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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.

Patient was initially diagnosed with Hodgkin Lymphoma, Nodular Sclerosing on 3/3/06.

Patient received ABVD x 2 cycles. Had disease reassessed in May, 2006, no response to treatment, showed evidence of progression (new adenopathy). Patient's pathology from 3/06 was sent for consult: Diagnosis was Hodgkin with some overlapping features of B-cell Non Hodgkin Lymphoma. Treated 5/18/06 with R-ICE FOR NHL.

Patient was initially diagnosed in 2017 with LR-5 lesions in segments 3 and 7 of liver and treated with radiofrequency ablation (RFA). Routine scans in 2019 show no evidence of residual or recurrent disease.

Surveillance imaging in 2020 identifies LR-TR viable segment 3 treatment zone with slowly growing arterially-enhancing nodule as well as increasing arterial enhancement in the neighboring parenchyma. No new LR-4 or LR-5 observations. Patient is not a surgical candidate but is treated with Y-90 radiotherapy.

Per Rule M10, tumors diagnosed more than 1 year apart are multiple primaries. However, there is no clear clinical statement of malignancy in this case.

Patient was found to have two tumors in the esophagus. The large tumor was diagnosed as adenocarcinoma with areas of neuroendocrine differentiation (small cell carcinoma). The smaller tumor was diagnosed as small cell carcinoma. If we accept the "areas of" to be part of the diagnosis, rule H16 indicates that histology for the large tumor would be coded 8045 (combined small cell and adenocarcinoma). If we ignore the "areas of," then histology for the large tumor would be coded to 8140 (adenocarcinoma). Either way, when counting primaries, rule M17 would be applied and the two tumors would be classified as separate primaries. However, it seems that the two tumors are probably the same disease process since they both show small cell carcinoma.

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.

Patient was diagnosed with lambda myeloma based on the M spike found on serum protein electrophoresis. A bone marrow biopsy was performed, but it was an insufficient sample.

SPEP is not listed in the Hematopoietic Database as a lab test that can be used as a definitive diagnostic method. Since the physician did base the diagnosis on the SPEP result, would it be appropriate to assign code 5 (Positive laboratory test/marker study) since there was no histological confirmation?

Under code 5, the Hematopoietic Manual states: Laboratory tests are listed under Definitive Diagnostic Methods in the Hematopoietic Database.

Patient was diagnosed with invasive lobular carcinoma of the right breast in April 2001. Following modified radical mastectomy in May 2001, the patient was disease free. In December 2008 the patient was diagnosed with a right chest wall mass, invasive poorly differentiated mammary carcinoma with lobular origin. If this is a new primary in 2008, would we code the primary site to breast or chest wall? Please see I&R answers 25924, 22163 and 26155 with similar case scenarios that give two different answers. One response indicates coding this type of scenario as new primary to chest wall and the other two responses indicate this should not be a new primary because the chest wall is a metastatic site. The pathology report does not state that this is metastatic and it is unknown if there is breast tissue left behind at the chest wall.

Patient was diagnosed with invasive ductal carcinoma with mucinous features in February 2021, left breast biopsies at 2:00 (3 cm from nipple) and 3:00 (8 cm from nipple) positions. Intraductal component was absent in those specimens.

Subsequent left breast total mastectomy in March 2021, provided a final diagnosis of multifocal mixed mucinous carcinoma, grade 1, 27 and 8 mm and ductal carcinoma in situ (DCIS), low to intermediate grade, with focal mucinous features. The Staging Summary lists Histologic Type as mixed mucinous carcinomafor both foci of invasive carcinoma. DCIS is also noted as present negative for extensive intraductal component.

There does not appear to be a clear instruction or code for this histology. As a central registry, we are unable to follow-up with the pathologist regarding this diagnosis.

Just to be clear, there are 2 foci of invasive mixed mucinous carcinoma in this case measuring 27 mm and 8 mm. The DCIS component measured 56 mm.

Patient was diagnosed with hemophagocytic lymphohistiocytosis on blood and bone marrow biopsy. This was also referred to in the chart as hemophagocytosis and hemophagocytic syndrome. Hemophagocytic syndrome is listed in the Heme DB as 9724/3. The patient had several rounds of fairly aggressive chemotherapy. Would the correct primary site for histology 9724/3 be C421 [bone marrow], or C779 [lymph nodes, NOS]? See SINQ 20100113.

Patient was diagnosed with essential thrombocytosis 9962/1 or 3 in 1998 (depending if ET was reportable in 1998), treated with Hydrea.

11-17-2022 Blood smear:  CALR + myeloproliferative neoplasm, Most Consistent with Primary Myelofibrosis 9961/3  (Noted CALR and ASXL1 mutations).

The following abstractor note from 9661/3 is confusing:  A diagnosis of "post essential thrombocythemia myelofibrosis" is a progression of essential thrombocythemia and would be the same primary.