Exercise #4
The patient was referred to a neurologist after reporting symptoms of vomiting, muscle weakness on one side of the face, and several episodes of slurred speech. The patient had an MRI on June 3, 2004 that showed a glioma in the brain stem. Through an infratentorial craniotomy, tumor was removed on June 30, 2004. The pathology report documented microscopic residual subependymal glioma in the fourth ventricle. On August 1, 2004 the patient had conformal radiation to the fourth ventricle.
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- Surgical procedure of primary site
55 - Gross total resection (When tumor is removed and only microscopic tumor residual remains, surgery is still considered total resection.)
- Surgical margins of primary site
2 - Microscopic residual tumor
- Scope of regional lymph node surgery
9 - Not applicable
- Radiation treatment volume
04 - Brain limited (The radiation was given to only part of the brain, fourth ventricle.)
- Regional treatment modality (radiation)
32 - Conformal therapy
- Chemotherapy
00 - None
- Hormone therapy
00 - None
- Immunotherapy
00 - None
- Hematologic transplant and endocrine procedures
00 - None