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Historically, multiple invasive ductal and lobular carcinomas diagnosed within 5 years were abstracted as a single primary. However, it is not clear if Rule M10 or M14 applies to this situation per the 2023 Solid Tumor Rules updates.

Rule M10 addresses multiple tumors of carcinoma of no special type (NST)/duct and lobular, but there is no timing criteria mentioned. Does M10 apply to cases diagnosed synchronously, or metachronously, or at least within 5 years? Should Rule M10 include a Note instructing registrars to accession a single primary for the scenario in question?

If timing matters for Rule M10, then the next rule that applies is M14. Rule M14 instructs one to abstract multiple primaries when separate/non-contiguous tumors are on different rows in Table 3, and carcinoma NST/duct and lobular carcinoma are on separate rows in Table 3.

The WHO Blue Books do not include dedifferentiated carcinoma as a valid histology for the breast.  However, there is known to be progression of ductal carcinoma that is essentially dedifferentiation of an estrogen receptor, progesterone receptor, and HER2 breast carcinoma to a triple negative "dedifferentiated" carcinoma which it appears this patient has. Whether we should accession this as a separate 8020/3 primary per M14 is unclear and the Solid Tumor Manual does not address this scenario.

In the examples below, are these a single or multiple primaries?

Example 1:

Tumor 1:  C509/left breast, 8520/2 (in situ lobular carcinoma), dx date-01/10/2019

Tumor 2:  C509/ left breast, 8500/3 (carcinoma NST), dx date-08/19/2021

Example 2:

Tumor 1:  C509, right breast, 8520/2, dx date 06/26/2014

Tumor 2:  C508, right breast, 8500/3, dx date-05/23/2019

There seems to be some conflicting info on this. In the 2020 Breast Rules there was a note add to the revision history. “M10 Same behavior requirement re-added.” Which is not in the rules now, nor was it noted to the revision changes in the last two change logs.

Inquiry 20200070 would seem to indicate that this is multiple primaries, but that contrasts with 20230010 which would seem to indicate a single primary, and an ASK A SEER Registrar question that we received a response to. I don’t see a scenario where rule M17, an invasive tumor DX more than 60 days after an in situ tumor would come into play.

If behavior no longer applies to rule M10, at what point did that change get made? Please advise.

An argument could be made to apply Rule M10 (timing rule which may result in reporting the case as an additional primary) because the 2022 primary included multiple non-invasive urothelial carcinoma tumors in both the bladder and other urinary sites (coded to site C689, not C679) following a long disease-free interval. While Rule M10 excludes multiple bladder tumors, does that also apply when new, multifocal urothelial tumors arise in both bladder and other urinary sites? Does the presence of any subsequent bladder tumor rule out the use of M10 and one must use M11 that indicates reporting this disease process is a single primary?

The final diagnosis on bone marrow biopsy was high grade myeloid stem cell neoplasm, 17% blasts by differential count.  The pathologist further states that this could be classified as “MDS with increased blasts (MDS-IB2) per the WHO 5th edition classification, or MDS/AML per the international consensus classification (ICC).”  FISH and cytogenetics revealed a loss of 7q, but no other AML-related genetic abnormalities. The physician confirms the patient has MDS/AML.

2021-Right pleural fluid:  Negative for carcinoma.

5/18/2021: Right iliac crest bone marrow core biopsy, aspirate smear, clot section and peripheral blood smear:  Hypercellular bone marrow, morphological findings are suspicious for a myeloproliferative neoplasm. Flow Cytometry: Slight immunophenotypic abnormalities of the myeloid cells. No abnormal B cell, T cell, or NK cell populations identified. Normal female karyotype. KARYOTYPE: 46,XX[20]. Negative for deletion of 13q14.3 (D13S319) by FISH. Negative for deletion of 13q34 (LAMP1) by FISH. Negative for hyperdiploidy involving chromosome 9 by FISH. Negative for t(9;22)(q34;q11.2) by FISH. Negative for deletion of the EGR1 gene on 5q31 by FISH. Negative for monosomy 5 by FISH. Negative for deletion of 7q31 by FISH. Negative for monosomy 7 by FISH. Negative for deletion of 20q12 by FISH. Negative for trisomy of chromosome 8 by FISH.

6/4/21-Left adrenal; biopsy: poorly-differentiated malignant neoplasm with extensive necrosis. Immunohistochemical stains show the neoplastic cells to be negative for CK7, TTF-1 and p63. Negative CK7 and TTF-1 would argue against a lung primary. Correlation with clinical and radiological findings is advised.

We are unable to contact the provider.

Patient was diagnosed with a pT1c prostate cancer in 2022. Patient was then treated with radical prostatectomy. No residual disease was found. Would the correct EOD prostate path extension code be 999 based on Note 8 (code 999 when radical prostatectomy is performed, but there is no information on the extension); or, would we use code 300 (confined to prostate) because the data item "...is used to assign pT category for prostate cancer based on radical prostatectomy specimens" and we know it was limited to the prostate because no residual was found?

The patient has adenopathy in multiple lymph node regions above and below the diaphragm and a lymph node biopsy pathology proved CLL/small lymphocytic lymphoma (SLL). Further work-up with peripheral blood proved an abnormal CD5-positive B-cell population comprising only a small percentage of the white blood cells (WBCs). The pathologist noted this neoplastic B-cell population comprises “3.5% of white blood cells and has an immunophenotype characteristic of CLL/SLL and is similar to the recent lymph node biopsy in this patient.” The managing physician indicated this was a Lugano Stage III SLL. The registrar coded the peripheral blood involvement in EOD Primary Tumor.

If this small percentage of WBCs with an abnormal B-cell population is included in EOD Primary Tumor as peripheral blood involvement, then this would indicate peripheral blood/bone marrow involvement and primary site would need to be coded to C421 per Rule PH5. Rules PH5 and PH6 confirm primary site must be coded C421 if peripheral blood or bone marrow are involved.

Is there a cutoff value for these abnormal B-cell populations in the peripheral blood? Or should these abnormal B-cell populations be ignored unless the pathologist states the abnormal B-cell population is consistent with CLL/SLL (not just immunophenotypically characteristic of CLL/SLL)?