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Question: 20130002 Status

Source 1:   Heme & Lymph Manual & DB
Source 2:   Heme & Lymph Manual & DB, MP Calculator

Multiple primaries--Heme & Lymphoid Neoplasms: How many primaries are accessioned, and what is the year of diagnosis, when the patient was initially diagnosed with poorly differentiated, diffuse lymphocytic lymphoma, small cleaved cell [9591/3] in 1991, followed by multiple recurrences and transformations? See Discussion.

5/1991 Left groin biopsy: Poorly differentiated, diffuse lymphocytic lymphoma, small cleaved cell [9591/3].

Subsequently, the patient had multiple recurrences.

7/1/08 Left axillary biopsy: Disease transformed to malignant lymphoma, large B-cell and a small focus of follicular lymphoma.

Patient was followed until there was no evidence of disease.

4/22/10 Left axillary biopsy: Recurrence of follicular lymphoma, grade 1. No large cell component was found. The bone marrow biopsy was negative for lymphoma. The patient was on observation.

11/02/10 MD note indicates the disease progressed to follicular lymphoma, grade 3. No large cell component was identified. The patient clinically has no evidence of disease on maintenance Rituxan.

For cases diagnosed 2010 and forward, access the Hematopoietic Database at

This case should be accessioned as a single primary, non-Hodgkin lymphoma (previously called poorly differentiated, diffuse lymphocytic lymphoma, small cleaved cell) [9591/3] diagnosed in 1991.

Determining the number of primaries is based on the rules in effect at the time of each diagnosis. The original lymphoma was diagnosed in 1991 and the first transformation to follicular lymphoma in 2008. The pre-2010 rules for coding histology and determining multiple primaries must be applied first because the rules changed for diagnoses occurring 2010 or later. Per the Single Versus Subsequent Primaries Table, poorly differentiated, diffuse lymphocytic lymphoma, small cleaved cell [9591/3] is the same primary as follicular lymphoma [9690].

The Heme DB and Manual are used to confirm that the 2010 recurrences of follicular lymphoma, grade 1 [9695/3], and follicular lymphoma, grade 3 [9698/3], are considered the same primary according to the Heme Calculator check required per Rule M15. Per the Heme DB Disease Information page, the diagnoses follicular lymphoma, grade 3 [9698/3] and follicular lymphoma, grade 1 [9695/3] are comparable to follicular lymphoma [9690] as stated in the Same Primary section.

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.

This SINQ question has been updated to the Hematopoietic & Lymphoid Neoplasm Manual & Database published January 2014. The original answer below was written based on the rules in 2012 The 2008 diagnosis and both diagnoses in 2010 are recurrences of the 1991 diagnosis, not new primaries.

Since the latest diagnosis is 2010, follow the rules in the 2010 Hematopoietic Manual and Database; however, there was an error in the 2010 multiple primaries calculator which has been corrected in the 2012 version.

Initial diagnosis: 9591/3. Second occurrence Malignant Lymphoma, Large B-cell. Small focus of follicuar lymphoma: 9690/3. This is the same primary.

4/2010: Follicular lymphoma, grade 1: 9695 and 11/2010: Follicular lymphoma, grade 3: 9698/3. The multiple primaries calculator in the 2012 Hematopoietic Database shows all of these as the same primary. The 2010 Hematopoietic Database would result in 3 primaries, which is incorrect.

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