MP/H Rules/Multiple primaries-–Brain:
Does a glioblastoma multiforme following
a low grade glioma (oligodendroglioma)
represent a new primary? See discussion.
In 2/08 patient underwent resection of
tumor of right frontal lobe. Path
diagnosis showed a low grade glioma,
favor low grade oligodendroglioma (WHO
grade II). In 02/09 biopsy of a left
thalamic mass showed glioblastoma
mutiforme. Per rule M6 glioblastoma
multiforme following a glial tumor is a
single primary. Per path diagnosis, the
first tumor represented a low grade
glioma. However, oligodendroglioma is
not on the glial branch of chart 1 in
the MP/H rules.
Glioblastoma multiforme following
oligodendroglioma are multiple primaries
according to rule M8. Rule M6 does not
apply. M6 applies only to glial tumors
as listed in chart 1. Chart 1 is based
on the WHO classification. The WHO
oligodendroglial tumors from glial
MP/H Rules/Multiple primaries-–Brain:
How is Chart 1 to be interpreted for the
determination of number of primaries in
the Multiple Primary/Histology rules for
malignant brain tumors? See discussion.
Patient was diagnosed in 2000 with
anaplastic astrocytoma of the left
temporal lobe. 8/07 biopsy of right
frontal lobe showed oligoastrocytoma.
MP/H rule M7 states that tumors with
ICD-O-3 histologies on the same branch
in chart 1 are a single primary. Chart
1 shows that both of the histologies for
our sample case are located on the glial
branch. However, the glial tumor branch
has three secondary branches. Does rule
M7 apply to secondary branches?
Anaplastic astrocytoma (9402) is
classified under the secondary branch
for astrocytic tumors. Oligoastrocytoma
(9382) is classified under the secondary
branch for mixed glioma. Does rule M7
or does rule M8 apply for this case?
Does this case represent one or two
Rule M8 applies. There are two
MP/H Rules/Histology--Esophagus: Should
the term "areas of" be used to code
histology? See discussion.
Patient was found to have two tumors in
the esophagus. The large tumor was
diagnosed as adenocarcinoma with areas
of neuroendocrine differentiation (small
cell carcinoma). The smaller tumor was
diagnosed as small cell carcinoma. If
we consider the "areas of" to be part of
the diagnosis, rule H16 indicates that
histology for the large tumor would be
coded 8045 (combined small cell and
adenocarcinoma). If we ignore the
"areas of," then histology for the large
tumor would be coded to 8140
(adenocarcinoma). Either way, when
counting primaries, rule M17 would be
applied and the two tumors would be
classified as separate primaries.
However, it seems that the two tumors
are probably the same disease process
since they both show small cell
Do not use the term "with areas of" to
determine a more specific histology for
the purposes of applying the MP/H
MP/H Rules/Multiple primaries--Lung:
How many primaries are to be accessioned
for the following case: Adenocarcinoma
of the lung in the right middle lobe of
the lung and bronchioalveolar carcinoma,
non-mucinous type in the right upper
lobe? See discussion.
Bilobectomy revealed two tumors,
adenocarcinoma in the right middle lobe
and bronchioalveoar carcinoma
non-mucinous type in the right upper
lobe. MP/H rule M10 states that tumors
with non-small cell carcinoma (8046) and
a more specific non-small cell type
(chart 1) are a single primary. Does
rule M10 apply to only those cases for
which one tumor is stated to be
non-small cell, NOS? Or do we use chart
1 to identify specific subtypes? For
this case, using chart 1, would we note
that bronchioalveolar is a subtype of
adenocarcinoma and count this case as a
single primary? Most of the MP/H rules
schemas offer an option of considering
an adenocarcinoma and a more specific
type of adenocarcinoma to be a single
primary. Would we apply rule M10 to this
case and count it as a single primary?
Or would we move on to rule M11 and
count the case as two primaries?
Rule M11 applies. Accession two
Rule M10 applies only
Surgery of Primary Site--Corpus uteri:
How are the surgery fields to be coded
when patient undergoes hysterectomy and
omentectomy for endometrial primary? See
The example for instruction 6 in the
2007 SEER manual on page 179 (for
surgery of primary site) states "code an
en bloc removal when the patient has a
hysterectomy and an omentectomy." There
is no Site-Specific Surgery code for
corpus uteri that combines hysterectomy
with omentectomy. Is the information
about removal of the omentum lost or is
it documented under Surgical Procedure
of Other Site?
Use the most appropriate code in the
"Surgery of Primary Site field." Do not
code the omentectomy in "Surgical
Procedure of Other Site" when it is
performed with a hysterectomy for an
MP/H Rules/Histology--Breast: How is
histology to be coded for a breast
primary described as tubular carcinoma
(well differentiated invasive ductal
carcinoma)? See discussion.
How are terms that are modified by
parentheses to be interpreted? Do terms
in parentheses modify the stated
diagnosis and thus have priority over
the stated diagnosis? Or would rule H17
apply and histology would be coded as
duct and other carcinoma? For this case,
the wording of the diagnosis and use of
parentheses seem to indicate that
tubular is a type of ductal carcinoma.
Tubular is not listed as a specific duct
carcinoma in the MP/H rules histology
tables for breast.
Code the histology as tubular carcinoma
[8211/3]. This is not a case of tubular
AND infiltrating duct. The histology is
stated to be tubular. Tubular is not a
specific type of duct carcinoma.
MP/H Rules/Multiple primaries—-Colon:
Is a colon tumor that is "recurrent at
the anastomotic junction" just over one
year after the diagnosis of a T4 colon
tumor to be counted as a new primary?
MP/H rules do not apply to mets.
However, it has been our experience that
pathologists and clinicians tend to use
the terms metastatic and recurrence
interchangeably. The term "recurrence"
is not limited to a tumor recurrence in
the same site as a previous cancer.
Sometimes it is obvious that the
clinician is using the term recurrence
to describe a met lesion. When a
"recurrence" is located in tissue that
is very different from the original
primary site, it is easy to recognize
that the intended meaning of the term is
mets. Example: Patient with squamous
cell carcinoma of the tongue with
recurrence in the lung. However, when
the met deposit occurs in similar
tissue, it is more difficult. Example
of a case where the use of the term
"recurrence" is ambiguous: In April
2008 patient was diagnosed with
adenocarcinoma of the ascending colon.
At the time of hemicolectomy the tumor
was noted to be plastered into the
paraduodenal and peripancreatic area.
Patient received one dose of adjuvant
chemo and then discontinued treatment.
In May 2009 the patient was found to
have adenocarcinoma in the transverse
colon. Path diagnosis for segmental
resection at that time showed colonic
adenocarcinoma. Tumor location: tumor
appears recurrent at anastomotic
junction. Abdominal wall mass showed
met adenocarcinoma. One has to wonder
if the pathologist found a met nodule at
the anastomotic site and called it
"recurrent." It is unlikely that the
pathologist will compare this specimen
to the previous tumor, having already
diagnosed it as "recurrent."
Rule M4 applies to the example of
adenoca of ascending colon diagnosed in
2008 followed by adenoca of transverse
colon diagnosed in 2009. When a colon
resection has taken place, the original
primary site is no longer present. Colon
resection usually includes a portion of
uninvolved colon on either side of the
tumor. A tumor diagnosed at the
anastomotic junction cannot be located
in the same site as the previous tumor.
Use of the term "recurrent" in this case
is not synonymous with "metastatic."
Apply the MP/H rules.
MP/H Rules/Multiple primaries-–Melanoma:
How many primaries are to be counted
for a case in which patient presents
with a malignant melanoma (NOS) and a
separate lentigo maligna, both on right
chest? See discussion.
MP/H rule M5 states that melanomas with
ICD-O-3 histology codes that are
different at the third number are
multiple primaries. However, the 2007
MP/H fundamentals Webcast session on
melanoma rules states that this is not
two histologic types. Lentigo maligna is
a growth pattern, not a histologic type.
Will clarification be included in the
next MP/H rules revision?
There are two primaries in this case.
Rule M5 applies. Clarifications
regarding histologic types of melanoma
will be added to the rules when they are
MP/H Rules/Multiple primaries--Breast:
How is the statement "either local
recurrence or potentially a met" to be
interpreted? See discussion.
Patient underwent mastectomy in 1986 for
infiltrating ductal carcinoma of left
breast. Excision of left chest wall mass
in March 2009 showed ductal carcinoma
consistent with breast primary. Path
comment stated it would be compatible
with either local recurrence or a met.
The patient's primary breast carcinoma
material is not available for direct
comparison. MP/H rules instruct us to
ignore mets. Reference SINQ 20051102;
The MP/H rules do not apply to
mestatasis. If there is no further
information available for this case, the
MP/H rules do not apply to the 2009
Grade-–Breast: How is grade to be coded
for a breast tumor that is described as
intermediate nuclear grade? See
Guidelines for selecting grade for
breast primaries prioritize nuclear
grade right after B&R grade. The
conversion table displays only numeric
values for nuclear grade. How is grade
to be coded for tumors in which nuclear
grade is described by terminology?
Example 1: Ductal carcinoma,
intermediate nuclear grade. Example 2:
Ductal carcinoma, high nuclear grade.
Example 3: Ductal carcinoma, moderate
nuclear grade. Example 4: DCIS,
intermediate nuclear grade. How is
grade to be coded for each of these
examples? Does it make a difference if
the tumor is invasive or in situ?
Use the table on page C-607 of the 2007
SEER manual. The terms "low,"
"intermediate," and "high" appear in the
column labeled "BR Grade." Use this
column to determine the appropriate
grade code when grade is described using
these terms. If the grade of an in situ
tumor is described using these terms,
use the table to determine the
appropriate code for the grade field.
Path: Invasive ductal
carcinoma, well differentiated, low
nuclear grade. What is the correct code
for low nuclear grade or is grade coded
to well differentiated?
Assign code 1 [Grade 1, well
differentiated.]. Use the table in the
2007 SEER manual on page C-607. Both
"low grade" and "well differentiated"
are coded 1 in the grade field.
MP/H Rules--Bladder: Rule M7 of the
says, "Tumors diagnosed more than three
(3) years apart are multiple primaries.
**" Is this supposed to say, "BLADDER
tumors diagnosed more than 3 years apart
are multiple primaries"? See discussion.
The reason I ask is that you could have
an invasive urothelial bladder tumor
diagnosed in 2004 and an in situ TCC of
the ureter diagnosed in 2009 and per
rule M7 this would be a separate
primary. Is that the intent of rule M7,
since it is before rule M8, that says,
"Urothelial tumors in two or more of the
following sites are a single primary:
Renal pelvis (C659) Ureter(C669) Bladder
(C670-C679) Urethra /prostatic urethra
Rule M7 pertains to renal pelvis,
ureter, bladder and other urinary sites
as defined by the topography codes
listed in the header of these
An invasive urothelial
MP/H Rules/Histology--Lung: Is the
second tumor a new primary in this
situation? See discussion.
Patient had a right lung lobectomy (RLL)
in Oct. 2006 diagnosed as
adenocarcinoma. In March of 2009, he
returned with 2 nodules in the right
upper lobe. He then had a RUL wedge
resection. Path report states: 2 foci
of MD adenocarcinoma with mixed mucinous
and micropapillary and solid patterns.
Comment: the present tumor is compared
to the previous adenocarcinoma reviewed
in 2006. Although there is some overlap
in their appearance, the present tumor
shows a much greater component of
mucinous adenocarcinoma. Since there is
some difference in the appearance, and
the nodule is located in a separate
lobe, this will be dictated as a
separate lung primary.
This is two primaries. Code the
Histologies described by the
MP/H Rules/Multiple Primaries--Thyroid:
Diagnosed with thyroid ca 11/95 and
treated with total thyroidectomy
(although path report only mentions the
left lobe) and ablation. Elevated
thyroglobulin level in 11/02 and stated
to have recurrent ca and again treated
with ablation. History on this case
states patient had a near total
thyroidectomy at diagnosis. Patient is
seen again at a third hospital 3/08.
Diagnosis again is recurrent ca
apparently because of a thyroid mass
that is palpable. No treatment was
performed and patient expired
4/08. Is this a new primary because
of MP/H rule M10?
The pathology report takes precedence
over the other information when there is
a discrepancy. Based on the information
available, only the left thyroid lobe
was removed 11/95.
Because there is a caveat in the SEER
PCM, 3rd edition to ignore adverbs such
as "strongly" when assessing
reportability, should a term such as
"likely" cancerous be considered
reportable given than the expression
"most likely" cancerous is reportable?
"Likely cancerous" is NOT reportable.
The CoC, NPCR and SEER have agreed to
a strict interpretation of the ambiguous
terms list. Terms that do not appear on
the list are not diagnostic of cancer.