Self Instructional Manual for Cancer Registrars - SEER - National ...
Self Instructional Manual for Cancer Registrars - SEER - National ...
Self Instructional Manual for Cancer Registrars - SEER - National ...
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EXAMPLE<br />
G9<br />
DEPARTMENT<br />
OF PATHOLOGY<br />
Name Ann Trum Reg. No. 000045<br />
Age 62 Sex Female Race Black Ward E510 Service Surge_ Date 1/15/91<br />
CLINICAL HISTORY: Fungating lesion of gastric antrum with liver metastases<br />
CLINICAL DIAGNOSIS: Gastric carcinoma with metastasis to liver<br />
Path. No. $91-0300 Specimen Antrum of Stomach<br />
DESCRIPTION:<br />
Received in <strong>for</strong>malin is a specimen stated to represent antrum of the stomach. The<br />
specimen measures 12 cm x 6 cm x 2.3 cm in greatest dimensions, respectively. The<br />
external surface has a small amount of attached mesentery and vessels. Noted in the<br />
mesentery are several firm, hard lymph nodes, the largest measuring 2.3 cm in greatest<br />
dimension. The cut surface appears gray-tan and somewhat necrotic. The serosal surface<br />
of the stomach appears congested, shows signs of surgical instrumentation, as the specimen<br />
has been previously opened. The interior of the specimen reveals a large fungating,<br />
ulcerating lesion in the distal two-thirds, almost filling the distal two-thirds. This lesion<br />
measures 9 cm x 4 cm. It is surrounded by what appears to be slightly hypertrophic<br />
yellow-tan mucosa in a ruga<strong>for</strong>m pattern. Cut surface of the lesion reveals it to involve<br />
the muscular wall. Sections taken are as follows:<br />
1. Sections through main tumor mass<br />
2. Section through margin of resection closest to mass (proximal)<br />
3. Section of margin of resection furthest from mass (distal)<br />
4. Lymph nodes in 1/2 superior mesentery near pylorus<br />
5. Lymph nodes in proximal 1/2 superior mesentery<br />
6. Lymph nodes distal 1/2 inferior mesentery<br />
7. Lymph nodes proximal 1/2 inferior mesentery<br />
DIAGNOSIS:<br />
1. Stomach: Poorly differentiated adenocarcinoma infiltrating through muscular<br />
wall and involving serosa.<br />
2. Duodenum: No tumor in sections examined.<br />
3. Stomach: Chronic gastritis with intestinalization of gastric mucosa.<br />
4. Seven lymph nodes: four contain metastatic carcinoma.<br />
5. Two lymph nodes: one contains metastatic carcinoma.<br />
6,7. Tumor nodules involving fat.<br />
Examined by Patrick Holly, MD<br />
Pathologist<br />
223