Report | Question ID | Question | Discussion | Answer | Year |
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20200007 | Multiple primaries--Heme & Lymphoid Neoplasms: How many primaries are accessioned when a patient is simultaneously diagnosed with systemic mastocytosis and chronic myelomonocytic leukemia (CMML-0) on a single bone marrow biopsy? See Discussion. |
The Hematopoietic and Lymphoid Neoplasms Database (Heme DB) definition for systemic mastocytosis with an associated hematological neoplasm (SM-AHN, 9741/3) states SM-AHN is a variant of systemic mastocytosis that arises with a myeloid disease of non-mast cell lineage (e.g., MDS, MPN, etc.) and that, However, SINQ 20130172 conflicts with the Heme DB stating the systemic mastocytosis and the associated hematological neoplasm are a single primary coded to a single histology (9741/3) per Rule M2. |
Abstract a single primary when the diagnosis is systemic mastocytosis with an associated clonal hematogoical non-mast cell lineage disease (SM-AHNMD) (9741/3). However, if the patient has a previous history of myelodysplastic syndrome, myeloproliferative neoplasm, myelodysplastic/myeloproliferative neoplasm or acute leukemia, abstract the SM-AHNMD as a second primary as stated in the Heme DB. SINQ 20130172 represents a single primary as there is no mention of a prior history of myelodysplastic syndrome, myeloproliferative neoplasm, myelodysplastic/myeloproliferative neoplasm or acute leukemia. |
2020 |
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20200055 | Solid Tumor Rules (2018)/Multiple primaries--Melanoma: Should a case with treatment delayed due to COVID-19 be abstracted as one or two primaries? It is uncertain if the invasive tumor would be a new tumor, or deeper extension/disease progression from the original tumor. See Discussion. |
11/18/2019 Left 1st Digit/Thumb Biopsy: Atypical Melanocytic Proliferation consistent with Early Acral Lentiginous Melanoma in situ. Margins Positive. (Not a reportable diagnosis for 2019.) 12/5/2019 Left 1st Digit Shave Biopsies: Malignant Melanoma in situ. Margins Positive. 1/15/2020 Started Aldara (treatment plan: use for ~3 months then Mohs/excision, but due to COVID could not get resection until 7/2020). 7/29/2020 Left Thumb Excision: Residual Melanoma in situ. Margins Positive. Treatment Plan: re-excision. 8/6/2020 Left Thumb Re-Excision: Atypical Lentiginous Melanocytic Proliferation at the 12-2 margin may represent the advancing edge of melanoma in situ. (8/19/2020 Plan to treat the 12-2 margin as positive with in situ; plan for re-excision). 8/20/2020 Left Thumb Re-Excision & Left Nail Plate Excision: Malignant Acral Lentiginous Melanoma with extensive melanoma in situ. Breslow 1.3mm. Margins Positive. Nail plate & bed epithelium with hemorrhage and a mild increase in melanocyte density likely represent melanoma in situ. 9/4/2020 Left thumb partial amputation & Left axillary Sentinel Lymph Node Excision: Residual Malignant Melanoma in situ. 0/3 sentinel nodes positive. |
Abstract a single primary using the Solid Tumor Rules for melanoma. Report this melanoma as invasive (/3) as documented in the information from 8/20/2020. The treatment delay does not influence the number of primaries to be reported. Registries in SEER regions: Report the COVID-related information as directed in the COVID-19 Abstraction Guidelines, https://seer.cancer.gov/tools/covid-19/. |
2020 |
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20230010 | Solid Tumor Rules/Multiple Primaries--Breast: How many primaries are accessioned when a 2020 diagnosis of invasive ductal carcinoma treated by lumpectomy is followed by a 2023 diagnosis of invasive lobular carcinoma treated by mastectomy? See Discussion. |
Historically, multiple invasive ductal and lobular carcinomas diagnosed within 5 years were abstracted as a single primary. However, it is not clear if Rule M10 or M14 applies to this situation per the 2023 Solid Tumor Rules updates. Rule M10 addresses multiple tumors of carcinoma of no special type (NST)/duct and lobular, but there is no timing criteria mentioned. Does M10 apply to cases diagnosed synchronously, or metachronously, or at least within 5 years? Should Rule M10 include a Note instructing registrars to accession a single primary for the scenario in question? If timing matters for Rule M10, then the next rule that applies is M14. Rule M14 instructs one to abstract multiple primaries when separate/non-contiguous tumors are on different rows in Table 3, and carcinoma NST/duct and lobular carcinoma are on separate rows in Table 3. |
Abstract a single primary using the Breast Solid Tumor Rules, Rule M10, assuming the tumors are in the same breast. This rule is specific to multiple tumors of carcinoma NST/duct and lobular. Timing is not a factor in this rule. As stated in ‘New for 2023,’ the rules for determining single versus multiple primaries in tumors with carcinoma NST/duct and lobular carcinoma have been revised and now align with ICD-O-3.2. Tumors occurring more than five years apart are multiple primaries and would have been caught at Rule M5. Thus, rule M10 pertains to tumors occuring less than five years apart. |
2023 |
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20230027 | Solid Tumor Rules/Multiple Primaries--Peripheral Nerves: How many primaries should be abstracted, and which M Rule applies, when a malignant peripheral nerve sheath tumor (MPNST) in the right arm (C471) is followed greater than one year later by a separate malignant peripheral nerve sheath tumor of the thoracic chest wall (C473)? See Discussion. |
Since the peripheral nerves are included in the Malignant CNS schema of the Solid Tumor Rules, neither the differences in subsite nor timing indicate these are separate primaries (Rule M10 indicates a single primary). However, these are separate MPNSTs in different sites and the tumors are not stated to be metastasis. Additionally, these are treated as separate primaries by the managing physician. While the malignant CNS tumors do not take timing into account, is this correct for these peripheral nerve tumors that are often treated similarly to soft tissue tumors? Should Rule M8 be updated to include tumors in different peripheral nerve subsites? |
Abstract a single primary using Solid Tumor Rules, Malignant CNS and Peripheral Nerves, Rule M10 based on the information provided. Rule M10 applies as both non-contiguous tumors are of the same histology; i.e., on the same row in Table 3. As MPNST can arise in many sites, look for information about the precise location and tissue type in which the tumor arose. For example, if the tumors are stated to arise in soft tissue, follow the Multiple Primary Rules for Other Sites. Both WHO Classification of Central Nervous System Tumors and WHO Classification of Soft Tissue and Bone Tumors state that MPNST is a malignant spindle cell tumor often arising from a peripheral nerve, from a pre-existing benign nerve sheath tumor, or in a patient with neurofibromatosis type 1 (NF1). Future updates will move C470-C479 from CNS to other sites module. |
2023 |
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20160002 | MP/H Rules/Histology--Breast: Which is the correct histology code to use and which MP/H rule applies in the case of a single lumpectomy specimen that demonstrates two separate tumors with the following histologies. 1) Invasive lobular carcinoma 2) Invasive ductal carcinoma with tubular features See discussion. |
Does ductal carcinoma with tubular features qualify for Breast MP/H Rule H28? Or, is it more appropriate to strictly follow Table 2 (not a type of ductal tumor) and apply Rule H29, thus losing the lobular component? |
Abstract a single primary using Rule M13. Assign 8523/3 using rule H29. The code for invasive ductal carcinoma with tubular features (8523/3) is higher than the code for invasive lobular carcinoma (8520/3). H28 does not apply because 8523/3 is not included as a type of duct carcinoma on Table 2. |
2016 |
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20230070 | Solid Tumor Rules/Multiple Primaries--Breast: How many primaries should be accessioned for a diagnosis of invasive carcinoma of the left breast (8500/3) in 2020 followed by a 2023 diagnosis of dedifferentiated carcinoma in the left breast (8020/3)? See Discussion. |
The WHO Blue Books do not include dedifferentiated carcinoma as a valid histology for the breast. However, there is known to be progression of ductal carcinoma that is essentially dedifferentiation of an estrogen receptor, progesterone receptor, and HER2 breast carcinoma to a triple negative "dedifferentiated" carcinoma which it appears this patient has. Whether we should accession this as a separate 8020/3 primary per M14 is unclear and the Solid Tumor Manual does not address this scenario. |
Abstract a single primary using Breast Solid Tumor Rules, Rule M18, as none of the previous rules apply. Undifferentiated carcinoma is a malignant epithelial tumour lacking overt evidence of a specific line of differentiation. Dedifferentiated carcinoma is composed of an undifferentiated carcinoma and a differentiated component. Dedifferentiated carcinoma (8020/3) as a morphology is associated with cancer of the endometrium and ovary rather than the breast. Breast cancer shows a broad spectrum of morphology with extensive variation in histological type and grade, related to the complexity of carcinogenesis. This includes initial genetic changes in the cell of origin, subsequent genetic and epigenetic alterations, and reprogramming that occur at various stages of development along with interaction of other factors that influence the process of differentiation. This scenario likely represents the process of phenotypic change of a carcinoma at a later stage, better known as transdifferentiation. |
2023 |
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20210012 | Solid Tumor Rules (2018, 2021/Multiple Primaries/)--Lung: How many primaries should be reported and what M rule applies when a diagnosis of presumed adenocarcinoma in situ (AIS) of the left lung follows a known diagnosis of progressive multifocal malignant adenocarcinoma in the right lung? See Discussion. |
Patient was initially diagnosed with a right lower lobe (RLL) lung adenocarcinoma in 2014 followed by subsequent right upper lobe (RUL) lung adenocarcinoma in 2016 (single primary). Both were treated with radiation and the nodules were seen as stable on surveillance. There was subsequent growth in the RUL nodule in 2019 and RLL nodule in 2020 as well as a new right middle lobe (RML) nodule in 2020. All left sided nodules were noted to be stable and/or ground glass opacities. There was no documented diagnosis of malignancy in the left lung until June 2020 when the physician noted that if there was a response in the left lung to systemic treatment, then this was probably multifocal AIS. However, only one tumor in the left lung responded to treatment. While it seems somewhat unlikely that only a single AIS in the contralateral lung should be metastasis from the right lung malignancy, it is difficult to apply the multiple tumors rules to this case. |
Abstract a single primary using 2018 Lung Solid Tumor Rule M9. The 2014 and 2016 R lung tumors were pathologically confirmed; it is not stated if they were resected. Follow up after XRT noted stable disease but no indication of NED. Subsequent right lung tumor is also the same primary. The issue is the assumed left lung adenocarcinoma in situ. It is not clear how long the left lung nodules were present, but they appeared to be stable as well and only diagnosed as a malignancy based on treatment response. At this time M9 applies and the left lung AIS is not a separate primary. We have discussed at length with lung pathology experts the issue of determining multiple primaries. Identifying and diagnosing lung tumors has become easier with new technology and the result is patients are being diagnosed with multiple lung tumors. Some lung experts feel we are under-reporting lung primaries but all noted the many issues with creating rules for consistency. |
2021 |
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20190096 | Solid Tumor Rules (2018)/Multiple primaries--Colon: Is a colorectal anastomotic site recurrence reportable, that is, a second primary, per Rule M7, third bullet, if there is no mention of mucosa but the tumor is seen on colonoscopy? See Discussion. |
Colon, Rectosigmoid, and Rectum Multiple Primary Rule M7 states, Abstract multiple primaries when a subsequent tumor arises at the anastomotic site AND the subsequent tumor arises in the mucosa. We identified tumors at the anastomotic site of previous colon primaries with no mention of mucosa in any of the available documentation. Are there any other indicators that would imply a tumor arising in the mucosa, or do we need this specific statement to apply rule M7? Example: Patient has a history of invasive ascending colon adenocarcinoma diagnosed in October 2017 status post hemicolectomy followed by adjuvant chemo. There is no documentation of disease until August 2019 colonoscopy which shows a mass in the ileocolic anastomosis. Biopsy of the anastomotic site is positive for adenocarcinoma consistent with recurrence of the patient's colonic adenocarcinoma. There is no mention of mucosa found on the pathology report. |
Abstract a single primary using 2018 Colon Solid Tumor Rule M8 in the example provided as there is a subsequent tumor occurring less than 24 months in the anastomotic site, with the same histology and no mention of mucosa. The new tumor would be a new primary when it meets any one of the criteria noted in M7. The tumor does not have to be stated to have arisen in the mucosa. M8 also has three options to determine if a single primary is present. |
2019 |
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20200022 | Solid Tumor Rules (2018)/Multiple primaries--Breast: How many primaries should be reported for a December 2013 diagnosis of lobular carcinoma in situ (8520/2) in the left breast, treated with a lumpectomy, followed by a July 2018 diagnosis of invasive ductal carcinoma (8500/3) also in the left breast? See Discussion. |
In the April and July 2019 updates to the Solid Tumor Rules, the term simultaneous and Note 1 indicating histologies must be the same behavior were removed from rule M10 (ductal and lobular are a single primary). We would like to confirm that rule M10 is the correct rule to apply to this case. This case is an invasive diagnosis approximately 4.5 years after an in situ diagnosis, so it seems like M17 should apply (invasive tumor following an in situ tumor more than 60 days later are multiple primaries). An invasive tumor following an in situ tumor more than 60 days later of the same histology is a new primary. Similarly, it seems like an invasive tumor following an in situ tumor more than 60 days later of different histologies should be a new primary. |
Abstract a single primary using 2018 Breast Solid Tumor Rule M10. Unless the tumors were diagnosed more than 5 years apart, they are a single primary. The 2021 breast update will include examples and notes plus updating table 2. |
2020 |
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20220047 | Solid Tumor Rules/Multiple Primaries--Head and Neck: Is a patient with 2020 neck mass, squamous cell carcinoma (SCC), p16-negative, who then had a biopsy of the right tonsil (C09.9) in July 2022, SCC p16-positive, one or two primaries? Is this coded to 8070/3 using pre-2022 rules or a new, second primary p16-positive, 8085/3. See Discussion. |
History provided by the oncologist Right neck mass since 2019; 04/07/20, initial biopsy p16-negative SCC, delay of treatment due to patient preference, agreed to biopsy of tonsil and work-up August 2022; right tonsil biopsy: p16-positive, G2 SCC, nodal mass at that time >6 cm with extensive extranodal extension, Stage III (cT2, cN3, cM0, p16-positive); based on this history, was staged as a tonsil primary and p16-positive. Patient details 1. March 2020, CT neck and chest revealed a 0.5 x 2.7 x 2.3 cm low-density necrotic nodal mass at right neck level 2 suspicious for metastatic disease. There was a slight asymmetric increased size of the right palatine tonsil. There are a few sub-4 mm pulmonary nodules which are nonspecific. 2. April 7, 2020, FNA of right neck mass with pathology revealed p16-negative SCC 3. April 20, 2020, PET/CT revealed 3 x 2 cm right-sided level 2 node with FDG avidity 4. May 5, 2020, flexible laryngoscopy showed no obvious primary lesion 5. May 2020, after evaluation by a medical oncology, patient declined any treatment 6. June 17, 2022, return visit in medical oncology after PET/CT demonstrates significant progression in the neck; patient definitively declines chemo, but would like surgical opinion. Now has more rapidly progressive disease with skin breakdown and weeping from malignant lesion right neck. 7. June 22, 2022, radiation oncology consultation 8. July 15, 2022, tonsil biopsy: Invasive squamous cell carcinoma, moderately differentiated with LVI, p16-positive 9. Patient now agreeing to treatment with radiation: Tooth extractions 8/30/2022, radiation planning 9/14/2022 10. Patient consulted with cancer specialist who explained surgery is not recommended given level of extranodal extension and risk of seventh cranial nerve paralysis and fistula formation with surgical excision and who recommended chemoradiation 11. September 9, 2022, patient presented for radiation CT simulation/treatment planning and informs treatment team. Patient declined/refuses concurrent chemotherapy despite recommendations from two cancer institutions. |
Abstract a single primary of the tonsil. The diagnosis date is March 2020 (the date of the CT scan). Assign 8070/3 for the histology. Metastases were found in 2020 before the primary of tonsil was determined in 2022. The oncologist information confirms this. |
2022 |