Uterus case scenario answers

Case Scenario 1
A 53 year old white female presented to her primary care physician with post-menopausal vaginal bleeding. The patient is not a smoker and does not use alcohol. She has no family history of malignancy. She had an endometrial biopsy that was positive for endometrial adenocarcinoma. She was sent to have a CT of the abdomen and pelvis and was found to have thickening of the uterus and enlarged lymph nodes suspicious for metastasis. She is here today for a hysterectomy. Operative Report
Palliative Laparoscopi ally Assisted Vaginal Hysterectomy with Bilateral Salpingo-Oophorectomy and Laparoscopic Retroperitoneal Lymph Node Sampling. Upon inspection of the patient's abdomen via laparoscopy, it was noted that the patient had adhesions of the omentum to the anterior abdominal wall. Significant matted lymphadenopathy was noted in the periaortic region as well as at the iliac arteries bilaterally. Dissection along the right retroperitoneal space revealed a significant amount of matted lymph nodes densely adherent to surrounding structures, including the right iliac artery and vein. The patient's ovaries and tubes appeared grossly normal. The patient's uterus was slightly enlarged in size, measuring approximately 8 to 10 weeks. The patient's small and large intestines appeared grossly normal, on laparoscopic inspection. The patient's appendix was noted to be completely normal. Aside from the grossly enlarged and positive lymph nodes, there did not appear to be any extrauterine disease. At completion of the surgery, the patient had remaining significant lymphadenopathy along the right and left iliac vessels as well as in the periaortic region. This disease was not debulked. Pathology Report
A: Right pelvic lymph node
B: Uterus, bilateral tubes and ovaries
Final Diagnosis
 Lymph node, right para aortic, biopsy o Metastatic poorly differentiated Carcinoma  Uterus, bilateral tubes and ovaries, hysterectomy and bilateral salpingoophorectomy o Histologic tumor type: undifferentiated carcinoma (see comment) o Myometrial invasion: tumor invades into the outer half of the myometrium to a o Lymph-vascular invasion: extensive lymph-vascular invasion is appreciated o Other organ involvement: Not appreciated o Lymph nodes: Sampled para aortic lymph node positive for metastasis o Pathologic TNM Stage: T1b, at least N1 (correlation with clinical findings is necessary to determine final pTNM stage as only one lymph node was sampled. *Diagnostic Comments: Noted in the endometrial cavity is an undifferentiated carcinoma. Noted are areas of endometrioid differentiation, though a majority of the tumor is high grade with no evidence of specific cell line differentiation. ER Note
The patient was admitted after presenting to the Emergency Department with complaints of nausea and
vomiting as well as altered mental status. The patient had a history of stage III endometrial carcinoma
status post vaginal hysterectomy and bilateral salpingo-oophorectomy 3 months prior and
chemotherapy with Taxol and carboplatin. She has had multiple admissions for nausea and vomiting as
well as pain control. She was accompanied by her sister who reported deterioration of mental status as
well as cognitive abilities. She also had daily nausea and vomiting with very poor p.o. intake. A CT scan
of the head was performed, and there were found to be brain metastases. This finding was discussed
with the patient's family and decision was made to change the patient's status to DNR/DNI and to make
arrangements for home hospice. During her hospital stay, she continued on fentanyl patch as well as
PCA and had p.r.n. Ativan added as well. The patient did have a known history of hypertension as well
as diabetes mellitus and as she progressed and was unable to tolerate p.o. medications, these and Accu-
Cheks were discontinued. By day of discharge, her fentanyl patch had been increased to 175 mcg an
hour and she was on 50 mcg PCA fentanyl. She was discharged to home hospice.
 What is the primary site?
 What is the grade/differentiation?
 What is the histology?
 What is grade path system/grade path
Stage/ Prognostic Factors
Treatment
Surgery Codes
Radiation Codes
Systemic Therapy Codes
Case Scenario 2
A 58 year-old presented for a routine PAP smear and was found to have squamous cell carcinoma. She is a smoker, occasional alcohol use, no family history of malignancy. She then had a colposcopy performed that revealed multiple lesions that had acetowhite epithelium, punctuation, atypical vessels from 4 o'clock to 8 o'clock, lying across the SQJ. This was clinically correlated with speculum examination which revealed an abnormal intrauterine mass > 4cm. The patient was then referred to radiology, where she received a PET/CT examination that revealed markedly hypermetabolic primary cervical cancer with metastatic lymph node involvement of a single right external iliac and two left external iliac lymph nodes. She was then referred to Heme/Onc and Radiation Oncology for further treatment. Radiation Oncology Initial Assessment
58 year-old female with a recent diagnosis of cervical cancer. Current working clinical FIGO stage 1B2
SCCA. Metastatic survey PET/CT revealed markedly hypermetabolic primary cervical cancer with
metastatic lymph node involvement of a single right external iliac and two left external iliac lymph
nodes. TNM staging is stage IIIB (T1N1M0). We will initiate weekly cisplatin at 35 mg/m2 weekly with
radiation. The risks and benefits of treatment were fully discussed with the patient, and she wishes to
proceed.
Radiation Oncology Treatment Summary
T1b N1 M0 squamous cell carcinoma of the cervix (IIIB).
Patient has completed her definitive radiation given with concurrent cisplatin. She received 45 Gy in 25
sessions to her pelvis utilizing a 4 field 3D conformal radiotherapy technique and 18 mV photons. She
received an additional 5.4 Gy in 3 sessions to the bilateral PET positive pelvic lymph nodes, for a total of
50.4 Gy in 28 sessions. These fields were treated utilizing parallel opposed anterior and posterior portals
and 18 mV photons. The PET-positive right pelvic lymph node received an additional 3.6 Gy in 2 sessions,
for a total of 54 Gy in 30 sessions. This region was treated utilizing parallel opposed anterior and
posterior portals and 18 mV photons for external beam radiotherapy. Treatment proceeded from
February 21 to April 4.
She also underwent an intracavitary brachytherapy boost using tandem and ovoid HDR applications
each of 7 Gy administered in 4 separate fractions for a total of 28 Gy to point A. She tolerated her
treatment well, noticing only some minimal vaginal bleeding and she had some mild diarrhea, which was
controlled well with Imodium. She will be returning to your care, but I would appreciate the opportunity
to check her progress from time to time. I have asked her to see me in a month. I also plan a 3-month
PET/CT scan to assess response to treatment.
Thank you for the opportunity of participating in her care.
 What is the primary site?
 What is the grade/differentiation?
 What is the histology?
 What is grade path system/grade path value?
Stage/ Prognostic Factors
Treatment
Surgery Codes
Radiation Codes
Systemic Therapy Codes

Source: http://crgc-cancer.org/wp-content/uploads/2012/pdf/Registrar_Gateway/NAACCR_Webinar/Uterus/UterusCaseSAnswers.pdf