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Operative Report Example 4

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Path. No.: S91-999

Name: Marie du Malade
Reg. No.: 000041

Age: 47
Sex: Female
Race: White
Location: _____
Date: 09/11/91

Address:________________________
Occupation:________________


History of Case: 47 year-old white female with ten-year history of gastric ulcer

Clinical Diagnosis: Carcinoma of the 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 at 1 cm in diameter penetrating well-circumscribed ulcer was found in the wall of the lesser curvature. This ulcer penetrated to a depth of 1 cm. 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.

Mictoscopic:

Microscopically there is a ragged ulcer penetrating to within 5 mm of the serosal surface. The ulcer is surrounded by dense connective response and chronic inflammatory infiltrate. The edges are not heaped up, but several sections of the ulcer reveal malignant changes. The tumor is superficial and composed of poorly formed glands and sheets of malignant cells. The cells are pleomorphic with small amounts of eosinophilic cytoplasm. The nuclei are either pyknotic or large with prominent nucleoli and clumped chromatin. Mitoses are rare. The tumor proper does not extend below the mucosa, but a single nest of malignant cells is seen in a submucosal lymphatic space. The surgical margins are free of tumor.

Four perigastric lymph nodes show no evidence of metastatic spread.

There are two segments of large peripheral nerve.

Diagnosis:

  1. Superficial spreading carcinoma rising in the margin of a chronic gastric ulcer - the surgical margins appear free of tumor.
  2. Perigastric lymph nodes (4) without demonstrable metastases.

Tish Ewing, MD
Pathologist