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We think this should be a single primary because the Solid Tumor rules do not apply to metastases. However, we are not sure whether or not the instructions outlined for prostate (SINQ 20180088, 20130221), that indicate we are to accession a new metastatic tumor only with a small cell neuroendocrine histology after an adenocarcinoma, also applies to lung primaries.

We are aware of a phenomenon in which lung adenocarcinoma cases treated with Erlotinib can transform to small cell, but do not know whether it impacts the number of reportable primaries.

SINQs 20190083, 20180088, and 20130221 all indicate diagnoses of prostate adenocarcinoma, followed by a diagnosis of metastatic small cell carcinoma of the prostate are separate primaries because these are distinctly different histologies. Does this logic still apply for 2023 and later since Rule M4 was added to the Other Sites M Rules? Rule M4 states, “Abstract multiple primaries when the patient has a subsequent small cell carcinoma of the prostate more than 1 year following a diagnosis of acinar adenocarcinoma and/or subtype/variant of acinar adenocarcinoma of prostate.”

This patient has a 2018 diagnosis of prostate adenocarcinoma treated with radical prostatectomy, followed by a 2023 diagnosis of metastatic small cell carcinoma of the prostate diagnosed on a liver metastasis core biopsy. Rule M4 does not indicate whether it applies to subsequent biopsy confirmed metastatic tumor only. When a diagnosis of small cell carcinoma follows a diagnosis of prostatic adenocarcinoma, it is almost always confirmed in metastatic sites rather than in the primary site. Does the logic in the referenced SINQs above still apply for Rule M4?

The patient is diagnosed by bilateral mammograms suspicious for malignancy in both breasts. A biopsy is done on one breast and is positive. The physician states that he will not biopsy the contralateral breast, as the patient has consented to bilateral mastectomy. The patient receives neoadjuvant chemo, follow by bilateral mastectomies. Both breasts are negative for residual cancer, stated as a complete response. Based on "suspicious for malignancy" can we accession two primaries and assume bilateral complete response?

At the central registry, we have accessioned this scenario as three primaries per Multiple Primaries/Histology (MP/H) Rule M10 (diagnosed more than 1 year apart), as the patient was stated to be disease free between each occurrence. However, the diagnosing/treating facility is not reporting these cases due to clinical statements of recurrent disease.

This is an example of a case type identified on casefinding audits conducted by our central registry in which we have learned SEER's expectation of MP/H rule application does not match hospital reporting. Can the 2018 version of the MP/H rules more clearly address how this type of clinically recurrent (multiple times) case should be handled?

A patient was diagnosed with hepatocellular cancer (HCC) in 2010, and underwent a hepatectomy, and then received a donor liver. In 2014, HCC was discovered in the liver once again. This likely is a new primary, but there are no specific rules to cover this. There are many odd situations involving transplanted organs, many of which pose reportability and multiple primary problems.

Patient has only a LUL tumor on imaging. The tumor board initially states, possibly a mixed tumor, likely IIIA SCC and/or IIIA or B small cell. Later, the physician refers to it as "Stage III lung cancer, mixed histology with small cell in the lymph node and squamous cell in the LUL mass." Patient has no further workup and has declined therapy.

Example 1: Lung-Wedge resection and subsequent left lower lobe lobectomy showed papillary epithelial neoplasia. Tumor board and subsequent reports state "nonsmall cell carcinoma of lung."

Example 2: Kidney-Partial nephrectomy showed epithelial neoplasm, clear cells with low grade cytology. Subsequent urology clinic notes state that path revealed clear cell renal carcinoma.

2004 SEER manual states that "cases clinically diagnosed are reportable. If the physician treats a patient for cancer in spite of the negative biopsy, accession the case." Do we also accession the case if primary site has been resected? Would diagnostic confirmation be coded 8 (clinical diagnosis only)?

Example: Brain MRI shows a mass along underside of right tentorium extending to posterior incisura consistent with meningioma. Spinal MRI shows mass at C4-5 level consistent with meningioma. Resection of spinal meningioma shows final diagnosis of meningioma and College of American Pathologists (CAP) protocol summary indicates Histologic Type (WHO classification of tumors of the central nervous system): Meningioma, meningothelial. There is no resection of the cerebral meningioma planned. Is the CAP protocol used if it provides a further subtype for meningiomas? Per Solid Tumor Rules, the final diagnosis has priority over the CAP summary. The answer to this question does affect the number of primaries accessioned in this case.

The patient has a history of CLL/SLL dating back to 2007, but has had progressive disease with development of a new left frontal brain tumor. The brain tumor resection proved CLL/SLL with large cell transformation, but neither the pathologist nor the managing physician called this a Richter transformation, Richter syndrome or provided a diagnosis of DLBCL. However, a large cell transformation of CLL/SLL is a Richter transformation. Can this be accessioned as a new acute neoplasm per Rule M10?