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10/2017 Bladder cancer diagnosed as invasive papillary urothelial bladder carcinoma (8130/3) (submucosal invasion).

12/2017 Surveillance scope and transurethral resection of bladder tumor (TURBT) finds “recurrent” bladder tumor, non-invasive papillary urothelial bladder carcinoma (8130/2) - same primary per 2007 Multiple Primaries/Histology, Rule M6, (both papillary urothelial bladder carcinomas).

4/2018 Radical nephrectomy found focally invasive urothelial carcinoma (8120/3) in the renal pelvis.

Is this a new primary per 2018 and forward STR, Rule M6, because it was more than 60 days since the 12/2017 in situ bladder recurrence? Or would one compare the 2018 diagnosis to the original invasive bladder tumor in 10/2017, and continue on to Rule M11, which says to abstract a single primary for urothelial carcinomas in multiple organs, regardless of behavior?

SINQ #20120080 said to compare to the original diagnosis and disregard intervening recurrences, but that pertained to the 2007 MP/H rules. Does this still apply for 2018 forward? STR, Rule M10, Note 3, states when there is a recurrence within three years of diagnosis, the “clock” starts over. The time interval is calculated from the date of last recurrence. Comparing each recurrence for urothelial carcinomas using Rule M6 could result in over-counting them. Can the instructions on how to calculate the 60-day interval be clarified in Rule M6?

The patient underwent a gross total resection of the 2005 glioblastoma multiforme (9440/3). The patient was subsequently diagnosed with a 2024 diagnosis of astrocytoma, IDH-mutant, WHO grade 4 (9445/3).

Should Rule M13 apply to the new 2024 diagnosis and a new primary be accessioned because astrocytoma, IDH-mutant, WHO grade 4 is listed on a different row than glioblastoma? It is unclear whether histology 9445 should be classified as being on a different row because it is also listed as a subtype/variant for glioblastoma in Table 3. Table 3 lists histology 9445 as both “Astrocytoma, IDH-mutant, WHO grade 4” and as “Glioblastoma IDH-mutant.”

Malignant Central Nervous System (CNS) Rule M5 instructs us to abstract a single primary (as malignant) when a single tumor is originally diagnosed as non-malignant, the “First course treatment was active surveillance (no tumor resection),” and the subsequent resection pathology is malignant.

This patient’s first course of treatment was not active surveillance. While the patient did not have first course tumor resection, the tumor was treated with Cabergoline.

Should Rule M5 apply because there was no tumor resection? If so, should Rule M5 clearly state no tumor resection is the criteria (not active surveillance)?

SINQ 20230023 does indicate a PitNET diagnosis following a diagnosis of pituitary adenoma does not fall into standard rules, but in the previous SINQ the first course treatment was a partial resection.

It is unclear whether other types of treatment could result in a new malignant PitNET, following a previously treated non-malignant pituitary tumor.

The patient underwent a resection of the transitional meningioma in 2012, but residual tumor was left behind. The patient was on surveillance until imaging showed growth of the residual tumor. The resection in 2022 proved atypical meningioma.

Rule M2, the first rule that applies, indicates this situation represents a single primary (a single tumor). However, Rule M4 states the transformation from a benign meningioma to a borderline meningioma would only be a single primary if the meningioma was a NOS.

This patient has microscopic confirmation of a meningioma showing different subtypes/variants (listed in Column 3, Table 6). Should this be accessioned as multiple primaries based on the transformation and distinctly different histologies?

Core biopsy of left breast at 2:00: Invasive ductal carcinoma, Nottingham score 6/9.

Core biopsy of left breast at 4:00: Invasive mucinous carcinoma (variant of ductal carcinoma), Nottingham score 5/9.

Post neo-adjuvant mastectomy: Main (largest tumor): Invasive ductal carcinoma, upper outer quadrant grade 2. Secondary tumor: mucinous carcinoma, grade 1 at 4:00.

The patient was initially diagnosed with invasive mammary carcinoma of the right breast in 2018, treated with lumpectomy, sentinel node biopsy, radiation, and hormones. Hormones were discontinued early due to dysfunctional uterine bleeding.

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.

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.

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.