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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 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?

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)?

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 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.

Since acellular dermal matrix/AlloDerm comes from human tissue donors with cells removed and sterilized to promote regenesis and decrease rejection, is Alloderm coded as "Tissue' as it also "provides an additional layer of tissue between the skin and the implant?

Pathology report: Brain tumor, left side: Gliotic cortex and subcortical white matter with meningioangiomatosis (see Comment). Comment This specimen represents a meningioangiomatous lesion located in the leptomeninges that projects along the Virchow-Robin spaces into the underlying cortex. The surrounding brain parenchyma demonstrates reactive changes with astrogliosis and microgliosis. An intraparenchymal neoplasm is not seen. Meningioangiomatosis is a rare benign meningovascular hamartomatous condition and usually appears in young patients.