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Glioblastoma multiforme is listed as a synonym for the preferred term glioblastoma, NOS (9440) per Table 3 Column 2. Therefore, it seems reasonable to assume that a diagnosis of glioblastoma, NOS would be a new primary if it followed a glial or astrocytic tumor. However, in general, the Solid Tumor Rules use the preferred terminology and/or indicate when a specific rule also includes any tumor diagnosed as a subtype/variant. Rule M6 does not explicitly include a diagnosis of glioblastoma, NOS or any of its subtypes/variants (e.g., glioblastoma IDH-mutant or gliosarcoma). Does Rule M6 apply to any diagnosis of glioblastoma, NOS and any of its synonyms or subtypes/variants?

The Solid Tumor Rules indicate bladder tumors that are urothelial carcinoma (8120) and small cell carcinoma (8041) are separate primaries per Rule M13 (Abstract multiple primaries when separate/non-contiguous tumors are on different rows in Table 2). These are distinctly different histologies and, presumably, one would want to capture the small cell carcinoma (or small cell carcinoma component) as this has a worse prognosis.

However, if a subsequent bladder tumor is composed of invasive urothelial carcinoma and small cell neuroendocrine carcinoma, the histology is coded as 8045/3 per Rule H4, but this is not abstracted as a multiple primary. The only M Rule that applies is Rule M18 (Abstract a single primary when tumors do not meet any of the above criteria). The mixed histology code 8045 is not included in Table 2, so none of the histology-based M Rules apply. Is the subsequent mixed invasive urothelial and small cell carcinoma tumor (8045/3) the same primary as a previously diagnosed invasive urothelial carcinoma (8120/3) when these tumors are diagnosed within three years?

Rule M11 states: Abstract a single primary when there are urothelial carcinomas in multiple urinary organs, but neither the Rule nor the Notes describe the timing of these multiple urinary organ carcinomas. Timing requirements for other rules are clearly stated.

Does Rule M11 have a timing requirement or is it intended to apply to all urothelial carcinoma tumors regardless of timing (and not already qualifying for application of a previous M rule)?

7/8/16 Urinary bladder, biopsy: Non-invasive low grade papillary urothelial carcinoma. Muscularis propria (detrusor muscle) is not identified.

9/2/16 Urinary bladder, bladder tumor, transurethral resection: High grade papillary urothelial carcinoma. No definite invasion identified. Muscularis propria (detrusor muscle) is identified and not involved by tumor.

1/7/17 A\S\Bladder: Noninvasive low grade papillary urothelial carcinoma. Granulomatous cystitis, consistent with BCG (Bacillus Calmette-Guerin) treatment. Lamina propria is not involved with tumor. Detrusor muscle is not identified.

4/4/17 Dome: Papillary urothelial carcinoma, low grade. No evidence of invasion. Muscularis propria is not present.

Patient is clearly followed for at least a year but no further information until 19 months later, 11/14/18, when biopsy of lung indicates metastatic disease.

11/14/18 Lung, right lower lobe, mass, biopsy: Metastatic urothelial carcinoma. Immunohistochemical analysis results (CK7 positive, CK20 focally positive, P63 positive, GATA3 positive, TTF1 negative and NAPSIN-A negative) support the diagnosis

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.

CT chest findings: 1. There is a dominant 1 cm. nodule in the left mid lung. 2. In addition, there is a new rather dominant bilobed nodule in the left lung base. 3. Distant metastases are not identified. Four months later, a doctor's note says routine follow-up visit status post Cyber Knife stereotactic body radiation therapy for synchronous early stage non-small cell carcinomas of the left upper and left lower lobes, both Stage IA. He is medically inoperable. This situation is described as a second primary tumor in AJCC8 page 438. However, by the 2018 Lung Solid Tumor rules, this would be a single primary, per rule M7. Is that correct?

Head and Neck Multiple Primary Rule M8 appears to be the first rule that applies to this case and instructs the user to abstract multiple primaries when separate/non-contiguous tumors are on different rows in the appropriate site table (Tables 1-9) in the Equivalent Terms and Definitions. Table 1 (tumors of the nasal cavity) shows Non-keratinizing squamous cell carcinoma and squamous cell carcinoma on different rows making the 2019 case a new primary. Is this correct?

According to the Multiple Primaries/Histology Rules in place at the time of the 2016 diagnosis, verrucous carcinoma was listed as a specific type of squamous carcinoma (Chart 1). However, in the current Solid Tumor Rules, verrucous carcinoma is not listed in Table 4 (Tumors of Oral Cavity and Mobile Tongue) either as a specific histology or as a specific subtype/variant of squamous carcinoma. The only subtype/variant listed for these sites is acantholytic squamous cell carcinoma (8075).

Verrucous carcinoma is not listed in Table 4, making it unclear if it should be a different histology for these specified sites. However, verrucous carcinoma is listed as a specific subtype/variant of squamous carcinoma for other sites (e.g., Table 3).

Recognizing the addition of the behavior requirement into this rule is an attempt to stop non-synchronous ductal carcinoma and lobular carcinomas from being accessioned as a single primary (SINQ 20200022), the issue with using behavior rather than timing is that now, synchronous separate/non-contiguous tumors that are invasive carcinoma NST (8500/3) and lobular carcinoma in situ (8520/2) (or vice versa) are separate primaries per M14.

Lobular and carcinoma, NST are separate rows in Table 3, so we cannot stop at M10 and code the mixed histology because there are two separate histologies with different behaviors. There is no rule that states we can just ignore the in situ tumors for the purpose of applying the M Rules. (We are instructed to ignore the in situ when coding histology only in certain circumstances.) The problem with Rule M10 appears to be related to timing.

This question was prompted from preparing SEER*Educate coding exercises. We will use the answer as a reference in the rationales.

Example: Right breast core biopsy found ductal carcinoma in situ in the upper outer quadrant. Subsequent resection has a final diagnosis of invasive mucinous carcinoma, grade 1, measuring approximately 7 mm, with close margins. See staging summary. Gross description mentions only the primary tumor with associated marker clip from previous biopsy.

Breast Cancer Staging Summary lists (testing and margins removed for brevity):

Procedure type: Lumpectomy.

Specimen laterality: Right.

Tumor size: 7mm.

Histologic type: Invasive mucinous carcinoma.

Histologic grade (Nottingham histologic score): Grade 1, (score 5/9).

Tumor focality: Single focus.

Lymph-vascular invasion: Not identified.

Treatment effect: No known therapy.

Ductal carcinoma in situ (DCIS): Present.

Architectural pattern: Cribriform.

Nuclear grade: Grade 1.

Necrosis: Not identified.

Calcifications: Not identified.

Estimated size/extent of DCIS: Spanning an area measuring 15mm.

Pathologic stage: pT1b, pNx. (AJCC 8th ed).

Distant metastasis: Not applicable.

Additional findings: Background lobular carcinoma in situ (LCIS), flat epithelial atypia (FEA), and atypical ductal hyperplasia (ADH).