Cancer Information Management

GYN Case 2 (Diagnosed and all treatment at the reporting facility)

02/22/2022 OB/GYN OFFICE VISIT: 60-year-old black female with postmenopausal bleeding. Scheduled for outpatient hysteroscopy at Scott Community Hospital.

02/25/2022 HYSTEROSCOPY: Endometrial curettage of abnormal area.

02/25/2022 PATHOLOGY: Endometrial biopsy: Endometrioid adenocarcinoma, FIGO grade 2.

02/26/2022 CT ABDOMEN/PELVIS: Within normal limits, no adenopathy.

02/28/2022 OB/GYN FOLLOW-UP VISIT: Endometrial biopsy positive for adenocarcinoma. Schedule for surgery at Scott Community Hospital.

03/09/2022 SURGERY: Total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic lymph node dissection, periaortic lymph node dissection.

03/09/2022 PATHOLOGY: Final Diagnosis: Uterus: Endometrioid adenocarcinoma of endometrium, 2.5 cm, FIGO grade 2. Myometrium invasion 5 mm. Myometrium thickness 20 mm. No lymphovascular invasion. All margins negative. Cervix, tubes, and ovaries negative. 3 left pelvic, 4 right pelvic and 2 periaortic lymph nodes examined, all negative. FIGO stage IA.

DICHARGE FROM HOSPITAL: 03/11/2022

04/10/2022 OB/GYN FOLLOW-UP VISIT: Patient is status post hysterectomy for a FIGO stage IA uterine cancer. No evidence of remaining disease, schedule for routine follow-up.

End