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Per SINQ 20091021 and 20021151, GIST cases are not reportable unless they are stated to be malignant. A pathologist or clinician must confirm the diagnosis of cancer. There are cases that are not stated to be malignant in the pathology report or confirmed as such by a clinician; however, these cases do have information that for other primary sites would typically be taken into consideration when determining reportability. The final diagnosis on the pathology report for all 16 cases is "GIST." The additional comment(s) for each of the 16 different cases is reported below. Are any of the following cases reportable?

1) Pathology report indicates that the bulk of the tumor is submucosal. It extends through the muscularis propria and abuts the serosa.

2) Pathology report states tumor extends to serosal surface of transverse colon, but not into muscularis propria. CD 117 and CD 34 are positive.

3) Pathology report indicates that tumor invades through the gastric wall to the serosal surface.

4) Pathology report indicates that tumor invades pericolic fat tissue.

5) No further information in pathology report, however, scans indicate omental caking.

6) No further information in pathology report, however, scans indicate hepatic metastases. Hepatic metastases are not biopsied.

7) Tumor stated to be unresectable and extends into pancreas. Chemotherapy given.

8) Pathology report states tumor is low to intermediate grade and involves serosal (visceral peritoneum).

9) Tumor size is 17.5 cm. Pathology report states "malignant risk".

10) Pathology report states tumor "into muscularis propria" or tumor "involves muscularis propria" or "infiltrates into muscularis propria".

11) Pathology report states, "high malignant potential; omentum inv by tumor." It is not stated in path report or final diagnosis to be malignant GIST.

12) Pathology report states that tumor arises from wall of small bowel and extends into thin serosal surface.

13) Pathology report states minimal invasion of lamina propria; does not penetrate muscularis propria.

14) Pathology report states, "high mitotic activity >10/50 HPF; high risk for aggressive behavior; moderate malignant potential."

15) Pathology report states tumor size is >5 cm. Intermediate risk for aggressive behavior; CD117+ KIT exon 11+.

16) Pathology report states "high risk of malignancy."

This patient was diagnosed with clear cell carcinoma of the right kidney in 2003, treated with nephrectomy. The tumor was limited to the kidney. An FNA of the pancreas in 11/07 was consistent with metastatic renal cell carcinoma. In 2009 the patient was diagnosed with a right renal fossa mass by CT. The mass was excised on 8/26/09 and showed, "recurrent renal cell ca, clear cell." The path specimen was labeled as, "soft tissue, rt renal fossa." The original 2003 slides were not reviewed and the renal fossa mass was not described as being metastatic.

If the renal fossa soft tissue mass is a new tumor, the MP/H rules for Other Sites directs you to code it as a new primary per rule M10 [Tumors diagnosed more than one (1) year apart are multiple primaries]. Would this be a new soft tissue tumor per rule M10? Or would this be a recurrence of the original kidney primary?

Patient was diagnosed in 2005 with multiple myeloma and following stem cell transplant 2005 was in complete remission.

On 2/1/10 an excisional biopsy of a soft tissue right flank mass showed plasmacytoma. On 3/2/10 the bone marrow biopsy was stated to be consistent with plasma cell dyscrasia. An outside attending physician stated the bone marrow biopsy was consistent with a relapse of myeloma. There was no radiologic evidence of disease elsewhere as of Feb 2010, only the soft tissue right flank mass. Patient initially presented for post-op radiation to the right flank and was treated 3/29/10. On 8/6/10 a biopsy of a right perinephric mass was positive for plasmacytoma. Subsequent xray on 8/16/10 of the right tibia and fibula showed lytic lesion consistent with progression of myeloma.

Using the Hematopoietic Database, the plasmacytoma in 2/1/10 is a second primary. How do the rules apply to the perinephric soft tissue disease and right tibia lesion? Are they separate new primaries? Or is all of this simply a recurrence of the original 2005 diagnosis as the attending physician states?

Per SINQ 20021106, for tumors diagnosed prior to 2007, a clinical diagnosis of metastatic gestational trophoblastic disease was to be coded to histology 9100/3 [Choriocarcinoma]. "Gestational trophoblastic neoplasia includes the diagnosis of choriocarcinoma."

The first MP/H rule that applies for this case is M4 [tumors in different segments of the colon]. Following rule M4, the case would be counted as two primaries and the histology would be coded per Rule H11. As these are multiple primaries, Rule H17 [Code 8220 (adenocarcinoma in adenomatous polyposis coli) when there are > 100 polyps identified in the specimen] would never apply, because H17 applies to multiple tumors abstracted as a single primary. However, Rule H17 seems to fit this case. Should Rule M3 be expanded to include a statement about > 100 polyps so these cases are not accessioned as multiple primaries?

Example: Total colectomy: 1) Distal tumor: - ulcerating moderately differentiated colonic adenocarcinoma, 3.2 cm in greatest dimension. Tumor invades through the muscularis propria into the subserosa (pt3). 2) Proximal tumor: exophytic moderately differentiated colonic adenocarcinoma, 2.9 cm in greatest dimension. Tumor invades submucosa (pt1). Multiple tubular adenomas present throughout the colon, approximate count greater than 200.

"Resection, periampullary duodenum: Gangliocytic paraganglioma, with metastasis to one large periduodunal lymph node. Six other small lymph nodes negative. COMMENT: The primary tumor in the duodenum is made up mainly endocrine cell component. This component appears to have metastasized to a periduodenal lymph node."