PathologySection: Kidney (left): AdenocarcinomaMACROSCOPICSp…
PathologySection: Kidney (left): AdenocarcinomaMACROSCOPICSpecimen type: Radical nephrectomyLaterality: LeftTumor site: Upper poleFocality: UnifocalTumor size: Greatest dimension is 7.2 cm.Macroscopic extent of tumor: Tumor extends into major veins.MICROSCOPICHistologic type: Clear cell (conventional) renal carcinomaHistologic grade: Furhman Nuclear Grade 2PATHOLOGIC STAGING (pTN)Primary tumor (pT): pT3Regional lymph nodes (pN): NxNumber of lymph nodes examined: 0Number of lymph nodes involved: 0Margins: Renal vein margin positiveAdrenal gland: UnevolvedVenous (large vessel) invasion (V) (excluding renal vein and inferior vena cava): NegativeLymphatic (small vessel) invasion (L): PresentAdditional pathologic findings: Chronic glomerulonephritis present in noninvolved renal parenchymaClinical history: A 76-year-old male with a left renal mass in the upper pole; hematuriaGross description section: Received in formalin, labeled “left kidney,” is a 12.2- × 7.1- × 2.5-cm kidney with unremarkable perirenal fat present at the upper pole (suture oriented, per requisition). A 2.3 cm in length segment of ureter exits from the hilum. The renal vein appears occluded. The cut sections demonstrate a 7.2- × 1.5- × 1.5-cm brown-orange circumscribed tumor with sharp borders present in the upper pole. Gerota’s fascia appears uninvolved. The tumor extends into the renal vein; the venous margin appears positive for tumor.Microscopic section: Microscopic examination was performed.Select the appropriate ICD-10-CM and CPT code(s):