8/22/16 Pathology perineal resection –Abdominal Tumor Site: Rectum Tumor Size: .5cm Histologic Type: Adenocarcinoma Histologic Grade: Low grade Tumor Extension: Tumor involves the lamina propria, but does not extent into the submucosa. Proximal and Distal Margins: Uninvolved by invasive carcinoma Circumferential Margin: Uninvolved by invasive carcinoma. Lymph-Vascular Invasion: Not identified Perineural invasion: Not identified Deposits: Not identified Number of Nodes Involved: 0 Number of Lymph Nodes Examined: 36 8/25/16 Discharge Summary The patient is recovering from his surgery and has been discharged home. 1/4/17 Follow-up Note The patient has just completed a full course of 5-FU, leucovorin, and oxaliplatin (FOLFOX). What is the grade/differentiation? What is the primary site? What is the histology? Stage/ Prognostic Factors Summary Tumor Size Summary TNM Clin T TNM Path T TNM Clin N TNM Path N TNM Clin M TNM Path M TNM Clin Stage TNM Path TNM Clin Descriptor TNM Path Descriptor TNM Clin Staged By TNM Path Staged By CS SSF 1 CS SSF 2 Regional Nodes Positive CS SSF 4 Regional Nodes Examined CS SSF 6 Mets at Dx - Bone CS SSF 8 Mets at Dx - Brain CS SSF 9 Mets at Dx - Liver Mets at Dx - Lung Mets at Dx - Other Mets at Dx Distant LN – Treatment Diagnostic Staging Procedure Surgery Codes Radiation Codes
8/22/16 Pathology –Abdominal perineal resection Tumor Site: Rectum Tumor Size: .5cm Histologic Type: Adenocarcinoma Histologic Grade: Low grade Tumor Extension: Tumor involves the lamina propria, but does not extent into the submucosa. Proximal and Distal Margins: Uninvolved by invasive carcinoma Circumferential Margin: Uninvolved by invasive carcinoma. Lymph-Vascular Invasion: Not identified Perineural invasion: Not identified Deposits: Not identified Number of Nodes Involved: 0 Number of Lymph Nodes Examined: 36 8/25/16 Discharge Summary The patient is recovering from his surgery and has been discharged home. 1/4/17 Follow-up Note The patient has just completed a full course of 5-FU, leucovorin, and oxaliplatin (FOLFOX). What is the primary site? What is the histology? What is the grade/differentiation? Stage/ Prognostic Factors Summary Tumor Size Summary TNM Clin T TNM Path T TNM Clin N TNM Path N TNM Clin M TNM Path M TNM Clin Stage TNM Path TNM Clin Descriptor TNM Path Descriptor TNM Clin Staged By TNM Path Staged By CS SSF 1 CS SSF 2 Regional Nodes Positive CS SSF 4 Regional Nodes Examined CS SSF 6 Mets at Dx - Bone CS SSF 8 Mets at Dx - Brain CS SSF 9 Mets at Dx - Liver Mets at Dx - Lung Mets at Dx - Other Mets at Dx – Distant LN Treatment Diagnostic Staging Procedure Surgery Codes Radiation Codes
Colon-2017-Case-Scenarios.docx