의학용어 잘 아시는 분 계신가요? 의무기록 해석 부탁드립니다.

의무기록 해석에 어려움이 있어 질문 남깁니다.

의학용어 잘 아시는 분 계신다면 번거로우시겠지만 하나하나 해석 부탁드립니다.

< Radiologic Report >

Abdomen CT (2018.04.06 outside film) :

RCC. Rt.

- size of 8.7cm in axial view 10cm in coronal view

- Probable fascial invasion

- No evidence of renal vein or IVC invasion

- No evidence of distant metastasis in the abdomen

- No significant in urinary bladder

2. Hematoma in urinary bladder

< Pathologic Report >

Kidney, right, radical nephrectomy (2018.05.01) :

Clear cell renal cell carcinoma with sarcomatoid feature

with 1) Tumor location : lower pole

2) Tumor size : 7.5×7cm

3) WHO / ISUP grade : 4

4) Sarcomatoid feature : Presnt

- Specify percentage of sarcomatoid element : 90%

5) Rhabdoid feature : Presnt

- Specify percentage of sarcomatoid element : 10%

6) Tumor necrosis : Present

- Specify percentage of necrosis : 5%

7) Tumor extent :

- Invades renal sinus fat and pelvicalyceal system

8) Lymph-vascular invasion :

- Macroscopic renal vein invasion (tumor thrombus) : Not identified

- Microscopic venous (Small vein) invasion : Not identified

- Lymphatic invasion : Not identified

9) Surgical margins :

- Perirenal soft tissue : Uninvovled

- Ureter margin : Uninvovled

Lymph nodes, biopsy : No metastasis in 1 lymph nodes : Total (0/1)

WBBS 판독결과

: Whole body bone image에서 bilateral LS junctions에 increased uptake 관찰되어, abdo-men CT (2019.02.20.)에서 보이는 L5~S1의 degenerative change에 match 되어 보임. 그 외 전신에 bone metastasis를 의심할만한 abnormal increased uptake 뚜렷하지 않음

#의료