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United States Government Work, uncopyrighted, public-domain,
DRAFT COPY ONLY. This document does not necessarily represent the views
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This document is provided "as is", without warranty of any kind,
express or implied, including but not limited to the warranties
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made with the document.
PRINCIPLE OF THE TEST.
Surgical Pathology and autopsy pathology specimens are received
in the Histology Laboratory from different areas of the hospital,
and must be entered into the computer, for proper organization of specimens.
This procedure covers anatomic pathology gross templates.
SPECIMEN REQUIRED.
All human tissue excised at surgery, outpatient clinics, fresh
or in fixative, along with a filled-out Tissue Examination Form
(U. S. Standard Form 515, USSF515).
REAGENTS, INSTRUMENTATION.
Any computer terminal in the hospital which is networked to CPRS
(Computer Patient Record System) and to the VistA®
(Veterans Information System Technology Architecture)
computer system (formerly, DHCP).
STEP-BY-STEP DESCRIPTION.
1. GROSS TEMPLATE:
BUNION SPECIMEN.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
AND "BONE, RIGHT FOOT (P)", AND CONSISTS OF FOUR FRAGMENTS OF BONE,
MEASURING ... CM IN AGGREGATE. THERE IS NO GROSS LESION IDENTIFIED.
REPRESENTATIVE SECTIONS ARE SUBMITTED.
SUMMARY OF SECTIONS:
1-1, 4 PIECES, FOR DECALCIFICATION.
1. GROSS TEMPLATE:
BONE MARROW BIOPSY.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
SUMMARY OF SECTIONS:
1-1, 4 PIECES, FOR DECALCIFICATION.
1. GROSS TEMPLATE:
GANGLION CYST SPECIMEN.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME AND
"GANGLION RIGHT WRIST", AND CONSISTS OF ONE PIECE
OF WHITE SOFT TISSUE, MEASURING ... CM. THE SPECIMEN IS
BISECTED AND SUBMITTED IN TOTO.
SUMMARY OF SECTIONS:
1-1, 2 PIECES.
1. GROSS TEMPLATE:
SKIN SHAVE BIOPSY.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
AND "LEFT SHOULDER", AND CONSISTS OF A SHAVE BIOPSY OF SKIN,
MEASURING ... CM. CENTRALLY LOCATED, THERE IS A PINK, PAPULAR
LESION, MEASURING ... CM. ON THE SKIN SURFACE. THE LESION IS
LESS THAN ... CM FROM THE CLOSEST MARGIN. THE MARGIN IS INKED BLACK
AND THE SPECIMEN IS SECTIONED AND SUBMITTED IN TOTO.
SUMMARY OF SECTIONS:
1-1, 4 PIECES.
2. GROSS TEMPLATE:
SKIN PUNCH BIOPSY.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
AND "RIGHT THIGH", AND CONSISTS OF A PUNCH BIOPSY OF SKIN,
MEASURING ... CM. CENTRALLY LOCATED, THERE IS A BROWN, MACULAR
LESION, MEASURING ... CM. ON THE SKIN SURFACE. THE LESION IS
... CM FROM THE CLOSEST MARGIN. THE MARGIN IS INKED BLACK
AND THE SPECIMEN IS BISECTED AND SUBMITTED IN TOTO.
SUMMARY OF SECTIONS:
1-1, 2 PIECES.
3. GROSS TEMPLATE:
SKIN ELLIPSE RESECTION.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
AND "SKIN OF LEFT SHOULDER". THE SPECIMEN CONSISTS OF AN ELLIPTICAL
PIECE OF SKIN, WITH UNDERLYING SUBCUTANEOUS TISSUE. THERE ARE SUTURES
DESIGNATING THE 3 O'CLOCK AND 12 O'CLOCK POSITIONS, RESPECTIVELY.
THE SPECIMEN MEASURES ... CM MEDIAL TO LATERAL, ... CM SUPERIOR TO INFERIOR,
AND ... CM ANTERIOR TO POSTERIOR. THE SURFACE OF THE SKIN IS INVOLVED
BY AN ILL-DEFINED, GRANULAR DIFFUSELY ERYTHEMATOUS LESION,
MEASURING ... CM. THIS ERYTHEMATOUS REGION IS LOCATED ... CM
FROM THE CLOSEST PERIPHERAL MARGIN (6 O'CLOCK). THE CUT SURFACE OF
THE SPECIMEN IS LIGHT TAN AND UNREMARKABLE. THE LESION IS ... CM FROM
THE CLOSEST DEEP RESECTION MARGIN. THE RESECTION MARGIN IS INKED BLACK,
AND THE SPECIMEN IS SERIALLY SECTIONED CLOCKWISE AND SUBMITTED IN TOTO.
SUMMARY OF SECTIONS:
1-1, SUPERIOR MARGIN (11 TO 1 O'CLOCK), SECTIONED, 4 PIECES.
1-2, 1 TO 3 O'CLOCK (SUPERIOR LATERAL), 3 PIECES.
1-3, 3 TO 5 O'CLOCK(INFERIOR LATERAL), 4 PIECES.
1-4, 7 TO 9 O'CLOCK (INFERIOR MEDIAL), 3 PIECES.
1-5, 9 TO 11 O'CLOCK (SUPERIR MEDIAL), 4 PIECES.
1-6, INFERIOR MARGIN (5 TO 7 0'CLOCK), SECTIONED, 5 PIECES.
4. GROSS TEMPLATE:
ENDOMETRIAL BIOPSY.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
AND "ENDOMETRIUM", AND CONSISTS OF MULTIPLE PIECES OF TAN SOFT TISSUE,
MEASURING ... CM. THE SPECIMEN IS SUBMITTED IN TOTO.
SUMMARY OF SECTIONS:
1-1, MULTIPLE PIECES.
4. GROSS TEMPLATE:
COLON POLYPECTOMY.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
AND "POLYP AT 22 CM", AND CONSISTS OF A SINGLE PIECE OF TISSUE
IN THE FORM OF A PEDUNCULATED POLYP WITH ATTACHED STALK.
THE SPECIMEN MEASURES ... CM. THE STALK MARGIN IS INKED BLACK.
THE SPECIMEN IS BISECTED AND SUBMITTED IN TOTO.
SUMMARY OF SECTIONS:
1-1, 1 PIECE.
4. GROSS TEMPLATE:
LARGE COLON POLYPECTOMY.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
AND "POLYP AT 33 CM", AND CONSISTS OF ONE MUSHROOM-SHAPED PIECE
OF TAN SOFT TISSUE, MEASURING ... CM. THE SPECIMEN IS BISECTED
AND SUBMITTED IN TOTO.
SUMMARY OF SECTIONS:
1-1, 2 PIECES.
4. GROSS TEMPLATE:
GASTRIC/ESOPHAGUS BIOPSY.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
AND "GASTRIC ANTRUM, 45 CM", AND CONSISTS OF THREE PIECES
OF TAN SOFT TISSUE, MEASURING ... CM. THE SPECIMEN IS SUBMITTED IN TOTO.
SUMMARY OF SECTIONS:
1-1, 3 PIECE.
5. GROSS TEMPLATE:
PARATHYROID.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED FRESH FOR FROZEN SECTION, LABELED WITH THE
PATIENT'S NAME AND "LEFT SUPERIOR PARATHYROID (F.S.)", AND CONSISTS OF
ONE PINK, OVOID, CIRCUMSCRIBED, SOFT NODULE, WEIGHING ... MG AND
MEASURING ... CM. THE SPECIMEN IS BISECTED, REVEALING A
HOMOGENEOUS SURFACE. ONE-HALF IS FROZEN. SMEARS ARE MADE. THE
SPECIMEN IS SUBMITTED IN TOTO.
SUMMARY OF SECTIONS:
1-1, 1 PIECE.
1-2, 1 PIECE.
FROZEN SECTION DIAGNOSIS:
1. PARATHYROID TISSUE, ... MG. CALLED TO O.R. #..., DR. SMITH,
AT ... A.M., 9/99/2009, BY DR. JONES, AND READ BACK.
CASE REVIEWED IN CONFERENCE.
6. GROSS TEMPLATE:
ORTHOPEDIC PROSTHESIS.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S
NAME AND "ORTHOPEDIC SCREWS FOR IDENTIFICATION ONLY",
AND CONSISTS OF TEN SMALL METAL SCREWS, MEASURING ... CM EACH.
THIS SPECIMEN IS FOR GROSS EXAMINATION ONLY.
7. GROSS TEMPLATE:
SKIN SHAVE BIOPSY.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
AND "RIGHT SHIN", AND CONSISTS OF ONE SHAVE SKIN BIOPSY, MEASURING
... CM. THE SURFACE IS NODULAR. THE MARGIN IS INKED BLACK,
AND THE SPECIMEN IS SECTIONED AND SUBMITTED IN TOTO.
SUMMARY OF SECTIONS:
1-1, TIPS, 2 PIECES.
1-2, MIDDLE, 3 PIECES.
8. GROSS TEMPLATE:
PROSTATE NEEDLE BIOPSY.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND TWO CONTAINERS.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
AND "RIGHT PROSTATE BIOPSY", AND CONSISTS OF SIX TAN CORE BIOPSIES,
MEASURING FROM ... CM TO ... CM IN LENGTH, AND 0.2 CM IN DIAMETER.
THE SPECIMEN IS SUBMITTED IN TOTO.
SUMMARY OF SECTIONS:
1-1, 6 PIECES.
2. SPECIMEN #2 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
AND "LEFT PROSTATE BIOPSY", AND CONSISTS OF SEVEN TAN CORE
MEASURING FROM ... CM TO ... CM IN LENGTH, AND 0.2 CM IN DIAMETER.
THE SPECIMEN IS SUBMITTED IN TOTO.
SUMMARY OF SECTIONS:
2-1, 7 PIECES.
9. GROSS TEMPLATE:
LIVER NEEDLE BIOPSY.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
AND "LIVER CORE BIOPSY", AND CONSISTS OF FOUR TAN CORE BIOPSIES,
MEASURING FROM ... CM TO ... CM IN LENGTH, AND 0.2 CM IN DIAMETER.
THE SPECIMEN IS SUBMITTED IN TOTO.
SUMMARY OF SECTIONS:
1-1, 4 PIECES.
10. GROSS TEMPLATE:
TEMPORAL ARTERY BIOPSY.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
AND "RIGHT TEMPORAL ARTERY BIOPSY (FRESH)", AND CONSISTS OF ONE
TUBULAR PORTION OF TISSUE, CONSISTENT WITH ARTERY, MEASURING ... CM
IN LENGTH BY ... CM IN DIAMETER. THERE IS NO GROSSLY DETECTIBLE LESION.
THE SPECIMEN IS SECTIONED AND SUBMITTED IN ITS ENTIRETY.
SUMMARY OF SECTIONS:
1-1, LONGITUDINAL AND CROSS SECTIONS OF ARTERY, 5 PIECES.
11. GROSS TEMPLATE:
LARYNGEAL BIOPSY.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
AND "LARYNGEAL MASS (P)", AND CONSISTS OF ONE PIECE OF TAN,
SOFT AND FRIABLE TISSUE, MEASURING ... CM. THE SPECIMEN IS SUBMITTED
IN TOTO.
SUMMARY OF SECTIONS:
1-1, 1 PIECE.
12. GROSS TEMPLATE:
BLADDER BIOPSY.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
AND "BLADDER DOME (P)", AND CONSISTS OF MULTIPLE FRAGMENTS
OF TAN-PINK SOFT TISSUE, MEASURING ... CM IN AGGREGATE.
THE SPECIMEN IS SUBMITTED IN TOTO.
SUMMARY OF SECTIONS:
1-1, 1 PIECE.
13. GROSS TEMPLATE:
BONE SPECIMEN FOR DEGENERATIVE JOINT DISEASE.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
AND "LEFT FEMORAL HEAD", AND CONSISTS OF
A ... CM FEMORAL HEAD AND ATTACHED NECK, WITH AN IRREGULAR
RESECTION MARGIN. THE ARTICULAR SURFACE IS COVERED BY AN IRREGULAR
CARTILAGINOUS SURFACE, WITH AREAS OF EBURNATION OF THE UNDERLYING BONE.
MULTIPLE PERIPHERAL OSTEOPHYTES ARE PRESENT. ALSO RECEIVED ARE
FOUR FRAGMENTS OF PINK-TAN FIBROUS TISSUE, MEASURING ... CM.
THOSE FRAGMENTS OF SOFT TISSUE ARE UNREMARKABLE. THIS SPECIMEN IS
FOR GROSS EXAMINATION ONLY.
14. GROSS TEMPLATE: TOOTH.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
AND "TOOTH #6, MAXILLARY RIGHT CANINE", AND CONSISTS OF ONE YELLOW-TAN
TOOTH WITH BROWN DISCOLORATION/METALLIC-FILLING MATERIAL, TOWARD THE
ROOT TIP, MEASURING ... CM. THE SPECIMEN IS FOR GROSS EXAMINATION.
15. GROSS TEMPLATE:
VASA DEFERENTIA.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND TWO CONTAINERS.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
AND "LEFT VAS DEFERENS (P)", AND CONSISTS OF ONE TUBULAR PINK
SOFT TISSUE, MEASURING ... CM IN LENGTH BY ... CM IN DIAMETER. THE
SPECIMEN IS BISECTED AND A LUMEN IS IDENTIFIED. THE SPECIMEN IS
SUBMITTED IN TOTO.
SUMMARY OF SECTIONS:
1-1, 2 PIECES.
2. SPECIMEN #2 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
AND "RIGHT VAS DEFERENS (P)", AND CONSISTS OF ONE TUBULAR PINK
SOFT TISSUE, MEASURING ... CM IN LENGTH BY ... CM IN DIAMETER. THE
SPECIMEN IS BISECTED AND A LUMEN IS IDENTIFIED. THE SPECIMEN IS
SUBMITTED IN TOTO.
SUMMARY OF SECTIONS:
2-1, 2 PIECES.
16. GROSS TEMPLATE:
NEPHRECTOMY SPECIMEN.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
AND "RIGHT KIDNEY (P)", AND CONSISTS OF A LEFT NEPHRECTOMY SPECIMEN,
WHICH INCLUDES RIGHT KIDNEY WITH ATTCHED PERIRENAL FAT, MEASURING ... CM,
AND WEIGHING ... GRAMS. THE ASSOCIATED URETER MEASURES
... CM IN LEGTH X ... CM IN DIAMETER, RENAL ARTERY MEASURES ... CM IN
LENGTH X ... CM IN DIAMETER, AND RENAL VEIN MEASURES ... IN LENGTH
BY ... CM IN DIAMETER. ON THE LATERAL UPPER POLE IS A ... CM,
WELL-DEMARCATED MASS ON THE OUTER SURFACE OF THE NORMAL GROSS APPEARING
CORTEX. THE MASS GROSSLY HAS A TRANSPARENT, THIN BORDER WITH THE
CORTEX. THE CORTEX UNDERLYING THE MASS IS SLIGHTLY ATROPHIC. THE CUT
SURFACE OF THE MASS IS WHITE-TAN, FLESHY, AND SOFT WITHOUT GROSS
NECROSIS AND HEMMORAHGE. THE MASS IS ... CM FROM THE CLOEST
SUPERIOR-ANTERIOR MARGIN, ... CM FROM THE LOWEST LATERAL MARGIN, ... CM
FROM THE SUPERIOR MARGIN, AND ... CM FROM PELVIS. THERE IS NO GROSS
INVOLVEMENT OF THE RENAL PELVIS. THE RENAL CORTEX IS TAN-BROWN WITH A
WELL-DEFINED CORTICAL MEDULLARY JUNCTION. THE PELVIS AND CALYCES ARE
COVERED BY SMOOTH, GLISTENING MUCOSA. THERE IS NO LESION IDENTIFIED IN
THE RENAL VEIN, URETER, AND ARTERY. THE CORTEX MEASURES ... CM AND
THE MEDULLA MEASURES ... CM. NO ADRENAL GLAND IS IDENTIFIED. THE
MARGINS ARE INKED BLACK. REPRESENTATIVE SECTIONS ARE SUBMITTED.
SUMMARY OF SECTIONS:
1-1, VESSEL AND URETERAL MARGIN, 3 PIECES
1-2, TUMOR WITH ANTERIOR MARGIN, 1 PIECE
1-3, TUMOR WITH LATERAL MARGIN, 1 PIECE
1-4, TUMOR WITH POSTERIOR MARGIN, 1 PIECE
1-5, SUPERIOR MARGIN, 1 PIECE
1-6, INFERIOR MARGIN, 1 PIECE
1-7 THRU 1-11, TUMOR WITH CAPSULE, 1 PIECE EACH
1-12, UNREMARKABLE KIDNEY, 1 PIECE
17. GROSS TEMPLATE:
.... SPECIMEN.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
51. GROSS TEMPLATE:
LEG AMPUTATION.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED FRESH, LABELED WITH THE PATIENT'S NAME AND
"RIGHT OR LEFT AKA", AND CONSISTS OF A RIGHT LOWER EXTREMITY AMPUTATED ABOVE
THE KNEE, MEASURING ... CM FROM THE PROXIMAL BONE RESECTION MARGIN TO THE
KNEE, ... CM FROM THE KNEE TO THE HEEL, ... CM HEEL TO TOE, ... CM ACROSS
THE DORSUM OF THE FOOT, ... CM IN DIAMETER AT THE CALF, ... CM IN DIAMETER
AT THE THIGH. THE SKIN IS LIGHTLY PIGMENTED AND WRINKLED. THERE IS A
GREEN-BLACK GANGRENOUS ULCERATION ON THE DORSUM AND ANTERIOR ANKLE,
MEASURING ... CM PROXIMAL TO DISTAL, ... CM MEDIAL TO LATERAL, AND
... CM IN DEPTH. THERE ARE TWO SLOUGHED AREAS IN THE ULCER BASE A RED-PINK
AND FLESHY. THE UNDERLYING BONE IS NOT INVOLVED. THE PROXIMAL TOES HAVE
BROWN-BLACK GANGRENOUS ULCERATION. THE UNDERLYING BONE IS NOT INVOLVED.
THE TOENAILS ARE YELLOW-WHITE, THICKENED AND OTHERWISE UNREMARKABLE.
IN THE SKIN ON THE PLANTAR SURFACE OF THE FOOT IS ... THE PROXIMAL BONE
MARGIN EXTENDS ... CM FROM THE PROXIMAL RESECTION MARGIN. THE BONE MARGIN
CONSISTS OF YELLOW-WHITE VIABLE BONE AND RED SOFT MARROW.
THE SOFT TISSUE RESECTION MARGIN CONSISTS OF YELLOW LOBULATED ADIPOSE
TISSUE OVERLYING RED, HOMOGENOUS, VIABLE MUSCLE. THE SKIN AT THE SOFT
TISSUE RESECTION MARGIN IS UNREMARKABLE. THE FEMORAL ARTERY SHOWS
PERCENT ATHEROSCLEROTIC OCCLUSION. THE POPLITEAL ARTERY SHOWS
PERCENT ATHEROSCLEROTIC OCCLUSION. THE POSTERIOR TIBIALIS ARTERY SHOWS
ATHEROSCLEROTIC OCCLUSION. THE ANTERIOR TIBIALIS ARTERY SHOWS
PERCENT ATHEROSCLEROTIC OCCLUSION.
THE SPECIMEN IS FOR GROSS EXAMINATION ONLY.
52. GROSS TEMPLATE:
OUTSIDE CONSULTATION.
Gross description:
1. RECEIVED ARE SEVENTEEN SLIDES FROM GOODTIMES LABORATORY,
INC., 123 HAPPY ROAD, SUITE 456, PODUNK, MD 12345,
VOICE 123-456-7890, FAX 123-456-7891.
SLIDES ARE LABELED S2003-001234: PATIENT
IDENTIFICATION AGREES WITH REQUISITION, SLIDES,
AND THE GOODTIMES LABORATORY REPORT. THE REPORT
INDICATES THAT THE PROSTATE HAS BEEN SAMPLED FROM
THE RIGHT APEX (RA), RIGHT MIDDLE (RM), RIGHT BASE (RB),
LEFT APEX (LA), LEFT MIDDLE (LM), AND LEFT BASE (LB).
SLIDES ARE LABELED AS FOLLOWS: SIX SLIDES LABELED .....
ADENOCARCINOMA OF PROSTATE, GLEASON SCORE 3+4=7, INVOLVING
20% OF TISSUE-BLOCKS RA, RM, AND RB.
BENIGN STROMAL AND GLANDULAR HYPERPLASIA
IN TISSUE-BLOCKS LA, LM, AND LB.
COMMENT: Case discussed with Dr. Urologist on 1/17/2003.
Case reviewed in conference. The Baltimore VAMHCS
diagnosis agrees with the Goodtimes Lab diagnosis.
53. GROSS TEMPLATE: UNORIENTED SKIN RESECTION SPECIMEN.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
AND "SKIN LESION ON BACK". THE SPECIMEN CONSISTS OF AN ELLIPTICAL FRAGMENT
OF LIGHT, TAN-WHITE SKIN, MEASURING ... CM. THE SKIN SPECIMEN
HAS BEEN EXCISED TO A DEPTH OF ... CM. THE SPECIMEN IS UNORIENTED.
IN ONE-HALF THE SPECIMEN, THERE IS A LIGHT-BROWN TO DARK-GRAY-BROWN
PIGMENTED, SLIGHTLY-DEPRESSED AREA, MEASURING ... CM.
THE TRANSVERSE MARGINS OF THE DEPRESSED AREA ARE ... CM AND ... CM.
THE LESION IS SLIGHTLY OFF-CENTER. THE SIDE WITH THE ... CM
TRANSVERSE MARGIN IS INKED BLUE, AND THE OPPOSITE SIDE,
WITH THE ... CM TRANSVERSE MARGIN IS INKED YELLOW.
THE SPECIMEN IS SERIALLY SECTIONED TRANSVERSELY,
AND SUBMITTED ENTIRELY IN THREE CASSETTES.
SUMMARY OF SECTIONS:
1-1, PERIPHERAL THIRD.
2-1, CENTRAL THIRD.
3-1, REMAINING THIRD.
54. GROSS TEMPLATE: ORIENTED SKIN RESECTION SPECIMEN.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
AND "SKIN OF LEFT KNEE". THE SPECIMEN CONSISTS OF AN ELLIPTICAL FRAGMENT
OF SKIN, WITH UNDERLYING SUBCUTANEOUS TISSUE. THERE ARE SUTURES DESIGNATING
THE 3 O'CLOCK AND 12 O'CLOCK POSITIONS, RESPECTIVELY. THE SPECIMEN
MEASURES ... CM MEDIAL TO LATERAL, ... CM SUPERIOR TO INFERIOR,
AND ... CM ANTERIOR TO POSTERIOR. THE SURFACE OF THE SKIN
IS INVOLVED BY AN ILL-DEFINED, GRANULAR DIFFUSELY ERYTHEMATOUS LESION,
MEASURING ... CM. THIS ERYTHEMATOUS REGION IS LOCATED ... CM
FROM THE CLOSEST PERIPHERAL MARGIN (6 O'CLOCK). THE CUT SURFACE OF
THE SPECIMEN IS LIGHT TAN AND UNREMARKABLE. THE LESION IS ... CM FROM
THE CLOSEST DEEP RESECTION MARGIN. THE RESECTION MARGIN IS INKED BLACK,
AND THE SPECIMEN IS SERIALLY SECTIONED CLOCKWISE AND SUBMITTED IN TOTO.
SUMMARY OF SECTIONS:
1-1, SUPERIOR MARGIN (11 TO 1 O'CLOCK), SECTIONED, 4 PIECES.
1-2, 1 TO 3 O'CLOCK (SUPERIOR LATERAL), 3 PIECES.
1-3, 3 TO 5 O'CLOCK(INFERIOR LATERAL), 4 PIECES.
1-4, 7 TO 9 O'CLOCK (INFERIOR MEDIAL), 3 PIECES.
1-5, 9 TO 11 O'CLOCK (SUPERIR MEDIAL), 4 PIECES.
1-6, INFERIOR MARGIN (5 TO 7 0'CLOCK), SECTIONED, 5 PIECES.
55. GROSS TEMPLATE: PROSTATECTOMY SPECIMEN.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED FRESH AND IS SUBSEQUENTLY FIXED IN
FORMALIN OVERNIGHT, LABELED WITH THE PATIENT'S IDENTIFICATION AND
"PROSTATE GLAND". IT CONSISTS OF ONE INTACT PROSTATE GLAND WITH
ATTACHED BILATERAL VASA DEFERENTIA AND SEMINAL VESICLES, WEIGHING ...
GRAMS AND MEASURING ... CM FROM BASE TO APEX, ... CM FROM THE TIP OF
THE SEMINAL VESICLES TO THE APEX, ... CM LEFT TO RIGHT, AND ... CM
ANTERIOR TO POSTERIOR. THE EXTERNAL SURFACE IS DULL RED-BROWN AND
UNREMARKABLE. THE CUT SURFACE OF THE PROSTATE VARIES FROM FIRM TO
RUBBERY, AND IS NODULAR, LIGHT TAN AND YELLOW. ILL-DEFINED, DIFFUSE
YELLOW STREAKS ARE NOTED WITHIN THE PROSTATE GLAND. NO DISCRETE
MASSES OR LESIONS ARE NOTED. THE RIGHT ANTERIOR SURFACE IS INKED
BLUE, THE LEFT ANTERIOR SURFACE IS INKED BLACK, AND THE POSTERIOR
SURFACE IS INKED GREEN. THE SPECIMEN IS SERIALLY SECTIONED AND EVERY
OTHER SECTION IS SUBMITTED.
SUMMARY OF SECTIONS:
1-1, PROXIMAL URETHRAL MARGIN, EN FACE, 1 PIECE.
1-2, LEFT VAS DEFERENS MARGIN AND SEMINAL VESICLE WITH PROSTATE,
2 PIECES.
1-3, RIGHT VAS DEFERENS MARGIN AND SEMINAL VESICLE WITH PROSTATE,
2 PIECES.
1-4, LEFT PROSTATE AT BASE, 1 PIECE.
1-5, RIGHT PROSTATE AT BASE, 1 PIECE.
1-6, LEFT PROSTATE DISTAL TO 1-4, 1 PIECE.
1-7, POSTERIOR ONE HALF OF 1-6, 2 PIECES.
1-8, RIGHT PROSTATE DISTAL TO 1-5, 1 PIECE.
1-9, POSTERIOR ONE HALF OF 1-8, 1 PIECE.
1-10, LEFT PROSTATE DISTAL TO 1-6, 2 PIECES.
1-11, POSTERIOR ONE HALF OF 1-10, 1 PIECE.
1-12, RIGHT PROSTATE DISTAL TO 1-8, 1 PIECE.
1-13, POSTERIOR ONE HALF OF 1-12, 1 PIECE.
1-14, LEFT DISTAL URETHRAL MARGIN, SECTIONED, 3 PIECES.
1-15, LEFT DISTAL URETHRAL MARGIN, SECTIONED, 6 PIECES.
1-16, RIGHT DISTAL URETHRAL MARGIN, SECTIONED, 8 PIECES.
1-17, RIGHT DISTAL URETHRAL MARGIN, SECTIONED, 7 PIECES.
56. GROSS TEMPLATE: LARYNGECTOMY SPECIMEN.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
AND "TOTAL LARYNGECTOMY BILATERAL SELECTIVE NECK DISSECTION (P)", AND
CONSISTS OF A LARYGECTOMY SPECIMEN ATTACHED TO THE BILATERAL RADICAL NECK
DISSECTION, MEASURING ... CM FROM SUPERIOR TO INFERIOR, ... CM
FROM ANTERIOR TO POSTERIOR, AND ... CM FROM RIGHT TO LEFT, NOT
INCLUDING THE RADICAL NECK DISSECTION. THE RIGHT RADICAL NECK
DISSECTION MEASURES ... CM, AND THE LEFT RADICAL NECK MEASURES ... CM.
THE THYROID PORTION CONSISTS OF ONLY OF THE RIGHT LOBE,
AND MEASURES ... CM. THE SPECIMEN IS INKED BLACK.
THERE IS ALSO AN ULCERATIVE LESION, MEASURING ... CM, WITH A DEPTH
OF ... CM IS LOCATED AT THE RIGHT FALSE VOCAL CORD. THE ULCER INVOLVES
THE RIGHT TRUE VOCAL CORD, AND ABUTS MIDLINE ANTERIORLY, AND IS ... CM
FROM MIDLINE POSTERIORLY. THE REST OF THE MUCOSA SURFACE IS TAN AND
UNREMARKABLE. SECTIONING SHOWS THAT A FIRM TISSUE EXTENDS FROM THE
ULCER BASE TO APPROXIMATELY ... CM FROM THE ADJACENT THYROID
CARTILAGE. THE RIGHT AND LEFT VERTICAL NECK PORTIONS ARE EACH DIVIDED
INTO THREE PARTS OF I, II, AND III, FROM SUPERIOR TO INFERIOR.
FOUR POSSIBLE LYMPH NODES ARE IDENTIFIED, RANGING IN GREATEST DIMENSION
FROM ... TO ... CM IN THE RIGHT LEVEL I. SIX POSSIBLE LYMPH NODES
ARE IDENTIFIED RANGING IN GREATEST DIMENSION FROM ... TO ... CM
IN THE RIGHT LEVEL II. EIGHT POSSIBLE LYMPH NODES ARE IDENTIFIED,
RANGING IN GREATEST DIMENSION FROM ... TO ... CM IN THE RIGHT LEVEL III.
FIVE POSSIBLE LYMPH NODES ARE IDENTIFIED, RANGING IN GREATEST DIMENSION
FROM ... TO ... CM IN THE LEFT LEVEL II. SIX POSSIBLE LYMPH NODES
ARE IDENTIFIED, RANGING IN GREATEST DIMENSION FROM ... TO ... CM
IN THE LEFT LEVEL II. FIVE POSSIBLE LYMPH NODES ARE IDENTIFIED,
RANGING IN GREATEST DIMENSION FROM ... TO ... CM IN THE LEFT LEVEL II.
REPRESENTATIVE SECTIONS ARE SUBMITTED.
SUMMARY OF SECTIONS:
1-1, ULCERATIVE LESION, 1 PIECE.
1-2, ULCERATIVE LESION, 1 PIECE.
1-3, RIGHT ARYEPIGLOTTIC FOLD, 1 PIECE.
1-4, MIDLINE EPIGLOTTIS, 1 PIECE.
1-5, LEFT CORDS, 1 PIECE.
1-6, THYROID, 1 PIECE.
1-7, INFERIOR MARGIN, 2 PIECES
1-8, RIGHT SOFT TISSUE MARGIN, 1 PIECE
1-9, ANTERIOR SOFT TISSUE MARGIN, 1 PIECE
1-10, LEFT SOFT TISSUE MARGIN, 1 PIECE.
1-11, RIGHT LEVEL I, 4 POSSIBLE LYMPH NODES, 4 PIECES.
1-12, RIGHT LEVEL II, 6 POSSIBLE LYMPH NODES, 6 PIECES.
1-13, RIGHT LEVEL III, 6 POSSIBLE LYMPH NODES, 6 PIECES.
1-14, RIGHT LEVEL I, 2 POSSIBLE LYMPH NODES, 2 PIECES.
1-15, LEFT LEVEL I, 5 POSSIBLE LYMPH NODES, 5 PIECES.
1-16, LEFT LEVEL II, 6 POSSIBLE LYMPH NODES, 6 PIECES.
1-17, LEFT LEVEL III, 5 POSSIBLE LYMPH NODES, 5 PIECES.
57. GROSS TEMPLATE: COLECTOMY SPECIMEN.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FRESH, LABELED WITH THE PATIENT'S
IDENTIFICATION AND "RIGHT COLON (P)", AND CONSISTS OF ONE RIGHT
HEMICOLECTOMY SPECIMEN, CONSISTING OF A PORTION OF TERMINAL ILEUM,
CECUM AND PORTION OF RIGHT COLON, WITH APPENDIX PRESENT.
THE SPECIMEN MEASURES ... IN LENGTH. THE SPECIMEN WAS RECEIVED
PREVIOUSLY OPENED FROM THE OPERATING ROOM. THE SEROSAL SURFACE
IS MOSTLY COVERED BY LOBULATED, YELLOW ADIPOSE TISSUE, WITH A
SMALL AMOUNT OF SMOOTH, GLISTENING, TAN-PINK SEROSA VISIBLE. THERE IS
A CIRCULAR, ERYTHEMATOUS, ULCERATED MUCOSAL LESION WITH ROLLED UP
BORDERS IN THE CECUM. THE LESION MEASURES ... CM, WITH A CRATER
DEPTH OF ... CM. THE CUT SURFACE OF THE LESION IS FLESHY TAN-PINK.
THE LESION EXTENDS TO A DEPTH OF ... CM, AND APPEARS TO INVADE UP TO,
BUT NOT THROUGH, THE SEROSA. THE LESION IS LOCATED ... CM
FROM THE ILEOCECAL VALVE, ... CM FROM THE PROXIMAL ILEAL MARGIN,
AND ... CM FROM THE DISTAL COLONIC MARGIN. THE REMAINING MUCOSA IS
SMOOTH, GLISTENING AND LIGHT TAN WITH THE NORMAL MUCOSAL FOLDINGS
NOTED. A SECOND POLYP-LIKE LESION, MEASURING ... CM IN GREATEST
DIMENSION, IS LOCATED ... CM FROM THE DISTAL COLONIC MARGIN. THE
RADIAL MARGIN IS INKED BLACK AND REPRESENTATIVE SECTIONS ARE SUBMITTED.
SUMMARY OF SECTIONS:
2-1, PROXIMAL SHAVE MARGIN, 1 PIECE.
2-2, DISTAL MARGIN, SHAVE, 1 PIECE.
2-3, CECUM MASS, 1 PIECE.
2-4, CECUM MASS, WITH ILEOCECAL VALVE, 1 PIECE.
2-5, CECAL MASS WITH NORMAL MUCOSA, 1 PIECE.
2-6, CECAL MASS WITH RADIAL MARGIN/FAT, 1 PIECE.
2-7, POLYP, 1 PIECE.
2-8, LYMPH NODES AND PROXIMAL ONE THIRD OF SPECIMEN, MULTIPLE PIECES.
2-9, TWO LYMPH NODES AND OVERLYING MASS, ONE TRISECTED AND INKED,
4 PIECES.
2-10, TWO LYMPH NODES AND OVERLYING MASS, BOTH BISECTED, ONE INKED
BLUE, 4 PIECES.
2-11, POSSIBLE LYMPH NODES AND OVERLYING MASS, MULTIPLE PIECES.
2-12, LYMPH NODES AND DISTAL THIRD, 5 PIECES.
2-13, LYMPH NODES AND DISTAL ONE THIRD, MULTIPLE PIECES.
2-14, APPENDIX, 3 PIECES.
58. GROSS TEMPLATE: PARTIAL GASTRECTOMY SPECIMEN.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S
IDENTIFICATION AND "SUBTOTAL GASTRECTOMY, STITCH MARKS DISTAL STOMA
(P)". THE SPECIMEN CONSISTS OF ONE PARTIAL GASTRECTOMY SPECIMEN,
WITH ATTACHED LESSER AND GREATER OMENTUM,
AND A SUTURE MARKING THE DISTAL END,
MEASURING ... CM IN LENGTH AND VARYING IN DIAMETER FROM ... CM AT THE
PROXIMAL END TO ... CM AT THE DISTAL END. TWO STAPLED RESECTION
MARGINS ARE PRESENT AT THE PROXIMAL AND DISTAL ENDS, MEASURING ... CM
AND ... CM, RESPECTIVELY. THE SPECIMEN IS RECEIVED OPENED, REVEALING
A SUBMUCOSAL MASS. THE SEROSAL SURFACE IS SMOOTH, GLISTENING AND
TAN-BROWN WITH NO EVIDENCE OF PERFORATION. THE AFOREMENTIONED
SUBMUCOSAL MASS MEASURES ... CM, AND IS LOCATED IN THE
UPPER ONE THIRD OF THE SPECIMEN. THE MASS EXTENDS FROM THE ANTERIOR
ASPECT OF THE LESSER CURVATURE, STRADDLES THE GREATER CURVATURE, AND
EXTENDS UP ONTO THE POSTERIOR SURFACE OF THE STOMACH. THE MASS
APPEARS TO DISTEND BUT NOT ERODE THROUGH THE OVERLYING MUCOSA, WHICH IS
THINNED OUT, RED-TAN AND BROWN WITH LOSS OF THE NORMAL MUCOSAL FOLDS.
THE CUT SURFACE IS HEMORRHAGIC, SOFT, FLESHY, AND TAN, WITH EXTENSIVE
CYSTIC DEGENERATION. THE MASS APPEARS WELL-CIRCUMSCRIBED, WITH A
PSEUDOCAPSULE AND NO INFILTRATION INTO THE SURROUNDING STOMACH OR
SEROSAL SURFACE. THE MASS IS LOCATED ... CM FROM THE PROXIMAL STAPLED
RESECTION MARGIN AND ... CM FROM THE DISTAL STAPLED RESECTION MARGIN.
THE REMAINDER OF THE STOMACH MUCOSA IS GLISTENING AND TAN, WITH NORMAL
GASTRIC FOLDS IDENTIFIED. NO DEFINITE LYMPH NODES ARE IDENTIFIED. THE
STAPLED RESECTION MARGINS AND SEROSAL SURFACE ARE INKED BLACK AND
REPRESENTATIVE SECTIONS ARE SUBMITTED.
SUMMARY OF SECTIONS:
1-1, PROXIMAL MARGIN, PERPENDICULAR SECTION WITH MASS, 1 PIECE.
1-2, MASS WITH UNINVOLVED MUCOSA, 1 PIECE.
1-3, MASS WITH OVERLYING MUCOSA, 2 PIECES.
1-4, MASS WITH SEROSA, 2 PIECES.
1-5, MASS WITH CYSTIC DEGENERATION, 1 PIECE.
1-6, MASS WITH OVERLYING MUCOSA, 1 PIECE.
1-7, MASS, 1 PIECE.
1-8, STOMACH PROXIMAL TO MASS, 1 PIECE.
1-9, STOMACH DISTAL TO MASS, 2 PIECES.
1-10, DISTAL MARGIN, EN FACE, 2 PIECES.
1-11, THROUGH 1-13, LESSER OMENTUM, POSSIBLE LYMPH NODES,
MULTIPLE PIECES EACH.
1-14, AND 1-15, GREATER OMENTUM, POSSIBLE LYMPH NODES,
MULTIPLE PIECES EACH.
59. GROSS TEMPLATE: LUNG WEDGE RESECTION SPECIMEN.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S
IDENTIFICATION AND "LEFT LOWER LOBE WEDGE (P)". IT CONSISTS OF ONE
WEDGE OF LUNG WITH A STAPLED RESECTION MARGIN RUNNING THE LENGTH OF
THE SPECIMEN, MEASURING ... CM AND WEIGHING ... GRAMS. THE
PLEURAL SURFACE IS SMOOTH, GLISTENING AND PURPLE-BROWN. THE CUT
SURFACE OF THE LUNG IS SPONGY RED-BROWN AND SLIGHTLY CONGESTED.
THERE IS A SINGLE, ILL-DEFINED, FIRM MASS, MEASURING ... CM.
THE MASS EXTENDS TO WITHIN 1 MM OF THE PLEURAL MARGIN,
AND WITHIN ... CM OF THE SURGICAL RESECTION MARGIN.
THE RESECTION MARGIN IS INKED BLUE, AND THE SPECIMEN
IS SERIALLY SECTIONED AND SUBMITTED IN TOTO.
SUMMARY OF SECTIONS:
1-1, LEFT LOWER LOBE WEDGE, 3 PIECES.
1-2, LEFT LOWER LOBE WEDGE, 4 PIECES.
1-3, LEFT LOWER LOBE WEDGE, 3 PIECES.
60. GROSS TEMPLATE: LUNG LOBECTOMY RESECTION SPECIMEN.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED FRESH IN FORMALIN FIXED OVERNIGHT, LABELED
WITH THE PATIENT'S NAME AND "LEFT UPPER LOBE (FRESH)" AND CONSISTS OF
A LEFT UPPER LUNG LOBE, MEASURING ... CM, AND WEIGHING ... GRAMS.
THE PLEURAL SURFACE IS PINK-PURPLE, SLIGHTLY WRINKLED AND GLISTENING.
THE SPECIMEN IS SERIALLY SECTIONED TO REVEAL THREE TAN, DISCRETE
LUNG MASSES, MEASURING ... CM, ... CM, AND ... CM.
THE FIRST TWO MASSES ABUT THE PLEURA AND ARE
... AND ... CM FROM THE RESECTION MARGINS, RESPECTIVELY. THE THIRD
MASS IS ... CM FROM THE PLEURAL SURFACE AND ... CM FROM THE CLOSEST
RESECTION MARGIN. THE THIRD MASS APPEARS TO INVOLVE THE BRONCHIAL
VASCULATURE. THE UNINVOLVED LUNG PARENCHYMA IS RED-BROWN AND SPONGY.
FOUR ANTHRACOTIC LYMPH NODES ARE IDENTIFIED, RANGING FROM ... TO ...
CM IN GREATEST DIMENSION. THE PLEURAL SURFACES OVER THE MASSES ARE
INKED BLUE AND THE RESECTION MARGIN IS INKED BLACK. THE MASSES AND
LYMPH NODE CANDIDATES ARE SUBMITTED ENTIRELY. A REPRESENTATIVE
SECTION OF THE UNINVOLVED LUNG IS SUBMITTED.
SUMMARY OF SECTIONS:
1-1, BRONCHIAL AND VASCULAR MARGINS, 7 PIECES.
1-2, MASS #1, 2 PIECES.
1-3, AND 3-4, MASS #2, 2 PIECES EACH.
1-5, MASS #3 AND RESECTION MARGIN, 1 PIECE.
1-6, THROUGH 3-8, MASS #3, 1 PIECE EACH.
1-9, UNINVOLVED LUNG, 1 PIECE.
1-10, FOUR LYMPH NODE CANDIDATES, 4 PIECES.
61. GROSS TEMPLATE: HYSTERECTOMY SPECIMEN.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
AND "UTERUS, CERVIX, RIGHT AND LEFT TUBES AND OVARIES (P)", AND
CONSISTS OF A DISTORTED UTERUS WITH AMPUTATED CERVIX AND UNATTACHED
LEFT AND RIGHT FALLOPIAN TUBES WITH EACH CORESPONDING OVARIES. THE
UTERUS WEIGHS ... GRAMS AND MEASURES ... CM LATERAL(CORNU)TO
LATERAL(CORNU), ... CM ANTERIOR TO POSTERIOR AND ... CM FROM THE
AMPUTATED CERVIX TO THE FUNDUS. THE ECTOCERVIX IS NOT INCLUDED IN THE
SPECIMEN. THE CERVICAL OS MEASURES ... CM IN DIAMETER. THE EXTERNAL
SURFACE OF THE UTERUS IS MARKEDLY DISTORTED BY PROTRUDING MYOMETIAL
NODULES AND SOME APPREAR LOCATED IN THE SUBSEROSA. A PROBE IS PLACED
THROUGH THE CERVICAL OS INTO THE ENDOMETRIAL CAVITY. THE UTERUS IS
THEN BISECTED FROM INFERIOR TO SUPERIOR, REVEALING MULTIPLE
SUENDOMETRIAL, INTRAMURAL, AND SUBSEROSAL NODULES, RANGING FROM ... CM
IN DIAMETER TO ... CM. THE NODULES ARE FIRM, WELL-CIRCUMSCRIBED,
AND THE CUT SURFACE IS TAN AND WHORLED. AN AREA OF BROWN COLORATION
IS NOTED IN ONE OF THE INTRAMURAL NODULES. THE ENDOMETRIAL CAVITY
IS OBLITERATED BY INTRAMURAL NODULES, AND IN PARTICULAR,
BY A PROTRUDING, POLYPOID SUBENDOMETRIAL NODULE MEASURING
... CM. THIS NODULE IS COVERED BY SOFT, FRIABLE, POSSIBLY
ENDOMETRIAL TISSUE. THE UNDISTORTED MYOMETRIUM AVERAGES ... CM IN
THICKNESS AND THE ENDOMETRIUM MEASURES LESS THAN ... CM. NO OTHER
LESIONS ARE IDENTIFIED. THE LEFT AND THE RIGHT FALLOPIAN TUBES AND
OVARIES ARE SECTIONED AND REVEALED NO GROSSLY DISCERNABLE
ABNORMALITIES. LEFT FALLOPIAN TUBE MEASURES ... CM IN LENGTH X ... CM
IN DIAMETER. LEFT OVARY MEASURES ... CM. RIGHT TUBE
MEASURES ... CM IN LENGTH X ... CM IN DIAMETER AND THE RIGHT OVARY IS
REPRESENTATIVE SECTIONS ARE SUBMITTED.
SUMMARY OF SECTIONS:
1-1, ENDOCERVIX, 6 AND 12 O'CLOCK, 2 PIECES.
1-2, SUBENDOMETRIAL POLYPOID NODULE WITH SURFACE FRIABLE TISSUE, 1 PIECE.
1-3, TRANSMURAL NODULE, POSTERIOR UTERUS, 2 PIECES.
1-4, SUBMUCOSAL NODULES, ANTERIOR UTERUS, 2 PIECES.
1-5, SUBSEROSAL NODULE, POSTERIOR UTERUS, 2 PIECES.
1-6, POSTERIOR MYOMETRIUM, 1 PIECE.
1-7, ANTERIOR MYOMETRIUM, 1 PIECE.
1-5, ENDOMETRIUM, RANDOM, 1 PIECE.
1-6, LEFT TUBE AND OVARY, 2 PIECES.
1-7, RIGHT TUBE AND OVARY, 2 PIECES.
INTRAOPERATIVE CONSULTATION: GROSS INSPECTION AND EVALUATION OF
OVARIAN NEOPLASM. GROSS DIAGNOSIS: 1. SIMPLE CYST.
FINAL DIAGNOSIS PENDING PERMANENT SECTIONS. REPORTED
TO DR. SMITH IN OPERATING ROOM ... AT 10:30 A.M., BY DR. JONES.
62. GROSS TEMPLATE: MASTECTOMY SPECIMEN.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
AND "RIGHT BREAST BIOPSY (SHORT SUTURE SUPERIOR, LONG SUTURE
LATERAL)", AND CONSISTS OF A YELLOW, IRREGULARLY SHAPED PIECE OF
FIBROADIPOSE TISSUE, MEASURING ... CM SUPERIOR TO INFERIOR, ... CM
MEDIAL TO LATERAL, AND ... CM ANTERIOR TO POSTERIOR. A SHORT SUTURE
DESIGNATES THE SUPERIOR SURFACE AND A LONG SUTURE DESIGNATES THE
LATERAL SURFACE. THERE IS A GUIDEWIRE ENTERING THE SUPERIOR-ANTERIOR
SURFACE, WITH THE TIP ENDING IN THE CENTRAL INFERIOR-POSTERIOR SURFACE.
IN THE CENTRAL POSTERIOR-INFERIOR SURFACE, THERE IS A BROWN
CAUTERIZED FIRM AREA, MEASURING ... CM. THE SPECIMEN
IS SERIALLY SECTIONED, MEDIAL TO LATERAL, TO REVEAL THAT THE TISSUE
UNDERLYING THE CAUTERIZED AREA IS WHITE AND FIBROTIC. THIS FIBROTIC
AREA MEASURES ... CM SUPERIOR TO INFERIOR, ... CM ANTERIOR TO
POSTERIOR AND ... CM MEDIAL TO LATERAL. THIS FIBROTIC AREA ABUTS THE
POSTERIOR MARGIN AND ABUTS THE ANTERIOR-INFERIOR MARGIN.
THE MEDIAL-LATERAL ENDS ARE FURTHER SECTIONED SUPERIOR-INFERIOR.
THE POSTERIOR SURFACE IS INKED BLUE. THE INFERIOR-ANTERIOR SURFACE
IS INKED RED, AND THE SUPERIOR-ANTERIOR SURFACE IS INKED YELLOW.
THE SPECIMEN IS SUBMITTED IN ITS ENTIRETY.
SUMMARY OF SECTIONS:
1-1, MEDIAL END, INFERIOR PORTION, MULTIPLE PIECES.
1-2, MEDIAL END, SUPERIOR PORTION, MULTIPLE PIECES.
1-3, LATERAL TO 1-1, AND 1-2, 1 PIECE.
1-4, LATERAL TO 1-3, INFERIOR PORTION, 1 PIECE.
1-5, LATERAL TO 1-3, SUPERIOR PORTION, 1 PIECE.
1-6, LATERAL TO 1-4, INFERIOR PORTION, 1 PIECE.
1-7, LATERAL TO 1-5, SUPERIOR PORTION, 1 PIECE.
1-8, LATERAL TO 1-6, INFERIOR PORTION, 1 PIECE.
1-9, LATERAL TO 1-7, SUPERIOR PORTION, 1 PIECE.
1-10, LATERAL END, INFERIOR PORTION, 3 PIECES.
1-11, LATERAL END, SUPERIOR PORTION, 3 PIECES.
1-12, SUPERIOR HALF, 1 PIECE.
1-13, INFERIOR HALF, 1 PIECE.
1-14, SUPERIOR HALF, 1 PIECE.
1-15, INFERIOR HALF, 1 PIECE.
63. GROSS TEMPLATE: THYROIDECTOMY SPECIMEN.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED FRESH, LABELED WITH THE PATIENT'S NAME AND
"LEFT THYROID LOBE, RULE OUT PAPILLARY CARCINOMA, SUTURE MARKS AREA FOR
FROZEN SECTION", AND CONSISTS OF A LEFT THYROID LOBE, MEASURING ... CM,
AND WEIGHING ... GRAMS. THE CAPSULAR SURFACE IS RED-BROWN AND SMOOTH.
THE THYROID LOBE HAS AN IRREGULAR OUTLINE. THE SPECIMEN
WAS PREVIOUSLY SECTIONED TO REVEAL A TAN-BROWN, GELATINOUS,
WELL-ENCAPSULATED NODULE, MEASURING ... CM. THERE IS A FIRM,
FIBROUS STELLATE SCAR WITHIN THE NODULE. A SUTURE MARKS THIS AREA
FOR FROZEN SECTION. THE APPARENT CAPSULAR SURFACES ARE INKED BLUE.
THE REMAINING THYROID PARENCHYMA IS RED-BROWN AND HOMOGENEOUS.
NO OTHER LESIONS ARE IDENTIFIED. THE ISTHMUS MARGIN IS NOT IDENTIFIED.
NO PARATHYROID GLANDS OR LYMPH NODES ARE IDENTIFIED. A PORTION
OF THE NODULE IS FROZEN. THE REMAINDER IS SUBMITTED FOR PERMANENT
SECTION.
SUMMARY OF SECTIONS:
1-1, NODULE, FROZEN SECTION CONTROL, 1 PIECE.
1-2, NODULE, WITH CAPSULE, 3 PIECES.
1-3, NODULE, WITH CAPSULE, 2 PIECES.
1-4, THROUGH 1-7, NODULE AND UNINVOLVED THYROID, 2 PIECES EACH.
1-8, UNINVOLVED THYROID, 1 PIECE.
1-9, UNINVOLVED THYROID, 4 PIECES.
1-10, THROUGH 1-13, UNINVOLVED THYROID, 2 PIECES EACH.
FROZEN SECTION DIAGNOSIS: 1. FOLLICULAR LESION. DEFER TO PERMANENT
SECTION. STATED TO DR. JONES AT 10:50 AM ON 2-15-03, AND READ BACK
TO DR. SMITH.
64. GROSS TEMPLATE: NEPHRECTOMY SPECIMEN.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
AND "LEFT KIDNEY WITH MASS", AND CONSISTS OF A LEFT NEPHRECTOMY SPECIMEN,
WHICH INCLUDES THE LEFT KIDNEY WITH ATTACHED PERIRENAL FAT,
MEASURING ... CM. THE CUT SURFACE OF THE RENAL PARENCHYMA DEMONSTRATES
AN ORANGE-TAN CENTRALLY NECROTIC MASS, COMPRESSING THE HILUM,
MEASURING ... CM. THE ADRENAL GLAND IS IDENTIFIED, MEASURING ... CM.
REPRESENTATIVE SECTIONS ARE SUBMITTED.
SUMMARY OF SECTIONS:
1-1, AND 1-2, VASCULAR AND URETERAL MARGIN, MULTIPLE PIECES EACH.
1-3, AND 1-4, MASS, 1 PIECE EACH.
1-5, MASS WITH HILUM, 1 PIECE.
1-6, MASS CLOSEST TO CAPSULE, 1 PIECE.
1-7, MASS WITH NECROSIS, 2 PIECES.
1-8, UNREMARKABLE KIDNEY, 1 PIECE.
1-9, MASS WITH HILUM, 1 PIECE.
65. GROSS TEMPLATE: RADICAL CYSTOPROSTATECTOMY SPECIMEN.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S
NAME AND "BLADDER AND PROSTATE" AND CONSISTS OF A CYSTOPROSTATECTOMY
SPECIMEN, AND BILATERAL SEMINAL VESICLES, WHICH MEASURE ... CM
TOTALLY AND WEIGH ... GRAMS. THE PELVIC DIAPHRAGM IS COVERING
THE SUPERIOR PART OF THE SPECIMEN, WHICH HAS A TAN-PINK, SMOOTH
SURFACE AND MEASURES ... CM. THE RIGHT URETER MEASURES ... CM
IN LENGTH AND ... CM IN DIAMETER AND THE LEFT URETER MEASURES ... CM
IN LENGTH AND ... CM IN DIAMETER. UPON OPENING THE BLADDER, THE
MUCOSA IS PINK-RED AND THERE IS AN ULCERATIVE TUMOR, MEASURING ... CM
ON THE RIGHT LATERAL INFERIOR SURFACE OF THE BLADDER, WITH A
MAXIMUN DEPTH OF INVASION ... CM ON GROSS INSPECTION. THE BLADDER
WALL THICKNESS IS ... CM. THE TUMOR IS CLOSE TO THE RIGHT URETERAL
ORIFICE, BUT THERE IS NO GROSS INVOLVEMENT OF THE URETERAL LUMINAL
SURFACE BY THE TUMOR. TUMOR ENCASED THE SEROSAL SURFACE OF THE RIGHT
URETER. NO GROSS INVOLVEMENT OF THE PERIVESICULAR FAT IS IDENTIFIED.
THE PROSTATE MEASURES ... CM. THE PROSTATIC URETHRA
MEASURES ... CM AND IS NOT GROSSLY INVOLVED BY THE TUMOR. THE CUT
SECTION OF THE PROSTATE SHOWS A NODULAR, TAN, SOLID TISSUE. NO OTHER
PATHOLOGICAL CHANGES IS IDENTIFIED GROSSLY. THE RIGHT AND LEFT
SEMINAL VESICLES ARE UNREMARKABLE. THE PROSTATE GLAND AND EXTERNAL
SURFACE OF THE BLADDER ADJACENT TO THE TUMOR ARE INKED BLACK AND
REPRESENTATIVE SECTIONS ARE SUBMITTED. NO LYMPH NODES ARE IDENTIFIED
IN THE PERIVESICULAR FAT. REPRESENTATIVE SECTIONS ARE SUBMITTED.
SUMMARY OF SECTIONS:
1-1, URETERAL MARGIN, 1 PIECE, EN FACE.
1-2, LEFT URETER, 1 PIECE.
1-3, ANTERIOR BLADDER, 1 PIECE.
1-4, SUPERIOR BLADDER, 1 PIECE.
1-5, POSTERIOR BLADDER, 1 PIECE.
1-6, INFERIOR BLADDER, 1 PIECE.
1-7, RIGHT URETER WITH SEROSAL ENCASING TUMOR, 1 PIECE.
1-8, THROUGH 1-12, BLADDER TUMOR, 1 PIECE EACH.
1-13, RIGHT PROSTATE AND SEMINAL VESICLE, 2 PIECES.
1-14, RIGHT PROSTATE, 2 PIECES.
1-15, LEFT PROSTATE AND SEMINAL VESICLE, 2 PIECES.
1-16, LEFT PROSTATE, 2 PIECES.
66. GROSS TEMPLATE: WHIPPLE PANCREATECTOMY SPECIMEN.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S NAME
AND "HEAD OF PANCREAS, DUODENUM AND BILE DUCT (FRESH)", AND CONSISTS
OF A WHIPPLE PANCREATECTOMY SPECIMEN. THE STOMACH MEASURES ... CM.
THE SEROSAL STAPLED RESECTION LINE IS IDENTIFIED, MEASURING ... CM.
THE SEROSAL SURFACE IS TAN-PINK, SMOOTH, AND GLISTENING.
THE ATTACHED OMENTUM MEASURES ... CM. THE DUODENUM MEASURES ... CM
IN LENGTH BY ... CM IN DIAMETER. A STAPLED RESECTION LINE IS
IDENTIFIED AT THE DISTAL END, MEASURING ... CM. THE SEROSAL SURFACE
IS TAN-PINK, SMOOTH, AND GLISTENING. THE PANCREAS MEASURES ... CM.
THE BILE DUCT MEASURES ... CM IN LENGTH BY ... CM IN DIAMETER.
THE MUCOSAL SURFACE OF THE STOMACH AND DUODENUM IS TAN-PINK WITH
FOLDS. NO FOCAL LESIONS ARE IDENTIFIED GROSSLY. THE BILE DUCT IS
PATENT AND LINED BY TAN-PINK MUCOSA. THE CUT SURFACE OF THE PANCREAS
IS TAN-YELLOW, LOBULATED, FOCALLY FIRM AND FIBROTIC. NO DISTINCT
NODULE OR MASS IS IDENTIFIED GROSSLY. THREE LYMPH NODE CANDIDATES ARE
IDENTIFIED, RANGING FROM ... TO ... CM IN GREATEST DIMENSION.
REPRESENTATIVE SECTIONS ARE SUBMITTED.
SUMMARY OF SECTIONS:
1-1, STOMACH, RESECTION MARGIN, 2 PIECES.
1-2, BILE DUCT, RESECTION MARGIN, 1 PIECE.
1-3, PANCREATIC NECK, MARGIN, 1 PIECE.
1-4, DUODENUM, RESECTION MARGIN, 1 PIECE.
1-5 THRU 1-6, AMPULLA OF VATER, 1 PIECE EACH.
1-7 THRU 1-9, PANCREAS, 1 PIECE EACH.
1-10, LYMPH NODE CANDIDATES, 3 PIECES.
1-11, STOMACH AND DUODENUM MUCOSA, 2 PIECES.
67. GROSS TEMPLATE: PAROTIDECTOMY SPECIMEN.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN SALINE, LABELED WITH THE PATIENT'S
IDENTIFICATION AND "LEFT PAROTID MASS". THE SPECIMEN IS FIXED
IN FORMALIN OVERNIGHT. IT CONSISTS OF ONE OVOID PIECE OF TISSUE,
COVERED BY RED-BROWN FIBROMEMBRANOUS TISSUE, WEIGHING
... GRAMS AND MEASURING ... CM. THE CUT SURFACE REVEALS A
WELL-CIRCUMSCRIBED, FLESHY TAN-PINK MASS, MEASURING ...
CM. A SMALL RIM OF UNREMARKABLE LOBULATED TAN SALIVARY GLAND TISSUE
AND RED-BROWN SKELETAL MUSCLE IS LOCATED TOWARD ONE POLE OF THE
SPECIMEN. THE TUMOR IS LOCATED LESS THAN ... CM FROM THE OPPOSITE
POLE. THE EXTERNAL SURFACE IS INKED BLUE AND THE SPECIMEN IS SERIALLY
SECTIONED. REPRESENTATIVE SECTIONS ARE SUBMITTED.
SUMMARY OF SECTIONS:
1-1, TUMOR AT ONE POLE MARGIN, EN FACE, 1 PIECE.
1-2, TUMOR, 2 PIECES.
1-3, TUMOR, 2 PIECES.
1-4, TUMOR WITH UNINVOLVED SALIVARY GLAND, 2 PIECES.
1-5, AND 1-6, TUMOR, 1 PIECE EACH.
1-7, OPPOSITE POLE INVOLVED BY TUMOR, 1 PIECE, EN FACE.
68. GROSS TEMPLATE: LYMPH NODE SPECIMEN.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S
IDENTIFICATION AND "RIGHT CERVICAL LYMPH NODE". IT CONSISTS OF TWO
OVOID TAN-GRAY LYMPH NODES, ONE BISECTED IN THE OPERATING ROOM,
MEASURING ... AND ... CM. THE CUT SURFACES ARE
HOMOGENEOUS, LIGHT TAN AND PINK. THE SPECIMEN IS SERIALLY SECTIONED
AND SUBMITTED IN TOTO.
SUMMARY OF SECTIONS:
1-1, LARGEST LYMPH NODE, 2 PIECES.
1-2, LARGEST LYMPH NODE, 3 PIECES.
1-3, THROUGH 1-4, LARGEST LYMPH NODE, 2 PIECES EACH.
1-5, AND 1-6, SMALLER LYMPH NODE, 4 PIECES EACH.
69. GROSS TEMPLATE: RADICAL NECK DISSECTION SPECIMEN.
Gross description:
PATIENT IDENTIFICATION AGREES WITH REQUISITION AND ONE CONTAINER.
1. SPECIMEN #1 IS RECEIVED IN FORMALIN, LABELED WITH THE PATIENT'S
NAME AND "RIGHT NECK DISSECTION LEVELS I THRU IV (P)", AND CONSISTS OF
A RED-TAN PIECE OF FIBROMUSCULAR TISSUE CONSISTENT WITH A RIGHT NECK
DISSECTION, WHICH MEASURES ... CM FROM SUPERIOR TO INFERIOR, ... CM
FROM MEDIAL TO LATERAL, AND ... CM FROM ANTERIOR TO POSTERIOR.
IN LEVEL I, THE SUBMANDIBULAR GLAND IS IDENTIFIED, MEASURING ... CM.
THE CUT SURFACE IS TAN, LOBULATED, AND OTHERWISE UNMREMARKABLE.
IN LEVEL I, ONE POSSIBLE LYMPH NODE IS IDENTIFIED, MEASURING
... CM. IN LEVEL II, THIRTEEN POSSIBLE LYMPH NODES ARE IDENTIFIED,
RANGING IN SIZE FROM ... CM TO ... CM. IN LEVEL III, THIRTEEN
POSSIBLE LYMPH NODES ARE IDENTIFIED, RANGING IN SIZE FROM
... CM TO ... CM. IN LEVEL IV, THREE POSSIBLE LYMPH NODES ARE IDENTIFIED,
RANGING IN SIZE FROM ... CM TO ... CM.
REPRESENTATIVE SECTIONS ARE SUBMITTED.
SUMMARY OF SECTION:
1-1, SUBMANDIBULAR GLAND, 1 PIECE.
1-2, LEVEL I, ONE LYMPH NODE, BISECTED, 2 PIECES.
1-3, LEVEL II, TWO LYMPH NODES, 2 PIECES.
1-4, LEVEL II, SEVEN LYMPH NODES, 7 PIECES.
1-5, LEVEL II, TWO LYMPH NODES, 2 PIECES.
1-6, LEVEL II, ONE LYMPH NODE, BISECTED, 2 PIECES.
1-7, LEVEL II, ONE LYMPH NODE, BISECTED, 2 PIECES.
1-8, LEVEL III, ONE LYMPH NODE, BISECTED, 2 PIECES.
1-9, LEVEL III, ONE LYMPH NODE, BISECTED, 2 PIECES.
1-10, LEVEL III, ONE LYMPH NODE, BISECTED, 2 PIECES.
1-11, LEVEL III, ONE LYMPH NODE, BISECTED, 2 PIECES.
1-12, LEVEL III, THREE LYMPH NODES, 3 PIECES.
1-13, LEVEL III, SIX LYMPH NODES, 6 PIECES.
1-14, LEVEL IV, THREE LYMPH NODES, 3 PIECES.
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