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Pathology reads: 1. FNA left groin lymph node tissue (smears and cell block): B-cell lymphoma, low grade. The concurrent flow cytometry (3-FC-16-288) identifies a monoclonal B cell population with immunophenotype of CD10++, CD5-, CD23-, CD20++ and unusual CD19-. Overall findings favor follicular lymphoma. FNA Specimen Adequacy: Evaluation for specimen adequacy: Immediate cytology smear review for specimen adequacy was performed at the time of the FNA procedure by pathologist. Smears reviewed from 2 passes in one reading. The specimen was adequate cytological evaluation. Surg Path Final Report Special Studies Immunohistochemistry (CD45, MCK, CD20, CD3, CD10, Bcl6, MUM1 \T\ Ki67) was performed on block 1A to confirm the diagnosis. All controls show appropriate reaction. Lymphoma cells are positive for CD45, CD20, CD10 and weakly positive for bcl6(+) and MUM1(+/-), and negative for MCK. CD3 highlights few T lymphocytes. Ki67 labeling index is low, less than 10%. The immunoprofile supports above diagnosis. Chromosomal study for t(14;18) translocation will be performed, and an addendum report will follow. Flow Final Report Comment: The lymphoma appears to be derived from germinal centre B cells. Together with the findings from the lymph node biopsy (3-FN16-416), follicular lymphoma is favored. However, negative CD19 and CD22 are unusual.

Cytology is not listed in the Priority Order for Using Documentation to Identify Histology (Histology Coding Rules) in the Head and Neck schema. Other schemas do include cytology in the hierarchy below tissue from a biopsy or resection. Cytology is often less specific than histology, so one would expect cytology to be listed below tissue in this hierarchy. Was this an oversight? Or would cytology be equivalent to histology if it provided the most specific histology for the case?

Immunostain results of the malignant cells show strong staining with p63 and negative staining with TTF-1 and Napsin. Rare cells stain with CK7. Findings are most compatible with squamous cell carcinoma. The patient is treated as if he has squamous cell carcinoma. The new histology coding rules say you cannot use ambiguous terms which modify the histology to code the histology. So is this 8010/3?

A question was posted to CAnswer forum 9/26/18 and answered stating that 8046 is not on the AJCC list of histologies for the lung chapter in the 8th edition. If the final diagnosis on the pathology report is just NSCLC, NOS with no subtype/variant, what histology/solid tumor rule would I use? In this situation, I am not able to query the pathologist. Would I code the histology to 8010 as per AJCC post?

The patient has one tumor each in the left parietal and left medial temporal lobe. The tumors were excised. The final diagnosis for the left parietal tumor is glioblastoma, IDH-wild type. he final diagnosis of the left medial temporal tumor is, at least anaplastic astrocytoma, WHO grade III; see comment. The comment states: There is a single focus of vascular hyperplasia, separate from neoplastic cells. No necrosis is identified. These findings on their own would warrant a diagnosis of anaplastic astrocytoma, WHO grade III. However, in the context of the patient's glioblastoma in the left parietal lobe, and imaging showing ring-enhancing lesions of the parietal and temporal lobes, this specimen is favored to be an un-sampled glioblastoma, WHO grade IV. The Solid Tumor Rules indicate we may no longer use terms like favor(s) to code the histology, leaving the final diagnosis as the priority source for coding histology per the Histology coding rules.

The tumor board review confirmed that, despite the anaplastic astrocytoma on pathology, they felt strongly that this is a multifocal glioblastoma and not an anaplastic astrocytoma. Both the pathologist's comment and the tumor board's assessment indicate this patient does not have two primaries. However, the Solid Tumor Rules do not give priority to the tumor board's assessment over the pathology, and registrars are not to use ambiguous terms to code histology thus leaving the two histologies to consider. Per the Solid Tumor Rules, one tumor that is glioblastoma and one tumor that is anaplastic astrocytoma are multiple primaries per M11 (Abstract multiple primaries when separate, non-contiguous tumors are on different rows in Table 3 in the Equivalent Terms and Definitions. Timing is irrelevant).

As a central registry, we cannot ask the pathologist or attending physician for clarification as suggested in Section 3 of the Malignant CNS and Peripheral Nerves Equivalent Terms and Definitions. We can only follow the current Solid Tumor Rules. In doing so, we would have to ignore both the pathologist's and tumor board's assessment that this patient has multifocal glioblastoma. Is there any concern that this will lead to over-reporting?

A patient has a left breast cancer diagnosed in 2011; then has a "recurrence" in her lymph nodes in 2017. In 2018, she has a new left breast mass that is the same histology and behavior as the 2011 cancer. Based on the 2017 "recurrence" in the lymph nodes, this is not a new breast primary, is that correct?

02/18 RUL biopsy: Moderatley differentiated adenocacarcinoma with acinar predominant pattern

04/18 RUL lobectomy: 6.5cm poorly differentiated adenocarcinoma with solid growth pattern and 1.1 cm separate adenocarcinoma with lepidic predominant pattern

Synoptic report:

Procedure: Lobectomy

Specimen Laterality: Right Tumor

Tumor Site: Upper lobe

Histologic Type: Invasive adenocarcinoma, solid predominant

Tumor Size: 6.5 Centimeters (cm)

Tumor Focality: Synchronous primary tumors in same lobe

Lymph Nodes Number of Lymph Nodes Involved: 0

Number of Lymph Nodes Examined: 12

Nodal Stations Examined: 4R: Lower paratracheal; 8R: Para-esophageal (below carina); 10R: Hilar; 7: Subcarinal

Pathologic Stage Classification (pTNM, AJCC 8th Edition)

Primary Tumor (pT): pT3

Regional Lymph Nodes (pN): pN0

The Histology Coding Instructions give priority to the Final Diagnosis over the CAP protocol. However, when pathology reports are formatted using the CAP protocol, the presence of in situ carcinoma is generally only mentioned in the CAP protocol. Can the presence of in situ tumor mentioned only in the CAP protocol be used to apply rule H7 (Single Tumor: Invasive and In Situ Components Module)? Or are the rules in the Single Tumor: Invasive Only module used?

Example: Final diagnosis is invasive ductal carcinoma. CAP protocol mentions,

The article I read (https://www.ncbi.nlm.nih.gov/pubmed/?term=28984674) makes the distinction between mesophrenic adenocarcinoma and mesophrenic-like adenocarcinoma. The authors propose the term mesonephric-like Mullerian adenocarcinoma. So would this be coded as Mullerian adenocarcinoma?