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| Report | Question ID | Question | Discussion | Answer | Cancer Site Category | Data Item Category | Year |
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20140010 | Multiple primaries--Heme & Lymphoid Neoplasms: Is this one primary or two? Follicular lymphoma grade 1 (9695/3) on 8/23/12 from an abdominal lymph node. On 1/6/14 an abdominal lymph node biopsy showed diffuse large b cell lymphoma arising from high grade follicle center cell lymphoma. Patient has been on observation. | 1st primary, 8/23/12: Follicular lymphoma, grade 1 2nd primary, 1/6/14: Diffuse Large B Cell Lymphoma Apply the multiple primary rules twice for this case. The 2012 diagnosis is follicular lymphoma. There are two histologies in 2014: diffuse large b cell lymphoma and follicle center cell lymphoma diagnosed at the same time in the same location. This is one primary per rule M4. Then compare the 2012 diagnosis to the 2014 diagnosis. Per the Hematopoietic Database, follicular lymphoma (all types) transforms to DLBCL. Per Rule M10, the DLBCL would be a second primary. |
Heme & Lymphoid Neoplasms | N/A | 2014 | |
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20130101 | Reportability--Heme & Lymphoid Neoplasms: Is plasma cell dyscrasia, favor MGUS vs. smoldering myeloma reportable? See Discussion. | The pathology report states, "plasma cell dyscrasia, favor MGUS vs. smoldering myeloma." The patient then died of a heart attack and no further information is available. If this is reportable, what histology code applies? | For cases diagnosed 2010 and forward, access the Hematopoietic Database at http://seer.cancer.gov/seertools/hemelymph.
This case is not reportable. Neither plasma cell dyscrasia nor MGUS are reportable. Smoldering myeloma was given as a possible diagnosis, but never confirmed.
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. |
Heme & Lymphoid Neoplasms | N/A | 2013 |
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20071051 | MP/H Rules/Multiple Primaries--Lung: Please clarify the multiple primary rule M6 and the explanatory note that states when there is a single tumor in each lung, they are to be reported as multiple primaries unless stated or proven to be metastasis. See Discussion. | Single tumor in left lung, single tumor in right lung. The rules take you to M6. Suppose the tumor in left lung is biopsied and there is a physician statement that right lung tumor is metastatic from left lung tumor. The note under M6 is "When there is a single tumor in each lung, abstract as multiple primaries unless stated or proven to be metastatic." In this case, is it a single primary or multiple primaries? | For cases diagnosed 2007 or later: When there is a single tumor in one lung and a single tumor in the other lung, apply rule M6 and abstract as multiple primaries. Use this rule whenever there is a single tumor in each lung, even when neither tumor is biopsied or resected.
This rule is unique to lung. Our physician advisors emphasized that it is very unlikely that a single tumor in one lung could be metastatic from a single tumor in the opposite lung. Therefore, the default is to abstract as multiple primaries.
The note at M6 means that there must be proof that one tumor is metastatic in order to abstract as a single primary. For example, a biopsy of the tumor proving that it is metastatic. An opinion or belief that one tumor is metastatic is not sufficient. In the absence of proof, use rule M6 and abstract as multiple primaries.
A list of MP/H clarifications will be available. This issue will be included on the list. |
Lung | N/A | 2007 |
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20130081 | Multiple primaries--Heme & Lymphoid Neoplasms: How many primaries are accessioned when a patient is clinically stated to have Stage III follicular lymphoma following a diagnosis suspicious for B-cell lymphoma and is subsequently diagnosed with large B-cell lymphoma? See Discussion. | 01/27/2012 R neck mass FNA: Suspicious for B-cell non-Hodgkin lymphoma. 02/17/2012 Cervical node bx: In situ involvement by follicular-like B-cells of uncertain significance +CD10. Two other cervical biopsies show infarcted, extensively necrotic lymphoid tissue highly suspicious for B-cell lymphoma.
03/20/2012 Bone marrow: Low grade B-cell lymphoproliferative disorder with plasmacytic differential.
04/18/2012 Medical Oncology treats patient for Stage III follicular lymphoma. 10/16/2012 Cervical LN core bx: CD10+ large B-cell lymphoma.
Should Rule M4 (single primary) and Module 6, Rule PH11 apply to this case? |
Updated May 2026
This case should be accessioned as two primaries: follicular lymphoma [9690/3] diagnosed 02/17/2012 and diffuse large B-cell lymphoma [9680/3] diagnosed 10/16/2012 per Rule M10. This patient was diagnosed with a chronic neoplasm (follicular lymphoma) followed later by an acute neoplasm (DLBCL) after the completion of the initial clinical workup for the chronic neoplasm.
The follicular lymphoma was initially diagnosed on 02/17/2012. The cervical node biopsies were "highly suspicious for B-cell lymphoma" [9591/3]. While "suspicious" is a reportable ambiguous term used to accession cases, suspicious cytologies are not SEER reportable and, therefore, the diagnosis date cannot be 01/27/2012. The histology of the first primary would be updated to 9690/3 [follicular lymphoma] based on the Medical Oncology note on 04/18/2012 that confirmed the histology was follicular lymphoma and the patient was being treated for such.
The diagnosis of DLBCL was made 8 months later. Rule M4 cannot apply to this case because the follicular lymphoma and DLBCL were not diagnosed in the same biopsy specimen. Rule M4 only applies when the two non-Hodgkin lymphomas are diagnosed in the same biopsy specimen. |
Heme & Lymphoid Neoplasms | N/A | 2013 |
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20170031 | MP/H Rules/Multiple primaries--Penis: How many primaries should be reported for a diagnosis of invasive squamous cell carcinoma (SCC) of the penis in 6/2011, treated with excision and fulguration followed by 10/2014 penile lesion found to be SCC with basaloid features focally highly suspicious for invasion? Clinically, the 2014 tumor is stated to be in situ and recurrent penile cancer and follow-up in 2/2015 indicates there was no evidence of tumor following treatment. Subsequently, in 3/2016 the patient has another penile lesion biopsy showing SCC in situ suspicious for invasion, clinically stated to be recurrent. See Discussion. |
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? |
Accession three tumors as the tumors were each diagnosed more than one year apart according to the MP/H Rule M10 for Other Sites. And, as you have noted, the patient was free of disease after each diagnosis. The MP/H rules have very clear instructions regarding the word "recurrence." See page 10, specifically A.7., https://seer.cancer.gov/tools/mphrules/2007_mphrules_manual_08242012.pdf SEER will evaluate the MP/H rules in the upcoming revision. |
N/A | N/A | 2017 |
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20180087 | Solid Tumor Rules (2018)/Multiple Primaries--Brain: How many primaries are there and what M Rule applies when two tumors identified in the brain are pathologically proven to be glioblastoma, IDH-wild type and anaplastic astrocytoma per the pathology report final diagnosis, but the diagnosis comment and tumor board indicates multifocal glioblastoma is favored? See Discussion. |
The patient has one tumor each in the left parietal and left medial temporal lobe. The tumors were excised. The final diagnosis for the left parietal tumor is glioblastoma, IDH-wild type. he final diagnosis of the left medial temporal tumor is, at least anaplastic astrocytoma, WHO grade III; see comment. The comment states: There is a single focus of vascular hyperplasia, separate from neoplastic cells. No necrosis is identified. These findings on their own would warrant a diagnosis of anaplastic astrocytoma, WHO grade III. However, in the context of the patient's glioblastoma in the left parietal lobe, and imaging showing ring-enhancing lesions of the parietal and temporal lobes, this specimen is favored to be an un-sampled glioblastoma, WHO grade IV. The Solid Tumor Rules indicate we may no longer use terms like favor(s) to code the histology, leaving the final diagnosis as the priority source for coding histology per the Histology coding rules. The tumor board review confirmed that, despite the anaplastic astrocytoma on pathology, they felt strongly that this is a multifocal glioblastoma and not an anaplastic astrocytoma. Both the pathologist's comment and the tumor board's assessment indicate this patient does not have two primaries. However, the Solid Tumor Rules do not give priority to the tumor board's assessment over the pathology, and registrars are not to use ambiguous terms to code histology thus leaving the two histologies to consider. Per the Solid Tumor Rules, one tumor that is glioblastoma and one tumor that is anaplastic astrocytoma are multiple primaries per M11 (Abstract multiple primaries when separate, non-contiguous tumors are on different rows in Table 3 in the Equivalent Terms and Definitions. Timing is irrelevant). As a central registry, we cannot ask the pathologist or attending physician for clarification as suggested in Section 3 of the Malignant CNS and Peripheral Nerves Equivalent Terms and Definitions. We can only follow the current Solid Tumor Rules. In doing so, we would have to ignore both the pathologist's and tumor board's assessment that this patient has multifocal glioblastoma. Is there any concern that this will lead to over-reporting? |
Abstract separate primaries based on the two histology codes as these are separate tumors on different rows in Table 3 of the 2018 Solid Tumor Rules for Malignant CNS, Rule M11. The priority order for using documentation to identify histology for Malignant CNS is to use pathology/tissue from the resection over the tumor board. |
Brain and CNS | N/A | 2018 |
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20170026 | Multiple Primaries/Histology Rules/Multiple primaries--Kidney, renal pelvis: Are tumors diagnosed more than three years apart multiple primaries according to Rule M7 in a case with metastasis? See Discussion. |
5/27/02 Transurethral resection of bladder tumor (TURBT)--papillary transitional cell carcinoma, +lamina propria, no muscle invasion. All urine cytologies in 2011 and 2012 (only follow up received) show no malignancy. 3/11/15 Lung fine needle aspirate--poorly differentiated carcinoma consistent with urothelial carcinoma. 4/30/15 Renal pelvis biopsy--low grade papillary urothelial carcinoma, no lamina propria invasion, no muscularis propria invasion. |
Rule M7 applies. Abstract the bladder diagnosis and the renal pelvis diagnosis as separate primaries. The lung diagnosis is metastatic. The MP/H rules do not apply to metastatic tumors. |
Kidney, renal pelvis | N/A | 2017 |
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20120088 | MP/H Rules/Multiple primaries--Head & Neck: How many primaries are accessioned and what rule applies if a patient has an extensive tumor in the left ethmoid sinus and a separate tumor in the right maxillary sinus? See Discussion. |
MRI and CT Neck Impression: Extensive tumor mass which likely originated within the left ethmoid sinus and extends intracranially via the cribriform plate into the anterior cranial fossa. There is involvement of the left orbit and extension into the superior aspect of the left maxillary sinuses as well as the nose. Second enhancing lesion within the right maxillary sinus measures almost 2 cm. The second mass within the floor of the right maxillary sinus, with similar imaging characteristics, is consistent with malignant involvement. The patient has an extensive ethmoid sinus tumor, biopsy showed squamous cell carcinoma. The ethmoid sinus is not a paired organ. The patient also has a small maxillary tumor with no histologic confirmation, Hem/Oncology chart notes state the right maxillary sinus mass is carcinoma. The maxillary sinus is a paired organ. Per the AJCC Manual (AJCC Manual for Staging, 7th edition, page 70), both the ethmoid and maxillary sinuses are further identified by their laterality (left and right). Why aren't the ethmoid sinuses a paired organ for the MP/H Rules? What MP rule applies to this case? |
For cases diagnosed 2007 or later, accession a single primary. The steps used to arrive at this decision are: Open the Multiple Primary and Histology Coding Rules Manual. Choose one of the three formats (i.e., flowchart, matrix or text). Go to the Head and Neck MP rules after determining the histology of each tumor - (8070/3 [squamous cell carcinoma] and 8010/3 [carcinoma, NOS]) because site specific rules have been developed for this primary. Start at the MULTIPLE TUMORS module, Rule M3. The rules are intended to be reviewed in consecutive order within a module. Abstract a single when one tumor is carcinoma, NOS [8010] and another tumor is a specific carcinoma, squamous cell carcinoma [8070] because the ethmoid sinus (site of origin) is not a paired site per the MP/H rules. We will review the list of paired organs for the next edition of the MP/H Rules. |
Head & Neck | N/A | 2012 |
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20110031 | Multiple primaries--Heme & Lymphoid Neoplasms: How many primaries are accessioned if patient initially diagnosed with granulocytic sarcoma on a vocal cord biopsy is subsequently diagnosed with acute myeloid leukemia more than 21 days later? See Discussion. | The patient has a history of refractory anemia with excess blasts diagnosed in 2008. A vocal cord biopsy performed on 6/2/2010 stated, "in view of a previous history of myelodysplastic syndrome this is indicative of transformation to acute leukemia" and consistent with granulocytic sarcoma. A bone marrow biopsy done on 7/19/2010 stated this was compatible with refractory anemia with excess blasts in transformation.
Granulocytic sarcoma is a solid manifestation of AML. When these diagnoses occur more than 21 days apart, are they separate primaries?
According to the WHO definition, this is acute myeloid leukemia complicating myelodysplasia. Which rule applies for this case? |
For cases diagnosed 2010 and forward, access the Hematopoietic Database at http://seer.cancer.gov/seertools/hemelymph.
This case should be accessioned as two primaries. The first is refractory anemia with excess blasts in 2008, and the second is AML June 2, 2010.
As for the disease occurring in 2010, granulocytic sarcoma does not transform into AML. Per the Abstractor Notes section in the Heme DB under the term "granulocytic sarcoma," it indicates that "Myeloid sarcoma (also known as granulocytic sarcoma) may occur de novo; it may precede or coincide with AML, or represent an acute blastic transformation of myelodysplastic syndromes." This means that when granulocytic/myeloid sarcoma is seen with AML, it represents a solid manifestation of the systemically involved AML. In other words, it is all the same disease process (coded to AML) if it occurs simultaneously.
In this case, when the physician gave a provisional diagnosis of "transformation to acute leukemia" it indicated he saw the solid deposits of myeloid cells on the vocal cord. Per Rule M3, AML and myeloid (granulocytic) sarcoma appearing simultaneously are a single primary coded to AML. When the patient has AML, solid myeloid deposits (myeloid sarcoma) may appear. This is a manifestation of the AML rather than a new primary. Rule PH10 states to code the histology to AML.
Under the Transformation section in the Heme DB for refractory anemia with excess blasts (a chronic neoplasm), it indicates this disease process does transform to acute myeloid leukemia, NOS (an acute neoplasm). In this case, the chronic and acute disease processes were diagnosed at different times. Per Rule M10, abstract as multiple primaries when a neoplasm is originally diagnosed in a chronic (less aggressive) phase AND second diagnosis of a blast or acute phase more than 21 days after the chronic diagnosis.
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. |
Heme & Lymphoid Neoplasms | N/A | 2011 |
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20021028 | EOD-Clinical Extension--Prostate: If the tumor arises in the prostatic apex, does that take priority over coding clinical extension based on the stage of cT1c? See discussion. | Physician states prostate primary is a cT1c. Pathology states adenocarcinoma, Gleason 3+3, right apex. All other biopsies were negative. Because the primary appears to be in the prostatic apex, do we code 33 or 15 for clinical extension? Which is more important for SEER? Do you want to capture the "apex" information or the "cT1c" information? | For cases diagnosed 1998-2003:
Code the EOD-Clinical Extension field to 33 [arising in prostatic apex]. Apex information takes priority. The only statement we have is cT1c by the urologist, and we don't know how that stage was determined. |
Prostate | N/A | 2002 |
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