Section: Kidney (left): Adenocarcinoma
MACROSCOPIC
Specimen type: Radical nephrectomy
Laterality: Left
Tumor site: Upper pole
Focality: Unifocal
Tumor size: Greatest dimension is 7.2 cm.
Macroscopic extent of tumor: Tumor extends into major veins.
MICROSCOPIC
Histologic type: Clear cell (conventional) renal carcinoma
Histologic grade: Furhman Nuclear Grade 2
PATHOLOGIC STAGING (pTN)
Primary tumor (pT): pT3
Regional lymph nodes (pN): Nx
Number of lymph nodes examined: 0
Number of lymph nodes involved: 0
Margins: Renal vein margin positive
Adrenal gland: Unevolved
Venous (large vessel) invasion (V) (excluding renal vein and inferior vena cava): Negative
Lymphatic (small vessel) invasion (L): Present
Additional pathologic findings: Chronic glomerulonephritis present in noninvolved renal parenchyma
Clinical history: A 76-year-old male with a left renal mass in the upper pole; hematuria
Gross 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):
A) C64.9, 88307-LT
B) C64.9, N08, 88307-LT
C) C64.2, N03.9, 88307
D) C64.8, 88307

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