Scenario: 2022
- Surgery Text: 09-30-2022 Left radioactive seed localized lumpectomy with lymphatic mapping and sentinel lymph node biopsy
- Operative Text [pertaining to lymph nodes]The patient was injected with 5 cc of Lymphazurin blue in the left side and a five-minute massage ensued. The patient was found to have a hot spot in the Left axilla. The blue lymphatic channels were followed to the hot and blue lymph nodes. These were excised and counted ex vivo. They were deep to the clavipectoral fascia. There were several very small sentinel nodes which were blue. There were no further blue lymphatic channels or hot spots. There were no further palpable nodes. It was felt that the area of concern had been adequately evaluated.
- Path Text: [lymph node portion]
- Status of Regional Lymph Nodes:
- Number of Sentinel Lymph Nodes Examined: 4
- Total Number of Lymph Nodes Examined: 06
- Number of Lymph Nodes with Isolated Tumor Cells: 0
- Number of Lymph Nodes with micrometastases (>0.2 mm to 0.2 cm): 0
- Number of Lymph Nodes with macrometastases (>0.2 cm): 0
| Data Field | Value | Rationale |
| Scope of Regional Lymph Node Surgery | 2 | STORE 2022 When a SLNBx is performed, additional non-sentinel nodes can be taken during the same operative procedure. These additional non-sentinel nodes are palpably abnormal and selectively removed (or harvested) as part of the SLNBx procedure by the surgeon or may be discovered by the pathologist. Code this as a SLNBx (code 2). If review of the operative report confirms that a regional lymph node dissection followed the SLNBx, code these cases as 6. |
| Date of Sentinel Lymph Node Biopsy | 09-30-2022 | STORE 2022 Records the date of the sentinel lymph node(s) biopsy procedure. This data item is required for CoC accredited facilities for cases diagnosed 01/01/2018 and later. This data item is required for breast and cutaneous melanoma cases only. |
| Sentinel Lymph Nodes Examined | 06 | STORE 2022 If, during a sentinel node biopsy procedure, a few non-sentinel nodes happen to be sampled, document the total number of nodes sampled during the sentinel node procedure in this data item. I.e., record the total number of nodes from the sentinel node biopsy procedure regardless of sentinel node status |
| Sentinel Lymph Nodes Positive | 00 | STORE 2022 If, during a sentinel node biopsy procedure, a few non-sentinel nodes happen to be sampled and are positive, document the total number of positive nodes identified during the sentinel node procedure in this data item. I.e., record the total number of positive nodes from the sentinel node biopsy procedure regardless of whether the nodes contain dye or colloidal material (tracer or radiotracer). |
| Date of Regional Lymph Node Dissection | BLANK | STORE 2022 Records the date non-sentinel regional node dissection was performed. [If you read the op report, the surgeon only performed a SLN procedure, a separate lymph node sampling was not performed, leave this date BLANK.] |
| Regional Lymph Nodes Examined | 06 | STORE 2022 The number of regional lymph nodes examined is cumulative from all procedures that removed lymph nodes through the completion of surgeries in the first course of treatment with the exception of aspiration or core biopsies coded to 95 |
| Regional Lymph Nodes Positive | 00 | STORE 2022 The number of regional lymph nodes positive is cumulative from all procedures that remove lymph nodes through the completion of surgeries in the first course of treatment |