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The 10/2023 TURBT final diagnosis is “Urothelial carcinoma with mixed histologic appearances, see synoptic summary below for details.” The synoptic report includes, “Histologic Type Comment: Invasive carcinoma percentages: Micropapillary 60-70%, high grade or poorly differentiated urothelial 20-30%, squamous 10-20%.” The squamous component is stated to be “Urothelial carcinoma with squamous differentiation.”

It appears there are two specific urothelial carcinoma subtypes to consider: Urothelial carcinoma, micropapillary variant (8131/3) and poorly differentiated carcinoma (8020/3). The squamous component would not be considered because there is no specific histology for “squamous differentiation.”

The micropapillary component is the predominant histology (60-70%) in this case, and it does seem like this is important to capture. However, the WHO Blue Book indicates poorly differentiated carcinoma of the bladder has a poor prognosis.

The 2023 SEER Manual indicates PRRT should be coded in the Other Therapy field per coding instruction 2.d.  Likewise, SINQ 20180106 instructs to code PRRT as Other Therapy, while the discussion portion clearly outlines the radioactive nature of this modality.

Would PRRT be best coded as a radioisotope in the Radiation Treatment Modality--Phase I, II, III field rather than in the Other Therapy field?

Can you provide clarification on Rectum primary surgical code 40 Pull through WITH sphincter preservation (colo-anal anastomosis)? Would this be code 30 or 40 due to the colorectal anastomosis? 

Now that there are specific surgery codes for shave and punch biopsies, are these biopsies always the Date of First Surgical Procedure (NAACCR Item #1200)? Or should we still be applying the Surgery of Primary Site 2023 instruction in the SEER Manual that states shave or punch biopsies are most often diagnostic; code as a surgical procedure only when the entire tumor is removed and margins are free/gross disease is removed?

We are aware of the instruction for melanoma cases outlined in SINQ 20230034; however, it is unclear if this should also apply to cutaneous lymphomas and Kaposi sarcomas, or if the intent of the procedure is used for these specific types of skin cases that typically present with multifocal involvement.

Example 1: Patient is diagnosed March 2023 with primary cutaneous T-cell lymphoma presenting as pink, tan patches on the trunk. Punch biopsy diagnosed CTCL and treatment was given via narrow band UVB phototherapy.

Example 2: Patient is diagnosed February 2023 with Kaposi sarcoma presenting as widespread violaceous macules, papules, plaques on the torso, bilateral extremities, and abdomen. Punch biopsy diagnosed Kaposi sarcoma.

Patient had a total abdominal hysterectomy-bilateral salpingo-oophorectomy performed in January 2023 with final diagnosis of myxoid and epithelioid leiomyosarcoma.

Diagnosis comment states: The tumor is 15 cm per report. It grows in nests and poorly formed interanastomosing trabeculae and cords that are separated by abundant myxoid background. The cells have an epithelioid morphology with eosinophilic cytoplasm, large nuclei, and very prominent nucleoli. The mitotic activity is overall low ranging from 1 to 3/10 HPFs.

Immunohistochemical stains performed at the outside hospital showed diffuse positivity for SMA, desmin, caldesmon, and PR. They are negative for CD10, claudin-4, calretinin, HBM45, MART1 (rare weakly positive cells), PANCK, and SOX10. This immunohistochemical profile supports a smooth muscle derivation of this neoplasm. As this tumor is extensively myxoid, diagnostic criteria differ from the spindle cell leiomyosarcoma.

Per Solid Tumor Rules Other Sites, Table 16: Uterine Corpus Histologies, Epithelioid Leiomyosarcoma (8891/3) and Myxoid Leiomyosarcoma (8896/3) are both subtypes of Sarcoma, NOS (8800/3).  Per Rule H21, use a combination code when there are multiple specific histologies AND the combination is listed in Table 2 OR there are coding instructions for the combination in the applicable histology Tables 3-21 OR you receive a combination code from Ask A SEER Registrar.  Since there is no combination listed in Table 2 and there is no instruction for the combination in Table 16, how should the histology be coded for this tumor?

Treatment for estrogen receptor positive (ER+) breast cancer started with tamoxifen (non-steroidal estrogen subcategory) and switched to letrozole (non-steroidal aromatase inhibitor subcategory). Patient being treated with immunotherapy, Avastin (cytostatic agent-antiangiogenesis agent subcategory), and then changed to Atezolizumab (monoclonal antibody subcategory).

Is Atezolizumab a new course of therapy because it is a different subcategory?

Example:  A prostate core biopsy showed intraductal carcinoma in 09/2022, which is an in situ tumor.  A core biopsy again showed intraductal carcinoma in 12/2022.  The subsequent radical prostatectomy in 04/2023, revealed multiple foci of invasive prostate adenocarcinoma with extensive intraductal carcinoma. 

Per Solid Tumor Rules, Other Sites, Rule M3, acinar adenocarcinoma of the prostate is always a single primary.  Note 4, this rule applies to subtype variants of acinar adenocarcinoma listed in Table 3, which has intraductal/ductal as a variant subtype of acinar adenocarcinoma. Does rule M3 apply to incidence cases (an invasive tumor following an in situ tumor)?