Report | Question ID | Question | Discussion | Answer | Year |
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20180026 | Solid Tumor Rules (2018)--Breast: How many primaries are accessioned when a prophylactic mastectomy reveals a final diagnosis of invasive tubular carcinoma, but the College of American Pathologists (CAP) Protocol includes ductal carcinoma in situ (DCIS) sized separately and it is not clear if these are different tumors? See Discussion. |
The patient was incidentally diagnosed with cancer on a prophylactic mastectomy, so there are no positive imaging findings to correlate the number of tumors/masses. The final diagnosis was invasive tubular carcinoma, and referred to the CAP Protocol. The CAP notes: However, it does not specify whether the single contiguous focus also includes the in situ component. The CAP goes on to note DCIS was present: The gross description does not provide any indication of either a single or multiple tumors/masses/lesions, though it was referred to as "Lesion 1" in the gross description with no indication of other lesions. The format of the CAP Protocol frequently does not specify whether the DCIS is a separate measured tumor, or if it is a component of the invasive tumor. This makes it difficult to determine whether the DCIS should be a separate primary when the invasive tumor is not also a type of ductal carcinoma. Per both the 2007 MP/H and 2018 Solid Tumor Rules, an invasive tubular carcinoma and a ductal carcinoma in situ would be multiple primaries if they were multiple tumors. Should we default to Rule M1: Abstract a single primary when it is not possible to determine if there is a single or multiple tumors? Or should we assume these are separate tumors because they were both sized, the focality only described a single invasive tumor, and the tumors are not both ductal carcinomas? |
Accession a single primary using Solid Tumor Rule M3. Based on the information provided, this was described as "Lesion 1' with no other lesions noted in the gross description. If the DCIS was a separate tumor, this would have been noted by the pathologist. Reminder, the breast CAP protocol is a checklist for pathologists to note their findings while reviewing the slides and/or specimen. The findings and notes should be consolidated into a final/synoptic report. |
2018 |
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20130122 | Multiple primaries--Heme & Lymphoid Neoplasms: How many primaries are accessioned when an excisional biopsy of a chest wall nodule shows diffuse large B-cell lymphoma (40%) and follicular lymphoma, grade 3A (60%)? See Discussion. | The patient presented with a right chest wall nodule. The PET scan showed widespread disease: subcutaneous nodule/mass in the left scalp and right chest wall; large right paraspinal mass; soft tissue density likely a second early paraspinal mass at the right costovertebral junction; right paravertebral mass; and abnormal bony foci in the right humeral head, right iliac crest, right acetabulum and right femur. The physical exam showed 2 cm left supraclavicular lymphadenopathy and a firm 3 cm mass in the right chest wall. Lungs were clear. Abdomen showed no masses or ascites, and no palpable hepatosplenomegaly.
Chest wall nodule excisional biopsy pathology: Lymph node and adjacent soft tissue: Malignant lymphoma with components: 1. Diffuse large B-cell lymphoma (40%). 2. Follicular lymphoma, grade 3A (60%). Pathology report note states the diffuse large cell lymphoma is probably arising from the follicular center cell lymphoma.
Should this be a single primary? There is no mention of cutaneous lymphoma. |
Accession a single primary per Rule M4. Code histology to 9680/3 [diffuse large B-cell lymphoma] per Rule PH11.
Per Rule M4, accession a single primary when two or more non-Hodgkin lymphomas are present in the same lymph node or organ.
Per Rule PH11 code the histology to diffuse large B-cell lymphoma (DLBCL) (9680/3) when DLBCL and any other non-Hodgkin lymphoma are present in the same lymph node(s), lymph node region(s), organ(s), tissue(s) or bone marrow.
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. |
2013 |
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20190045 | Solid Tumor Rules (2018)/Multiple Primaries--Head & Neck: How many primaries are accessioned and what M Rule applies when a patient is diagnosed with a right lateral tongue (C023) tumor in 2016 that was verrucous carcinoma (8051), followed by a new left tongue border (C021) tumor in 2019 that was squamous cell carcinoma, NOS (8070)? See Discussion. |
According to the Multiple Primaries/Histology Rules in place at the time of the 2016 diagnosis, verrucous carcinoma was listed as a specific type of squamous carcinoma (Chart 1). However, in the current Solid Tumor Rules, verrucous carcinoma is not listed in Table 4 (Tumors of Oral Cavity and Mobile Tongue) either as a specific histology or as a specific subtype/variant of squamous carcinoma. The only subtype/variant listed for these sites is acantholytic squamous cell carcinoma (8075). Verrucous carcinoma is not listed in Table 4, making it unclear if it should be a different histology for these specified sites. However, verrucous carcinoma is listed as a specific subtype/variant of squamous carcinoma for other sites (e.g., Table 3). |
Accession a single primary based on the 2018 Head and Neck Solid Tumor Rule M13 as none of the other rules apply to the situation. Not all histology codes are contained in the tables in the Solid Tumor Rules as they list the more common histologies. Verrucous carcinoma is a subtype of squamous cell carcinoma according to Table 3 of the Rules. Solid Tumor rule tables are based on 4th Ed WHO Blue Books. Verrucous SCC is not included in oral cavity/mobile tongue chapter. |
2019 |
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20071114 | Ambiguous Terminology/Date of Diagnosis: How would you code the diagnosis date when the body of an imaging report uses reportable ambiguous terminology while the final impression in that same report uses non-reportable ambiguous terminology? Would you code the diagnosis date to the date of the scan or to the subsequent biopsy date that confirmed a malignancy? See Discussion. | Within the body of a mammogram report, the radiologist stated, "diffuse inflammatory tissue throughout the rt breast w/ large rt axillary lymph nodes, consistent with an inflammatory carcinoma of rt breast." His final impression, however, said "extremely suspicious rt breast w/ extremely dense breast parenchyma and adenopathy in axilla, suggesting an inflammatory carcinoma." The patient then went on to have a biopsy, which was indeed positive for cancer. | Accept the reportable ambiguous terminology from the body of the mammogram. Record the date of the mammogram as the date of diagnosis. The guidelines on page 4 of the 2007 SEER manual addressing discrepancies within the medical record can be applied to discrepancies within one report. The instructions are: If one section of the medical record(s) uses a reportable term such as apparently and another section of the medical record(s) uses a term that is not on the reportable list, accept the reportable term and accession the case. |
2007 |
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20220049 | Solid Tumor Rules/Multiple Primaries--Lung: How many cases should be abstracted for a patient with 2022 wedge biopsy of right upper lobe acinar predominant lung adenocarcinoma and wedge biopsy of right lower lobe lepidic predominant adenocarcinoma if there is concern for diffuse spread throughout the lungs secondary to the lymphangitic carcinomatosis and possible diffuse pneumonic type of adenocarcinoma? See Discussion. |
Acinar predominant adenocarcinoma measures at least 12 mm and involves wedge biopsy margins, while the lepidic predominant adenocarcinoma measures 11 mm and does not involve the margins of that separate specimen. Pathologist also notes, “CT findings of diffuse coarse reticular nodular opacity, these findings may represent pneumonic type adenocarcinoma/diffuse pulmonary involvement or intrapulmonary metastasis. Both of these scenarios have the corresponding stages of pT4 (if thought to be ipsilateral) or M1a (if thought to also involve the contralateral lobe).” Patient declined any further treatment and transitioned to hospice before expiring less than 1 month after wedge biopsies. It is unclear if Rule M6 would apply to these two specimens with different subtypes since this scenario is not specifically addressed in the M rule definitions. |
Abstract two separate primaries when separate/non-contiguous tumors are two or more different subtypes/variants in Column 3 of Table 3 using Rule M6 in the Solid Tumor Rules (September 2021 Update). They represent two subtypes/variants of the same NOS histology. When coding histology, tissue from pathology takes precedence over imaging, including when stated as differential diagnoses based on the CT scan, as noted by the pathologist in this example. |
2022 |
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20180083 | Solid Tumor Rules (2018)/Multiple primaries--Bladder: How many primaries are abstracted and which M Rule applies when a patient is diagnosed with an invasive urothelial carcinoma tumor of the bladder, followed less than three years later by an invasive urothelial carcinoma and small cell neuroendocrine carcinoma tumor of the bladder? See Discussion. |
The Solid Tumor Rules indicate bladder tumors that are urothelial carcinoma (8120) and small cell carcinoma (8041) are separate primaries per Rule M13 (Abstract multiple primaries when separate/non-contiguous tumors are on different rows in Table 2). These are distinctly different histologies and, presumably, one would want to capture the small cell carcinoma (or small cell carcinoma component) as this has a worse prognosis. However, if a subsequent bladder tumor is composed of invasive urothelial carcinoma and small cell neuroendocrine carcinoma, the histology is coded as 8045/3 per Rule H4, but this is not abstracted as a multiple primary. The only M Rule that applies is Rule M18 (Abstract a single primary when tumors do not meet any of the above criteria). The mixed histology code 8045 is not included in Table 2, so none of the histology-based M Rules apply. Is the subsequent mixed invasive urothelial and small cell carcinoma tumor (8045/3) the same primary as a previously diagnosed invasive urothelial carcinoma (8120/3) when these tumors are diagnosed within three years? |
Abstract two separate primaries using Solid Tumor Rules Urinary Sites Rule M13. While not stated in the urinary sites rules, these are separate histology codes in two different rows in Table 2 of the Rules. The initial histology is 8120 and the subsequent tumor is 8045 using Rule H4. Adding 8045 to Table 2 will cause issues. Small cell neuroendocrine in the bladder is very rare, extremely aggressive, and usually has a component of urothelial carcinoma. |
2018 |
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20210014 | Solid Tumor Rules (2018, 2021)/Multiple Primaries--Lung: How many primaries should be reported for a 4/2019 diagnosis of left upper lobe (LUL) adenosquamous carcinoma (left lingula mass biopsy: adenosquamous carcinoma; LUL lung biopsy: pulmonary adenocarcinoma, stated to be a collision tumor and single primary per the Tumor Board), treated with radiation followed by an enlarging LUL mass in 7/2020 found to be squamous cell carcinoma? See Discussion. |
The physician stated the prior LUL adenosquamous carcinoma was PD-L1 negative and the LUL squamous cell carcinoma is PD-L1 positive and is calling it a new primary. 5/22-7/3/19 6000x30 IMRT Photons LUL lung Chemo refused Not a Surg candidate 10/01/2019 CT Chest: IMP: In comparison to CT chest 03/06/2019 and PET/CT 03/21/2019, left lingular mass has mildly decreased in size. Left apical anterior and posterior lung lesions more anterior lesion appears slightly increased in size, the other slight decreased in size, with adjacent areas of atelectasis and scarring. 06/23/2020 CT Chest: MP: In comparison to CT chest 10/1/2019, left lingular mass has increased in size concerning for increasing tumor with adjacent thicker focal pleural thickening involving the chest wall, concerning for possible chest wall invasion. Left apical anterior and posterior lung lesions appears more solid in appearance, representing known adeno CA, given that the appearance has changed, is concerning for residual tumor. 07/06/2020 PET: Hypermetabolic lingular mass and peripheral nodularity has increased in size and FDG avidity on the prior PET/CT. Left apical nodular opacity is difficult to separate from fairly uniform mild left apical pleural hypermetabolism which may be treatment related and/or neoplastic. |
Abstract two primaries: 8560 and 8140 using rule M6. One of the original tumors with adenosquamous now shows only residual SCC following XRT. PD-L-1 is not used to determine multiple primaries. Assuming three tumors (the post-XRT SCC is not a new tumor but residual from one of the adenosquamous tumors) there are two primaries: 8560 and 8140 per M6. For collision tumors, each histology identified in the tumor is used to determine multiple primaries. |
2021 |
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20180004 | Reportability/MP/H Rules/Multiple primaries: Is a ganglioneuroblastoma (9490/3) following a melanoma (8720/3) a new primary if the diagnosing pathologist states: "Given the clinical context and patient age, then I believe that this may represent transdifferentiation of metastatic melanoma'? If this is a new primary, what MP/H rule would apply? See Discussion. |
March 2017 lung biopsy showing metastatic melanoma. Subsequent workup shows imaging with additional metastatic involvement of multiple bone sites but no primary tumor is identified. Chemotherapy is started in May 2017. July 2017 biopsy of right lower quadrant mass has a final diagnosis of ganglioneuroblastoma and pathologist's comment states I believe that this may represent transdifferentiation of metastatic melanoma. Later, partial colectomy of transverse colon Gross Description indicates this was centered in the mesentery. |
Abstract two primaries: 1. unknown primary site and 2. peripheral nerves and autonomic nervous system of abdomen, based on Multiple Primaries/Histology for Other Sites Rule M11 (topography codes that differ at the second or third character). While it is possible in rare cases that one tumor transforms into the other, transformations do not factor into the current MP/H rules. |
2018 |
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20210039 | Multiple primaries/Heme & Lymphoid Neoplasms--Lymphoma: Is a 2021 right tongue base biopsy showing diffuse large B-cell lymphoma (DLBCL) (9680/3) a new primary following a prior history of hairy cell leukemia-variant (HCL-v) (9591/3) in 2011? See discussion. |
Patient was diagnosed with low-grade non-Hodgkin lymphoma in 2011, later classified as hairy cell leukemia-variant. Right cervical node biopsy in 2020 proved HCL-v and a subsequent 2021 right tongue base biopsy showed DLBCL. The tongue base biopsy path includes the comment, patient has history of HCL-v, but the morphology and flow cytology features are different from the patient's previous right cervical node biopsy. This DLBCL likely represents a second de novo lymphoma, but cannot exclude an unusual transformation of the prior HCL-v. Per Heme Rule M7, abstract a single primary when a more specific histology is diagnosed after an NOS if the Heme DB confirms the same primary. The histology code for HCL-v, 9591/3 is a non-specific code, but it seems like a specific histology. The Heme Calculator does say 9591 and 9680 are the same primary, but we are unsure if that is correct for this case of HCL-v followed by DLBCL. |
Abstract two primaries. This is a transformation from a chronic disease (the Hairy Cell Variant) to an acute disease (DLBCL). Although this rare situation is not clearly covered in the Hematopoietic rules, the fact that this was originally a Hairy Cell Leukemia variant means that the DLBCL is a new primary. |
2021 |
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20210056 | 2018 Solid Tumor Rules/Multiple Primaries--Breast: How many primaries should be reported when a left breast simple mastectomy identifies focal Paget disease of the nipple and 12 axillary nodes positive for metastatic lobular carcinoma (no primary lobular breast tumor identified)? |
Abstract two primaries, one lobular carcinoma (8520/3) and another one Paget disease of the breast (8540/3) using the 2018 Breast Solid Tumor Rules, Rule M9: Abstract multiple primaries when the diagnosis is Paget disease with underlying tumor which is NOT duct. Example: Paget disease of the nipple with underlying lobular carcinoma are multiple primaries. Additionally, Table 2, Histology Combination Codes, Note 2 states: Lobular carcinoma and Paget are separate primaries (see Lobular carcinoma and any histology in Table 3 with exception of duct carcinoma/carcinoma NST/DCIS (and subtypes/variants) 8500 and Paget disease, in situ and invasive). While not identified in the pathology of the mastectomy, the lobular carcinoma is likely underlying as it was identified in the axillary lymph nodes. The 2021 SEER Manual states: If the only pathologic specimen is from a metastatic site, code the appropriate histology code and the malignant behavior code (/3). The primary site and its metastatic site(s) have the same histology. |
2021 |