment does not differ by keratinization or HPV status. Coding two primaries would be incorrect and inflate incidence rates. Per our expert, this is an unusual occurrence. The rules cover 85% of cases but there will always be situations that do not fit a rule. This case is an example of that. A new GYN specific Solid Tumor Rules module is under development and a rule to address this situation could be included. |
2023 |
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20230070 | Solid Tumor Rules/Multiple Primaries--Breast: How many primaries should be accessioned for a diagnosis of invasive carcinoma of the left breast (8500/3) in 2020 followed by a 2023 diagnosis of dedifferentiated carcinoma in the left breast (8020/3)? See Discussion. |
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. |
Abstract a single primary using Breast Solid Tumor Rules, Rule M18, as none of the previous rules apply. Undifferentiated carcinoma is a malignant epithelial tumour lacking overt evidence of a specific line of differentiation. Dedifferentiated carcinoma is composed of an undifferentiated carcinoma and a differentiated component. Dedifferentiated carcinoma (8020/3) as a morphology is associated with cancer of the endometrium and ovary rather than the breast. Breast cancer shows a broad spectrum of morphology with extensive variation in histological type and grade, related to the complexity of carcinogenesis. This includes initial genetic changes in the cell of origin, subsequent genetic and epigenetic alterations, and reprogramming that occur at various stages of development along with interaction of other factors that influence the process of differentiation. This scenario likely represents the process of phenotypic change of a carcinoma at a later stage, better known as transdifferentiation. |
2023 |
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20240050 | Solid Tumor Rules/Multiple Primaries--Vulva: Why is there no M Rule in the Other Sites Multiple Primary Rules related to extramammary Paget disease of the vulva? See Discussion. |
The only Other Sites H Rule related to extramammary Paget disease is included in the Multiple Tumors Abstracted as a Single Primary module. Rule H28 instructs one to code the histology of the underlying tumor when there is extramammary Paget disease and an underlying tumor of the anus, perianal region, or vulva. Therefore, a vulvar extramammary Paget disease with underlying adenocarcinoma is coded as adenocarcinoma (8140/3), and not extramammary Paget disease (8542/3). However, there is no M Rule confirming extramammary Paget disease and the underlying adenocarcinoma are a single primary (i.e., multiple tumors abstracted as a single primary) making it difficult for one to use the Multiple Tumors Abstracted as a Single Primary H rules module. We recognize this is a longstanding histology coding rule, but how are registrars supposed to arrive at Rule H28 when the M Rules must be applied first and do not instruct one to accession a single primary? Moreover, if this is to be a single primary (per rule M2), why is there no H Rule in the Single Tumor module? |
In sites other than breast (see Breast Solid Tumor Rules M8/M9), Paget disease with underlying invasive disease is a single primary and the underlying histology is coded. Primary Paget disease of the vulva is uncommon, and we cannot create rules for all possible situations in the Other Sites module. A GYN specific module is in development, and we will look into adding a Paget-related rule. It will differ because Paget in breast is a different situation while Paget in the vulva is always adenocarcinoma. Paget disease of the vulva is an in-situ adenocarcinoma of vulvar skin with or without an underlying adenocarcinoma (WHO Classification of Female Genital Tumors, 5th ed.). When there is a statement of “underlying” adenocarcinoma, it is a single primary as with Breast Solid Tumor Rule M8. |
2024 |
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20240004 | Reportability/Histology--Skin: Is a malignant spindle cell neoplasm consistent with atypical fibroxanthoma reportable for cases diagnosed 1/1/2023 and later, after thorough immunohistochemical work-up? See Discussion. |
Appendix E1 in both the 2023 and 2024 SEER Program Coding and Staging Manual (SPCSM) lists these malignant spindle cell neoplasms, consistent with atypical fibroxanthoma, as reportable when other tumors have been ruled out with immunohistochemistry. This contradicts both SINQ 20190102 and the Solid Tumor Rules (STRs) general instructions indicating ambiguous terminology (e.g., “consistent with”) cannot be used to code the more specific histology when there is a NOS (malignant spindle cell neoplasm, 8004/3) and a more specific (malignant atypical fibroxanthoma, 8830/3) histology. These tumors are typically diagnosed and treated in dermatology offices, so further chart review or confirmation by a physician is not possible for central registries. As non-melanoma skin primaries are included in the Other Sites schema, and this schema was updated for cases diagnosed 2023 and later, which instruction applies to 2023+ diagnoses? Should these continue to be collected per Appendix E1 despite the conflict with the STR Manual and SINQ? If these are reportable, should the SINQ and STR Manual be updated to reflect this? Or should these be non-reportable per the STR Manual and SINQ? |
Report malignant spindle cell neoplasms consistent with atypical fibroxanthoma as directed by Appendix E.1 of the 2023 and 2024 versions of the SEER Manual using 8830/3 (fibroxanthoma, malignant). We will update the answer in SINQ 20190102. While the Other Sites Solid Tumor Rules address coding an NOS and specific histology sub-type/variant, this situation is not specifically addressed. We will also review the rules. |
2024 |
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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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20240075 | 2024 SEER Manual/Reportability--Breast: Is "lobular intraepithelial neoplasia" (LIN) a glandular intraepithelial neoplasia? If so, is lobular neoplasia II (LN II)/LIN II non-reportable, similar to PanIN II - SINQ 20240026? See Discussion. |
The Reportable Diagnosis List indicates "Lobular neoplasia grade II (LN II)/lobular intraepithelial neoplasia grade II (LIN II) breast (C500-C509)" is reportable. The ICD-O-3.2 lists “Glandular intraepithelial neoplasia, grade II” and “Glandular intraepithelial neoplasia, low grade” as histology code 8148 with behavior of /0 (benign). |
Report LN II and LN III along with LIN II and LIN III and assign code 8520/2. WHO Classification of Breast Tumors, 5th edition, lists lobular neoplasia as acceptable, related terminology for lobular carcinoma in situ. |
2024 |
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20240073 | Solid Tumor Rules/Multiple Primaries--Bladder: Urinary Sites Solid Tumor Rules (STRs), Rule M6, says to abstract multiple primaries when an invasive tumor occurs more than 60 days after an in situ tumor. Does that 60-day interval apply to the original diagnosis date, or to the latest recurrence? See Discussion. |
10/2017 Bladder cancer diagnosed as invasive papillary urothelial bladder carcinoma (8130/3) (submucosal invasion). 12/2017 Surveillance scope and transurethral resection of bladder tumor (TURBT) finds “recurrent” bladder tumor, non-invasive papillary urothelial bladder carcinoma (8130/2) - same primary per 2007 Multiple Primaries/Histology, Rule M6, (both papillary urothelial bladder carcinomas). 4/2018 Radical nephrectomy found focally invasive urothelial carcinoma (8120/3) in the renal pelvis. Is this a new primary per 2018 and forward STR, Rule M6, because it was more than 60 days since the 12/2017 in situ bladder recurrence? Or would one compare the 2018 diagnosis to the original invasive bladder tumor in 10/2017, and continue on to Rule M11, which says to abstract a single primary for urothelial carcinomas in multiple organs, regardless of behavior? SINQ #20120080 said to compare to the original diagnosis and disregard intervening recurrences, but that pertained to the 2007 MP/H rules. Does this still apply for 2018 forward? STR, Rule M10, Note 3, states when there is a recurrence within three years of diagnosis, the “clock” starts over. The time interval is calculated from the date of last recurrence. Comparing each recurrence for urothelial carcinomas using Rule M6 could result in over-counting them. Can the instructions on how to calculate the 60-day interval be clarified in Rule M6? |
Abstract a single primary for this scenario based on Urinary Sites STRs. 10/2017 and 12/2017 bladder diagnoses: Single primary (Rule M15: Abstract a single primary when synchronous, separate/non-contiguous tumors are on the same row in Table 2 in the Equivalent Terms and Definitions). This interval is not indicative of recurrence as there is no clinically disease free period on follow-up. Use the Multiple Primary Rules as written to determine whether a subsequent tumor is a new primary or a recurrence as stated in the General Instructions. The only exception is when a pathologist compares slides from the subsequent tumor to the “original” tumor and documents the subsequent tumor is a recurrence of the previous primary. Never code multiple primaries based only on a physician’s statement of “recurrence” or “recurrent.” 12/2017 (bladder) and 4/2018 diagnoses (renal pelvis): Single primary (Rule M11: Abstract a single primary when there are urothelial carcinomas in multiple urinary organs; behavior is irrelevant.) |
2024 |
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20240058 | Summary Stage 2018--Ovary: What is the summary stage for an ovarian primary in 2024, in which the ovary capsule was ruptured with surgical spill? See Discussion. |
In this case, the surgeon ruptured the ovarian tumor to drain it prior to removal causing the surgical spill. Regional lymph nodes are negative and there is no metastasis. The capsule was then noted as ruptured on pathology. Does it matter if the surgeon was the one who ruptured the capsule? Would the stage change if the surgeon intentionally ruptured the capsule to drain the tumor intraoperatively causing some surgical spill? The scenarios of an intentional and not intentional rupture are not specified in SEER Summary Stage 2018. |
Code SEER Summary Stage 2018 to Localized, Code 1. Per consult with AJCC and noted in the Primary Peritoneal Chapter in AJCC 8th edition, an intraoperative rupture is coded as a surgical spill. A capsule rupture is when the capsule ruptures prior to the surgery (Summary Stage Regional, Code 2). |
2024 |