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ID Question Discussion Answer Last Updated
20100002 Reportability/Histol
ogy--Colon: The
microscopic
description and the
FDX state large
tubulovillous
adenoma of the cecum
with focal surface
high grade
dysplasia. The CAP
protocol has
histologic type as
adenocarcinoma and
pT as pTis.
Which has
priority? Is the
case reportable?
The case is
reportable because
carcinoma in situ is
stated. Carcinoma in
situ has higher
priority than severe
dysplasia or high
grade
dysplasia.

Pe
r AJCC 6th edition
colon chapter, the
terms "high grade
dysplasia" or
"severe dysplasia"
may be synonymous
with carcinoma in
situ. Because the
pathologist gave
carcinoma in situ
information within
the CAP, (s)he is
apparently defining
the dysplasia as in
situ carcinoma.

03/24/10
20091131 Multiplicity
Counter/Type of
Multiple
Tumors--Breast: How
many tumors should
be counted and what
is the correct code
for Type of Multiple
Tumors? See
discussion.
Lumpectomy path
shows 2 foci of
invasive ductal
carcinoma, 1.5 cm &
3 mm sizes, and CAP
summary lists "DCIS:
focally seen", no
further description.
Re-excision path
finds a 1.5 mm focus
of residual invasive
carcinoma, very
close to the new
inferior margin (so
registrar assumes
probably not part of
the previously
excised mass), and
no mention of any
more
in-situ.

Can we
assume the DCIS was
associated with/part
of the invasive
tumors since not
measured or
described
separately? If we
say there are 3
tumors (for the
measured invasive
foci), should Type
of Multiple Tumors
be in situ +
invasive, or just
invasive?

Code 03 [3 tumors]
in the multiplicity
counter. Do not
count the "focally
seen" DCIS since it
is not
measured.

Code
30 [In situ and
invasive] in Type of
Multiple Tumors
Reported as One
Primary. The single
primary reported for
this case is a
combination of in
situ and invasive
tumors.

03/24/10
20091130 MPH/Rules/Histology-
-Breast: How are the
following two
examples coded? 1.
Infiltrating ductal
carcinoma, mucinous
type 2.
Infiltrating ductal
carcinoma with
features of tubular
carcinoma

S
ee Discussion.

We have a difference
of opinion on which
rule applies. Some
registrars believe
that the first rule
that applies for
both scenarios is
Rule H12 (code the
most specific
histologic term)
because “type” and
“with features of”
are used in the
pathological
diagnosis. They are
coding 8480 and 8211
respectively for the
above examples.
Other registrars are
stopping at Rule H17
because they do not
believe these are
examples of duct
carcinomas since the
histological code is
not included in the
Rule description nor
are these
histologies included
in Table 2. They
are coding to 8523
for both examples.
Code 8523
for

1.
Infiltrating ductal
carcinoma, mucinous
type

AND

> 2. Infiltrating
ductal carcinoma
with features of
tubular
carcinoma

T
he infiltrating
ductal types in Rule
H12 are listed
(8022, 8035,
8501-8508) and do
not include mucinous
nor tubular. We
cannot use this
rule. The first rule
that applies to
these single tumors
is H17, code to
8523. If you look
up 8523 in the
numerical morphology
section of ICD-O-3,
you will see similar
examples included in
the definition of
this code.

03/10/10
20091129 Primary
Site--Breast: What
is the code for
subsite? Invasive
Paget Disease of the
nipple with an
infiltrating ductal
carcinoma of the
lower inner
quadrant?
Code C50.9. Code
the last digit of
the primary site to
'9' for single
primaries when
multiple tumors
arise in different
subsites of the same
anatomic site and
the point of origin
cannot be
determined. Nipple
(C50.0) and LIQ
(C50.3) fit this
rule. This is a
single primary per
MP/H Breast Rule M9.
03/26/10
20091128 MP/H Rules/Multiple
Primaries--Breast:
How many primaries
and what site to
code if considered
multiple? Patient
was diagnosed with
lobular carcinoma
invasive of the
right breast in
April 2001. Came
back for MRM 5-2001
considered disease
free. In December
2008 the patient was
diagnosed with a
right chest wall
mass, invasive
poorly diff mammary
carcinoma with
lobular origin. If
this is a new
primary in 2008,
would we code to
breast or chest
wall? Please see
discussion.
Please see I & R
answers for multiple
primaries 25924,
22163 and 26155
which give two
different answers.
One stating to code
as new primary to
chest wall and the
other two state not
a new primary since
chest wall is a
metastatic site.
The path report does
not state that this
is metastatic and it
is unknown if there
is breast tissue
left behind at the
chest wall.
This case is a
single primary. The
chest wall (NOS) is
a metastatic site
for breast cancer.
There is no mention
of residual breast
tissue, so the 2008
diagnosis cannot be
a new
primary.

Ch
est wall is an
ambiguous term, it
can mean the
internal chest wall
or the external
chest wall. When the
path report states
that the
"recurrence" is in
residual breast
tissue, this is most
likely the external
chest wall and the
residual breast
tissue is part of
the breast not
removed by the MRM.
In contrast, skin or
the chest wall, NOS,
are regional mets.

03/26/10
20091127 MP/H Rules/Multiple
primaries--Benign
CNS: We have a
patient with
Neurofibromatosis 2
(NF2) who also has
meningiomas
diagnosed on the
left and right side
of the brain as well
as multiple
meningiomas of the
spinal cord. Are the
meningiomas all one
primary (separate
from the NF2): C70.9
and 9530/1?
This is three
primaries. MP/H
Benign CNS Rule M4,
the meningiomas of
the meninges/brain
(C70.0) and
meninges/CNS (C70.1)
are multiple
primares. Code the
histology to 9530/1
(Rule H6) because
there are multiple
tumors. Per Rule M5,
the meningiomas of
the right and left
side of the brain
are multiple
primaries. Code
each of them to
9530/0, Rule H2
because they are
separate primaries.
03/10/10
20091126 MP/H Rules/Multiple
Primaries: How many
primaries should be
abstracted for
multiple occurrences
of VAIN III and one
occurrence of SCCA
of the vagina? See
discussion.
Patient had vaginal
intraepithelial
neoplasia (VAIN III)
in March of 2001.
She had a partial
vaginectomy and then
continues to have
laser surgery in
2002, 2003, 2005 and
2006 for
recurrences. In
12/2006 she is
diagnosed with SCCA
of the vagina with
microinvasion (new
primary). Then in
2/2008 she has VAIN
III again -- new
primary according to
rule M10 (more than
1 year later). Then
she has invasive
SCCA of the vagina
in 9/2008. Is this
another new primary
per rule M15
(invasive after in
situ)? Every
instance in 2008 is
called a recurrence,
but we disregard
that statement.
There are two
primaries according
to the information
provided.

1.
VAIN III March 2001.

2. SCCA of
vagina Dec. 2006
(invasive tumor
following an in situ

The 2007 MP/H
rules apply to new
tumors, which means
that there has been
a disease-free
interval at some
point. In this case,
the patient has
never been declared
disease-free (NED)
using the
information provided
in the question. The
consistent
recurrence of VAIN
is typical of this
disease.

03/26/10
20091125 Ambiguous
Terminology/Reportab
ility--Thyroid:
Should a thyroid
case be accessioned
based only on a
cytology that is
consistent with
papillary
carcinoma? See
discussion.
Instructions in the
2007 SPCM state that
we are not to
accession a case
based only on a
suspicious cytology.
Does this rule
apply only to the
term "suspicious" or
does it apply to all
ambiguous terms?
Example: FNA of
thyroid nodule is
consistent with
papillary carcinoma.
Do not accession the
case if the cytology
is the only
information in the
medical record. The
phrase "Do not
accession a case
based only on
suspicious cytology"
means that the
cytology is the only
information in the
record. If there is
other information
that supports the
suspicion of cancer
(radiology reports,
physician
statements,
surgery), then
accession the case.
The phrase
"suspicious
cytology" includes
all of the ambiguous
terms.
03/24/10
20091124 CS Eval--Lung: How
is CS Reg Nodes Eval
to be coded for the
following sequence
of events: FNA of a
paratracheal lymph
node is positive for
adenocarcinoma.
Patient undergoes
neoadjuvant
chemoradiation
therapy. Subsequent
excision of multiple
lymph node fragments
show adenocarcinoma?
The CS scheme for
lung shows that code
1 under CS Reg Nodes
Eval is a path
staging basis.
However, the
definition for code
1 also states that
no regional lymph
nodes were removed
for examination.
Would we use code 1
anyway because it is
a path staging
basis? If we select
code 5 because
regional lymph nodes
were dissected, the
staging basis would
be clinical. If we
select code 6, the
staging basis would
be y.
Use code "6" for the
CS LN evaluation
field. As explained
on page 113 in the
2007 SEER Manual,
when post-operative
disease is more
extensive despite
neoadjuvant therapy,
this can be coded as
the evaluation
field. In this
case, only an FNA
was done on lymph
nodes
pre-operatively, but
actual lymph nodes
were removed and
documented in the
post-neoadjuvant
excision of the
lymph nodes which
documented that they
are histologically
positive -- proving
that the neoadjuvant
therapy did not
work.
03/24/10
20091123 Reportability: Is a
tumor reportable if
path reads a
non-reportable
diagnosis at the
time of removal but
subsequent clinical
statements state
that the patient had
a reportable tumor?
The 2007 SEER Manual
(page 3) states that
cases diagnosed
clinically are
reportable.
Exception 2 states
that if enough time
has passed that it
is reasonable to
assume that the
physician has seen
the negative
pathology, but the
clinician continues
to call this a
reportable disease,
accession the case.
SEER reporting
guidelines state
that severe
dysplasia is not
reportable, however,
many clinicians
consider it to be
equivalent to
carcinoma in
situ.
Example
1: In 09-2007 path
for excisional
biopsy of right
floor of mouth is
read as severe
dysplasia. At the
time, the case is
not accessioned
based on
non-reportable
pathology. Patient
is subsequently
admitted in 3-09.
Clinical history
states that patient
was diagnosed with
squamous cell
carcinoma in 2007,
treated with laser.
Is this reportable?
If yes, how is
behavior to be
coded? How is
"Ambiguous
Terminology at
Diagnosis" to be
coded?

Example 2: In
2-08, punch biopsy
of skin lesion shows
atypical melanocytic
hyperplasia. In
3-08, patient is
admitted for
re-excision.
Clinical diagnosis
states re-excision
being done for
melanoma in situ.

Reference:
SINQ 20061123
A tumor that is
non-reportable based
on the pathology
report diagnosis
should not be
accessioned if later
clinician statements
mistakenly refer to
it as a reportable
tumor. The exception
in the 2007 SEER
manual on page 3 is
indended to allow
the registrar to
accession a case
when the clinician
actually disagrees
with the pathology
report and
clinically diagnoses
a reportable tumor.
03/26/10
20091113 MP/H
Rules/Histology-–Bre
ast: How is
histology to be
coded for a case in
which a biopsy
showed Paget disease
but mastectomy
specimen does not
show Paget disease?
See discussion.
Biopsy of nipple
shows Paget disease.
Subsequent
mastectomy shows two
tumors that are
infiltrating ductal
carcinoma. Nipple
is negative. How do
we code histology?
Per MP/H rule M9,
this is all counted
as a single primary.
Do we code
histology from the
most representative
specimen and lose
the information
about the Paget
disease?
Code the histology
8541/3 [Paget
disease and
infiltrating duct
carcinoma]. Paget
disease of the
nipple and
infiltrating duct
are separate tumors.
For each tumor, take
the histology from
the most
representative
specimen. The biopsy
is the most
representative
specimen for the
Paget disease. The
mastectomy is the
most representative
specimen for the
infiltrating duct.
According to the
multiple primary
rules, tumors that
are Paget disease
and duct are a
single primary (M9).
According to the
histology rules,
assign code 8541/3
(H26).
03/22/10
20091109 Surgery of Primary
Site: How is EMR
(endoscopic mucosal
resection) for
esophageal, gastric
or colon cancer
coded? We know that
a specimen is sent
to pathology and
margins are
documented in the
path report. Would
the correct code be
local tumor
excision, NOS with
pathology specimen
(20) or would a more
specific code such
as electrocautery
(22) be preferred?
Assign code 20
[local tumor
excision, NOS] for
esophageal, gastric
or colon endoscopic
mucosal resection
(EMR) without
further information.
If there is
additional
information
specifying
electrocautery,
laser or PDT (for
example), assign a
more specific code.
03/10/10