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For cases diagnosed 2007 or later, this case is a single primary. The chest wall (NOS) is a metastatic site for breast cancer. There is no mention of residual breast tissue, so the 2008 diagnosis cannot be a new primary.

"Chest wall" is an ambiguous term. It can mean the internal chest wall or the external chest wall. When the path report states that the "recurrence" is in residual breast tissue, this is most likely the external chest wall and the residual breast tissue is part of the breast not removed by the MRM. In contrast, skin or the chest wall, NOS, are regional metastases.

The following answers depend on what this pathologist means by "ductal (tubular)." According to the WHO classification, tubular is not a duct subtype. Check with the pathologist if possible to determine if the intended meaning is "tubular carcinoma" or "duct carcinoma".

If the pathologist uses the expression "ductal (tubular)" as an equivalent of "tubular carcinoma": Accession two primaries, a tubular carcinoma [8211/3] and a ductal carcinoma in situ, solid type [8230/2].

For cases diagnosed 2007 and later, the steps used to arrive at this decision are:

Determine the provisional histologies of these tumors in order to apply the Multiple Primary rules. Open the Multiple Primary and Histology Coding Rules manual. For a breast primary, use the Breast Histology rules to determine the histology codes because there are site specific rules for breast primaries.

Determine the histology of in situ carcinoma, solid type ductal carcinoma in situ. Start at Rule H1. The rules are intended to be reviewed in consecutive order within the applicable Module. Code the more specific histologic term when the diagnosis is intraductal carcinoma and a type of intraductal carcinoma. Solid is a specific type of DCIS. The histology is 8230/2.

Determine the histology of the invasive carcinoma, tubular carcinoma. Start at Rule H10. Code the histology when only one histologic type is identified, Tubular carcinoma was the only type identified. The histology is 8211/3.

Go to the Breast MP rules found in the Multiple Primary and Histology Coding Rules Manual after determining the histology of each tumor. Start at the MULTIPLE TUMORS Module, Rule M4, because the patient has a single invasive tumor and separate foci of DCIS. These tumors have ICD-O-3 histology codes that are different at the third (xxx) number and are, therefore, multiple primaries.

If the pathologist uses the expression "ductal (tubular)" as an equivalent of "duct carcinoma": Accession a single primary, a duct carcinoma [8500/3].

For cases diagnosed 2007 and later, the steps used to arrive at this decision are:

Go to the Breast MP rules found in the Multiple Primary and Histology Coding Rules Manual. Start at the MULTIPLE TUMORS Module, Rule M4 because the patient has a single invasive duct carcinoma and separate foci of solid type ductal carcinoma in situ. Multiple intraductal and/or duct carcinomas are a single primary. Table 1 identifies solid type as a specific type of intraductal carcinoma.

Go to the Breast Histology rules found in the Multiple Primary and Histology Coding Rules Manual. Start at the MULTIPLE TUMORS ABSTRACTED AS A SINGLE PRIMARY Module, Rule H20. Code the invasive histology when both invasive and in situ tumors are present. Code the histology as 8500/3 [duct carcinoma].

This tumor in 2010 represents a recurrence; it is not a new primary. This second tumor would be coded as a new primary ONLY if the pathology report states that it originated in breast tissue that was still present on the chest wall. When there is no mention of breast tissue in a subsequent resection, the later occurring tumor is regional metastases to the chest wall (i.e., a recurrence of the original tumor).

In turn, this means that there was at least a focus of invasion present in the original tumor that was not identified by the pathologist. The behavior code on the original abstract must be changed from a /2 to a /3 and the stage must be changed from in situ to localized.

For cases diagnosed 2007 or later, accession two primaries, invasive mucinous carcinoma [8480/3] and in situ ductal carcinoma, solid and cribriform types [8523/2].

The steps used to arrive at this decision are:

Go to the Breast MP rules found in the Multiple Primary and Histology Coding Rules Manual after determining the histology of each tumor (8480/3 and 8523/2).

Start at the MULTIPLE TUMORS module, rule M4. These tumors have ICD-O-3 histology codes that are different at the second (xxx) and third (xxx) number and are, therefore, multiple primaries.

For cases diagnosed 2007 or later, accession two primaries, ductal carcinoma with mucinous differentiation [8523/3] and ductal carcinoma, NOS [8500/3]. 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 Breast MP rules because site specific rules have been developed for this primary.

Start at the MULTIPLE TUMORS module, rule M4. The rules are intended to be reviewed in consecutive order within a module. These tumors have ICD-O-3 histology codes that are different that the third (xxx) digit and are, therefore, multiple primaries.

Ductal carcinoma with mucinous differentiation is not a specific type of ductal carcinoma identified in either Table 1 or 2. (To locate Tables 1 and 2, go to Breast under the Terms & Definitions section of the manual.) It is ductal carcinoma mixed with another type of carcinoma (mucinous carcinoma in this case) see Table 3. Rule M11 does not apply.

For cases diagnosed 2007 or later, accession two primaries, right breast cancer diagnosed in June 2006 and a subsequent right breast primary diagnosed in December 2011.

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 Breast MP rules because site specific rules exist for this primary.

Start at the MULTIPLE TUMORS module, rule M4. The rules are intended to be reviewed in consecutive order within a module. Accession two primaries, tumors diagnosed more than five (5) years apart are multiple primaries.

If the pathology report stated the tumor originated in residual breast tissue, then this is a new tumor and, therefore, a new primary per rule M5. If the pathology report stated the tumor arose in the chest wall and/or there is no designation of residual breast tissue, then this is a regional metastasis and not a new primary.

Apply Rule M10 to this case. Tubulolobular is now classified as a variant of lobular. Code to lobular, NOS (8520) because Tubulolobular does not have a specific ICD-O-3 code.

Accession two breast primaries, one right and one left, rule M7. "Suspicious" is reportable ambiguous terminology.

Based on the information provided, this is a single primary. The 2011 tumor was not completely removed and progressed over the years. MP/H Rule M3 for malignant brain cancer applies. Do not change the original histology code. Use text fields to document the later histologic type of anaplastic astrocytoma, WHO grade III.

For cases diagnosed 2007 or later, this is four primaries.

Report NF2 because it occurs with reportable neoplasms. Note: Report NF only once per patient.

Per MP/H Benign CNS Rule M4, the meningiomas of the meninges/brain (C70.0) and meninges/CNS (C70.1) are multiple primaries. Code the meningiomas of the spine to the histology to 9530/1 [Multiple meningiomas] (Rule H6) because there are multiple tumors in the spine.

Per Rule M5, the meningiomas of the right and left side of the brain are multiple primaries. Code of each to the histology 9530/0 [Meningioma, NOS] per Rule H2 because they are separate primaries (assuming there is one tumor on each side of the brain).