yankeeviv
我心匪石，不可轉也。我心匪席，不可卷也。
正文
1. Sep 28, 2015 PET/CT SKULL TO MID THIGH INT TX 78815PI
INDICATION:
Lung cancer. 162. Colon cancer. 153.9 evaluate extent of disease.
TECHNIQUE:
Approximately 60 minutes following injection 11 mCi F-18 FDG, PET/CT imaging performed from the base of skull to the mid thighs. Study is performed utilizing images in attenuated and not attenuated corrected modes. Images are reviewed on a workstation in sagittal, axial and coronal views and MIP image. Study is done in conjunction with a CT examination primarily for purposes of anatomic correlation and for attenuation correction but also for diagnostic interpretation.
Oral contrast administered.
Patient had a fasting blood glucose of 196 mg/dL.
COMPARISON:
none
FINDINGS:
Unremarkable FDG uptake is seen in the visualized brain.
There is no evidence of FDG avid lymphadenopathy in the neck.
Physiologic FDG uptake is seen in the thyroid gland.
Evaluation of the thorax performed.
Pulmonary reticular interstitial disease with subpleural fibrosis is seen. Motion degrades imaging of the lungs. Subpleural ill-defined nodular opacity noted within the lateral left upper lung lobe (series 3, image 145), 1.5 cm, which has slightly increased FDG uptake, with maximum standard uptake value ( SUV max) 2.3. Anterior left upper lung lobe 9 mm (image 158) and 1.7 cm (image 177) nodular densities are seen which without significant increased FDG uptake compared to the surrounding lung. Right upper lung lobe subpleural nodular densities are seen largest measuring 2 cm (image 142), without significant increased FDG uptake compared to the surrounding lung. There is no evidence of a pericardial or pleural effusion. Enlarged mediastinal lymph nodes with FDG uptake isointense to the mediastinal soft tissues (not significantly FDG avid) are seen in the precarinal, prevascular, posterior right para-esophageal regions measuring up to 1.4 cm in short axis diameter. There is no evidence of hilar lymphadenopathy.
Unremarkable FDG uptake is seen within the breasts. There is no evidence of axillary lymphadenopathy.
Evaluation of the abdomen and pelvis performed.
Unremarkable FDG uptake is seen in the liver parenchyma. There is no evidence of an FDG avid liver mass. The gallbladder, pancreas, spleen, right adrenal gland and left adrenal gland appear unremarkable with physiologic FDG tracer localization. IVC unremarkable. Calcified atheromatous plaquing noted of the aorta. No aortic aneurysm. Right kidney, left kidney, renal collecting systems and urinary bladder have physiologic FDG tracer localization. Prostate gland and seminal vesicles have unremarkable FDG uptake. The stomach, small and large bowel have physiologic FDG uptake. Mild diverticulosis is seen of the colon. There is no evidence of FDG avid lymphadenopathy.
Evaluation of the musculoskeletal structures performed.
There is no evidence of FDG avid osseous malignancy. Degenerative arthropathy noted in the dorsal spine.
IMPRESSION:
Pulmonary interstitial disease and fibrosis. Ill-defined pulmonary nodular densities are seen with mild increased FDG uptake or without significant increased FDG uptake which are possibly due to benign infectious inflammatory disease.
Enlarged non-FDG avid mediastinal lymphadenopathy is seen of nonspecific etiology possibly due to infectious or inflammatory disease versus hypometabolic/low-grade malignant neoplasia.
There is no evidence of FDG avid metastatic malignancy in the abdomen or pelvis or skeletal structures.
Read by: VADDE, KAVITHA , MD
Lung cancer. 162. Colon cancer. 153.9 evaluate extent of disease.
TECHNIQUE:
Approximately 60 minutes following injection 11 mCi F-18 FDG, PET/CT imaging performed from the base of skull to the mid thighs. Study is performed utilizing images in attenuated and not attenuated corrected modes. Images are reviewed on a workstation in sagittal, axial and coronal views and MIP image. Study is done in conjunction with a CT examination primarily for purposes of anatomic correlation and for attenuation correction but also for diagnostic interpretation.
Oral contrast administered.
Patient had a fasting blood glucose of 196 mg/dL.
COMPARISON:
none
FINDINGS:
Unremarkable FDG uptake is seen in the visualized brain.
There is no evidence of FDG avid lymphadenopathy in the neck.
Physiologic FDG uptake is seen in the thyroid gland.
Evaluation of the thorax performed.
Pulmonary reticular interstitial disease with subpleural fibrosis is seen. Motion degrades imaging of the lungs. Subpleural ill-defined nodular opacity noted within the lateral left upper lung lobe (series 3, image 145), 1.5 cm, which has slightly increased FDG uptake, with maximum standard uptake value ( SUV max) 2.3. Anterior left upper lung lobe 9 mm (image 158) and 1.7 cm (image 177) nodular densities are seen which without significant increased FDG uptake compared to the surrounding lung. Right upper lung lobe subpleural nodular densities are seen largest measuring 2 cm (image 142), without significant increased FDG uptake compared to the surrounding lung. There is no evidence of a pericardial or pleural effusion. Enlarged mediastinal lymph nodes with FDG uptake isointense to the mediastinal soft tissues (not significantly FDG avid) are seen in the precarinal, prevascular, posterior right para-esophageal regions measuring up to 1.4 cm in short axis diameter. There is no evidence of hilar lymphadenopathy.
Unremarkable FDG uptake is seen within the breasts. There is no evidence of axillary lymphadenopathy.
Evaluation of the abdomen and pelvis performed.
Unremarkable FDG uptake is seen in the liver parenchyma. There is no evidence of an FDG avid liver mass. The gallbladder, pancreas, spleen, right adrenal gland and left adrenal gland appear unremarkable with physiologic FDG tracer localization. IVC unremarkable. Calcified atheromatous plaquing noted of the aorta. No aortic aneurysm. Right kidney, left kidney, renal collecting systems and urinary bladder have physiologic FDG tracer localization. Prostate gland and seminal vesicles have unremarkable FDG uptake. The stomach, small and large bowel have physiologic FDG uptake. Mild diverticulosis is seen of the colon. There is no evidence of FDG avid lymphadenopathy.
Evaluation of the musculoskeletal structures performed.
There is no evidence of FDG avid osseous malignancy. Degenerative arthropathy noted in the dorsal spine.
IMPRESSION:
Pulmonary interstitial disease and fibrosis. Ill-defined pulmonary nodular densities are seen with mild increased FDG uptake or without significant increased FDG uptake which are possibly due to benign infectious inflammatory disease.
Enlarged non-FDG avid mediastinal lymphadenopathy is seen of nonspecific etiology possibly due to infectious or inflammatory disease versus hypometabolic/low-grade malignant neoplasia.
There is no evidence of FDG avid metastatic malignancy in the abdomen or pelvis or skeletal structures.
Read by: VADDE, KAVITHA , MD
Provider Comments: This result has been automatically released to your health record at the direction of your provider. Your provider may not have yet reviewed this result
2. Oct 01, 2015 Clinical Slide review 1/5 from Hackensack UMC
SURGICAL PATHOLOGY REPORT
PATIENT: RICHMOND, ROBERT ACCESSION #: OR15-000318
MR #: 10153577 SEX: M DATE 10/01/2015
COLLECTED:
D.O.B: 11/16/1956 AGE: 58 DATE 10/02/2015
RECEIVED:
PHYSICIAN: Steven Brower, M.D. DATE 10/05/2015
REPORTED:
COPY TO: MMF Office LOCATION: OP^O
Clinical Slide review from Hackensack University Medical Center,
History: Department of Pathology, 30 Prospect Avenue, Hackensack,
NJ 07601; 4 slides received labeled S-14-0027961 (1A-4
CDX2, 1A-5 CK7, 1A-6 CK20, 1A-7 H&E), dated 12/12/14
SPECIMEN: Slide review
DIAGNOSIS (gross and microscopic):
Slide Review:
CT guided core biopsy, right upper lobe of lung mass:
1. Metastatic adenocarcinoma of gastrointestinal origin.
2. Immunohistochemical stains show CDX2 to be diffusely positive, CK20
focally positive, and CK7 negative, supporting the above diagnosis. Per
report, TTF-1 and Napsin A stains are negative.
MT:pt
GROSS DESCRIPTION:
Four slides are received for review.
Slides are returned to Hackensack University Medical Center on
10/22/15.
Mikhail Tismenetsky, M.D.
PATIENT: RICHMOND, ROBERT ACCESSION #: OR15-000318
MR #: 10153577 SEX: M DATE 10/01/2015
COLLECTED:
D.O.B: 11/16/1956 AGE: 58 DATE 10/02/2015
RECEIVED:
PHYSICIAN: Steven Brower, M.D. DATE 10/05/2015
REPORTED:
COPY TO: MMF Office LOCATION: OP^O
Clinical Slide review from Hackensack University Medical Center,
History: Department of Pathology, 30 Prospect Avenue, Hackensack,
NJ 07601; 4 slides received labeled S-14-0027961 (1A-4
CDX2, 1A-5 CK7, 1A-6 CK20, 1A-7 H&E), dated 12/12/14
SPECIMEN: Slide review
DIAGNOSIS (gross and microscopic):
Slide Review:
CT guided core biopsy, right upper lobe of lung mass:
1. Metastatic adenocarcinoma of gastrointestinal origin.
2. Immunohistochemical stains show CDX2 to be diffusely positive, CK20
focally positive, and CK7 negative, supporting the above diagnosis. Per
report, TTF-1 and Napsin A stains are negative.
MT:pt
GROSS DESCRIPTION:
Four slides are received for review.
Slides are returned to Hackensack University Medical Center on
10/22/15.
Mikhail Tismenetsky, M.D.
Provider Comments: This result has been automatically released to your health record at the direction of your provider. Your provider may not have yet reviewed this result.
3. Oct 01, 2015 Clinical Slide review 2/5 from Hackensack UMC
SURGICAL PATHOLOGY REPORT
PATIENT: RICHMOND, ROBERT ACCESSION #: OR15-000317
MR #: 10153577 SEX: M DATE 10/01/2015
COLLECTED:
D.O.B: 11/16/1956 AGE: 58 DATE 10/02/2015
RECEIVED:
PHYSICIAN: Steven Brower, M.D. DATE 10/05/2015
REPORTED:
COPY TO: MMF Office LOCATION: OP^O
Clinical Slide review from Hackensack University Medical Center,
History: Department of Pathology, 30 Prospect Ave., Hackensack, NJ
07601; 4 slides labeled S14-0027647 (1A-1, 1B-1, 2A-1, 3A-
1), dated 12/10/14
SPECIMEN: Slide review
DIAGNOSIS (gross and microscopic):
Slide Review:
Skin, posterior neck, excisions (three sites):
Consistent with benign follicular cysts.
MT:ke
GROSS DESCRIPTION:
Four slides are received for review.
The slides are returned to Hackensack University Medical Center on
10/6/15.
Mikhail Tismenetsky, M.D.
4. Oct 01, 2015 Clinical Slide review 3/5 from Hackensack UMC
SURGICAL PATHOLOGY REPORT
PATIENT: RICHMOND, ROBERT ACCESSION #: OR15-000320
MR #: 10153577 SEX: M DATE 10/01/2015
COLLECTED:
D.O.B: 11/16/1956 AGE: 58 DATE 10/02/2015
RECEIVED:
PHYSICIAN: Steven Brower, M.D. DATE 10/05/2015
REPORTED:
COPY TO: MMF Office LOCATION: OP^O
Clinical Slide review from Hackensack University Medical Center,
History: Department of Pathology, 30 Prospect Ave., Hackensack, NJ
07601; 23 slides labeled S14-0028472 (1A-1, 1A-2, 1A-3,
2A-1, 2A-2, 2A-3, 3A-1, 3A-2 3A-3, 4A-1, 4A-2, 4A-3, 4A-
4, 4A-5, 5A-1, 5A-2, 6A-1, 6A-2, 7A-1, 7A-2, 7A-3, 7A-4,
7A-5), dated 12/18/14
SPECIMEN: Slide review
DIAGNOSIS (gross and microscopic):
Slide Review:
1. Stomach, body, biopsy:
Essentially unremarkable gastric mucosa.
2. Stomach, body, biopsy:
Essentially unremarkable gastric mucosa.
3. Stomach, body, biopsy:
Essentially unremarkable gastric mucosa.
4. Gastroesophageal junction, biopsy:
1. Squamous esophageal and specialized metaplastic columnar mucosa
consistent with Barrett?s esophagus.
2. Negative for dysplasia.
5. Colon, cecum, biopsy:
Fragments of tubular adenoma(s).
6. Colon, ascending, biopsy:
Framents of tubular adenoma(s).
7. Colon, ascending, biopsy:
1. Intramucosal adenocarcinoma.
2. No invasion is seen.
3. Separate fragments of serrated adenoma.
MT:ke
GROSS DESCRIPTION:
Twenty three slides are received for review.
The slides are returned to Hackensack UMC on 10/22/15.
Mikhail Tismenetsky, M.D.
PATIENT: RICHMOND, ROBERT ACCESSION #: OR15-000320
MR #: 10153577 SEX: M DATE 10/01/2015
COLLECTED:
D.O.B: 11/16/1956 AGE: 58 DATE 10/02/2015
RECEIVED:
PHYSICIAN: Steven Brower, M.D. DATE 10/05/2015
REPORTED:
COPY TO: MMF Office LOCATION: OP^O
Clinical Slide review from Hackensack University Medical Center,
History: Department of Pathology, 30 Prospect Ave., Hackensack, NJ
07601; 23 slides labeled S14-0028472 (1A-1, 1A-2, 1A-3,
2A-1, 2A-2, 2A-3, 3A-1, 3A-2 3A-3, 4A-1, 4A-2, 4A-3, 4A-
4, 4A-5, 5A-1, 5A-2, 6A-1, 6A-2, 7A-1, 7A-2, 7A-3, 7A-4,
7A-5), dated 12/18/14
SPECIMEN: Slide review
DIAGNOSIS (gross and microscopic):
Slide Review:
1. Stomach, body, biopsy:
Essentially unremarkable gastric mucosa.
2. Stomach, body, biopsy:
Essentially unremarkable gastric mucosa.
3. Stomach, body, biopsy:
Essentially unremarkable gastric mucosa.
4. Gastroesophageal junction, biopsy:
1. Squamous esophageal and specialized metaplastic columnar mucosa
consistent with Barrett?s esophagus.
2. Negative for dysplasia.
5. Colon, cecum, biopsy:
Fragments of tubular adenoma(s).
6. Colon, ascending, biopsy:
Framents of tubular adenoma(s).
7. Colon, ascending, biopsy:
1. Intramucosal adenocarcinoma.
2. No invasion is seen.
3. Separate fragments of serrated adenoma.
MT:ke
GROSS DESCRIPTION:
Twenty three slides are received for review.
The slides are returned to Hackensack UMC on 10/22/15.
Mikhail Tismenetsky, M.D.
5. Oct 01, 2015 Clinical Slide review 4/5 from Hackensack UMC
SURGICAL PATHOLOGY REPORT
PATIENT: RICHMOND, ROBERT ACCESSION #: OR15-000319
MR #: 10153577 SEX: M DATE 10/01/2015
COLLECTED:
D.O.B: 11/16/1956 AGE: 58 DATE 10/02/2015
RECEIVED:
PHYSICIAN: Steven Brower, M.D. DATE 10/05/2015
REPORTED:
COPY TO: MMF Office LOCATION: OP^O
Clinical Slide review from Hackensack University Medical Center,
History: Department of Pathology, 30 Prospect Avenue, Hackensack,
NJ 07601; 2 slides received labeled S-14-0028217 (1A-2,
1A-5), dated 12/16/14
SPECIMEN: Slide review
DIAGNOSIS (gross and microscopic):
Slide Review:
CT guided core biopsy, left upper lobe of lung mass:
1. Moderately differentiated adenocarcinoma of primary lung origin.
2. Immunohistochemical stain for TTF-1 is positive. Per report, the
tumor is also positive for CK7 and negative for Napsin A, CK20, and CDX2,
supporting the above diagnosis.
MT:pt
GROSS DESCRIPTION:
Two slides are received for review.
Slides are returned to Hackensack University Medical Center on
10/22/15.
Mikhail Tismenetsky, M.D.
PATIENT: RICHMOND, ROBERT ACCESSION #: OR15-000319
MR #: 10153577 SEX: M DATE 10/01/2015
COLLECTED:
D.O.B: 11/16/1956 AGE: 58 DATE 10/02/2015
RECEIVED:
PHYSICIAN: Steven Brower, M.D. DATE 10/05/2015
REPORTED:
COPY TO: MMF Office LOCATION: OP^O
Clinical Slide review from Hackensack University Medical Center,
History: Department of Pathology, 30 Prospect Avenue, Hackensack,
NJ 07601; 2 slides received labeled S-14-0028217 (1A-2,
1A-5), dated 12/16/14
SPECIMEN: Slide review
DIAGNOSIS (gross and microscopic):
Slide Review:
CT guided core biopsy, left upper lobe of lung mass:
1. Moderately differentiated adenocarcinoma of primary lung origin.
2. Immunohistochemical stain for TTF-1 is positive. Per report, the
tumor is also positive for CK7 and negative for Napsin A, CK20, and CDX2,
supporting the above diagnosis.
MT:pt
GROSS DESCRIPTION:
Two slides are received for review.
Slides are returned to Hackensack University Medical Center on
10/22/15.
Mikhail Tismenetsky, M.D.
6. Oct 01, 2015 Clinical Slide review 5/5 from Hackensack UMC
FINE NEEDLE ASPIRATE REPORT
PATIENT: RICHMOND, ROBERT ACCESSION #: F15-003843
MR #: 10153577 SEX: M DATE 10/01/2015
COLLECTED:
D.O.B: 11/16/1956 AGE: 58 DATE RECEIVED: 10/02/2015
PHYSICIAN: Steven Brower, M.D. DATE REPORTED: 10/05/2015
COPY TO: MMF Office LOCATION: OP^O
Clinical Slide review from Hackensack University Medical Center,
History: Department of Pathology, 30 Prospect Avenue, Hackensack,
NJ 07601; 3 slides are received labeled FN-14-0008195 (1-
-1, 1--2, 1A-1), dated 12/12/14
SPECIMEN: Slide review
DIAGNOSIS (gross and microscopic):
Slide Review:
CT guided fine needle aspiration biopsy, right upper lobe of lung mass:
Positive for malignant cells - adenocarcinoma with necrosis, consistent
with gastrointestinal origin (see concurrent core biopsy results OR15-
318).
MT:pt
GROSS DESCRIPTION:
Three slides are received for review.
Slides are returned to Hackensack University Medical Center on 10/22/15.
Mikhail Tismenetsky, M.D.
7. Oct 14, 2015. SURG PATH (Colonoscopy)
SURGICAL PATHOLOGY REPORT
PATIENT: RICHMOND, ROBERT ACCESSION #: S15-009100
MR #: 10153577 SEX: M DATE 10/14/2015
COLLECTED:
D.O.B: 11/16/1956 AGE: 58 DATE 10/14/2015
RECEIVED:
PHYSICIAN: Walter Klein, M.D. DATE 10/15/2015
REPORTED:
COPY TO: Steven Brower M.D. LOCATION: ENDO^O
Clinical Admission Dx: History of cancer; Pre-Op Dx: Ascending
History: colon mass; Post-Op Dx: Colon cancer; Distal ascending
colon cancer with known lung metastasis
SPECIMEN: Ascending colon cancer biopsy
DIAGNOSIS (gross and microscopic):
1. Serrated adenoma with focal high grade dysplasia.
2. No carcinoma is seen.
mt/mc
GROSS DESCRIPTION:
The specimen consists of multiple fragments of tissue measuring from
0.1 to 0.5 cm. in greatest dimension. TE-1 CI:PS
CODE 1
:
Mikhail Tismenetsky, M.D.
PATIENT: RICHMOND, ROBERT ACCESSION #: S15-009100
MR #: 10153577 SEX: M DATE 10/14/2015
COLLECTED:
D.O.B: 11/16/1956 AGE: 58 DATE 10/14/2015
RECEIVED:
PHYSICIAN: Walter Klein, M.D. DATE 10/15/2015
REPORTED:
COPY TO: Steven Brower M.D. LOCATION: ENDO^O
Clinical Admission Dx: History of cancer; Pre-Op Dx: Ascending
History: colon mass; Post-Op Dx: Colon cancer; Distal ascending
colon cancer with known lung metastasis
SPECIMEN: Ascending colon cancer biopsy
DIAGNOSIS (gross and microscopic):
1. Serrated adenoma with focal high grade dysplasia.
2. No carcinoma is seen.
mt/mc
GROSS DESCRIPTION:
The specimen consists of multiple fragments of tissue measuring from
0.1 to 0.5 cm. in greatest dimension. TE-1 CI:PS
CODE 1
:
Mikhail Tismenetsky, M.D.
8. Oct 22, 2015. SURG PATH (Colonectomy)
SURGICAL PATHOLOGY REPORT
PATIENT: RICHMOND, ROBERT ACCESSION #: S15-009347
MR #: 10153577 SEX: M DATE 10/22/2015
COLLECTED:
D.O.B: 11/16/1956 AGE: 58 DATE 10/22/2015
RECEIVED:
PHYSICIAN: Steven Brower, M.D. DATE 10/27/2015
REPORTED:
LOCATION: 84A847701^I
Clinical Admission, Pre and Post-Op Dx: Prior right ascending
History: colon cancer, synchronous right lung colon metastasis,
synchronous left lung primary non small cell carcinoma
SPECIMEN: Right colon
DIAGNOSIS (gross and microscopic):
1. Focal intramucosal adenocarcinoma arising in a sessile and serrated
adenoma.
2. The tumor is associated with ink tattoo.
3. Twenty-four benign lymph nodes.
4. Two small hyperplastic polyps.
5. Unremarkable appendix.
6. Rare colonic diverticula.
7. Unremarkable margins of resection.
SYNOPTIC REPORT:
Specimen type: Right hemicolectomy
Tumor site: Ascending
Tumor type: Intramucosal adenocarcinoma, arising in a serrated adenoma
Tumor size: Adenoma is 2.5 cm. in greatest dimension.
Histologic grade: low grade
Depth of invasion: No invasion
Margins: Negative
Lymphovascular invasion: Negative
Perineural invasion: Negative
Number of positive lymph nodes: 0
Total number of lymph nodes: 24
Pathologic staging: pTisN0
jt/mc
GROSS DESCRIPTION:
The specimen consists of a right hemicolectomy specimen with terminal
ileum measuring 11 cm. in length by 4 cm. in circumference. The colon
measures 39 cm. in length by 11 cm. in circumference at the distal
margin. The cecum measures 7.5 x 5 cm. Appendix is present measuring 9
cm. in length and 0.7 cm. in diameter. The colon was partially opened
in the ascending colon area. There is an area of inked tattoo visible
from serosal surface in the ascending colon. Opening the specimen
reveals a 2.5 x 1.7 x 0.5 cm. irregular polypoid mass in the ascending
colon at 11 cm. from the ileocecal valve and 27 cm. from the distal
margin. The tumor appears to be soft and superficial and is adjacent to
an area of ink tattoo. The colon also shows occasional diverticula with
fecal material and two small superficial polyps measuring up to 0.5 cm.
The remainder of the colon and terminal ileum are unremarkable. The
appendix is unremarkable. Small lymph nodes are dissected from the fat
and submitted entirely. R-18 Summary of sections: #1-proximal
margin, #2-distal margin, #3-appendix, #4-10- lymph nodes, #11-12 small
polyps, #13-18 entire tumor and tattooed area, #19 diverticulum.
CODE 1
:
Jausheng Tzeng, M.D.
PATIENT: RICHMOND, ROBERT ACCESSION #: S15-009347
MR #: 10153577 SEX: M DATE 10/22/2015
COLLECTED:
D.O.B: 11/16/1956 AGE: 58 DATE 10/22/2015
RECEIVED:
PHYSICIAN: Steven Brower, M.D. DATE 10/27/2015
REPORTED:
LOCATION: 84A847701^I
Clinical Admission, Pre and Post-Op Dx: Prior right ascending
History: colon cancer, synchronous right lung colon metastasis,
synchronous left lung primary non small cell carcinoma
SPECIMEN: Right colon
DIAGNOSIS (gross and microscopic):
1. Focal intramucosal adenocarcinoma arising in a sessile and serrated
adenoma.
2. The tumor is associated with ink tattoo.
3. Twenty-four benign lymph nodes.
4. Two small hyperplastic polyps.
5. Unremarkable appendix.
6. Rare colonic diverticula.
7. Unremarkable margins of resection.
SYNOPTIC REPORT:
Specimen type: Right hemicolectomy
Tumor site: Ascending
Tumor type: Intramucosal adenocarcinoma, arising in a serrated adenoma
Tumor size: Adenoma is 2.5 cm. in greatest dimension.
Histologic grade: low grade
Depth of invasion: No invasion
Margins: Negative
Lymphovascular invasion: Negative
Perineural invasion: Negative
Number of positive lymph nodes: 0
Total number of lymph nodes: 24
Pathologic staging: pTisN0
jt/mc
GROSS DESCRIPTION:
The specimen consists of a right hemicolectomy specimen with terminal
ileum measuring 11 cm. in length by 4 cm. in circumference. The colon
measures 39 cm. in length by 11 cm. in circumference at the distal
margin. The cecum measures 7.5 x 5 cm. Appendix is present measuring 9
cm. in length and 0.7 cm. in diameter. The colon was partially opened
in the ascending colon area. There is an area of inked tattoo visible
from serosal surface in the ascending colon. Opening the specimen
reveals a 2.5 x 1.7 x 0.5 cm. irregular polypoid mass in the ascending
colon at 11 cm. from the ileocecal valve and 27 cm. from the distal
margin. The tumor appears to be soft and superficial and is adjacent to
an area of ink tattoo. The colon also shows occasional diverticula with
fecal material and two small superficial polyps measuring up to 0.5 cm.
The remainder of the colon and terminal ileum are unremarkable. The
appendix is unremarkable. Small lymph nodes are dissected from the fat
and submitted entirely. R-18 Summary of sections: #1-proximal
margin, #2-distal margin, #3-appendix, #4-10- lymph nodes, #11-12 small
polyps, #13-18 entire tumor and tattooed area, #19 diverticulum.
CODE 1
:
Jausheng Tzeng, M.D.
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