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Report Produced: 02/18/2026 09:20 AM

Report Question ID Question Discussion Answer Year
20130035

Multiple primaries--Heme & Lymphoid Neoplasms: How many primaries are accessioned and what rule applies when a subsequent diagnosis of diffuse large B-cell lymphoma (95%) and follicular lymphoma, grade 3 (5%) is made following an original diagnosis of low grade CD-10 positive B-cell lymphoma, most consistent with low grade follicular lymphoma (FL) ? See Discussion.

In 2011, patient presented with a large mesenteric mass, numerous other smaller mesenteric lymph nodes, moderate retroperitoneal and extensive iliac chain adenopathy greater on right; small inguinal nodes are also present mostly on right side and splenomegaly per the CT scan. Abdominal pelvic mass needle biopsies showed low grade CD-10 positive B-cell lymphoma, most consistent with low grade follicular lymphoma (FL). The patient was treated with R-CVP with unknown response.

In June 2012, patient presented again for laparoscopy and lymph node biopsy for stated recurrence of lymphoma found on CT scan. A large mass was seen in mesentery of bowel. Abdominal mass biopsy showed diffuse large B-cell lymphoma (DLBCL). Abdominal mass #2 excisional biopsy showed diffuse large B-cell lymphoma, 95%, and follicular lymphoma grade 3, 5%. The majority of the tumor is now DLBCL.

For cases diagnosed 2010 and forward, access the Hematopoietic Database at http://seer.cancer.gov/seertools/hemelymph.

This case should be accessioned as a single primary, diffuse large B-cell lymphoma diagnosed in 2011 per Rule M7. Note 4 for Rule M7 states to change the histology code on the original abstract to the more specific histology, diffuse large B-cell lymphoma in this case. There is no time restriction for rule M7. Apply rule PH11 and code the histology as 9680/3 [DLBCL] when both DLBCL and follicular lymphoma are present in the same lymph node(s).

Ambiguous terminology is not used to code a more specific histologic type per the Heme Manual. The information submitted states only that this low grade B-cell lymphoma was "most consistent with follicular lymphoma." The term "consistent with" is an ambiguous term per SEER and cannot be used to code the histology of the 2011 neoplasm as follicular lymphoma. There was no subsequent clinical statement that this patient was diagnosed with follicular lymphoma in 2011.

SEER*Educate provides training on how to use the Heme Manual and DB. If you are unsure how to arrive at the answer in this SINQ question, refer to SEER*Educate to practice coding hematopoietic and lymphoid neoplasms. Review the step-by-step instructions provided for each case scenario to learn how to use the application and manual to arrive at the answer provided. https://educate.fhcrc.org/LandingPage.aspx.

Although the ambiguous terminology on the pathology report is not used to code the histology to follicular lymphoma, had there been a subsequent clinical statement that this patient had follicular lymphoma, the histology would be coded to follicular lymphoma [9690/3]. A diagnosis of follicular lymphoma followed by a diagnosis of DLBCL more than 21 days later is a new primary per rule M12.

 2013
20130056 Primary site/Histology--Heme & Lymphoid Neoplasms: How are the site and histology fields coded if a bone marrow biopsy shows, "B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma and Burkitt lymphoma," but the patient has no palpable lymphadenopathy and no scans were done? See Discussion. Should the primary site be C779 or C421? Is the correct histology 9684/3 [malignant lymphoma, large B-cell, diffuse, immunoblastic, NOS]?

For cases diagnosed 2010 and forward, access the Hematopoietic Database at http://seer.cancer.gov/seertools/hemelymph.

Code the primary site to C421 [bone marrow] and the histology to 9680/3 [diffuse large B-cell lymphoma] per Rule PH26. B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma and Burkitt lymphoma is listed under Alternative Names section of the Heme BD for DLBCL [9680/3]. This patient has bone marrow involvement only. The Note for Rule PH26 instructs one to code the primary site to the bone marrow when all physical exams or work-up were negative for lymph node, tissue, or organ involvement OR no other work-up was done.

The histology is not coded 9684/3 [malignant lymphoma, large B-cell, diffuse, immunoblastic, NOS]. This histology code became obsolete in 1/1/2010. Diffuse large B-cell lymphoma, immunoblastic variant is also listed under Alternative Names section of the Heme BD for DLBCL.

SEER*Educate provides training on how to use the Heme Manual and DB. If you are unsure how to arrive at the answer in this SINQ question, refer to SEER*Educate to practice coding hematopoietic and lymphoid neoplasms. Review the step-by-step instructions provided for each case scenario to learn how to use the application and manual to arrive at the answer provided. https://educate.fhcrc.org/LandingPage.aspx.

2013
20130079

Reportability--Heme & Lymphoid Neoplasms: Is plasma cell dyscrasia reportable and synonymous with multiple myeloma? See Discussion.

Bone marrow biopsy and aspirate: Plasma cell dyscrasia with IgG kappa expression with FISH (+) for the following abnormalities: 3 copies of 1q21 (25/30 plasma cells) and an extra CCND1 signal (25/34 plasma cells) which is indicative of the presence of other chromosome 11 abnormalities possibly trisomy 11, a change known to occur in plasma cell neoplasms. Flow cytometry: A monoclonal plasma cell population is present, co-expressing cIgG, cKappa, CD56, & CD117 (up to 14% of analyzed cells).

For cases diagnosed 2010 and forward, access the Hematopoietic Database at http://seer.cancer.gov/seertools/hemelymph.

Plasma cell dyscrasia and multiple myeloma are not synonymous terms. Plasma cell dyscrasia is not listed in the Alternate Names section of the Heme DB for plasma cell myeloma (multiple myeloma). Plasma cell dyscrasia is listed in the Alternate Names section of the Heme DB for MGUS [9765/1], which is not a reportable disease.

Plasma cell dyscrasia (PCD) is not reportable. PCD is a diverse group of neoplastic diseases that produces a serum M component (monoclonal immunoglobulin).

Usually these patients have a plasma cell morphology such as multiple myeloma or heavy chain disease. However, the registrar cannot diagnose multiple myeloma or heavy chain disease (or any other plasma cell neoplasm). There must be a physician statement and/or a positive biopsy to confirm a reportable diagnosis.

SEER*Educate provides training on how to use the Heme Manual and DB. If you are unsure how to arrive at the answer in this SINQ question, refer to SEER*Educate to practice coding hematopoietic and lymphoid neoplasms. Review the step-by-step instructions provided for each case scenario to learn how to use the application and manual to arrive at the answer provided. https://educate.fhcrc.org/LandingPage.aspx.

 2013
20130115 Histology--Heme & Lymphoid Neoplasms: How is histology coded when the biopsy final diagnosis is "low grade B-cell lymphoma of unclear subtype (splenic marginal zone lymphoma?)" and the hematologist clinically diagnoses this as splenic marginal zone lymphoma? See Discussion.

This patient has massive splenomegaly. The biopsy final diagnosis was "low grade B lymphoma of unclear subtype (splenic marginal zone lymphoma?)." The pathologist's comment states, "Because of the clinical context (lymphocytosis and splenomegaly) a splenic marginal zone lymphoma is a possibility." There are no other histologic diagnoses. All the flow cytometry reports are as unclear as the biopsy.

The hematologist, after seeing the pathology report, states, "The bone marrow biopsy shows a significant infiltration by mature lymphocytes; their markers strongly suggest a marginal zone lymphoma, probably of splenic origin The final diagnosis is a splenic marginal zone lymphoma."

Should the clinical diagnosis of splenic marginal zone lymphoma [9689/3] be coded when a clinical diagnosis is not listed as a definitive diagnostic method for this neoplasm? Or should the histology be coded as low grade B-cell lymphoma [9591/3]? The clinicians will expect the case to be coded as a splenic marginal zone lymphoma when there's no doubt about the diagnosis.

For cases diagnosed 2010 and forward, access the Hematopoietic Database at http://seer.cancer.gov/seertools/hemelymph.

Code the histology to 9689/3 [splenic marginal zone lymphoma] per Rule PH29 and Case Reportability Instruction #6 in the Heme Manual. Case Reportability Instruction #6 indicates, "Report the case when there is a (physician's statement) of reportable hematopoietic or lymphoid neoplasm."

The pathology gave an NOS diagnosis, low grade B-cell lymphoma [9591/3]. The physician clinically stated this was a splenic marginal zone lymphoma [9689/3]. Rule PH 29 states to code the specific histology when the diagnosis is one non-specific histology AND one specific histology AND the Heme DB MP Calculator indicates they are the same primary. Per the Multiple Primaries Calculator, these two histologies indicate the same primary.

SEER*Educate provides training on how to use the Heme Manual and DB. If you are unsure how to arrive at the answer in this SINQ question, refer to SEER*Educate to practice coding hematopoietic and lymphoid neoplasms. Review the step-by-step instructions provided for each case scenario to learn how to use the application and manual to arrive at the answer provided. https://educate.fhcrc.org/LandingPage.aspx.

2013
20130183

Reportability--Heme & Lymphoid Neoplasms: Is a peripheral blood finding consistent with involvement by monoclonal, lambda-restricted mature B cell population with co-expression of CD5 and CD23 reportable if, immunophenotypically, the case is consistent with a chronic lymphocytic leukemia/small lymphocytic lymphoma? See Discussion.

Peripheral blood: Final diagnosis: Leukocytosis absolute lymphocytosis monoclonal, lambda restricted B-cell population w/co-expression of CD5 and CD23 absolute increase in CD4=helper T cells. See comment.

Comment: Peripheral blood findings are consistent with involvement by monoclonal, lambda-restricted mature B cell population with co-expression of CD5 and CD23, which is immunophenotypically consistent with a chronic lymphocytic leukemia/small lymphocytic lymphoma immunophenotype. However, the absolute monoclonal population is only 3.02k/ul.

According to WHO criteria, in the absence of extramedullary tissue involvement, the monoclonal lymphocyte population must be greater than or equal to 5.0 k/ul. Therefore, in the absence of clinical evidence of extramedullary tissue involvement, the diagnosis is most consistent with a monoclonal B cell lymphocytosis. Review of initial analysis reveals well-defined groups of cells within lymphocyte, monocyte and granulocyte gates as defined by CD45 and sid-scatter characteristics (%'s are listed). Overall, peripheral blood findings are consistent with involvement by monoclonal, lambada-restricted B cell population with a chronic lymphocytic leukemia/small lymphocytic lymphoma immunophenotype.

For cases diagnosed 2010 and forward, access the Hematopoietic Database at http://seer.cancer.gov/seertools/hemelymph.

This case is reportable. Code histology to 9823/3 [CLL/SLL].

Ambiguous terminology is used to accession cases (determine reportability) because it has been used for over 30 years to do so. Any deviation from using ambiguous terminology to determine case reportability would cause the reporting of incidence counts to vary. In this case, there was a reportable, ambiguous terminology diagnosis on peripheral blood that is "consistent with" involvement by chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) immunophenotype.

The ambiguous terminology "consistent with" in the flow cytometry report is acceptable to determine reportability. Given that it is the only reportable histology mentioned in the scenario, it is also used to code histology. The instruction "Do not code histology based on ambiguous terminology" is intended to be used when there is a reportable NOS histology and reportable more specific histology stated in the diagnosis. Ambiguous terminology cannot be used to report the more specific diagnosis in cases of Heme & Lymphoid neoplasms.

SEER*Educate provides training on how to use the Heme Manual and DB. If you are unsure how to arrive at the answer in this SINQ question, refer to SEER*Educate to practice coding hematopoietic and lymphoid neoplasms. Review the step-by-step instructions provided for each case scenario to learn how to use the application and manual to arrive at the answer provided. https://educate.fhcrc.org/LandingPage.aspx.

 2013
20130028 Primary site--CLL/SLL: How is the primary site coded and what rule applies when no bone marrow biopsy is performed on a patient diagnosed with chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) which was based on the results of an axillary biopsy, positive peripheral blood and a CT scan showing multiple lymph nodes involved above and below the diaphragm? See Discussion The physician staged this as Stage 0 CLL/SLL. Should the primary site be coded to lymph nodes if the MD stated this was leukemia?

For cases diagnosed 2010 and forward, access the Hematopoietic Database at http://seer.cancer.gov/seertools/hemelymph.

Code the primary site to C421 [bone marrow] per Rule PH5. Code the primary site to the bone marrow when the peripheral blood is involved, even if no bone marrow biopsy is performed.

According to the notes for Rule PH5, CLL always has peripheral blood involvement (PH5 Note 1). CLL/SLL may also have involvement of lymph node regions in later stages (PH5, Note 2). For this patient a bone marrow biopsy was not performed but he had extensive lymph node and peripheral blood involvement. Therefore, the primary site is coded to C421. In addition, the physician's documentation specifies this patient has Stage 0 disease which indicates this disease process is being classified as leukemia (CLL).

SEER*Educate provides training on how to use the Heme Manual and DB. If you are unsure how to arrive at the answer in this SINQ question, refer to SEER*Educate to practice coding hematopoietic and lymphoid neoplasms. Review the step-by-step instructions provided for each case scenario to learn how to use the application and manual to arrive at the answer provided. https://educate.fhcrc.org/LandingPage.aspx.

2013
20130146 Histology--Heme & Lymphoid Neoplasms: What is the histology code for a diagnosis of myeloproliferative neoplasm/myelodysplastic syndrome overlap?

For cases diagnosed 2010 and forward, access the Hematopoietic Database at http://seer.cancer.gov/seertools/hemelymph.

Code the histology to 9975/3 [myelodysplastic/myeloproliferative neoplasm, unclassifiable]. Per the Definition section in the Heme DB, this neoplasm has the, "Clinical laboratory and morphological features of myeloproliferative neoplasm but fails to meet the criteria for a specific myeloproliferative neoplasm; or presents with features that overlap two or more MPN neoplasms."

SEER*Educate provides training on how to use the Heme Manual and DB. If you are unsure how to arrive at the answer in this SINQ question, refer to SEER*Educate to practice coding hematopoietic and lymphoid neoplasms. Review the step-by-step instructions provided for each case scenario to learn how to use the application and manual to arrive at the answer provided. https://educate.fhcrc.org/LandingPage.aspx.

2013
20130161 Primary Site--Heme & Lymphoid Neoplasms: Is the primary site coded to C779 or C421 for a bone marrow that is positive for B-cell acute lymphoblastic leukemia, the peripheral blood demonstrates leukemic involvement and the PET scan shows involvement of abdominal lymph nodes, spleen and throughout the bones? See Discussion.

1/11/13 Bone marrow bx: B-cell acute lymphoblastic leukemia. Flow cytometry of peripheral blood shows leukemia involvement.

PET scan shows involvement of abdominal lymph nodes, spleen and throughout the bones. The patient has an elevated WBC, anemia and thrombocytopenia.

The answer to SINQ 20120047 (which is no longer visible in the system) said to code B lymphoblastic leukemia/lymphoma to bone marrow for primary site if there is bone marrow involvement. The Heme/Lymph Manual Rule PH7 says to code bone marrow as the primary site if bone marrow is the only site involved.

Following the manual, the primary site would be C779. However, according to the answer to SINQ 20120047, the primary site would be C421. Which is correct?

For cases diagnosed 2010 and forward, access the Hematopoietic Database at http://seer.cancer.gov/seertools/hemelymph.

Per the Heme DB, the histology B-cell acute lymphoblastic leukemia is synonymous with B lymphoblastic leukemia/lymphoma, NOS. Per Rule PH8, for a neoplasm that can manifest as either leukemia lymphoma or leukemia lymphoma, one is to code the primary site to the site of origin when lymph node(s) or lymph node region(s), tissue(s) or organs are involved. The Note 4 instruction states it is necessary to go to Module 7 (Rules PH18-PH27) to code the more specific primary site. In this case, use Rule PH22 to code primary site to C779 [lymph nodes, NOS] for the case you describe.

In this case, there is involvement of abdominal lymph nodes, spleen, bone marrow and bone. There is no indication of the primary site. Per the Heme DB, the most frequent sites of involvement for the lymphoma are bone and lymph nodes. This is a Stage IV lymphoma.

The now inactivated SINQ 20120047, stated that based on the sites of involvement, this histology could be coded as either leukemia or lymphoma. If the only involvement is the bone marrow, the site is coded to C421 [bone marrow]. The involvement of peripheral blood does not change the primary site because such involvement is part of the leukemic process.

SEER*Educate provides training on how to use the Heme Manual and DB. If you are unsure how to arrive at the answer in this SINQ question, refer to SEER*Educate to practice coding hematopoietic and lymphoid neoplasms. Review the step-by-step instructions provided for each case scenario to learn how to use the application and manual to arrive at the answer provided. https://educate.fhcrc.org/LandingPage.aspx.

2013
20130055 Primary site--Heme & Lymphoid Neoplasms: How is the primary site coded for a lymphoma with multifocal bone and epidural involvement but no lymph node involvement if the physician does not clearly state the primary site? See Discussion.

MRI Lumbar spine: Bony metastatic disease most evident at L5, L3 and T10. There is marrow tumor in the posterior elements of T12 and T10. The 14 mm epidural mass represents epidural tumor, likely metastatic, extending into the left intervertebral foramen at T12-L1.

PET scan: Hypermetabolic activity corresponding to epidural mass at the level of T12 and L1 concerning for malignancy. Other small areas of hypermetabolic activity in the left mandible and both femoral necks. There is no hypermetabolic activity corresponding to the areas of abnormal marrow edema in the vertebral bodies which enhanced on MRI scan in the lumbar and lower thoracic spine. No lymph nodes mentioned.

Biopsy epidural mass: Diffuse large B-cell lymphoma with a background of follicular lymphoma, consistent with a large cell transformation. Flow cytometry confirms a mixed large and small cell population of lymphoma (55% large cells).

T12/L1 Bone Biopsy: Bone and marrow with atypical paratrabecular lymphoid infiltrates, suspicious for involvement by follicular lymphoma. Negative for large cell lymphoma.

For cases diagnosed 2010 and forward, access the Hematopoietic Database at http://seer.cancer.gov/seertools/hemelymph.

Code the primary site of the diffuse large B-cell lymphoma [9680/3] to C809 [unknown primary site] per Rule PH27. The patient has involvement of multiple bones and an epidural mass with no evidence of nodal involvement. Code the primary site to unknown [C809] when multiple organs are involved without any lymph node involvement, even when there is no statement from the physician regarding primary site.

SEER*Educate provides training on how to use the Heme Manual and DB. If you are unsure how to arrive at the answer in this SINQ question, refer to SEER*Educate to practice coding hematopoietic and lymphoid neoplasms. Review the step-by-step instructions provided for each case scenario to learn how to use the application and manual to arrive at the answer provided. https://educate.fhcrc.org/LandingPage.aspx.

 2013
20130057 Histology--Heme & Lymphoid Neoplasms: How is the histology coded if the bone marrow biopsy favors lymphoplasmacytoid lymphoma and the physician states the diagnosis is lymphoplasmacytic lymphoma-Waldenstrom's macroglobulinemia? See Discussion.

Bone marrow biopsy: Focal bone marrow involvement with B-cell lymphoproliferative disorder. Comment: This patient has 2 monoclonal proteins in serum, IgM kappa and IgG kappa clones. The marrow does have focal involvement with a small cell lymphoproliferative disorder. A lymphoplasmacytoid lymphoma is favored.

Flow Cytometry: Bone marrow reveals a low level, kappa-bearing-B-lymphoproliferative population that has an immunophenotype compatible with mantle cell lymphoma or related small, mature non-Hodgkin lymphoproliferative disorder.

Physician statement: lymphoplasmacytic lymphoma-Waldenstrom's macroglobulinemia.

Per the Heme DB, the criteria to diagnosis WM is the serum paraprotein IgM. This patient's IgM was 6020 mg/dL. It was described as elevated per the physician. The physician also states the patient's IgG is elevated. According to the Heme DB, when both IgG and IgM are elevated it is indicative of LPL.

For cases diagnosed 2010 and forward, access the Hematopoietic Database at http://seer.cancer.gov/seertools/hemelymph.

Code the histology to 9671/3 [lymphoplasmactyic lymphoma (LPL)] per the Heme DB Abstractor Notes and Rule PH17. When IgG and IgM are elevated, code to lymphoplasmacytic lymphoma. Waldenstrom's macroglobulinemia is caused by increased lymphocytes which causes an increase in IgM. LPL has mixed abnormalities, both the lymphocytes and plasma cells are increased which results in an abnormally high IgM and IgG.

SEER*Educate provides training on how to use the Heme Manual and DB. If you are unsure how to arrive at the answer in this SINQ question, refer to SEER*Educate to practice coding hematopoietic and lymphoid neoplasms. Review the step-by-step instructions provided for each case scenario to learn how to use the application and manual to arrive at the answer provided. https://educate.fhcrc.org/LandingPage.aspx.

2013