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Abstract a single primary using Solid Tumor Rules, Malignant CNS and Peripheral Nerves, Rule M10 based on the information provided.  Rule M10 applies as both non-contiguous tumors are of the same histology; i.e., on the same row in Table 3. As MPNST can arise in many sites, look for information about the precise location and tissue type in which the tumor arose. For example, if the tumors are stated to arise in soft tissue, follow the Multiple Primary Rules for Other Sites.

Both WHO Classification of Central Nervous System Tumors and WHO Classification of Soft Tissue and Bone Tumors state that MPNST is a malignant spindle cell tumor often arising from a peripheral nerve, from a pre-existing benign nerve sheath tumor, or in a patient with neurofibromatosis type 1 (NF1).

Future updates will move C470-C479 from CNS to other sites module.

Abstract a single primary using Breast Solid Tumor Rules, Rule M18, as none of the previous rules apply.

Undifferentiated carcinoma is a malignant epithelial tumour lacking overt evidence of a specific line of differentiation. Dedifferentiated carcinoma is composed of an undifferentiated carcinoma and a differentiated component. Dedifferentiated carcinoma (8020/3) as a morphology is associated with cancer of the endometrium and ovary rather than the breast.  Breast cancer shows a broad spectrum of morphology with extensive variation in histological type and grade, related to the complexity of carcinogenesis.  This includes initial genetic changes in the cell of origin, subsequent genetic and epigenetic alterations, and reprogramming that occur at various stages of development along with interaction of other factors that influence the process of differentiation.  This scenario likely represents the process of phenotypic change of a carcinoma at a later stage, better known as transdifferentiation.

Pituitary microadenoma is reportable. Assign 8272/0. "Micro" refers to size of the adenoma. 

Per the SEER Program Coding and Staging Manual 2022, a reportable intracranial or CNS neoplasm identified only by diagnostic imaging is reportable, and "consistent with" is listed on the Ambiguous Terms to be used for Reportability list. As a result, this case is reportable.

The patient's previous acinar adenocarcinoma in the right lower lobe of the lung in 2020 and squamous cell carcinoma in the right middle lobe of the lung in 2021 were correctly abstracted as two primaries per rule M8 as they are in different rows in Table 3. The NSCLC, RUL (8046) diagnosed in 2022 would not be abstracted as a third primary because NSCLC is a broad category which includes all histologies in Table 3 (except for small cell carcinoma/neuroendocrine tumors (NET Tumors) 8041 and all subtypes), and because it was diagnosed less than 3 years after the 2021 squamous cell carcinoma, RML (8070).

Assign as Stage IV as recommended by our expert hematological oncologist. This is a rare occurrence and this type of presentation does not fit the definition of intraocular extension. Stage IV is probably the best stage for this type of presentation, since there are two extranodal organs involved, even though they involve a bilateral site.

EOD Primary Tumor: 700

SS: 7 (Distant)

Scope of Regional Lymph Node Surgery:  Assign code 7, Sentinel node biopsy and code 3, 4, or 5 at different times. In this case, the SLNBx (code 2) preceded the regional node dissection (code 5: 4 or more regional lymph nodes removed), i.e., procedures performed in separate surgical events.

Sentinel Lymph Nodes Examined:  Assign code 98, Sentinel lymph nodes were biopsied, but the number is unknown. In this case, only the results were provided.

Sentinel Lymph Nodes Positive:  Assign code 01, Sentinel nodes are positive (code exact number of nodes positive). In this case, there was one positive sentinel node.

This case does not fall into the standard rules. WHO criteria for diagnosing pituitary adenoma have recently changed (per 5th Ed WHO CNS book) and we will likely see more PitNET’ s than pituitary adenomas in the future.  PitNET may be invasive or non-invasive but the likelihood of the pathologists providing this information is low. Since we don’t know if the 2018 adenoma was a PitNET based on current criteria or if it transformed to the malignant neoplasm, err on the side of caution and abstract a second primary per M5.

This issue is new, and we’ve received numerous questions concerning pathologist reviewing older cases of pituitary adenoma and reclassifying them as PitNET using the new criteria.

Assign 000 for EOD Regional Nodes when you have a pathology only report with a localized tumor based on Breslow’s depth and/or Clark’s Level (per EOD and/or Summary Stage) and no information on regional lymph nodes or mets. When the tumor is noted to be regional or distant based on Breslow’s Depth and/or Clark’s based on the definitions in EOD and/or Summary Stage, do not assume that the nodes are negative and assign 999. Clarification will be added to the EOD manual.

In the absence of information to the contrary, thyroid FNAs designated as Bethesda classification category VI are reportable. Thyroid FNAs designated as Bethesda classification category V are not reportable unless there is additional information confirming a reportable diagnosis. For both Bethesda V and VI, NCCN Guidelines recommend total thyroidectomy or lobectomy (depending on tumor size and nodal involvement) for the purposes of definitive diagnosis/treatment, so additional information should be available.

We will add this to the next version of the SEER manual.

In your example, nodule 1 Bethesda V is not reportable. Nodule 2 Bethesda VI is reportable.

This is reportable as 9591/3, B-cell lymphoma, NOS.All diagnoses in the differential are all B-cell lymphomas. The pathologist knows it a B-cell lymphoma but has not determined the subtype. If at a later time a specific lymphoma is determined, update the histology code accordingly.