9.4 Ambiguous Terminology: Reportable Terms, Cytology, Discrepancies & "References of Last Resort"
Key Takeaways
Terms that constitute a diagnosis: apparent(ly), appears, comparable with, compatible with, consistent with, favor(s), malignant appearing, most likely, presumed, probable, suspect(ed), suspicious (for) and typical of.
Terms that do not constitute a diagnosis without more information: cannot be ruled out, equivocal, possible, potentially malignant, questionable, rule out, suggests and worrisome; synonyms such as "likely" do not count.
For intracranial and CNS sites only, "tumor" and "neoplasm" preceded by a reportable ambiguous term are reportable (2004+), but "mass" and "lesion" are not.
Cytology reported with an ambiguous term is not diagnostic by itself; the case is abstracted only when a positive biopsy or a physician's clinical impression of cancer supports it.
A later biopsy, resection or physician statement that disproves an ambiguous diagnosis means the case is not accessioned; the ambiguous-term lists are used only as "references of last resort."
The problem the lists solve
Clinicians hedge: "probable pancreatic carcinoma," "cannot rule out lymphoma." If each registrar interpreted these words differently, incidence counts would vary from registry to registry. STORE and the SEER Program Coding and Staging Manual therefore publish ambiguous terminology lists that give consistent answers for reportability. The same idea appears in the staging manuals, which have their own ambiguous-term rules for deciding whether a structure is involved.
The lists (STORE 2025)
| Terms that constitute a diagnosis | Terms that do not constitute a diagnosis without additional information |
|---|---|
| Apparent(ly) | Cannot be ruled out |
| Appears | Equivocal |
| Comparable with | Possible |
| Compatible with | Potentially malignant |
| Consistent with | Questionable |
| Favors | Rule out |
| Malignant appearing | Suggests |
| Most likely | Worrisome |
| Presumed | |
| Probable | |
| Suspect(ed) | |
| Suspicious (for) | |
| Typical of | |
| Tumor and neoplasm: 2004+ diagnoses, only for C70.0–C72.9 and C75.1–C75.3 |
Rules for using the lists:
- Words not on the list do not count. STORE says synonyms of these terms do not constitute a diagnosis ("likely" alone is not "most likely"). The SEER manual accepts a close grammatical form such as "favored" for "favors," but not true synonyms such as "supposed" for "presumed."
- The term must modify a reportable diagnosis. "Consistent with carcinoma" is reportable. "Consistent with neoplasm" is not, except at intracranial and CNS sites, because "neoplasm" alone does not specify malignancy.
- For CNS, "mass" and "lesion" are never reportable terms, even with a reportable ambiguous term in front of them.
- The lists apply to any source document: pathology, imaging, operative and clinical reports. STORE's own example: a pathology report that says "suspicious for malignancy" is indicative of cancer.
"References of last resort"
STORE and the SEER manual state that the first resource for an unclear case is the physician who diagnosed or staged the tumor. Next come the full medical record and related reports. The ambiguous-terminology lists are used only when the situation remains unclear and cannot be discussed with the physician or pathologist. If the record contains a clear statement of malignancy, or a clear statement that there is none, do not use the lists.
Cytology: the key exception
- Cytology described with an ambiguous term is not diagnostic by itself, even when the term (for example, "suspicious") is on the reportable list.
- Abstract the case only when a positive biopsy or a physician's clinical impression of cancer supports the cytology.
- Cytology that is positive for malignant cells is reportable.
- Date of diagnosis: when a later definitive diagnosis confirms it, the date of the suspicious cytology or suspicious pathology becomes the date of diagnosis. STORE's example: cytology "suspicious" June 12, 2010, pathology positive July 2, 2010, so the date of diagnosis is June 12, 2010.
Resolving conflicting information
| Situation | Action |
|---|---|
| One report uses both a reportable and a non-reportable term (for example, "consistent with hepatocellular carcinoma" in the discussion and "possibly HCC" in the impression) | Accession: accept the reportable term |
| The original source uses a non-reportable term ("possible melanoma"), and a later unrelated note lists "history of melanoma" with no treatment or other evidence | Do not accession: give priority to the original source |
| Imaging is "suspicious for carcinoma," then biopsy or resection is negative | Do not accession: the later tissue diagnosis disproves the ambiguous one |
| A physician documents a definitive clinical diagnosis of cancer and treats it, although the imaging report used a non-reportable term | Accession: a physician's clinical diagnosis constitutes a diagnosis |
| "Malignant until proven otherwise," with no information to the contrary | Accession (SEER), and update the case if later workup disproves it |
| "Highly suspicious for, but not diagnostic of, carcinoma" | Do not accession (SEER treats this as equivalent to "not diagnostic") |
A negative biopsy usually settles the question, but not always. If the managing physician still documents a clinical diagnosis of cancer and treats it despite a non-diagnostic biopsy, the physician's diagnosis governs. When in doubt, ask the physician.
Worked examples
- CT impression: "3 cm right upper lobe mass, consistent with bronchogenic carcinoma." The patient declines biopsy and enters hospice. → Reportable ("consistent with"). Diagnostic Confirmation is 7 (radiography or imaging only), assuming the physician relies on the imaging.
- CT impression: "Spiculated nodule; malignancy cannot be ruled out." No further workup. → Not reportable. Keep it in suspense if follow-up is expected.
- Pleural fluid cytology: "Atypical cells suspicious for adenocarcinoma." No biopsy, and no physician statement of cancer. → Not reportable on cytology alone.
- MRI brain: "Findings consistent with meningioma." → Reportable (a CNS tumor described with a reportable term). This is a non-malignant CNS case with Summary Stage 8.
- MRI brain: "Enhancing lesion, probable glioma." → Reportable, because "probable" modifies a diagnosis (glioma), not the word "lesion."
- Mammogram: "BI-RADS 5." → Not reportable for CoC on its own; it needs a biopsy or a physician's statement (STORE).
With no other information available, which diagnostic statement establishes a reportable case?
"Pancreatic head mass, cannot rule out adenocarcinoma"
"Liver lesions, possibly metastatic carcinoma"
"Left breast mass, most likely carcinoma"
"Renal mass, likely renal cell carcinoma"
A pleural fluid cytology report reads "malignant cells present, consistent with adenocarcinoma." In a second case, a bronchial washing is reported as "atypical cells, suspicious for malignancy," and no biopsy or physician statement of cancer follows. How should these two cases be handled?
Both are reportable, because "consistent with" and "suspicious for" are both reportable terms.
Neither is reportable, because cytology is never used for case ascertainment.
The second is reportable and the first is not, because "suspicious" outranks "consistent with."
The first is reportable because the cytology is positive for malignant cells; the second is not, because ambiguous cytology alone is not diagnostic.
An abdominal CT report's discussion states "the lesion is consistent with hepatocellular carcinoma," but the final impression says "1 cm liver lesion, possibly hepatocellular carcinoma." No other information is available. What should the registrar do?
Not accession, because the final impression always overrides the discussion.
Place the case in permanent suspense, because the report contradicts itself.
Accession only if the patient's AFP is elevated.
Accession the case, because a single report using both a reportable and a non-reportable term is resolved in favor of the reportable term.
Sections you finish are checked off in the contents.