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After more than seven years, the patient in this case decided to proceed with the originally suggested standard therapy. Is this a multiple primary case because the tumors are "diagnosed" more than 3 years apart? Or should we assume this is further progression of the 2000 case because it was originally only treated with alternative therapies? The clinician in this case indicates the patient is being referred for treatment to the right upper lung originally diagnosed in 2000.

7-03-97 PE: Past history significant for cavernous hemangiomas. Has had radiation and was on high-dose steroids in early 1996. Patient reports subsequent MRI done and neurologist gave "clean bill of health."

1-26-99 MRI BRAIN. Clinical information: history of intracranial cavernous hemangiomas. Comparison with prior brain MRI in 12/15/95. IMP: Upper medullary, right parieto-occipital, left frontal cavernous hemangiomas without interval change in size as compared to 12/15/95.

1-25-06 MRI BRAIN. Clinical info: history of prior radiation for cavernous angiomas. Comparison made with prior exam on 1/26/99. Impression: Multiple, variable sized cavernous angiomas within medulla, pontomedullary junction, midbrain, & cerebral hemispheres. Dominant lesion centered within posterior pontomedullary junction. FINDINGS: 8mm lesion in posterior pontomedullary junction. 2mm lesion within right paracentral portion of medulla. Several less than 5mm lesions noted within brain stem bilateral. Two, less than 1-2mm, areas within right inferior aspect of right and left cerebellar hemispheres. 1cm lesion centered within white matter within right posterior parietal/occipital region. Several small, less than 1-2mm, lesion within surrounding white matter. 3rd dominant lesion within left frontal lobe equal 6mm. Several 1-2mm foci of susceptibility artifact within subcortical white matter of high right and left cerebral hemispheres consistent with small cavernous angiomas.

Patient diagnosed with adenocarcinoma of the rectum in March 2006, underwent chemo and radiation therapy as treatment. Patient seen in April 2007 for surveillance colonoscopy. HPI stated patient underwent chemorad with good results. Colonoscopy showed "persistent" disease. Abdominal perineal resection was done in May 2007. Path showed adenocarcinoma of the rectum.

Keeping in mind that we are not to use a clinical statement for determining recurrences, is the April 2007 occurrence counted as a new primary?

A bilateral fallopian tube primary was coded to multiple primaries. However, the AJCC staging for T1b says, "tumor limited to both tubes"

and T1c "tumor limited to one or both tubes." The tumor is T1c according to the pathologist. Is this two T1c primaries or one?

Rectal tumor resection (APR) path report final dx: "mucinous carcinoma, see comment". The comment is the CAP-format tumor summary, which states "histologic type: adenocarcinoma with extensive mucin production (mucinous or colloid carcinoma). Additional pathologic findings: adenomas - tumor arises in a tubulovillous adenoma".

If you follow the rules and only use the final dx, you would code a different histology than if you use the 'additional path findings.'

Left mainstem bronchus mass excised: metaplastic endobronchial mucosa with submucosa containing an infiltrating poorly diff malignant tumor. Origin of tumor is not identified in overlying mucosa. IHC stains will be performed.

Addendum #1. IHC stains show well diff neuroendocrine neoplasm, favor carcinoid. Recommend sending this to expert in lung neoplastic pathologist.

Addendum #2. (lung path specialist) oncocytic neuroendocrine neoplasm.

Is this 8246 or 8290 or something else?

Scenario: Addendum from Mayo Clinic review, IHC and consultation made dx of "anaplastic glioneuronal neoplasm with spongioblastic architecture". The original micro states 'high grade glial neoplasm w/o characteristic features of glioblastoma multiforme in that it lacks areas of significant necrosis, no nuclear palisading nor endothelial vascular proliferation...."