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Reason for Visit
Reason Comments
POST OP 2 weeks, 2/22/2015
ANORECTAL PROBLEM
Visit Diagnoses
Encounter for examination following surgery - Primary
Follow-up examination, following other surgery
Genital warts
Condyloma acuminatum
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Accession Number S15-2556
FINAL DIAGNOSIS:
1) DISTAL RECTAL MASS, TRANSANAL DISC EXCISION:
HIGH GRADE SQUAMOUS INTRAEPITHELIAL LESION (AIN 3).
ANTERIOR AND POSTERIOR DISTAL MARGINS INVOLVED BY HIGH
SQUAMOUS INTRAEPITHELIAL LESION.
NO INVASIVE CARCINOMA IDENTIFIED.
POLYPOID RECTAL MUCOSA WITH PROLAPSE CHANGES AND
EROSIONS.
2) PERIANAL SKIN BIOPSY:
HIGH GRADE SQUAMOUS INTRAEPITHELIAL LESION (AIN 3).
MARGIN FOCALLY INVOLVED BY HIGH GRADE SQUAMOUS
INTRAEPITHELIAL LESION.
3) PERIANAL CONDYLOMA BIOPSY:
HIGH GRADE SQUAMOUS INTRAEPITHELIAL LESION (AIN 3).
MARGIN FOCALLY INVOLVED BY HIGH GRADE SQUAMOUS
INTRAEPITHELIAL LESION.
QC:A
RRR:cr
COMMENT:
This case was reviewed by Dr. Peterson, who agrees with the diagnosis.
Electronically Signed By
Rob R. Roth, MD
HISTORY:
Distal rectal mass.
GROSS DESCRIPTION:
PART 1: MASS, DISTAL RECTUM:
(GF/ll) Received fresh from the operating room labeled Lanakila Washington,
designated "distal rectal mass," is a previously pinned out portion of pale
tissue measuring 4 x 2 cm. The specimen is anatomically oriented with color
coated hypodermic needles, designated as follows: gray needle-proximal, orange
needle-distal, green needle-posterior, and pink needle-anterior as noted on the
requisition form. The mucosal surface is remarkable for a polypoid red-tan
lesion which dominates the entire specimen. The margins are inked by quadrant
as
follows: anterior proximal-blue, anterior distal-black, posterior
proximal-purple and posterior distal-green. The specimen is now perpendicularly
sectioned along the anterior and posterior aspects. Entirely submitted
sequentially progressing from anterior to posterior in cassettes 1a-1f.
PART 2: PERIANAL SKIN LESION:
(GF/ll) Received in formalin labeled Lanakila Washington, designated "perianal
skin lesion," is an elliptoid portion of hair bearing gray-tan unoriented skin
measuring 2 x 0.9 cm. The skin is smooth with a centrally located raised
tan-brown soft to rubbery nodular mass measuring 1.1 cm in greatest dimension.
The skin tips are inked blue and black respectively. Perpendicularly sectioned
along its long axis. Entirely submitted in cassette 2a.
PART 3: PERIANAL CONDYLOMA:
(GF/ll) Received in formalin labeled Lanakila Washington, designated "perianal
condyloma," is a purple-gray hair bearing fine granular unoriented skin portion
measuring 0.7 x 0.5 cm. Marked black and trisected. Entirely submitted in
cassette 3a.
MICROSCOPIC DESCRIPTION:
PART 1: MASS, DISTAL RECTUM:
Sections examined.
PART 2: PERIANAL SKIN LESION:
Levels examined.
PART 3: PERIANAL CONDYLOMA:
Levels examined.
Diagnosed at:
Tacoma General Hospital
315 Martin Luther King Jr. Way
Tacoma, WA 98405
General Information
Collected:
02/19/2015 12:00 AM
Resulted:
02/20/2015 2:33 PM
Ordered By:
Joshua E Levin, MD