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Malignant Central Nervous System (CNS) Rule M5 instructs us to abstract a single primary (as malignant) when a single tumor is originally diagnosed as non-malignant, the “First course treatment was active surveillance (no tumor resection),” and the subsequent resection pathology is malignant.

This patient’s first course of treatment was not active surveillance. While the patient did not have first course tumor resection, the tumor was treated with Cabergoline.

Should Rule M5 apply because there was no tumor resection? If so, should Rule M5 clearly state no tumor resection is the criteria (not active surveillance)?

SINQ 20230023 does indicate a PitNET diagnosis following a diagnosis of pituitary adenoma does not fall into standard rules, but in the previous SINQ the first course treatment was a partial resection.

It is unclear whether other types of treatment could result in a new malignant PitNET, following a previously treated non-malignant pituitary tumor.

In the NAACCR Coding Pitfalls 2023 webinar, the example of DCIS, solid type is given. The webinar advised us to code 8230/2 (ductal carcinoma in situ, solid type). When going through the beginning of the solid tumor rules in the Changes from 2007 MPH Rules section it states "DCIS/Carcinoma NST in situ has a major classification change. Subtypes/variant, architecture, pattern, and features ARE NOT CODED. The majority of in situ tumors will be coded to DCIS 8500/2." In the equivalent or equal terms section it lists "Type, subtype, variant" can be used interchangeably.

Since the example has it listed as as ductal carcinoma in situ, solid "type," would we code 8500/2 or 8230/2? 

In this case, the surgeon ruptured the ovarian tumor to drain it prior to removal causing the surgical spill. Regional lymph nodes are negative and there is no metastasis. The capsule was then noted as ruptured on pathology.

Does it matter if the surgeon was the one who ruptured the capsule? Would the stage change if the surgeon intentionally ruptured the capsule to drain the tumor intraoperatively causing some surgical spill? The scenarios of an intentional and not intentional rupture are not specified in SEER Summary Stage 2018.

2012 Total abdominal hysterectomy - bilateral salpingo-oophorectomy

Primary Site – Ovary, Right

Histology - Small-Cell Carcinoma (Hypercalcemic Type), Large-Cell Variant

2024 Total abdominal hysterectomy - bilateral salpingo-oophorectomy

Primary Site – Ovary, Left

Histology - Small-Cell Carcinoma (Hypercalcemic Type), Large-Cell Variant

The WHO Classification of Hematopoietic Tumors (Blue Book), 5th edition states: “Rare cases of classic follicular lymphoma with cytological features of follicular lymphoma (FL) grade 3A can present with a prominent diffuse pattern. In the previous edition, such cases were defined as diffuse large B-cell lymphoma (DLBCL). Currently, it is uncertain whether such cases should be classified as FL or diffuse large B-cell lymphoma; and in such cases, individual treatment choices should be made in multidisciplinary conference settings taking into consideration clinical, laboratory, and imaging parameters. The presence of diffuse areas composed entirely or predominantly of large cells, however, warrants a diagnosis of diffuse large B-cell lymphoma.”

Our concern is that the Hematopoietic (Heme) Manual and Database do not provide instruction for coding this scenario. We hesitate to interpret the terms “equivalent to” as ambiguous because one could argue it is unambiguous. Barring this argument, the M and H rules would indicate this is a diagnosis of diffuse large B-cell lymphoma. However, the physician does not seem to agree with the pathologist.

Rule M15

Abstract a single primary when synchronous, separate/non-contiguous tumors are on the same row in Table 2 in the Equivalent Terms and Definitions.

Note: The same row means the tumors are

• The same histology (same four-digit ICD-O code) OR

• One is the preferred term (column 1) and the other is a synonym for the preferred term (column 2) OR

• A NOS (column 1/column 2) and the other is a subtype/variant of that NOS (column 3) OR

• A NOS histology in column 3 with an indented subtype/variant

Example: TURBT shows invasive papillary urothelial carcinoma 8130/3 and CIS/in situ urothelial carcinoma 8120/2. Abstract a single primary. Papillary urothelial carcinoma and urothelial carcinoma are on the same row in Table 3.

An 80-year-old post-menopausal female (status post hysterectomy for benign reasons) presents with a retroperitoneal mass on imaging. The pre-operative imaging shows the cervix and uterus are absent. Patient undergoes a robotic left salpingo-oophorectomy with biopsy of the retroperitoneal mass.

Patient was diagnosed in July 2022 with biopsy confirmed left kidney renal cell carcinoma. Initially, partial nephrectomy was planned for February 2023 but canceled at the last moment due to the patient’s “history of narcotic use.” The details of that cancellation were otherwise unclear. It appears the treatment plan was changed due to patient non-compliance.

Patient then had cryoablation of the tumor in May of 2023. Subsequent imaging in October found residual tumor, but no disease progression was noted. Again, additional ablation was offered but patient decided on surgical treatment which did not occur until December 2023.

Is the cryoablation second course due to a change of plan if there is no disease progression, recurrence, or treatment failure?

If the cryoablation is first course treatment, then would the partial resection also be first course treatment because it was documented as the treatment plan?