Scenario: 01-01-2021 core biopsy rectum+ moderately differentiated adenocarcinoma, clinical stage cT3 cN0 cM0 Stage 2A. Patient undergoes neoadjuvant chemoradiation. Prior to surgery, endoscopy showed no residual tumor, thus did not go on to further surgical resection. Question: Can you assign…
Note the new COVID fields & text requirements-for 2020+ [once available in your software] Scenario: 03-15-2020 needle biopsy right breast infiltrating ductal carcinoma grade 2 ER+PR+HER2+ [1.2cm on mammogram] 03-17-2020 Due to Covid-19 started on hormonal therapy until surgery can…
Scenario: 10-01-2020 FNA RUL: adenocarcinoma 10-30-2020 RUL Lobectomy: Histology: adenocarcinoma, acinar predominant (acinar 60%, solid predominant 20%, lepidic predominant 20%) Question: How would you assign histology? 8140 Adenocarcinoma 8551 Acinar adenocarcinoma / Adenocarcinoma, acinar predominant 8230 Solid adenocarcinoma / Adenocarcinoma,…
Scenario: 10-01-2020 Patient presents with elevated PSA 9.8, DRE-bilateral nodules right and left lobe, no adenopathy noted 10-23-2020 Transperineal prostate biopsy: A. Right Base: Prostatic Adenocarcinoma Gleason Score 8 (4 + 4), Grade Group 4, Involving 70% of Prostate Tissue Volume…
4-12-2020 CT scan of Abdomen and Pelvis: 1.2cm transverse colon that extends into surrounding pericolonic tissues. There are enlarged pericolic lymph nodes consistent with involvement. There is also right lung metastasis and liver metastasis seen on CT. Patient has liver…
Scenario: 06-13-2020 patient presents with 1cm mass RUOQ breast & no lymphadenopathy on physical exam 06-15-2020 Mammogram: 1.2cm right breast mass, no adenopathy 06-26-2020 CT Chest/Ab/Pelvis-Negative for mets 07-01-2020 needle biopsy breast: invasive ductal ca grade 3 ER 90% +PR…
Scenario: 06-13-2020 patient presents with 5.7cm mass RUOQ breast & no lymphadenopathy on physical exam 06-15-2020 Mammogram: 5.9 cm right breast mass, no adenopathy 06-26-2020 CT Chest/Ab/Pelvis-Negative for mets 07-01-2020 needle biopsy breast: invasive ductal ca grade 3 ER 90%…
Scenario: (Biopsy proven Rectum primary with biopsy proven mets to liver) Colonoscopy biopsy rectum+ moderately differentiated adenocarcinoma. Needle biopsy of liver + metastatic adenocarcinoma, CT/EUS show clinical T3, clinical N1 case. No resection is done, patient has pathologically confirmed mets…
Scenario: Surgeon Op Note: Procedure(s): LEFT MASTECTOMY, SENTINEL LYMPH NODE BIOPSY, LEFT AXILLARY LYMPH NODE DISSECTION Surgical Technique: Skin incision was made to include the area of retracted skin in an ellipse superior to the nipple. Plastic Surgeon Note: Procedure(s):1) RIGHT…
Scenario: 06-18-2020 Ovarian primary TAH/BSO- endometrioid adenocarcinoma-FIGO grade 1, however, focal areas (1-2%) with high nuclear grade, consistent with FIGO grade 2 Question: How would the pathological grade be coded? 1 G1: Well differentiated 2 G2: Moderately differentiated 3 G3:…