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Operative Report Example 1

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Path. No.: S91-210

Name: Sally Sacqueski
Reg. No.: 000038

Age: 66
Sex: Female
Race: White
Location: _____
Date: 02/11/91

Address:________________________
Occupation:________________

History of Case: Multiple TURB for Grade II TCC with microinvasion; multiple tumors

Clinical Diagnosis: Carcinoma of bladder; R/O scalene node metastasis

Post-operative Diagnosis: Carcinoma of bladder

Surgeon: So Long, MD

Operation: Bx of bladder & L scalene node

Gross Description:

The specimen is received in two parts. They are labeled #1, "biopsy bladder tumor", and #2, "scalene node, left". Part #1 consists of multiple fragments of gray-brown tissue which appear slightly hemorrhagic. They are submitted in their entirety for processing. Part #2 consists of multiple fragments of fatty yellow tissue which range in size from 0.2 to 1.0 cm in diameter. They are submitted in their entirety for processing.

Microscopic:

Section of bladder contains areas of transitional cell carcinoma. No area of invasion can be identified. A marked acute and chronic inflammatory reaction with eosinophils is noted together with some necrosis. Sections are examined at six levels. Section of lymph node contains normal node with reactive germinal centers.

Diagnosis:

  1. Papillary transitional cell carcinoma, grade II, bladder, biopsy
  2. Acute and chronic inflammation, most consistent with recent biopsy procedure
  3. Scalene lymph node, left, no pathologic diagnosis

Mike O'Seen,MD
Pathologist