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The Equivalent Terms and Definitions sections in the Solid Tumor Rules for these schemas identify which sites must have laterality coded, but there is no instruction for coding laterality when bilateral tumors are a single primary. The SEER Manual currently only indicates code 4 (bilateral) is seldom used (e.g., bilateral ovarian tumors, Wilms tumors, etc.) but does not indicate laterality code 4 should be used for CNS tumors. Is this note going to be updated or should a non-bilateral code be applied?

Example: MRI demonstrates multiple left-sided dural-based meningiomas including a 4.4 cm left posterior fossa meningioma, a 0.8 cm left frontal-parietal meningioma and a right posterior frontal meningioma. The large left posterior fossa meningioma was resected and proved atypical meningioma. Should the laterality be 4 (bilateral) as the patient had both left and right-sided meningiomas confirmed to be a single primary? Or should the laterality be coded as 2 (left) since only the large left-sided meningioma was proven to be a borderline tumor (atypical meningioma, 9539/1) and the others were benign?

Patient had a breast excision that proved a single tumor with no evidence of invasive carcinoma. The final diagnosis stated: Size (extent) of EPC DCIS: Spanning approximately 1.3 cm. The pathologist did not describe separate foci of DCIS; only one tumor comprised of both encapsulated papillary carcinoma and DCIS. The encapsulated papillary carcinoma was not described as invasive. The pathology noted: This case is best classified as EPC conventional DCIS. No conventional stromal invasion is identified. Solid Tumor Rule M2 confirms a single tumor is a single primary.

However, there does not appear to be an H Rule that instructs how to code histology. The Single Tumor: In Situ Only module, has only three H Rules and none of them apply to this case. The patient does not have Paget disease (H1), does not have a single histology (H2, there are multiple histologies present as DCIS and EPC are listed on different rows in Table 3) and does not have DCIS and LCIS (H3). How does one arrive at the correct histology for this case?

A patient has a left breast cancer diagnosed in 2011; then has a "recurrence" in her lymph nodes in 2017. In 2018, she has a new left breast mass that is the same histology and behavior as the 2011 cancer. Based on the 2017 "recurrence" in the lymph nodes, this is not a new breast primary, is that correct?

Patient presented with hoarseness and palpable neck mass. No palpable adenopathy (per hospital abstract).

02/19/16 Thyroid Ultrasound: Right thyroid lobe with mass, 63X35X44XMM (per hospital abstract).

06/01/16 Right thyroid lobectomy, radical resection right laryngeal tumor (per hospital abstract).

06/01/16 Operative Procedure: Tumor was invading laryngeal soft tissue and cartilage anteriorly and to the right. There may be a small amount of residual tumor invading cartilage although this was not clear (per hospital abstract).

GROSS DESCRIPTION: 1. The specimen is received fresh for intraoperative consultation, labeled with the patient's name and "right thyroid mass." It consists of a 3.0 x 2.2 x 2.0 cm irregular, ragged fragment of tan-red, firm, rubbery soft tissue. The specimen is serially sectioned to reveal a tan-red, gritty cut surface with focal fleshy areas. A touch prep is performed. A representative section is submitted for frozen section analysis in 1FSA. A portion of tissue is submitted for flow cytometry with the accession number MSO-16-1786. The remaining specimen is entirely submitted in 4 additional cassettes (1B-1E). 2. The specimen is received in formalin and is labeled "right thyroid lobe." It consists of a thyroid lobe measuring 4.3 x 4.0 x 1.3 cm and weighing 10.0 g. The external surface is covered by a thin fibrous capsule with a focal area of roughening on the posterior surface. The lobe is inked black posterior, blue anterior and orange isthmus margin. Serial sectioning reveals a red-brown and beefy parenchyma. A definitive nodule is not grossly identified. The entire specimen is serially submitted from superior to inferior in 9 cassettes. 3. The specimen is received in formalin, labeled with the patient's name and "right neck/laryngeal mass." It consists of an irregular, focally nodular red-tan mass measuring 7.0 x 5.5 x 4.0 cm and weighing 54 g. The convex portion of the specimen is mostly encapsulated with focal adherent red-brown striated skeletal muscle. The concave portion of the specimen is focally ragged and disrupted. The convex portion of the specimen is inked black and the concave portion is inked blue. The specimen is serially sectioned to reveal a white-grey to red, granular, gritty cut surface with focal fleshy areas. Representative sections are submitted in 12 cassettes.

Final DX DIAGNOSIS: 1. Right thyroid mass excision Plasma cell tumor /plasmacytoma 3 cm. Tumor cells are positive for kappa and negative for lambda immunostains. Recommend correlation with flow cytometry MSO-16-1786, monoclonal plasma cell population with cytoplasmic kappa positivity. Ki-67 stains 7 percent of cells. Focal stromal hyalinization. Congo red stain for amyloid negative. No thyroidal tissue identified. 2. Right thyroid lobe excision Benign thyroid tissue with focal solid cell nest negative for malignancy. One out of two 1/2 perithyroidal lymph nodes positive for plasma cell tumor. 3. Laryngeal mass excision Plasma cell tumor /plasmacytoma 7 cm involving soft tissue and skeletal muscle. Tumor cells are positive for kappa and negative for lambda immunostains. Ki-67 stains 7 percent of cells. Focal stromal hyalinization and calcification. Congo red stain for amyloid negative

From a number of definitions reviewed, it seems unclear if it's part of the appendix or the cecum of the colon. For example: The cecum is usually located in the right iliac fossa. In the pole of the cecum, there is often the appearance of fusion of the three teniae coli around the appendix, giving rise to the tri-radiate fold (Mercedes Benz sign), but the anatomy can be variable. The most reliable landmarks of the cecum are the appendiceal orifice and ileocecal valve. The appendiceal orifice is usually an unimpressive slit, often crescentic in shape. The ileocecal valve is made up of the superior and inferior lips (usually not seen en face) and is the gateway leading into the terminal ileum. It is located on the prominent ileocecal fold encircling the cecum, between 3 and 5 cm distal to the cecal pole. (https://www.sciencedirect.com/science/article/pii/S2212097113701730)

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?

The hospital registrar reports that the case was identified at the hospital because of the referral for chemotherapy for the metastatic GIST. The records from the out-of-state hospital mentioned a history of a small bowel resection in 2003 for a borderline tumor. The registrar went back through the hospital's old records and found the surgery was done for GIST of low malignant potential at her facility. The question is whether to report the case or not, and if reported, is 2003 the diagnosis date.

The rules say to change the behavior and backdate the diagnosiswhen a tumor is presumed benign and islater diagnosed as malignant. Another problem for this case is that the out-of-state hospital did not review the slides from the 2003 surgery.