Total # of Lymph Nodes (1990) Total # of Nodal Stations sampled/harvested: (2000) Lung CA Resection Margins (2010) Yes No If (2020) R1 (microscopic residual tumor present) R2 (macroscopic (gross) residual tumor present) G. Esophageal Cancer Clinical Staging: Pre-treatment Esophageal cancer staging - to be completed if esophageal cancer suspected, documented OR esophagus resection performed. Clinical staging determines the treatment plan. Clinical Staging Done ClinStagDoneEsoph (2030) Yes No Radiologic / Endoscopic Staging Procedures If Clinical Staging Done is Yes → PET or (2040) Yes No (2050) Yes No (2060) Yes No (2090) Yes No Invasive Staging Procedures VATS – for (2100) Yes No Laparoscopy – for (2110) Yes No Endoscopic Mucosal (2120) Yes No Other: Yes (2130) Esophageal (2150) T0 No evidence of primary tumor Tis High grade dysplasia T1 Tumor invades lamina propria, mucosa or submucosa T2 Tumor invades muscularis propria T3 Tumor invades adventitia T4 Tumor invades adjacent structures Clinical Diagnosis of Nodal (2160) Yes (N1, N2 or N3) No Esophageal CA (2170) M0 No Distant Metastasis M1 Distant Metastasis Tumor Location (check all that apply): Cervical Esophagus (15 – < 20 cm) Yes (2180) Upper Thoracic (20 - < 25 cm) Yes (2190) Middle Thoracic (25 - < 30 cm) Yes (2200) Lower Thoracic, including EG Junction (30 – 42 cm) Yes (2210) Pathological Staging - Esophagus Esophagus to be completed if esophageal cancer documented AND esophageal resection performed (Pre-Operative Evaluation – Esophageal Cancer = Yes) (8th Edition) Esophageal Cancer Results ClinStageEsophResult (2220) No cancer found, benign tumor Esophageal cancer present Esophageal Tumor: PathStageEsophT (2230)
Air leak > 5 days (3430) Yes No Atelectasis req. (3440) Yes No Pleural Effusion req. (3450) Yes No (3460) Yes No Acute Respiratory Distress Syndrome (3470) Yes No Respiratory Failure RespFail (3480) Yes No Bronchopleural (3490) Yes No Pulmonary (3500) Yes No Pneumothorax req. CT (3510) Yes No Initial Vent Support > 48 (3520) Yes No (3530) Yes No Other Pulmonary Event OtherPul (3550) Yes No Cardiovascular Atrial arrhythmia req. (3560) Yes No Ventricular arrhythmia req. (3570) Yes No Myocardial (3580) Yes No Deep venous thrombosis (DVT) req. (3590) Yes No Other CV (3600) Yes No Gastrointestinal Ileus Ileus (3610) Yes No Anastomotic leak requiring medical treatment (3620) Yes No Dilation (3630) Yes No Conduit Necrosis Requiring Surgery CondNecSurg (3640) Yes No Delayed conduit emptying requiring intervention (pyloric dilatation or botox) or maintenance of NG drainage > 7days post op DelayCondEmp (3650) Yes No Clostridium Difficile infection CDiff (3660) Yes No Other GI (3670) Yes No Hematology Packed red blood (3680) Yes No *transfusions documented here do not include blood given in OR* If Yes→ # Units (3690) Urologic Urinary tract (3700) Yes No Urinary retention req. (3710) Yes No Discharged with Foley (3720) Yes No Infection Empyema req. (3730) Yes No Surgical Site (3740) None Superficial Deep Organ space Sepsis Sepsis (3750) Yes No Another infection req. IV (3760) Yes No Neurology New central neurological (3770) Yes No Recurrent laryngeal nerve paresis (3780) Yes No Delirium Delirium (3790) Yes No Other neurological (3800) Yes No Miscellaneous New renal failure per RIFLE (3810) Yes No Chylothorax req. medical (3820) Yes No