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Example G6

PATHOLOGICAL REPORT


Name: Ben Hurtin          Path. No.: S91-1017       Reg. No.: 000042

Age:74       Sex:Male                    Race:White        Location:______  
Service:Surgery                                                    Date: 03/17/91

Address:________________________      Occupation:________________


HISTORY OF CASE: Melanoma (R) arm; pos (R) axillary node

CLINICAL DIAGNOSIS: Melanoma Stage III

POST-OPERATIVE DIAGNOSIS: Carcinoma of bladder

Surgeon: Otto Fixum, MD          Operation: R axillary node dissection

GROSS DESCRIPTION:

 

The specimen is received in two portions. Part 1 labeled "axillary node, right" consists of a single lymph node with attached fibroadipose tissue. The specimen is bisected and submitted in toto. Part 2 is received in a steel pan. It is labeled "contents, right axillary node dissection". A solitary silk suture identifies the highest axillary level which is separated and designated #3. A portion of pectoralis major muscle measuring 7.0 x 5.0 x 2.0 cm in thickness is attached to this portion. Level II contains a mass 6.5 x 3.5 cm which is firm and on cut surface contains a homogeneous flesh-like mass which is light gray in color and firm in consistency. Photographs are made. Several small nodes are identified in level I which consists primarily of adipose tissue.

MICROSCOPIC:

 

Sections of 18 lymph nodes revealed in 3 of them diffuse replacement of normal lymphoid tissue by epithelioid-in-appearance malignant cells. The mitotic activity is marked and nuclei disclose prominent pleomorphism. No melanin pigment is identified.

DIAGNOSIS:

 

Metastatic malignant melanoma, in 3 of 18 (Level I (one), level II (one), and level III (one)), right axillary lymph nodes.

Mac McSmall,MD
Pathologist

 


Suggested Abstraction

Example G6 can be abstracted as follows:

03/17/91. Path. Rpt. S91-1017:

Right axillary node dissection. Metastatic malignant melanoma in 3/18 nodes, one node in each level Dx: metas. Malignant melanoma