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For cases diagnosed 2007 or later: The 2011 diagnosis of adenocarcinoma, NOS in the left lower lobe lung is a separate primary.

The steps used to arrive at this decision are:

Open the Multiple Primary and Histology Coding Rules manual. For a lung primary, use the Lung Multiple Primary rules to determine the number of primaries.

The 2010 right lung bi-lobectomy showed two separate tumors that were determined to be two primaries: clear cell adenocarcinoma [8310/3] and adenocarcinoma, NOS [8140/3]. The histology of the new left lung mass is adenocarcinoma, NOS [8140/3].

Start at Rule M3 using the MULTIPLE TUMORS module because this patient has more than one tumor. The rules are intended to be reviewed in consecutive order within the module (i.e., from Rule M3 to Rule M12 in this case). Stop at the first rule that applies to the case you are processing. This patient has two tumors in each lung with ICD-O-3 histology codes that are different at the second (xxxx) digit. Abstract the LLL adenocarcinoma as a new primary [C343, 8140/3].

The patient has two tumors in each lung. The right lung showed adenocarcinoma and clear cell adenocarcinoma. The two tumors in the left lung were both adenocarcinomas. Clear cell adenocarcinoma [8310] on the right is different at the second digit from adenocarcinoma [8140] on the left. Rule M12 cannot be applied to this case, because Rule M7 is the first rule that applies to this case when processing the rules in consecutive order.

This is a metaplastic carcinoma as stated in the path diagnosis. Rule H14 applies. Assign code 8575/3. According to the WHO Classification, metaplastic carcinoma is a general term for a group of neoplasms characterized by a mixture of adenocarcinoma with dominant areas of spindle cell, squamous, and/or mesenchymal differentiation.

Use the Multiple Primary and Histology Coding Rules Manual for cases diagnosed 2007 or later to determine the histology for this case. Code histology to 8575/3 [metaplastic carcinoma] as stated in the pathology diagnosis.

Open the Multiple Primary and Histology Coding Rules manual. Choose one of the three formats (i.e., flowchart, matrix or text) under the Breast Histo rules determine histology for the case.

Go to the SINGLE TUMOR: INVASIVE CARCINOMA ONLY module. The rules are intended to be reviewed in consecutive order within the module from Rule H10 to Rule H19. You stop at the first rule that applies to the case you are processing.

Code the histology when only one histologic type is identified. According to the WHO Classification, metaplastic carcinoma is a general term for a group of neoplasms characterized by a mixture of adenocarcinoma with dominant areas of spindle cell, squamous, and/or mesenchymal differentiation.

The date of diagnosis is 2/25/10 and diagnostic confirmation is coded to 8 [clinical diagnosis only].

As the cytogenetics state, you need clinicopathologic correlation to get confirm a reportable diagnosis. There is no reportable diagnosis from the bone marrow biopsy. The cytogenetics were done (the pathologic part) and then the physician confirmed refractory cytopenia with multilineage dysplasia [9985/3] (the clinical part). The diagnostic process and the determination of a reportable diagnosis were completed when the clinician made the statement that this is refractory cytopenia with multilineage dysplasia.

SEER*Educate provides training on how to use the Heme Manual and DB. If you are unsure how to arrive at the answer in this SINQ question, refer to SEER*Educate to practice coding hematopoietic and lymphoid neoplasms. Review the step-by-step instructions provided for each case scenario to learn how to use the application and manual to arrive at the answer provided. https://educate.fhcrc.org/LandingPage.aspx.

For cases diagnosed 2010 and forward, access the Hematopoietic Database at http://seer.cancer.gov/seertools/hemelymph.

This is a single primary and the primary site and histology is coded as bone marrow [C421] and CLL/SLL [9823/3]. The code 9670/3 [malignant lymphoma, small B lymphocytes, NOS] used for SLL is now obsolete.

Per the Abstractor Notes section in the Heme DB indicates that SLL is, "usually associated with CLL and coded CLL/SLL 9823/3. Small lymphocytic lymphoma (SLL) is almost identical to CLL. A somewhat arbitrary distinction is drawn between them based on the relative degree of marrow and nodal involvement and the numbers of circulating cells."

Per the Definition section in the Heme DB it states that, "CLL by definition involves blood and bone marrow at time of diagnosis." Check the PRIMARY SITE and MODULE RULE sections that indicate the primary site is C421, Rule PH5. Per this rule, code the primary site bone marrow (C421) and code the histology B-cell chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) [9823/3] when the diagnosis is B-cell chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) AND peripheral blood is involved (the bone marrow may also be involved).

This may appear to contradict the physician's diagnosis, but the 2008 WHO no longer codes CLL and SLL as separate neoplasms, rather one neoplasm, CLL/SLL, which reflects the actual neoplastic process. Those patients with SLL usually manifest CLL during the neoplastic process and those patients with CLL usually manifest SLL during the neoplastic process. WHO recommends coding to CLL/SLL rather than coding two primaries when the other neoplasm manifests.

SEER*Educate provides training on how to use the Heme Manual and DB. If you are unsure how to arrive at the answer in this SINQ question, refer to SEER*Educate to practice coding hematopoietic and lymphoid neoplasms. Review the step-by-step instructions provided for each case scenario to learn how to use the application and manual to arrive at the answer provided. https://educate.fhcrc.org/LandingPage.aspx.

According to the MP/H rules, code histology to 8120/3 [urothelial carcinoma] for cases diagnosed 2007 or later. The term "glandular differentiation" is equivalent to adenocarcinoma differentiation. 8120/3 [urothelial carcinoma] would be the best way to code a "biphasic pattern with cautery-distorted urothelial carcinoma and adenocarcinoma" according to a pathologist consultant.

The steps used to arrive at this decision are as follows:

Go to the Urinary Histo rules found in the Multiple Primary and Histology Coding Rules Manual.

Start at the MULTIPLE TUMORS ABSTRACTED AS A SINGLE PRIMARY module, rule H9. Code the histology to 8120 [transitional cell/urothelial carcinoma] when there is transitional cell carcinoma with glandular differentiation.

For cases diagnosed 2010 and forward, access the Hematopoietic Database at http://seer.cancer.gov/seertools/hemelymph.

The patient only has two primaries: cutaneous T-cell lymphoma diagnosed in the 1980s and diffuse large B-cell lymphoma of the bowel diagnosed in 1991.

The DLBCL of the brain does not represent a new primary. It is progression of the 1991 disease process with the same histology. Under the Alternate Names section in the Heme DB, one synonym for DLBCL is "Primary DLBCL of the CNS." The histology code for both the 1991 bowel neoplasm and the current CNS neoplasm is 9680/3. Per Rule M2, a single histology is a single primary.

SEER*Educate provides training on how to use the Heme Manual and DB. If you are unsure how to arrive at the answer in this SINQ question, refer to SEER*Educate to practice coding hematopoietic and lymphoid neoplasms. Review the step-by-step instructions provided for each case scenario to learn how to use the application and manual to arrive at the answer provided. https://educate.fhcrc.org/LandingPage.aspx.

For cases diagnosed 2010 and forward, access the Hematopoietic Database at http://seer.cancer.gov/seertools/hemelymph.

Code the histology as Myelodysplastic syndrome, unclassifiable [9989/3].

Ambiguous terminology is used to accession cases (determine reportability). While ambiguous terminology is generally not used to code a specific histology, it can be used to code histology if it is the .

The statement that you do not use ambiguous terms to code histology is intended for those NOS histologies with an ambiguous term being used to describe the subtype. For example, if the physician states this is a myelodysplastic syndrome, NOS, refractory thrombocytopenia. The correct histology would be MDS, NOS [9989/3] and not refractory thrombocytopenia [9992/3].

SEER*Educate provides training on how to use the Heme Manual and DB. If you are unsure how to arrive at the answer in this SINQ question, refer to SEER*Educate to practice coding hematopoietic and lymphoid neoplasms. Review the step-by-step instructions provided for each case scenario to learn how to use the application and manual to arrive at the answer provided. https://educate.fhcrc.org/LandingPage.aspx.

For cases diagnosed 2010 and forward, access the Hematopoietic Database at http://seer.cancer.gov/seertools/hemelymph.

This case should not be accessioned. In situ lymphoma is not reportable for any of the standard setters (CoC, NPCR, or SEER). In the Case Reportability Instructions, the NOTE under Rule 3 states, "Do report in situ (/2) lymphomas."

SEER*Educate provides training on how to use the Heme Manual and DB. If you are unsure how to arrive at the answer in this SINQ question, refer to SEER*Educate to practice coding hematopoietic and lymphoid neoplasms. Review the step-by-step instructions provided for each case scenario to learn how to use the application and manual to arrive at the answer provided. https://educate.fhcrc.org/LandingPage.aspx.

Code the histology to 8082/3 [urothelial carcinoma, plasmacytoid].

The Multiple Primary and Histology Coding Rules Manual is the correct source for coding histology for cases diagnosed 2007 or later. Unfortunately, in this case there is no current rule that directs you appropriately to Table 1 from Rule H7 to find this histology combination. We need to add an example under Rule H7 that instructs you to "See Table 1" for an urothelial carcinoma diagnosis that mentions a more specific cell type (e.g., plasmacytoid). We will add a reference to Table 1 in Rule H7 in the updates to MP/H Rules.