Self Instructional Manual for Cancer Registrars - SEER - National ...

EXAMPLE
G5
PATHOLOGICAL SPECIMEN REPORT
Path. No. $91-999
Name Marie du Malade Reg. No. 000041
Age 47 Sex Female Race White Location Service Date 9/11/91
Address Occupation Teacher
HISTORY OF CASE: 47-year-old while female with ten-year history of gastric ulcer
CLINICAL DIAGNOSIS: Carcinoma of stomach
Surgeon George Flatus, MD Operation Vagotomy & subtotal gastrectomy
GROSS DESCRIPTION:
Received were three specimens: The first consisted of a portion of stomach measuring
13 x 7 x 2.5 cm. There was a portion of mesentery attached to the lesser curvature and
there was a firm indurated area in the wall of the lesser curvature. The serosal surface
was smooth and glistening and slightly hemorrhagic. On opening the specimen a 1 em in
diameter penetrating well-circumscribed ulcer was found in the wall of the lesser
curvature. This ulcer penetrated to a depth of 1 era. The ulcer was 3 cm from the
proximal portion of the specimen and 4.5 cm from the distal portion. The edges of the
ulcer were heaped up and firm, but there appeared to be no involvement of the
surrounding mucosa. The rugae or folds radiate toward the center of the ulcer from the
superior side, and the mucosa of the distal portion of the stomach was smooth.
The second specimen consisted of a portion of the left anterior vagus. Specimen consisted
of a piece of pale gray-white, soft tissue measuring 0.8 cm in length. The entire specimen
was submitted for examination.
The third specimen was labeled right posterior vagus and consisted of a piece of soft,
gray-white tissue measuring 2 cm in length and 0.4 cm in diameter. Entire specimen was
submitted for examination.
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