California Cancer Reporting System Standards Volume I: Abstracting and Coding Procedures
Vague or ambiguous terms are sometimes used by physicians to describe a tumor when its behavior is uncertain. This occurs primarily when there is no histologic diagnosis.
The terms listed below are reportable when they are used with a term such as cancer, carcinoma, sarcoma, etc.
Ambiguous terms that are reportable (used to determine reportability):
Apparent(ly) (malignant)
Appears to*
Comparable with*
Compatible with (a malignancy)*
Consistent with (a malignancy)
Favor (a malignancy)
Malignant appearing*
Most likely (malignant)
Presumed (malignant)
Probable (malignancy)
Suspect or suspected (malignancy)
Suspicious (of malignancy)
Typical (of/for malignancy)
*Effective for cases diagnosed January 1, 1988 and forward.
The only reportable ambiguous terms are those listed above. Ambiguous terms not on this list would not be considered reportable and should not be abstracted.
The registrar should determine malignancy from the resources available for all cases where there is a clear statement of malignancy. In those cases, the ambiguous terminology list would not be applicable.
Ambiguous terms may be located in any source document, such as pathology, operative, radiology, or clinical reports. This does not include tumor marker reports.
Do not report a case when cytology, biopsy, excision, resection, or physician’s statement proves the ambiguous diagnosis is not reportable.
Do not substitute synonyms such as “supposed” for presumed or “equal” for comparable. Do not substitute “likely” for “most likely.”
Report the case when there are reportable and non-reportable ambiguous terms within the medical record.
Report the case when there is a single report and it has a reportable term and a term not listed on the reportable list.
Do not report if the original source document used a non-reportable ambiguous term and later documents refer to a history of cancer.
If cytology is reported as “suspicious,” DO NOT interpret this as a diagnosis of cancer. Abstract the case if a positive biopsy or a physician’s clinical impression of cancer supports the cytology findings.
FNA “suspicious” for cancer cannot be used for the date of diagnosis without a physician statement or other indication of malignancy.
Text must document the physician statement of malignancy referencing the date of the suspicious cytology as date of diagnosis.
In the absence of a documented physician statement as outlined above, if a FNA “suspicious” for cancer is followed by a definitive procedure such as a tissue biopsy, surgery, scan or other procedure confirming the cancer, the date of the procedure would be the date of diagnosis.
In addition, a cytologically confirmed case with a negative biopsy must be evaluated carefully. If the biopsy rules out the presence of cancer, do not report the case. But if a negative biopsy does not rule out the presence of cancer, the case is considered to be cytologically confirmed and is reportable. See Diagnostic Confirmation for further information.
A urine cytology positive for malignancy is reportable. Report these cases when they are encountered. This is effective with cases diagnosed 1/1/2013 and forward. Do not implement new/additional casefinding methods to capture these cases.
Exception: When a subsequent biopsy of a urinary site is negative, do not report the case.
Code the primary site to C689 in the absence of any other information.
As always, do not report cytology cases with ambiguous terminology.
Benign and borderline primary intracranial and CNS tumors:
Use the above “Ambiguous terms that are reportable” list to identify benign and borderline primary intracranial and CNS tumors that are reportable.
If any of the reportable ambiguous terms precede either the word “tumor” or the word “neoplasm”, report the case.
For information on ambiguous terms for extent of disease, please see Ambiguous Terms for Extent of Disease.