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Code 9920/3 is not included under rule M3. However, disease process knowledge would indicate that because the patient has an underlying AML subtype, the leukemia cutis is due to the AML cells that have migrated into the skin tissue. This appears to be a single advanced disease process essentially diagnosed simultaneously.

02/18 RUL biopsy: Moderatley differentiated adenocacarcinoma with acinar predominant pattern

04/18 RUL lobectomy: 6.5cm poorly differentiated adenocarcinoma with solid growth pattern and 1.1 cm separate adenocarcinoma with lepidic predominant pattern

Synoptic report:

Procedure: Lobectomy

Specimen Laterality: Right Tumor

Tumor Site: Upper lobe

Histologic Type: Invasive adenocarcinoma, solid predominant

Tumor Size: 6.5 Centimeters (cm)

Tumor Focality: Synchronous primary tumors in same lobe

Lymph Nodes Number of Lymph Nodes Involved: 0

Number of Lymph Nodes Examined: 12

Nodal Stations Examined: 4R: Lower paratracheal; 8R: Para-esophageal (below carina); 10R: Hilar; 7: Subcarinal

Pathologic Stage Classification (pTNM, AJCC 8th Edition)

Primary Tumor (pT): pT3

Regional Lymph Nodes (pN): pN0

There is a group of patients diagnosed within the past few years with ovarian cancers who are now enrolled in a clinical trial and are being screened as potential patients for a particular protocol. The screening for these particular cases is being done by a pathologist who has a particular interest in GYN pathology. As the pathologist is screening the cases, there are some which the pathologist is reclassifying as being fallopian tube primaries rather than ovarian primaries. This is apparently due to newly emerging findings and literature. The problem for me is that these cases have been entered into the registry as ovarian primaries, which was correct as of the time of the initial diagnosis. Should the abstracts remain as they were initially coded, since the diagnosis was ovarian cancer at the time they were diagnosed, or should these cases be updated to reflect the current pathologist's interpretation that these are fallopian tube primaries?

Instruction number 1 under the Coding Multiple Histologies instructions states to code histology when the histology is described as subtype, type or variant. The general rules do indicate we can code the histology identified as type, but when applying the H Rules, it seems an argument could be made for either H1 or H3. H1 applies if you ignore the diagnosis of carcinoma and only code the histologic type: urothelial carcinoma. However, the rules do seem to imply that you take all histologies into account (e.g., code the subtype/variant when there is a not otherwise specified (NOS) and single subtype/variant). Following this logic, Rule H3 seems to be the only rule that fits, and one would code the subtype/variant urothelial carcinoma when the diagnosis is carcinoma NOS, histologic type: urothelial carcinoma.

The problem is that urothelial carcinoma is not a subtype/variant of carcinoma (NOS) per Table 2. The entry for Carcinoma NOS in Table 2 states, Subtypes of carcinoma NOS include adenocarcinoma and all subtypes/variants of adenocarcinoma. To some, urothelial carcinoma is a more specific type of carcinoma; however, urothelial carcinoma is not also listed as a subtype of carcinoma or of adenocarcinoma; only adenocarcinoma is categorized as a subtype of carcinoma. Consistently applying the rules becomes an issue when rules are interpreted in different ways. Should this Table be amended to include urothelial carcinoma as a subtype/variant of carcinoma NOS with the same caveat given to adenocarcinoma in Table 2?

Example: Operative report states, partial simple vulvectomy, anoscopy with normal-appearing clitoris, clitoral prepuce, bilateral labia majora, and labia minora. There is a 1.5 x 1 cm raised, hyperpigmented lesion which appears consistent with VIN 3 on the perineal body, just to the right of midline, and not touching the midline. It goes quite close to the anus but is not touching the anus.

Final diagnosis on resection is, Invasive squamous cell carcinoma arising in a background of high-grade squamous intraepithelial neoplasia (VIN III) with the following features: Location: perineum. Focal invasion arising in setting of 1 cm area of VIN III.

The Summary Cancer Data does not seem to describe a more specific histology, but it does describe the tumor histology with the worst outcome and the most extensive tumor. The anaplastic carcinoma grossly extended into skeletal muscle and gave rise to multiple regional lymph node metastases. The more appropriate histology seems to be 8021.

However, current MP/H Rules for a single tumor indicate the histology should be coded to the numerically higher histology code (8260). Coding the histology to 8260 does not account for the more aggressive tumor. Should this histology be 8260 or 8021?

8/1/2016 Left Abdomen biopsy: Early melanoma in situ (C445-2, 8720/2).

9/2/2016 Upper back: Superficially invasive malignant melanoma (C445-9, 8720/3).

Does rule M4 apply and multiple primaries should be reported or does rule M8 apply and a single primary should be reported?

The clinical documentation clearly identifies residual tumor after the 2011 craniotomy. Scans demonstrated slow enlargement of the tumor over the years, which resulted in a repeat craniotomy. The pathologist noted in the diagnosis comment section of the pathology report that

Is this a single primary per MP/H Rule M3 (A single tumor is always a single primary), or an additional brain malignancy per MP/H Rule M8 (Tumors with ICD-O-3 histology codes on different branches in Chart 1 or Chart 2 are multiple primaries)?

Pathology states: Translocation renal cell carcinoma. Comment Tumor morphology and IHC profile consistent with MiT family translocation RCC with Xp11 translocation.

Urinary bladder: Invasive urothelial carcinoma, high-grade, 4.5cm, predominantly solid type, arising in background of carcinoma in-situ, carcinoma grossly extends into perivesical adipose tissue; lymph-vascular invasion is seen.