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):

History: A 62-year-old woman (height, 1.7 m; weight, 61 kg) was scheduled for resection of a sigmoid colon carcinoma. Her medical history revealed hypothyroidism, vitamin B12 deficiency, and stiff person syndrome. This syndrome started with low back pain, which rendered her unable to walk. She was experiencing stiffness, involuntary jerks, and painful cramps. Neurologic examination revealed extreme hypertonia of the body and proximal legs, with intercurrent, painful spasms. Reflexes were symmetrical without Babinski signs. Laboratory findings showed positive glutamic acid decarboxylase (GAD) and negative amphiphysin antibodies. The patient was successfully treated with baclofen and diazepam. Subsequently, prednisone as immunosuppressive therapy was started. The stiffness diminished, and the patient was able to walk unaided. The neurologic examination was unremarkable, except for a slight stiffness in the legs. Her medication at admission was prednisone 20 mg once a day, baclofen 12.5 mg twice a day (daily dose = 25 mg), diazepam 7.5 mg twice a day (daily dose = 15 mg), levothyroxine 25 μg once a day, and vitamin B12 injections. Her medical history included urologic and gynecologic surgery under general anesthesia before she experienced SPS. Procedure: No premedication was given. Anesthesia was induced with propofol (2.5 mg/kg) and sufentanil (0.25 μg/kg). After the administration of atracurium (0.6 mg/kg), the trachea was intubated, and anesthesia was continued with isoflurane (0.6–1.0 vol %) and oxygen/air for the duration of the procedure. Cefuroxime 1,500 mg, clindamycin 600 mg, and dexamethasone 10 mg were administered IV. In the following 2 hours, additional atracurium (35 mg), sufentanil (10 μg), and morphine (8 mg) were administered. At the end of the procedure, which was uneventful, neuromuscular monitoring showed four strong twitches. Although the patient was responsive, she could not open her eyes, grasp with either hand, or generate tidal volumes beyond 200 mL. Neostigmine 2 mg (0.03 mg/kg) and glycopyrrolate 0.2 mg did not alter the clinical signs of muscle weakness. The patient was sedated with propofol and further mechanically ventilated in the recovery room. After 1 hour, the sedation was stopped and mechanical ventilation was terminated. At that time, baclofen 12.5 mg was administered into the gastric tube. Two hours later she was in a good clinical condition, and her trachea was extubated. Select the appropriate ICD-10-CM and CPT code(s):

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