PATIENT:
XXXXXX, XXXX
MR #:
XXXXXXX
SPECIMEN #:
XXXXX
ROOM #
XXX
SEX:
XXXXXX
DATE OF BIRTH: XX/XX/XX
PHYSICIAN:
XXXXXX, X.
PROCEDURE:
ABDOMINAL RESECTION
PROCEDURE DATE: XX/XX/XX
CLINICAL DIAGNOSIS: CARCINOMA OF RECTUM
CLINICAL HISTORY: UNSTATED
GROSS DESCRIPTION: The specimen is received in three portions:
Portion 1 is stated to be “colon” and consists of a portion of large intestine, measure 28.0
cm in length, and 6.0 cm in greatest diameter. The serosal surface is reddish-tan, smooth
and glistening, with attached epiploic adipose tissue. The mucosal surface is tan-red,
smooth and glistening, with normal folds. At 0.5 cm from one surgical margin, there is a
flat, fungating ulcerated mass, which occupies more than two-thirds of the circumference
of the lumen and measures 6.5 x 3.5-cm in greatest diameter. Grossly, the tumor invades
the serosal surface in the central portion. The surgical margin close to the tumor is inked.
Representative sections of the tumor are submitted in 3 cassettes. Cassette A contains the
surgical margin close to the tumor submitted in CM; surgical margin far from tumor
submitted in FM; random sections in R, nodes close to tumor submitted in CN; nodes far
from tumor submitted in FN.
Portion 2 is stated to be “proximal ring” and consists of a ring of tan-pink soft tissue,
measuring 1.5 x 1.4 x 0.5-cm, which has attached staples. The stapled portion of the
specimen is removed, and the remainder of the specimen is submitted in cassette B.
Portion three is stated to be “distal ring” and consists of a fragment of pinkish-tan, soft
tissue, measuring 2.3 x 1.4 x 0.3-cm, and has some attached staples. The stapled portion
is removed, and the remainder of the specimen is submitted is cassette C.
DIAGNOSES (GROSS AND MICROSCOPIC)
A:
Colon resection—infiltrating, moderately differentiated adenocarcinoma with
transmural invasion into pericolonic fat.
— No tumor seen in proximal and distal margins of resection.
— Nine lymph nodes isolated, no tumor seen.
— Based on the available histologic information, the tumor is classified as T3,
N0, MX.
PATHOLOGY REPORT
PATIENT: XXXXXX, XXXX
MR #: XXXXXXX
DATE: XX/XX/XX
Page 2
B:
C:
Proximal ring, segment—segment of large bowel with no evidence of
malignancy.
Distal ring, segment—segment of large bowel with no evidence of malignancy.
_______________________________
PATHOLOGIST: XXXX XXXXXX, MD
XX/EC
D: XX/XX/XX
T: XX/XX/XX