SEER Logo

SEER Training Modules

Biopsy Example

View the suggested abstraction.


Name: Sammy Kidd
Hospital No.: 0000037

Sex: Male
Age: 56
Race: White
Clinical Diagnosis: Carcinoma of Bladder

Address: _______________________________
Path No.: S91-1017

Clinic or Floor:___________________________
Surgery Date: 03/31/91


Pathologic Diagnosis: Papillary transitional cell carcinoma, GR III


Operation: Multiple biopsies of bladder

Attending Physician: O.P. Bixby, MD

Gross:

The specimen is submitted in formalin in two parts.

Part one is labeled "random bladder biopsy" and consists of two fragments of tissue each measuring approximately 1 x 1 mm.

Part two is labeled "right anterior bladder wall" and consists of multiple fragments of tissue measuring from 1 x 0.5 x 0.5 cm to 2 x 1 x 0.5 cm. This tissue is dark and appears to have hyperplastic epithelium and underlying muscularity.

Microscopic:

Sections of random bladder biopsies show mild to moderate epithelial atypia. Sections of urinary bladder labeled "right anterior bladder wall" show a papillary neoplasm with markedly atypical cells and high mitotic activity invading in solid nests into the lamina propria, but not the muscularis. Adjacent mucosa shows severe atypia.

Diagnosis:

Urinary bladder (biopsy) - Papillary transitional cell carcinoma, Grade III.
Urinary bladder (random biopsies) - Mild to moderate epithelial atypia.


Ralph Abitt, MD
Pathologist