After Vats surgery 2/16

Stage II Adenocarcinoma.

Pathology reports Separate tumor nodules (metastases) in same lobe.

Metastases within the same lobe. They Want to know if I want them to do another surgery and take out entire lower lobe.

.5cm margin listed in pathology report.

A study I reviewed on safe margins for lung cancer. This finding revealed that the surgical margin was unsafe when the margin distance was < 1 cm.

He should have removed entire lobe. Margins are not considered safe.

Another surgery? I am sick to my stomach.

It is also present in the viserial pleuralm

Lung, right, superior and medial segment, segmentectomy:

Adenocarcinoma, multifocal, dominant nodule measuring 2.5 cm acinar, lepidic, mucinous and papillary types, with multiple satellite nodules in close proximity to the dominant nodule, measuring 02.-0.5 cm

TUMOR

Tumor Focality: Separate tumor nodules (metastases) in same lobe (pT3)

Tumor Site: Lower lobe of lung

Tumor Size:

Total Tumor Size (size of entire tumor): Greatest Dimension (Centimeters): 2.5 cm

Histologic Type: Invasive acinar adenocarcinoma

Histologic Grade: G2, moderately differentiated

?????Visceral Pleura Invasion: Present

?????Lymphovascular Invasion: Present

This finding revealed that the surgical margin was unsafe when the margin distance was < 1 cm.

Lymphovascular invasion is defined as the presence of tumor cells found inside small blood vessels or lymphatic channels within the tumor and surrounding tissues in the primary site. The tumor cells have broken free of the primary tumor and now have the capability to float throughout the body.

Conclusions: LVI is associated with an increased risk of harboring regional LN involvement. LVI is also an adverse prognostic factor for the development of distant metastases and long-term survival.

NP Travis called.

Stage II Adenocarcinoma. He Made appt with oncologist Dr Chae Apr 6, 11am. Will try to get me in sooner.

Pathology reports Separate tumor nodules (metastases) in same lobe.

Metastases within the same lobe. Wants to know if I want them to do another surgery and take out entire lower lobe.

.5cm margin listed in pathology report.

A study I reviewed on safe margins for lung cancer. This finding revealed that the surgical margin was unsafe when the margin distance was < 1 cm.

He should have removed entire lobe. Margins are not considered safe. Another surgery? I am sick to my stomach.

Otherwise report good. Only thing to have made it better was to have done this sooner.

Call me when you can.

Case ReportYour ValueSurgical Pathology Report Case: NMS23-07502

Authorizing Provider: Bharat, Ankit, MD Collected: 02/16/2023 0952

Ordering Location: NM Surgery Received: 02/16/2023 1003

Pathologist: Yeldandi, Anjana V., MD

Specimens: A) - Lobe, Right Middle, right middle lobe wedge

B) - Chest, Level 7

C) - Chest, 12 R

D) - Lung, Right, Superior and medial segmentectomy. Freeze nodule and bronchial

margin.

E) - Lobe, Right Lower, Right lower lobe wedge

F) - Lobe, Right Lower, Right lower lobe wedge

G) - Chest, Level 8

H) - Chest, 4RFinal DiagnosisYour Value

A. Lung, right middle lobe, wedge resection:

Lung parenchyma with 1 benign intraparenchymal anthracotic lymph node.

B. Lymph nodes, level 7, excision:

1 lymph node negative for metastatic tumor.

C. Lymph nodes, 12 R, excision:

1 lymph node negative for metastatic tumor.

D. Lung, right, superior and medial segment, segmentectomy:

Adenocarcinoma, multifocal, dominant nodule measuring 2.5 cm acinar, lepidic, mucinous and papillary types, with multiple satellite nodules in close proximity to the dominant nodule, measuring 02.-0.5 cm. See comment

Bronchial and vascular margins of resection negative for carcinoma.

Focus of neuroendocrine cell hyperplasia.

One intraparenchymal lymph node, benign.

E. Lung, right lower lobe, wedge resection:

Focus of alveolar cell hyperplasia.

Focus of meningothelial nodule.

F. Lung, right lower lobe, wedge resection:

Lung parenchyma with focal nonspecific lymphoid aggregate, benign.

G. Lymph nodes, level 8, excision:

2 lymph nodes negative for metastatic carcinoma.

H. Lymph nodes, 4R, excision:

Four lymph nodes negative for metastatic carcinoma

CommentYour Value

Multiple satellite nodules interpreted as and favored to be intrapulmonary mets with aerogenous spread.

Immunoprofile of the tumor:

CK7 Positive

CK20 Negative

CDX2 Negative

TTF-1 Positive (with patchy negative foci)

Napsin A Positive (with patchy negative foci)

Immunohistochemical analysis for PD-L1 was performed using the Ventana SP263 clone. 

Approximately <1% of the tumor shows membranous staining for PD-L1.

This test was developed and its performance characteristics were determined by the Northwestern Memorial Hospital Immunohistochemistry Laboratory. It has not been cleared or approved by the U.S. Food and Drug Administration. The FDA has determined that such clearance or approval is not necessary. This test is used for clinical purposes. It should not be regarded as investigational or for research. This laboratory is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA-88) as qualified to perform high complex clinical laboratory testing.

The positive controls demonstrate appropriate positive staining. The known tissue negative controls are negative. The non-immune serum control was non-reactive.

Synoptic ReportsYour ValueLUNG

LUNG: RESECTION - All Specimens

8th Edition - Protocol posted: 6/22/2022

SPECIMEN

Procedure: Wedge resection

Procedure: Segmentectomy

Specimen Laterality: Right

TUMOR

Tumor Focality: Separate tumor nodules (metastases) in same lobe (pT3)

Tumor Site: Lower lobe of lung

Tumor Size:

Total Tumor Size (size of entire tumor): Greatest Dimension (Centimeters): 2.5 cm

Histologic Type: Invasive acinar adenocarcinoma

Histologic Grade: G2, moderately differentiated

Visceral Pleura Invasion: Present

Direct Invasion of Adjacent Structures: Not applicable (no adjacent structures present)

Treatment Effect: No known presurgical therapy

Lymphovascular Invasion: Present

MARGINS

Margin Status for Invasive Carcinoma: All margins negative for invasive carcinoma

Closest Margin(s) to Invasive Carcinoma: Parenchymal

Distance from Invasive Carcinoma to Closest Margin: At least: 0.5 cm

Margin Status for Non-Invasive Tumor: All margins negative for non-invasive tumor

REGIONAL LYMPH NODES

Lymph Node(s) from Prior Procedures: No known prior lymph node sampling performed

Regional Lymph Node Status:

: All regional lymph nodes negative for tumor

Number of Lymph Nodes Examined: At least: 10

Nodal Site(s) Examined: 4R: Lower paratracheal

Nodal Site(s) Examined: 8R: Para-esophageal (below carina)

Nodal Site(s) Examined: 12R: Lobar

Nodal Site(s) Examined: 7: Subcarina

PATHOLOGIC STAGE CLASSIFICATION (pTNM, AJCC 8th Edition)

The suffix m (or a specific number) should only be used in the setting of multifocal ground-glass / lepidic nodules that histologically present as adenocarcinomas with prominent lepidic component or multifocal tumors of same histologic type that are too numerous for individual separate synoptic report and that are not better classified as intrapulmonary metastases (e.g. numerous carcinoid tumors). Multiple primary lung cancers showing different histologic type or different morphology based on comprehensive histologic subtyping are better staged as independent tumors without m suffix.

pT Category: pT3

pN Category: pN0Clinical InformationYour Value

Pre-op Diagnosis: Lung nodule [R91.1]

Post-op Diagnosis: Lung nodule [R91.1]

Microscopic DescriptionYour Value

This test was developed and its performance characteristics determined by

Northwestern Medicine.

It has not been cleared or approved by the U. S. Food and Drug Administration. The FDA has determined that such clearance or approval is not necessary. This test may be used for clinical purpose. It should not be regarded as investigational or for research. This laboratory is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA) as qualified to perform high complexity clinical laboratory testing. In cases which have decalcified tissues, the results should be interpreted with caution given the possibility of false negatives. The positive controls demonstrate appropriate positive staining. The known tissue negative controls are negative. The non-immune serum control was non-reactive.

Gross DescriptionYour Value

A.

Received fresh intraoperatively for consultation from Dr. Bharat, labeled with the patient's name and designated on the container as "right middle lobe wedge", is a 3.0 x 0.5 x 0.5 cm lung wedge. The staple line is removed and the specimen is frozen entirely. The intraoperative consultation diagnosis is, "LUNG PARENCHYMA WITH LYMPHOID AGGREGATE NODULE AND REACTIVE TYPE 2 PRE-PNEUMOCYTES. NO DEFINITIVE MALIGNANCY IDENTIFIED", communicated to Dr. Bharat in operating room F32 by Dr. Yang at 1025 on February 16, 2023. The frozen section remnant is submitted entirely in A1.

Grossed by Allison Martino MS, PA (ASCP)

B.

The specimen is received fresh labeled with patient's name, medical record number, and "level 7". It consists of 1 pink–tan lymph node candidate, 2.1 x 1.6 x 1.0 cm. The specimen is serially sectioned and entirely submitted in cassettes B1-B2.

Grossed by Lynette Desjarlais, MS, PA(ASCP)

C.

The specimen is received fresh labeled with patient's name, medical record number, and "12 R". It consists of a red–brown lymph node candidate, 1.3 x 0.9 x 0.4 cm. The specimen is bisected and entirely submitted in cassette C1.

Grossed by Lynette Desjarlais, MS, PA(ASCP)

D.

Specimen D is received fresh for frozen section analysis for Dr. Bharat labeled with patient's name, medical record number and designated as "superior and medial segmentectomy, freeze nodule and bronchial margin." It consists of a 44.9 gram lung segmentectomy specimen, 7.6 x 5.2 x 2.5 cm. The pleural surface is purple–gray, smooth and glistening with 2 irregular staple lines, 5 and 10 cm in length. The staple line are removed, and the underlying parenchyma is inked green. The specimen is serially sectioned demonstrating an ill-defined tan–gray, firm nodule, 2.5 x 1.8 x 1.5 cm. The mass is 0.8 cm from the nearest pleural surface, 0.5 cm from the parenchymal margin, and 1.2 cm from the vascular and bronchial margins. The remaining parenchyma is red–brown, soft and spongy. No additional masses or lesions are grossly identified. Photographs are taken for documentation. Representative sections are submitted in cassettes as follows:

D1 = representative nodule, frozen section remnant

D2 = bronchial margin, frozen section remnant

D3 = vascular margins

D4-D6 = remainder of nodule, to include nearest bronchial vascular margins and D5

D7 = uninvolved parenchyma.

Grossed by Lynette Desjarlais, MS, PA(ASCP)

The frozen section diagnosis rendered by Dr. Yang for Dr. Bharat is "D1: LUNG ADENOCARCINOMA. D2: BRONCHIAL MARGIN, NEGATIVE FOR CARCINOMA" at 1214 on 2/16/23.

E.

Specimen E is received fresh for frozen section analysis for Dr. Bahart labeled with patient's name, medical record number and designated as "right lower lobe wedge." It consists of a pink–tan lung wedge specimen, 3.1 x 1 x 0.5 cm. The specimen is serially sectioned and entirely submitted for frozen sectioning. The frozen section remnant is entirely submitted in cassette E1.

Grossed by Lynette Desjarlais, MS, PA(ASCP)

The frozen section diagnosis rendered by Dr. Yang for Dr. Bahart is "FOCAL NODULAR PNEUMOCYTE PROLIFERATION AND BRONCHIALIZATION" at 1214 on 2/16/23.

F.

The specimen is received fresh labeled with patient's name, medical record number, and "right lower lobe wedge". It consists of a purple–gray, 0.2 g lung wedge specimen, 3.5 x 0.8 x 0.4 cm. The pleural surface is smooth and glistening with 1 irregular staple line. The specimen is serially sectioned demonstrating tan–brown, soft and spongy parenchyma. No masses or lesions are grossly identified. The specimen is entirely submitted in cassette F1.

Grossed by Lynette Desjarlais, MS, PA(ASCP)

G.

The specimen is received fresh labeled with patient's name, medical record number, and "level 8". It consists of 1 yellow–tan lymph node candidate , 0.9 x 0.7 x 0.5 cm. The specimen is entirely submitted in cassette G1, in toto.

Grossed by Lynette Desjarlais, MS, PA(ASCP)

H.

The specimen is received fresh labeled with patient's name, medical record number, and "4R". It consists of 1 yellow–tan possible lymph node, 2.5 x 1.9 x 1.3 cm. The specimen is serially sectioned and entirely submitted in cassettes H1-H3.

Grossed by Lynette Desjarlais, MS, PA(ASCP)

General Information

Ordered by Ankit Bharat

Collected on 02/16/2023 9:52 AM from Lobe, Right Middle (Tissue)

Collected on 02/16/2023 9:57 AM from Chest (Tissue)

Collected on 02/16/2023 11:20 AM from Chest (Tissue)

Collected on 02/16/2023 11:41 AM from Lung, Right (Tissue)

Collected on 02/16/2023 11:45 AM from Lobe, Right Lower (Tissue)

Collected on 02/16/2023 11:48 AM from Lobe, Right Lower (Tissue)

Collected on 02/16/2023 11:54 AM from Chest (Tissue)

Collected on 02/16/2023 11:54 AM from Chest (Tissue)

Resulted on 02/24/2023 5:08 PM

Result Status: Final result