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The patient has a history of CLL/SLL dating back to 2007, but has had progressive disease with development of a new left frontal brain tumor. The brain tumor resection proved CLL/SLL with large cell transformation, but neither the pathologist nor the managing physician called this a Richter transformation, Richter syndrome or provided a diagnosis of DLBCL. However, a large cell transformation of CLL/SLL is a Richter transformation. Can this be accessioned as a new acute neoplasm per Rule M10?

Patient had radical resection of pelvic giant cell tumor of bone in August 2012. Final diagnosis clarified that no features to suggest a frankly malignant giant cell tumor were identified.

July 2013 left upper lobe nodules were removed and found to be consistent with multifocal metastatic lung involvement with a previous pelvic giant cell tumor of bone. However, the pathology report comment specifies there are no histological high-grade features to suggest a malignancy:

While SINQ 20091087 may apply, these metastases clearly arrived in the lung by hematogenous spread. The previous SINQ note refers to a case where the implants/metastases can seed the surrounding pelvic and abdominal structures by rupture of the tumor or intraoperative tumor spillage. That type of spread is not quite the same as the current case showing tumor cells leaving the primary tumor/site and travelling through the blood to implant in the lungs.

Patient was diagnosed with DCIS of the left breast in June 2014. The patient had a simple mastectomy with 2 axillary lymph nodes removed. The final diagnosis was intermediate to high grade ductal carcinoma in situ, predominantly micropapillary type, forming a 1.4 cm mass. No invasive carcinoma identified. Margins negative. In April 2017, the patient was found to have parietoccipital bone lesions, which were resected. The resulting diagnosis was metastatic carcinoma, morphologically consistent with breast primary " See Comment: The previous breast lesion is not available for review at the time of signout. However, the tumor is morphologically compatible with a breast primary.

SINQ 20110111 would not make this is new primary. However, it seems that rule M8 might apply. An invasive tumor following an in situ tumor more than 60 days after diagnosis is a multiple primary. See Note 2: Abstract as multiple primaries even if the medical record/physician states it is recurrence or progression of disease.

I recently did a presentation on coding the data item Race. In my presentation I discussed understanding geography help code race in some circumstances. One of the slides demonstrates how large Polynesia is and what Pacific islands are found in Polynesia, such as, Tahiti, Samoa, and even Hawaii, all of which have their own codes. Someone in the audience asked "How do you code New Zealand? Upon some research, New Zealand is not listed in Appendix D of the SEER coding manual. We could code them 01-White. But research shows there is a very large indigenous population. Technically, New Zealand is located within the boundaries of Polynesia - Code 25 (Polynesian).

Discussion: Example: Shave biopsy with superficial spreading melanoma, Breslow 0.25 mm, Clark level II. Excision with no residual melanoma and gross description of specimen size is 4.0 x 1.6 cm skin ellipse excised to a depth of 1.8 cm.

We have differing opinions in our registry.

Opinion 1: We can assume margins are greater than 1 cm based on the excision specimen size when there is no residual tumor on excision and all dimensions of the excision specimen are more than 1 cm. Surgery would be coded in 40s range.

Opinion 2: We should assume the melanoma defect was in the middle of the excision specimen, so for a skin ellipse that is 4.0 x 1.6 cm, there would be a 2 cm and 0.8 cm margin (respectively) from the middle of the specimen, thus margins are not > 1 cm. Surgery would be coded in 30s range.

Per Rule M8, this is a single primary as there are multiple urothelial tumors as outlined in Table 1 (papillary urothelial carcinoma [8130] and sarcomatoid urothelial carcinoma [8122]) simultaneously present in multiple urinary organs (bladder, ureter and renal pelvis). As Rule M8 indicates these are a single primary, despite the histologies differing at the third digit (8130 vs 8122), then Rule H14 (Code the histology of the most invasive tumor) seems to be the most applicable histology rule. Following Rule H14 (in the Text version of the MP/H Rules), the histology would be coded as 8122 (sarcomatoid urothelial carcinoma) since the renal pelvis tumor was the most invasive tumor present.

However, in both the Matrix and Flowchart versions of the MP/H Rules, Rule H14 contains a note (missing from the Text version) that states that this rule should only be used when the first three numbers of the histology codes are identical (This is a single primary). Rule M8 clearly tells us these are a single primary, despite the differences at the third digit of the histology. Further defaulting to Rule H15 (Code the numerically higher histology code) in this case would ignore the histology of the tumor with the worse prognosis (the most invasive tumor). Was this note included in the Matrix and Flowchart versions in error?

Patient has only a LUL tumor on imaging. The tumor board initially states, possibly a mixed tumor, likely IIIA SCC and/or IIIA or B small cell. Later, the physician refers to it as "Stage III lung cancer, mixed histology with small cell in the lymph node and squamous cell in the LUL mass." Patient has no further workup and has declined therapy.

The patient is diagnosed by bilateral mammograms suspicious for malignancy in both breasts. A biopsy is done on one breast and is positive. The physician states that he will not biopsy the contralateral breast, as the patient has consented to bilateral mastectomy. The patient receives neoadjuvant chemo, follow by bilateral mastectomies. Both breasts are negative for residual cancer, stated as a complete response. Based on "suspicious for malignancy" can we accession two primaries and assume bilateral complete response?

Patient has an April 2009 biopsy proven diagnosis of cholangiocarcinoma with a single liver mass in segment 4 that was treated with TACE and systemic chemotherapy. The treated lesion was stated to be stable in subsequent scans performed between 2010 and late 2015.

December 2015 imaging identified a new mass in the left hepatic lobe consistent with cholangiocarcinoma. Is the 2015 tumor a new primary?

In auditing files for expected (but not received) abstracts due from facilities, we've observed these types of cases not being consistently reported as multiple primaries.

The physician consult in this case further specifies that the large granular lymphocyte disorder represents an autoimmune disease of autoimmune T-cell mediated mechanism. Is this a reportable diagnosis?