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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.

For cases diagnosed prior to 1/1/2010:Code CMML for this case. Code the histology at initial diagnosis. This patient had rapid progression, but the initial diagnosis was "more compatible with CMML/MPD."

For cases diagnosed 1/1/10 and later, refer to the Hematopoietic and Lymphoid Neoplasm Case Reportability and Coding Manual and the Hematopoietic Database (Hematopoietic DB) provided by SEER on its website to research your question. If those resources do not adequately address your issue, submit a new question to SINQ.

This case is reportable.

It is possible that the polypectomy removed the entire tumor. Invasive carcinoma in a polyp does not mean that is has invaded the stalk of the polyp. If the stalk is not invaded, all of the cancer may have been removed by a polypectomy.

This case is reportable as carcinoma in situ. The histology code is 8263/2 [adenocarcinoma in situ in a tubulovillous adenoma].

According to our pathologist consultant, a "comment" in a path report is a part of the diagnosis - it often elaborates on or clarifies the diagnosis. Placing [carcinoma in situ] in the comment, even in parentheses, indicates that is the appropriate diagnosis for our purposes.

This is a single primary per Lung rule M7. First determine the histology for each tumor. Both tumors are coded 8140/3 because the histologies are a PATTERN. Reference: Coding Multiple Histologies (precedes histology rules) Instruction 2 says do not code pattern . If the word pattern was not in the diagnosis, you would code the specific histology.

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: 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 greater than 21 days later by an acute neoplasm (DLBCL).

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 simultaneously. Rule M4 only applies when the two non-Hodgkin lymphomas are diagnosed simultaneously AND in the same location.

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 1998-2003, code EOD using the best information available. In this example, the post-treatment description of lymph nodes. A post-treatment description of lymph nodes can be used to code lymph node involvement in the absence of disease progression. Pre-operative treatment does not affect lymph node involvement.

Case example: Code lymph nodes as involved (codes 1-4 depending on size and number) based on the later CT report.

For cases diagnosed 2007 or later:

Code histology to 8244/3 [composite carcinoid]. Rule H9 applies: Code 8244 [composite carcinoid] when the diagnosis is adenocarcinoma and carcinoid tumor. WHO describes these tumors as "mixed adenoneuroendocrine carcinoma (MANEC)." They have components of adenocarcinoma mixed with high-grade neuroendocrine carcinoma (NEC), which can be either small cell or large cell.

The next version of the MP/H rules for colon will make this clear by adding a note regarding this issue to Rule H9.

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.