AORTIC VALVE TISSUE, EXCISION:

1. HYALINIZED AND CALCIFIED VEGETATIONS.
2. AORTIC STENOSIS, CLINICALLY.
3. NO EVIDENCE OF MALIGNANCY.

APPENDIX, APPENDECTOMY:

1. ACUTE APPENDICITIS.
2. ACUTE APPENDICITIS WITH PERFORATION AND ABSCESS.
3. ACUTE GANGRENOUS APPENDICITIS WITH PERFORATION.
4. FOCAL ISCHEMIC NECROSIS.
5. FIBROUS OBLITERATION OF DISTAL LUMEN.
6. FECALITH (Gross diagnosis).
7. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
CERVIX, UTERUS, BILATERAL OVARIES AND FALLOPIAN TUBES, HYSTERECTOMY AND BILATERAL SALPINGO-OOPHORECTOMY:

1. TOTAL WEIGHT –  204gms.
2. UNREMARKABLE ENDOCERVIX AND ECTOCERVIX.
3. ENDOMETRIUM -  PRONOUNCED PROGESTATIONAL EFFECTS.
4. MYOMETRIUM -  INTRAMURAL LEIOMYOMAS X 2, LARGEST 0.6cm.
5. LEFT AND RIGHT OVARIES -  FOLLICULAR CYSTS.
6. LEFT AND RIGHT FALLOPIAN TUBES –

            - STATUS POST PREVIOUS SEGMENTAL SALPINGECTOMY.
      - FOCAL ENDOMETRIOSIS.

1. NO EVIDENCE OF DYSPLASIA, HYPERPLASIA, OR MALIGNANCY.

 
 
UTERUS, CERVIX, BILATERAL FALLOPIAN TUBES, HYSTERECTOMY AND BILATERAL SALPINGECTOMIES:

1. TOTAL WEIGHT –  124gms.
2. UNREMARKABLE ENDOCERVIX AND ECTOCERVIX.
3. ENDOMETRIUM -  BASALIS TYPE GLANDS WITH FOCAL SUPERFICIAL SECRETORY PATTERN.
4. MYOMETRIUM -  FOCAL ADENOMYOSIS.
5. LEFT AND RIGHT FALLOPIAN TUBES – PARATUBAL CYSTS, x2, LARGEST 1.5cm.
6. NO EVIDENCE OF DYSPLASIA, HYPERPLASIA, OR MALIGNANCY.

 
 
UTERUS, CERVIX , BILATERAL OVARIES AND FALLOPIAN TUBES, HYSTERECTOMY AND BILATERAL SALPINGO-OOPHORECTOMY:

1. TOTAL WEIGHT –  120gms.
2. ENDOCERVIX AND ECTOCERVIX – CHRONIC CERVICITIS, NABOTHIAN CYSTS.
3. ENDOMETRIUM -  FOCAL SECRETORY PATTERN.
4. MYOMETRIUM -  UNREMARKABLE.
5. LEFT AND RIGHT OVARIES -  HEMORRHAGIC CORPUS LUTEUM, FOLLICULAR CYSTS AND CORPORA ALBICANTIA.

                        -FOCAL ENDOMETRIOSIS.
                        -TUBO-OVARIAN ADHESIONS

1. LEFT AND RIGHT FALLOPIAN TUBES – FOCAL ENDOMETRIOSIS.
2. NO EVIDENCE OF DYSPLASIA, HYPERPLASIA, OR MALIGNANCY.

 
 
UTERUS, BILATERAL OVARIES AND FALLOPIAN TUBES, HYSTERECTOMY AND BILATERAL SALPINGO-OOPHORECTOMY:

1. TOTAL WEIGHT –  246gms.
2. CERVIX -  NABOTHIAN CYSTS.

                -  SQUAMOUS METAPLASIA.

1. ENDOMETRIUM       -  FOCUS OF COMPLEX HYPERPLASIA WITH MILD ATYPIA, 0.9cm.

                                        -  PROLIFERATIVE PATTERN.
                                                                -  ENDOMETRIAL POLYP.

1. MYOMETRIUM -  INTRAMURAL LEIOMYOMAS X 2, LARGEST 2cm.
2. LEFT AND RIGHT OVARIES -  FOLLICULAR CYSTS.
3. LEFT AND RIGHT FALLOPIAN TUBES – PARATUBAL CYSTS, LARGEST 1.6cm.
4. NO DEFINITIVE EVIDENCE OF MALIGNANCY.

 
INTERPRETATION:
 
CERVIX, UTERUS, HYSTERECTOMY:

1. TOTAL WEIGHT –  68gms.
2. UNREMARKABLE ENDOCERVIX AND ECTOCERVIX.
3. ENDOMETRIUM -  EARLY SECRETORY PATTERN.
4. MYOMETRIUM -  UNREMARKABLE.
5. NO EVIDENCE OF DYSPLASIA, HYPERPLASIA, OR MALIGNANCY.

 
 
 
INTERPRETATION:
 
UTERUS, BILATERAL OVARIES AND FALLOPIAN TUBES, HYSTERECTOMY AND BILATERAL SALPINGO-OOPHORECTOMY:

1. TOTAL WEIGHT –  246gms.
2. CERVIX -  NABOTHIAN CYSTS.

              -  SQUAMOUS METAPLASIA.

1. ENDOMETRIUM      -  FOCAL ENDOMETRIOID CARCINOMA IN  A FOCUS OF ENDOMETRIAL INTRAEPITHELIAL NEOPLASIA / ATYPICAL COMPLEX HYPERPLASIA, LESS THAN 1.2 cm, LIMITED TO ENDOMETRIUM, NO MYOMETRIAL INVASION IDENTIFIED (see comment).

                              -  BACKGROUND PROLIFERATIVE PATTERN.
                                                -  ENDOMETRIAL POLYP.

1. MYOMETRIUM -  MULTIPLE INTRAMURAL LEIOMYOMAS, LARGEST 2cm.

                         -  ADENOMYOSIS.

1. LEFT AND RIGHT OVARIES -  FOLLICULAR CYSTS.
2. LEFT AND RIGHT FALLOPIAN TUBES – PARATUBAL CYSTS, LARGEST 1.6cm.

 
Surgical Pathology Cancer Case Summary
Protocol posting date: June 2017
COMMENT:
In some areas the architectural complexity approaches that of Grade I endometrial carcinoma. This case was submitted for intradepartmental review with agreement in diagnosis.
The entire endometrium was examined microscopically.
Dr. Lopez was unavailable for discussion of this case on 8-11-2017.
According to the Society of Gynecology Oncology clinical practice statement all women diagnosed with endometrial cancer should undergo systematic clinical screening for Lynch syndrome and/or molecular screening. Molecular tumor testing on cancers diagnosed at age less than 60 regardless of personal or family cancer history is recommended.
Therefore block 1U will be submitted for Lynch Syndrome molecular testing.  A separate report will follow.
 
 
SPECIMEN 1.  UTERINE TUMOR, EXCISION:

1. LEIOMYOMA, BENIGN, 13 cm, 483 gms.
2. NO EVIDENCE OF MALIGNANCY.

 
SPECIMEN 2.  UTERUS, OVARIES & TUBES, HYSTERECTOMY AND BILATERAL SALPINGO-OOPHORECTOMY:

1. UTERUS AND CERVIX WEIGHT –  26gms.
2. UNREMARKABLE ENDOCERVIX AND ECTOCERVIX.
3. ENDOMETRIUM -  MARKED ATROPHY, INACTIVE.
4. MYOMETRIUM -  DISRUPTED SURGICAL DEFECT.
5. LEFT AND RIGHT OVARIES -  ATROPHIC CHANGES.
6. LEFT AND RIGHT FALLOPIAN TUBES –  UNREMARKABLE.
7. NO EVIDENCE OF DYSPLASIA, HYPERPLASIA, OR MALIGNANCY.

 
CERVIX, UTERUS, BILATERAL OVARIES AND FALLOPIAN TUBES, HYSTERECTOMY AND BILATERAL SALPINGO-OOPHORECTOMY:

1. UNREMARKABLE ENDOCERVIX AND ECTOCERVIX.
2. CORPUS OF UTERUS WEIGHT –  62gms.
3. ENDOMETRIUM -  ATROPHIC, INACTIVE.  SMALL ENDOMETRIAL POLYP.
4. MYOMETRIUM -  INTRAMURAL LEIOMYOMAS X 2, LARGEST 1.6cm.

                                           -  ADENOMYOMA, 2.2cm.

1. LEFT OVARY -  BENIGN MUCINOUS CYSTADENOMA, 12cm, 678gms.
2. RIGHT OVARY -  UNREMARKABLE.
3. RIGHT FALLOPIAN TUBE – BENIGN PARATUBAL CYSTS.
4. LEFT FALLOPIAN TUBE -  UNREMARKABLE.
5. NO EVIDENCE OF DYSPLASIA, HYPERPLASIA, OR MALIGNANCY.

 
 
 
SPECIMEN 1.  ENDOMETRIAL CURETTINGS:

1. PROLIFERATIVE PATTERN.
2. UNREMARKABLE ENDOCERVICAL MUCOSA.
3. NO EVIDENCE OF DYSPLASIA, HYPERPLASIA OR MALIGNANCY.

 
SPECIMEN 2.  UTERUS, CERVIX, HYSTERECTOMY:

1. TOTAL WEIGHT –  222gms.
2. ACUTE AND CHRONIC CERVICITIS, MILD.

      - FOCAL SQUAMOUS METAPLASIA.

1. ENDOMETRIUM -  PROLIFERATIVE PATTERN.
2. MYOMETRIUM -  INTRAMURAL LEIOMYOMA, 4.5cm.
3. NO EVIDENCE OF DYSPLASIA, HYPERPLASIA, OR MALIGNANCY.

 
SPECIMEN 3.  LEFT TUBE AND OVARY, LEFT SALPINGO-OOPHORECTOMY:

1. OVARY -  FOLLICULAR CYSTS.
2. FALLOPIAN TUBE – PARATUBAL CYST, 1.3cm.
3. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
SPECIMEN 4.  RIGHT FALLOPIAN TUBE, SALPINGECTOMY:

1. PARATUBAL CYST, 0.8cm.
2. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
 

INTERPRETATION:
 
ASCITES FLUID, PARACENTESIS, CYTOLOGY:

1. NO MALIGNANT CELLS DETECTED.
2. MODERATE NUMBERS OF MIXED INFLAMMATORY CELLS, PREDOMINANTLY LYMPHOID WITH FEW ADMIXED NEUTROPHILS.
3. REACTIVE-APPEARING MESOTHELIAL CELLS AND MACROPHAGES.
4. BACKGROUND BLOOD.

 
 
 
SPECIMEN ADEQUACY:
The specimen is satisfactory.
 
MICROSCOPIC:
There are two H&E stained slides prepared from one cell block and two Pap stained cytospin preparations examined microscopically.  There are inflammatory cells, benign appearing mesothelial cells and red blood cells.  There are no malignant cells detected.
 
 
ASCITES FLUID, PARACENTESIS, CELL BLOCK AND CYTOSPIN PREPARATIONS, CYTOLOGY:

1. NO MALIGNANT CELLS DETECTED.
2. MODERATE NUMBERS OF LYMPHOID CELLS.
3. REACTIVE-APPEARING MESOTHELIAL CELLS AND MACROPHAGES.

 
 
 
 
 
 
 
SPECIMEN ADEQUACY:
The specimen is satisfactory.
 
MICROSCOPIC:
There are two H&E stained slides prepared from one cell block and two Pap stained cytospin preparations examined microscopically.  There are lymphoid cells, benign reactive appearing mesothelial cells and macrophages.  There are no malignant cells detected.
 
 
 
ASCITES FLUID, PARACENTESIS, CELL BLOCK AND CYTOSPIN PREPARATIONS, CYTOLOGY:

1. NO MALIGNANT CELLS DETECTED.
2. MODERATE NUMBERS OF MIXED INFLAMMATORY CELLS.
3. REACTIVE-APPEARING MESOTHELIAL CELLS AND MACROPHAGES.
4. BACKGROUND BLOOD.

 
 
ASCITES FLUID, PARACENTESIS, CELL BLOCK AND CYTOSPIN PREPARATIONS, CYTOLOGY:

1. NO MALIGNANT CELLS DETECTED.
2. BENIGN MESOTHELIAL CELLS AND MACROPHAGES.
3. FEW INFLAMMATORY CELLS AND RED BLOOD CELLS

 
 
 
 
 
LEFT SIDE PERITONEAL FLUID, PARACENTESIS:
METASTATIC ADENOCARCINOMA, SUSPICIOUS FOR MULLERIAN PRIMARY (See comment).
 
COMMENT:
The cells are degenerated, and the interpretation is made with caution due to the scarcity of malignant cells.  Multiple immunohistochemical stains were examined, and suggest a mullerian primary.  Clinical correlation is recommended.
This case was submitted for intradepartmental review with agreement in diagnosis.
The findings and diagnosis of this case were discussed with Dr. Padmaja Polavarapu MD, on 12-14-2017, who said she would discuss this case with Dr. Nunez at Mission Hospital..
 
 
 
 
 
SPECIMEN ADEQUACY:   Adequate.
 
MICROSCOPIC:   There are 6 H&E stained slides prepared from 3 cell blocks and 4 Pap stained cytospin preparations, and 10 immunostains examined microscopically. 
 
IMMUNOHISTOCHEMICAL STAINS:  (all stains examined with appropriate controls):
MOC-31 – Positive in few malignant cells.
Mesothelin – N/A due to the section falling off the slide..
Calretinin - Negative in malignant cells.
Ber-EP4 - Positive in malignant cells.
PAX8- Positive in malignant cells.
WT1- Negative in malignant cells.
GATA3- Negative in malignant cells.
p53- Positive in malignant cells.
ER- Negative in malignant cells.
TTF1-  N/A due to cells of interest not present in this section.
 
Immunohistochemical stains were technically performed at Mid-Valley Pathology, PLLC (2300 West Pike Blvd, Suite 103-B, Weslaco, TX 78596) and interpreted at Knapp Medical Center Dept Pathology (1401 East 8th Street, Weslaco, TX, CLIA#45D0503943). Stain controls are adequate.
 
Final Diagnosis performed by
Alberto Gonzalez, MD
Pathologist
Electronically signed 12/14/2017 1:06:04PM
 
 

 
 
PERITONEAL FLUID, CELL BLOCK AND CYTOSPIN PREPARATIONS, CYTOLOGY:

1. NO MALIGNANT CELLS DETECTED (Immunostains done, see below).
2. INCREASED NUMBERS OF INFLAMMATORY CELLS,  RED BLOOD CELLS.
3. PROTEINACEOUS BACKGROUND.

 
 
 
 
 
 
SPECIMEN ADEQUACY:
Satisfactory specimen.
 
MICROSCOPIC:
There are 2 H&E stained sections from 1 cell block and 2 Pap stained cytospin preparations examined microscopically and exhibit increased numbers of mixed inflammatory cells, few benign mesothelial cells, and red blood cells in a proteinaceous background..  There are no malignant cells detected.
 
IMMUNOHISTOCHEMICAL STAINS:  (all stains examined with appropriate controls):
MOC-31 – Negative.
Mesothelin – Negative..
Calretinin – Negative.
Ber-EP4 - Negative.
 

 
Due to the scan amount of viable tumor present in the above biopsy, ancillary biomarkers will be deferred to the pending resection specimen.
 
 
 
SPECIMEN 1.  TRANSVERSE COLON POLYP, BIOPSY:

1. TUBULAR ADENOMA.
2. NO EVIDENCE OF HIGH-GRADE DYSPLASIA OR MALIGNANCY.

 
SPECIMEN 2.  DESCENDING COLON POLYP, BIOPSY:

1. SESSILE SERRATED POLYP.
2. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
SPECIMEN 1.  DESCENDING COLON POLYP , @30cm., BIOPSY:

1. TUBULAR ADENOMA.
2. MARGIN OF STALK FREE OF DYSPLASIA.
3. NO EVIDENCE OF HIGH-GRADE DYSPLASIA OR MALIGNANCY.

 
 
COMMENT:
Colonoscopy report per Dr. Sy-Castillo dated 11-30-2017:  Findings -  Cecum -  Flat polyp of size 1.5cm.  Polypectomy done by snare cautery, raised with saline instilled, biopsies taken.
Colonoscopy report per Dr. Sy-Castillo dated 12-28-2017:  Findings -  Ascending colon -  Sessile polyp of size 8mm.  Polypectomy done by snare cautery.
 
Colonoscopy report per Dr. Khizar Ahsan dated 1-30-2018:  Findings -  Sigmoid colon -  Sessile polyp of size 4mm.  Polypectomy done using biopsy forceps #2.


 
Colonoscopy report per Dr. Green dated 1-29-2018:  Findings -  A 3 mm polyp was found in the cecum.  The polyp was flat.  The polyp was removed with a cold biopsy forceps.  Resection and retrieval were complete.
 
 
 
Transverse colon -  Sessile polyp of size 2mm.  Polypectomy done using biopsy forceps #1.
 
 
Colonoscopy report per Dr. Berg dated  9-xx-2017:  Impression -  Polyps.
Colonoscopy report per Dr. Grigg dated 9-xx-2017:  Impression -  Polyps.
The upper GI endoscopy report and the colonoscopy report were unavailable for review at the time of this dictation.
 
The upper GI endoscopy report was unavailable for review at this time.
 
The colonoscopy report was unavailable for review at this time.
 
SPECIMEN 1.  ASCENDING COLON POLYPS X4, BX 6:

1. FRAGMENTS OF TUBULAR ADENOMA(S).
2. NO EVIDENCE OF HIGH-GRADE DYSPLASIA OR MALIGNANCY.

 
SPECIMEN 2.  TRANSVERSE COLON POLYPS X3, BX 6: :

1. FRAGMENTS OF TUBULAR ADENOMA(S).
2. NO EVIDENCE OF HIGH-GRADE DYSPLASIA OR MALIGNANCY.

 
SPECIMEN 3.  SIGMOID COLON POLYP, BX X1:

1. HYPERPLASTIC POLYP.
2. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
 
 
RECTAL POLYP, BIOPSY:

1. HYPERPLASTIC POLYP.
2. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
 
DESCENDING COLON POLYP, BIOPSY:

1. HYPERPLASTIC POLYP.
2. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
RECTAL MUCOSA WITH SUPERFICIAL HYPERPLASTIC CHANGES, POSSIBLY REPRESENTING A DIMINUTIVE HYPERPLASTIC POLYP. 
 
 
SIGMOID COLON POLYP, BIOPSY:

1. SMALL LYMPHOID AGGREGATE .
2. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
 
DESCENDING COLON POLYP, BIOPSY x 3:

1. COLONIC MUCOSA WITH PROMINENT LYMPHOID AGGREGATE.
2. HYPERPLASTIC CHANGES
3. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
ANAL VERGE, BX x 4:

1. ANAL-RECTAL MUCOSA WITH REACTIVE CHANGES, MILD ACUTE INFLAMMATION.
2. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
 
ASCENDING COLON POLYP MASS, BIOPSY:

1. TUBULAR ADENOMA. (See comment).
2. NO EVIDENCE OF HIGH-GRADE DYSPLASIA OR MALIGNANCY.

 
COMMENT:
In the setting of a mass lesion, more severe dysplasia or invasive carcinoma in unsampled areas cannot be excluded.
The colonoscopy report was unavailable for review at this time.
This case was submitted for intradepartmental review with agreement in diagnosis.
 
 

 
SPECIMEN 1.  GASTRIC ANTRUM, BX:

1. REACTIVE/CHEMICAL GASTROPATHY AND MILD CHRONIC GASTRITIS.
2. NEGATIVE FOR INTESTINAL METAPLASIA (Alcian blue/PAS stain examined).
3. NO HELICOBACTER PYLORI ORGANISMS IDENTIFIED ON IMMUNOSTAIN.
4. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
SPECIMEN 2.  GASTRIC BODY, BX:

1. CHRONIC GASTRITIS WITH ATROPHY.
2. FOCAL INTESTINAL METAPLASIA (Alcian blue/PAS stain examined).
3. NO HELICOBACTER PYLORI ORGANISMS IDENTIFIED ON IMMUNOSTAIN.
4. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
SPECIMEN 3.  GE JUNCTION, BX:

1. SQUAMOUS MUCOSA WITH INCREASED INTRAEPITHELIAL EOSINOPHILS, UP TO 22 PER HPF (SEE COMMENT).
2. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
COMMENT:
Approximately 22 intraepithelial eosinophils per high power field in the highest count area are noted in the esophageal mucosa.  The differential diagnosis includes both eosinophilic esophagitis and reflux esophagitis.  The number of intraepithelial eosinophils is significantly more than what is usually seen with reflux esophagitis.
 

GENERAL GI TRACT:
 
Amyloid:
giamylcom1
COMMENT: No submucosa is identified in this biopsy.  A deeper biopsy is recommended for adequate evaluation for amyloid.
 
giamylcom2
COMMENT: By immunohistochemistry, the amyloid is negative for both light chains, amyloid A, transthyretin, and beta-2-microglobulin, indicating it is likely not derived from these proteins.  However, false negatives may occasionally occur with amyloid immunostaining and correlation with SPEP/UPEP/serum free light chains is suggested for confirmation.  It is possible this may represent another genetic/familial form of amyloid.  If further typing of amyloid is indicated, mass spectrometry for amyloid protein content may be considered.
 
Cautery artefact:
gicautcom
 
COMMENT: The presence of marked cautery artifact precludes accurate assessment of the specimen.
 
IgG4:
gilgG4com
COMMENT: Increased numbers of IgG4-positive plasma cells may be seen in IgG4-related fibrosclerosing diseases as well as in nonspecific inflammatory conditions.  Clinical correlation is essential.
 
Mast cells:
gimastcom1
COMMENT: Immunohistochemical stain for tryptase performed on  biopsy reveals  mast cells per high-power field.  This finding suggests an increase in the number of mast cells, which may be seen in a subset of patients with irritable bowel syndrome.
 
gimast
-     Colonic or small intestinal mucosa with no significant histopathologic changes on routine H&E sections
-     Immunostain for tryptase reveals an average of  mast cells per high power field (see Comment)
 
gimastcom2
COMMENT: On the immunostain for tryptase performed on the  biopsy, an average of approximately  mast cells per high power field (range:  to  mast cells per high power field) was observed (averaged over  consecutive high power fields).
The normal range of mast cells within the gastrointestinal mucosa has not been well documented in the literature.  For example, in the study by Jakate et al., the upper limit of normal was considered to be 20 mast cells per high power field, based on a study of biopsies from the duodenum (n = 25) and colon (n = 25) from adult patients with conditions unrelated to diarrhea.  In contrast, in the study by Hahn et al., the number of mast cells ranged from 4 to 51 per high power field (mean = 27) in duodenal mucosa (n = 10) and from 10 to 31 per high power field (mean = 21) in colonic mucosa (n = 10) in normal control patients without a history of diarrhea, nausea, or vomiting.
 
References:
1)   Jakate S, et al.  Mastocytic enterocolitis.  Increased mucosal mast cells in chronic intractable diarrhea.  Arch Pathol Lab Med 130: 362-367, 2006.
2)   Hahn HP, et al.  Immunoreactivity for CD25 in gastrointestinal mucosal mast cells is specific for systemic mastocytosis.  Am J Surg Pathol 31: 1669-1676, 2007.
 
Submucosal lesion:
gisubcom
No submucosal tissue is represented in the biopsy specimen.  The possibility of a clinically significant lesion in the submucosa or deeper layers of the gastrointestinal wall therefore cannot be excluded.  Correlation with endoscopic observations and/or findings on imaging studies is recommended.
 
ANUS (AN):
Benign papillomatous verruciform keratosis:
anbenker
 
-     Benign papillomatous verruciform keratosis
 
APPENDIX (AP):
Appendicitis/periappendicitis:
appericom
COMMENT: Acute periappendicitis in the absence of acute inflammation in the appendiceal wall or mucosa suggests secondary inflammation of the appendix due to the presence of an extra-appendiceal intra-abdominal acute inflammatory process.  Correlation with complete clinical information (including operative findings) is recommended.
 
Granulomas in appendix:
apgrancom
 
COMMENT: The possible etiologies of the granulomatous inflammation in the appendix include infection (particularly yersinial, mycobacterial, and fungal), foreign body reaction, Crohn's disease and sarcoidosis.  Granulomatous inflammation of the appendix may also be seen in "interval appendicitis" (appendectomy performed after resolution of an episode of acute appendicitis).  In addition, granulomatous appendicitis may be idiopathic.  Correlation with complete clinical information is recommended.
 
COLON (CO):
Chronic constipation:
coconst
 
-     Clinical history of chronic constipation
-     No significant histopathologic abnormalities in the neuromuscular apparatus (see comment)
 
coconstcom
COMMENT: The number and distribution of ganglion cells and nerve plexi appear to be within normal limits.  No obvious hypertrophic or degenerative changes of the muscularis propria and mucosae are noted.  There is no significant inflammation or mural fibrosis.  Immunohistochemically, smoothelin, desmin and smooth muscle actin stain the muscularis mucosae and both layers of the muscularis propria appropriately.  CD117 immunostain demonstrates a normal number and distribution of interstitial cells of Cajal.  S-100 immunostain highlights a normal distribution of nerves in the submucosal and intermyenteric nerve plexi.
 
Colitis:
cofaccom
COMMENT: Focal active colitis may be seen in association with infection, ischemia, inflammatory bowel disease (IBD), diverticulosis, drug use, and bowel preparation effect or may occur as an incidental histologic finding.  No other diagnostic abnormality or histologic alterations suggestive of IBD are noted in the biopsies.  Correlation with complete clinical information and endoscopic observations is recommended.
 
coibddyscom
COMMENT: The histologic features alone cannot differentiate IBD-associated low grade dysplasia from sporadic adenoma.  Correlation with endoscopic findings is recommended.
 
coibdpatchycom
COMMENT: The histologic findings in this series of colorectal biopsies are consistent with chronic inflammatory bowel disease.  Although the presence of some patchiness of inflammation in some of the specimens raises the possibility of Crohn's disease, no granulomas are identified in any of the specimens, and patchiness of inflammation may be seen in patients with ulcerative colitis following treatment.  No viral inclusions are identified in any of the specimens, and there is no evidence of dysplasia.  Correlation with complete clinical information and endoscopic observations is recommended.
 
coielcom
COMMENT: The increase in the number of intraepithelial lymphocytes seen in the random colon biopsies is of uncertain etiology.  Although this finding raises the possibility of lymphocytic colitis, the biopsies lack other features typical of lymphocytic colitis, including a significant increase in the number of chronic inflammatory cells in the lamina propria and surface epithelial damage.  Other conditions in which increased numbers of intraepithelial lymphocytes may be seen in colorectal mucosa include (but are not limited to) infectious colitis, Crohn's disease, celiac disease, autoimmune disorders, and medication effect (e.g., NSAID effect).  Clinical correlation is recommended.
 
Muciphages:
comucicom
COMMENT: The presence of increased muciphages in the lamina propria is usually physiologic and is of no clinical significance.
 
Spirochetosis:
cospircom
COMMENT: There is controversy in the literature with regard to whether intestinal spirochetosis is an asymptomatic condition or may be responsible for diarrheal disease or other symptomatology.  The presence of intestinal spirochetosis in this case is not associated with significant inflammation.  Clinical correlation is recommended.
 
DUODENUM (DU)
Increased intraepithelial lymphocytes:
duielcom
COMMENT: Intraepithelial lymphocytosis may be seen in duodenal or small intestinal mucosa with preserved villous architecture in a variety of conditions including mild forms of gluten sensitive enteropathy, Helicobacter pylori gastritis, infective enteritis, peptic injury, drug effect (e.g., NSAID injury), bacterial overgrowth, morbid obesity, Crohn's disease, non-gluten food sensitivity, IgA deficiency, common variable immunodeficiency, and systemic autoimmune disorders.  Correlation with complete clinical information is recommended.
 
ESOPHAGUS (ES)
Eosinophilic esophagitis:
eseoscom
COMMENT: The differential diagnosis of increased eosinophils within esophageal squamous epithelium includes (but is not limited to) reflux esophagitis, eosinophilic esophagitis, reaction to medication, collagen vascular disease, and Crohn's disease.
 
Lymphocytic esophagitis:
eslymcom
COMMENT: This pattern of esophageal inflammation may be seen in association with a number of different conditions, including (but not limited to) gastroesophageal reflux disease, drug effect, allergies, Crohn's disease, Helicobacter gastritis, and celiac sprue.  Correlation with complete clinical information and endoscopic observations is recommended.
 
 
Reflux vs. eosinophilic esophagitis:
esre/eecom
COMMENT: Approximately  intraepithelial eosinophils per high power field are noted in the esophageal mucosa.  The differential diagnosis includes both eosinophilic esophagitis and reflux esophagitis.  The number of intraepithelial eosinophils is significantly more than what is usually seen with reflux esophagitis, but is less than is typically present in eosinophilic esophagitis. Correlation with complete clinical information and endoscopic observations is recommended.  If clinically indicated, additional biopsies from the proximal and mid esophagus may be useful to help differentiate between these two entities.
 
Esophagitis dissecans superficialis:
esdisscom
COMMENT: The histologic features seen in the biopsy have been described in association with the endoscopic finding of "sloughing esophagitis", also referred to as "esophagitis dissecans superficialis".  This condition has been reported to be seen in association with medications, trauma (physical or contact), esophageal stricture, heavy smoking, immunosuppression, and skin conditions.  Clinical correlation is recommended.
 
 
GASTROESOPHAGEAL JUNCTION (GEJ):
Intestinal metaplasia at GE junction:
gejimcom
COMMENT: The presence of intestinal metaplasia in biopsies from the GE junction may represent either short segment Barrett esophagus or intestinal metaplasia of the gastric cardia.  Correlation with endoscopic findings and exact site of procurement of biopsies is recommended.
 
 
Possible reflux changes in vicinity of GE junction:
gejprecom
COMMENT: The histologic features raise the possibility of gastroesophageal reflux disease.  However, such reactive and hyperplastic epithelial changes may be seen in the distal 2.5 cm of the esophagus in the absence of clinical symptoms of reflux disease; these findings in biopsies from the gastroesophageal junction (in the absence of significant inflammation of the squamous mucosa) are therefore not specific for reflux disease.  Correlation with clinical history and endoscopic observations is recommended.
 
 
POLYPS (PO):
pocardcom
COMMENT: Cardiac-type polyps are characterized by foveolar hyperplasia and a chronic inflammatory infiltrate within the lamina propria.  They are benign and show no significant association with esophagitis, gastroesophageal reflux disease, or gastritis. 
 
Reference: Melton SD and Genta RM.  Gastric cardiac polyps: a clinicopathologic study of 330 cases.  Am J Surg Pathol, 2010; 34:1792-1797.
 
pohgdcacom
COMMENT: The possibility that high grade dysplasia or invasive carcinoma may be present in the non-biopsied portions of the lesion cannot be excluded.
 
 
poneurcom
COMMENT: Benign mucosal neuromas in the gastrointestinal tract may occur sporadically and in association with a variety of other conditions, including von Recklinghausen's disease, MEN2 syndrome, tuberous sclerosis, Cowden's syndrome, and other polyposis syndromes.  Clinical correlation is recommended.
 
 
popgacom
COMMENT: The majority of pyloric gland adenomas occur in the stomach, but they may also occur elsewhere in the gastrointestinal tract, including the duodenum and biliary tract.  Pyloric gland adenomas may or may not be associated with con­ven­tional/adeno­ma­tous dysplasia.  In the stomach, they are commonly accompanied by intestinal metaplasia and autoimmune gastritis.  Despite their bland histologic appearance, they may evolve into invasive adenocarcinoma.
 
References:
1.   Chen ZM, et al. Pyloric gland adenoma: an entity distinct from gastric foveolar type adenoma.  Am J Surg Pathol.  2009; 33:186-193.
2.   Vieth M, et al.  Pyloric gland adenoma: a clinico-pathological analysis of 90 cases.  Virchows Arch. 2003; 442:317-321.
 
 
 
SMALL INTESTINE (SI):
Vacuolated enterocytes:
sivaccom
COMMENT: In most cases, vacuolization of the cytoplasm of enterocytes in duodenal or small intestinal biopsies is due to recent ingestion of a fat-containing meal and is a reflection of normal absorption of dietary lipid.  Rarely, vacuolization of enterocyte epithelium may be a manifestation of abetalipoproteinemia, hypobetalipoproteinemia, or other disorders resulting in lipid accumulation within enterocytes.  Clinical correlation is recommended.
 
 
STOMACH (S):
Chronic active gastritis without Helicobacter:
scagnohpcom
COMMENT: The histologic pattern of inflammation is suggestive of H. pylori infection, but H. pylori organisms are not seen.  The absence of identifiable H. pylori may be due to inadequate sampling or previous treatment with antibiotics or PPI therapy.  Clinical correlation is recommended.
 
 
Multifocal intestinal metaplasia:
smultimcom
COMMENT: The histologic findings are suggestive of chronic atrophic gastritis.  No dysplasia is seen in these biopsies.  However, this condition is associated with an increased risk of gastric carcinoma.  Appropriate follow up is therefore recommended.
 
 
Granulomas in stomach:
sgrancom
COMMENT: Granulomas can be seen in the stomach in association with infections, Crohn's disease, foreign material, chronic granulomatous disease, and sarcoidosis and may also be seen in the stomachs of otherwise healthy individuals.  GMS and acid-fast stains are negative for mycobacteria and acid-fast bacilli, respectively.  Clinical correlation is recommended.
 
Increased eosinophils in stomach:
seoscom
COMMENT: The differential diagnosis of increased eosinophils in the gastric mucosa includes (but is not limited to) drug effect, infections (particularly parasitic), connective tissue disease, hematopoietic disorders, food allergy, other allergic conditions, and eosinophilic gastroenteritis.  Clinical correlation is recommended.
 
 
 
Collagenous gastritis:
scollcom
COMMENT: Collagenous gastritis in adults may be seen in association with autoimmune disease, other intestinal diseases such as celiac disease, collagenous sprue, and collagenous colitis, and medication use.  Clinical correlation is recommended.
 
 
Lymphocytic gastritis:
slymcom1
COMMENT: Lymphocytic gastritis may occur as an isolated condition or in association with other conditions, including (but not limited to) H. pylori gastritis, celiac disease, lymphocytic enterocolitis, medication use, and Crohn's disease.  No Helicobacter organisms are identified in this case, and there is no histologic evidence of celiac disease in the duodenal biopsy specimen.  Correlation with complete clinical information and endoscopic observations is recommended.
 
 
slymcom2
COMMENT: Lymphocytic gastritis may occur as an isolated condition or in association with other conditions, including (but not limited to) H. pylori gastritis, celiac disease, lymphocytic enterocolitis, medication use, and Crohn's disease.  Correlation with complete clinical information and endoscopic observations is recommended.  Appropriate serologic testing for celiac disease and/or biopsy sampling of the duodenum and colon may be helpful in more precisely defining the etiology.
 
Increased iron in stomach:
sironcom1
COMMENT: The iron deposition is primarily seen within the lamina propria.  This pattern of iron deposition in the stomach is often related to prior inflammation/mucosal hemorrhage or to use of oral iron supplements.
 
 
sironcom2
COMMENT: The iron deposition within gastric glandular cells may be associated with systemic iron overload.  Correlation with complete clinical information is recommended.
 
 
 

SPECIAL STAINS:  Alcian blue/PAS x 2.
 
IMMUNOHISTOCHEMICAL STAINS:              H. pylori x 1,    Gastrin x 1,   Chromogranin A x 1.
 
Immunohistochemical stains were technically performed at Mid Valley Pathology (2300 West Pike Blvd ste 103B Weslaco TX 78596, CLIA# 45D2119325) and interpreted at Knapp Medical Center Dept Pathology (1401 East 8th Street, Weslaco, TX, CLIA#45D0503943). Stain controls are adequate.
 
 
HISTOCHEMICAL STAINS:
Alcian Blue/PAS x1.
 
IMMUNOHISTOCHEMICAL STAINS:
Helicobacter pylori immunostain x1.
 
Immunohistochemical stain for H. pylori organisms was technically performed at Mid Valley Pathology (2300 West Pike Blvd ste 103B Weslaco TX 78596, CLIA# 45D2119325) and interpreted at Knapp Medical Center Dept Pathology (1401 East 8th Street, Weslaco, TX, CLIA#45D0503943). Stain controls are adequate.
 
Immunohistochemical stains were technically performed at Mid Valley Pathology (2300 West Pike Blvd ste 103B Weslaco TX 78596, CLIA# 45D2119325) and interpreted at Knapp Medical Center Dept Pathology (1401 East 8th Street, Weslaco, TX, CLIA#45D0503943). Stain controls are adequate.
 
 
 
Immunohistochemical stains were technically performed at Neogenomics (Irvine 5 Jenner Street, Suite 100, Irvine, CA 92618) and interpreted at Knapp Medical Center Dept Pathology (1401 East 8th Street, Weslaco, TX, CLIA#45D0503943). Stain controls are adequate.
 
 
SPECIMEN 1. STOMACH, BIOPSY:

1. CHRONIC INACTIVE GASTRITIS, VERY MILD.
2. NEGATIVE FOR INTESTINAL METAPLASIA (ALCIAN BLUE/PAS STAIN EXAMINED)
3. NO HELICOBACTER PYLORI ORGANISMS DETECTED ON IMMUNOSTAIN.
4. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
SPECIMEN 2. DESCENDING COLON POLYP, BIOPSY:

1. FRAGMENTS OF TUBULAR ADENOMA.
2. NO EVIDENCE OF HIGH-GRADE DYSPLASIA OR MALIGNANCY.

 
COMMENT:
The upper GI endoscopy report and the colonoscopy report were unavailable for review at the time of this dictation.
 
The upper GI endoscopy report was unavailable for review at this time.
 
06/09/2017 AG/vv
Sections of the entirely submitted first specimen labelled "gastric biopsy" show two fragments of gastric antral mucosa with very mild superficial chronic inactive inflammation.
 
Alcian blue/pas stain (with appropriate control) – no intestinal metaplasia seen.
 
Immunohistochemical stain for H. pylori organisms (with appropriate control) – no organisms detected.
 
Sections of the entirely submitted second specimen labelled "descending colon polyp" show 4/9 fragments of colonic mucosa with low-grade adenomatous changes.  There is no high-grade dysplasia or malignancy seen.
 
 
 
 
SPECIMEN 1.  SMALL BOWEL, BIOPSY:

1. NO SIGNIFICANT HISTOPATHOLOGIC CHANGES.
2. NO EVIDENCE OF GIARDIASIS, CELIA SPRUE OR WHIPPLE'S DISEASE.
3. NEGATIVE FOR GASTRIC FOVEOLAR METAPLASIA (ALCIAN BLUE/PAS STAIN EXAMINED).
4. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
SPECIMEN 2.  STOMACH, RANDOM BIOPSY:

1. CHRONIC GASTRITIS, VERY MILD.
2. NEGATIVE FOR INTESTINAL METAPLASIA (ALCIAN BLUE/PAS STAIN EXAMINED).
3. NO HELICOBACTER PYLORI ORGANISMS DETECTED ON IMMUNOSTAIN.
4. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
SPECIMEN 3.  GASTRIC POLYP, BIOPSY:

1. POLYPOID FOVEOLAR HYPERPLASIA.
2. CHRONIC GASTRITIS, VERY MILD.
3. NEGATIVE FOR INTESTINAL METAPLASIA (ALCIAN BLUE/PAS STAIN EXAMINED).
4. NO HELICOBACTER PYLORI ORGANISMS DETECTED ON IMMUNOSTAIN.
5. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
COMMENT:
Upper GI endoscopy report per Dr. Grigg dated 08/XX/2017 - impression - gastritis.  Polyp status post biopsy.
Colonoscopy report per Dr. Grigg dated 06/26/2017 - impression – One polyp.
 
 
 
DESCENDING COLON POLYP, POLYPECTOMY.

1. TUBULAR ADENOMA.
2. NO EVIDENCE OF HIGH-GRADE DYSPLASIA OR MALIGNANCY.

 
COMMENT:
The colonoscopy report was unavailable for review at this time.
 
SPECIMEN 1.  SMALL BOWEL, BIOPSY:

1. NO SIGNIFICANT HISTOPATHOLOGIC CHANGES.
2. NO EVIDENCE OF GIARDIASIS, CELIA SPRUE OR WHIPPLE'S DISEASE.
3. NEGATIVE FOR GASTRIC FOVEOLAR METAPLASIA (ALCIAN BLUE/PAS STAIN EXAMINED).
4. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
SPECIMEN 2.  STOMACH, RANDOM BIOPSY:

1. CHRONIC GASTRITIS, VERY MILD.
2. NEGATIVE FOR INTESTINAL METAPLASIA (ALCIAN BLUE/PAS STAIN EXAMINED).
3. NO HELICOBACTER PYLORI ORGANISMS DETECTED ON IMMUNOSTAIN.
4. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
SPECIMEN 3.  TRANSVERSE COLON POLYP, BIOPSY:

1. TUBULAR ADENOMA.
2. NO EVIDENCE OF HIGH-GRADE DYSPLASIA OR MALIGNANCY.

 
SPECIMEN 4.  COLON, RANDOM BIOPSIES:

1. NO SIGNIFICANT HISTOPATHOLOGIC CHANGES.
2. NO SIGNIFICANT ACTIVE INFLAMMATION, CHRONIC CHANGES, GRANULOMAS OR EVIDENCE OF MICROSCOPIC COLITIS IDENTIFIED (TRICHROME STAIN EXAMINED).
3. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
SPECIMEN 5.  ASCENDING COLON POLYP, POLYPECTOMY:

1. TUBULAR ADENOMA.
2. NO EVIDENCE OF HIGH-GRADE DYSPLASIA OR MALIGNANCY.

 
SPECIMEN 6.  SPENIC FLEXURE POLYP, POLYPECTOMY:

1. TUBULAR ADENOMA.
2. NO EVIDENCE OF HIGH-GRADE DYSPLASIA OR MALIGNANCY.

SPECIMEN 1.  ASCENDING COLON POLYP, BIOPSY:

1. HYPERPLASTIC POLYP.
2. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
SPECIMEN 2.  TRANSVERSE COLON POLYP, BIOPSY:

1. TUBULAR ADENOMA.
2. NO EVIDENCE OF HIGH-GRADE DYSPLASIA OR MALIGNANCY.

 
SPECIMEN 3.  DESCENDING COLON POLYP, BIOPSY:

1. TUBULAR ADENOMA.
2. NO EVIDENCE OF HIGH-GRADE DYSPLASIA OR MALIGNANCY.

 
SPECIMEN 4.  RECTAL POLYP, BIOPSY:

1. HYPERPLASTIC POLYP.
2. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
 
COMMENT:
Colonoscopy report per Dr. Grigg dated 7-25-2017:  Impression -  Polyps.
 
The specimens appear switched.  The diagnosis for specimen “A” reflects that of specimen “B” and vice versa.
Upper GI endoscopy report per Dr. Grigg dated 10-31-2017:  Findings -  Fundus -  Mucosal inflammation and erythema.  Gastric polyps s/p bx.
 
Upper GI endoscopy report per Dr. Grigg dated 9-27-2017:  Impression -  Mild gastritis.
 
Body -  Mucosal inflammation and erythema s/p bx.
Antrum -  Mucosal inflammation and erythema s/p bx.
This case was submitted for intradepartmental review, and was reviewed by Dr. McPhaul who agrees with the diagnosis.
 
SPECIMEN 1.  TRANSVERSE COLON POLYP, BIOPSY:

1. TUBULAR ADENOMA.
2. NO EVIDENCE OF HIGH-GRADE DYSPLASIA OR MALIGNANCY.

 
SPECIMEN 3.  DESCENDING COLON POLYP, BIOPSY:

1. SESSILE SERRATED POLYP.
2. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
 
SIGMOID COLON POLYP, BIOPSY:

1. SMALL LYMPHOID AGGREGATE .
2. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
 

HISTOCHEMICAL STAINS:  All stains with appropriate controls.
Alcian Blue/PAS x1.
 
IMMUNOHISTOCHEMICAL STAINS:
Helicobacter pylori immunostain x1.
 
Immunohistochemical stain for H. pylori organisms was technically performed at Mid Valley Pathology (2300 West Pike Blvd ste 103B Weslaco TX 78596, CLIA# 45D2119325) and interpreted at Knapp Medical Center Dept Pathology (1401 East 8th Street, Weslaco, TX, CLIA#45D0503943). Stain controls are adequate.
 
 
Upper GI endoscopy report per Dr. Grigg dated 09/XX/2017 - Impression - Gastritis.  Polyp status post biopsy.
COMMENT:
Upper GI endoscopy report per Dr. Grigg dated 01/10/2018 - Impression – Normal esophagus.  Biopsied.
-  Erythematous mucosa in the stomach.  Biopsied.
-  Normal duodenal bulb and second portion of the duodenum.  Biopsied.
 
Upper GI endoscopy report per Dr. Sy-Castillo dated 12/27/2017 – Findings:  Antrum -  Biopsy taken with forceps.  Mild gastritis.
 
Upper GI endoscopy report per Dr. Khizar Ahsan dated 1/28/2018 – Findings:  Antrum -  Biopsy taken with forceps.
 
COMMENT:
Upper GI endoscopy report per Dr. Khizar  Ahsan dated 1/04/2018 – Findings:  Antrum -  Mild gastritis.  Biopsy taken.
Second portion -  Biopsy taken with forceps.  #2.
 
 
 
 
 
 
Upper GI endoscopy report per Dr. Berg dated 09/25/2017 - impression -  The patient has marked gastritis in the body and antrum.  There is no active bleeding.  Biopsies were taken..
 
The upper GI endoscopy report and the colonoscopy report were unavailable for review at the time of this dictation.
 
The upper GI endoscopy report was unavailable for review at this time.
 
INTERPRETATION:
 
 
 
GASTRIC ANTRUM, BIOPSY:

1. ANTRAL-OXYNTIC MUCOSA WITH MILD CHRONIC GASTRITIS.
2. NO HELICOBACTER PYLORI IDENTIFIED ON IMMUNOSTAIN.
3. NO INTESTINAL METAPLASIA (ALCIAN BLUE/PAS) OR DYSPLASIA IDENTIFIED.

 
 
GASTRIC ANTRUM, BIOPSY:

1. MODERATE CHRONIC GASTRITIS.
2. NO HELICOBACTER PYLORI IDENTIFIED ON IMMUNOSTAIN.
3. NO INTESTINAL METAPLASIA (ALCIAN BLUE/PAS) OR DYSPLASIA IDENTIFIED.

 
 
SPECIMEN 1.  ANTRUM,  BIOPSY:

1. ANTRAL MUCOSA WITH FEATURES CONSISTENT WITH REACTIVE/CHEMICAL GASTROPATHY.
2. NO HELICOBACTER PYLORI IDENTIFIED ON IMMUNOSTAIN.
3. NO INTESTINAL METAPLASIA (ALCIAN BLUE/PAS) OR DYSPLASIA IDENTIFIED.

 
SPECIMEN 2.  FUNDUS POLYP, BIOPSY:

1. FUNDIC GLAND POLYP.
2. NO HELICOBACTER PYLORI IDENTIFIED ON IMMUNOSTAIN.
3. NO INTESTINAL METAPLASIA (ALCIAN BLUE/PAS) OR DYSPLASIA IDENTIFIED.

 
 
ANTRUM,  BIOPSY:

1. ANTRAL MUCOSA WITH FEATURES CONSISTENT WITH REACTIVE/CHEMICAL GASTROPATHY.
2. FEW MILDLY DILATED LAMINA PROPRIA VESSELS.
3. NO HELICOBACTER PYLORI IDENTIFIED ON IMMUNOSTAIN.
4. NO INTESTINAL METAPLASIA (ALCIAN BLUE/PAS) OR DYSPLASIA IDENTIFIED.

 
Dilated lamina propria vessels is suggestive of portal hypertensive gastropathy.
 
STOMACH, RANDOM BIOPSY:
            - ANTRAL AND OXYNTIC MUCOSA WITH REACTIVE CHANGES
            - NO HELICOBACTER PYLORI IDENTIFIED ON IMMUNOSTAIN.
            - FOCAL INTESTINAL METAPLASIA (ALCIAN BLUE/PAS EXAMINED).
            - NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.
 
GASTRIC BIOPSY:

1. OXYNTIC MUCOSA WITH REACTIVE GASTROPATHY.
2. NO HELICOBACTER PYLORI IDENTIFIED ON IMMUNOSTAIN.
3. NO INTESTINAL METAPLASIA IDENTIFIED.
4. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
 
STOMACH, RANDOM BIOPSY:
            - ANTRAL-OXYNTIC MUCOSA WITH MILD CHRONIC GASTRITIS AND REACTIVE CHANGES
            - NO HELICOBACTER PYLORI IDENTIFIED ON IMMUNOSTAIN.
            - NO INTESTINAL METAPLASIA (ALCIAN BLUE/PAS) OR DYSPLASIA IDENTIFIED.
            - NO EVIDENCE OF MALIGNANCY.
 
 
 
1. STOMACH, BIOPSY:
            - ANTRAL-OXYNTIC MUCOSA WITH MILD CHRONIC GASTRITIS AND REACTIVE CHANGES
            - FEATURES SUGGESTIVE OF PPI EFFECT.
            - NO HELICOBACTER PYLORI IDENTIFIED ON IMMUNOSTAIN.
            - NO INTESTINAL METAPLASIA (ALCIAN BLUE/PAS) OR DYSPLASIA IDENTIFIED.
 
2. STOMACH, POLYP, BIOPSY:
            - FUNDIC GLAND POLYP.
            - NO HELICOBACTER PYLORI IDENTIFIED ON IMMUNOSTAIN.
            - NO INTESTINAL METAPLASIA (ALCIAN BLUE/PAS) OR DYSPLASIA IDENTIFIED.
 
STOMACH, BIOPSY:

1. REACTIVE CHANGES AND FEATURES SUGGESTIVE OF PPI EFFECT.
2. NO HELICOBACTER PYLORI IDENTIFIED ON IMMUNOSTAIN.
3. NO INTESTINAL METAPLASIA (ALCIAN BLUE/PAS stain examined).
4. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
 
 
 
1. STOMACH, BIOPSY:
ANTRAL MUCOSA WITH FEATURES CONSISTENT WITH REACTIVE/CHEMICAL GASTROPATHY, MILD CHRONIC GASTRITIS AND FOCAL EROSION
NO HELICOBACTER PYLORI IDENTIFIED ON IMMUNOSTAIN.
NO INTESTINAL METAPLASIA (ALCIAN BLUE/PAS) OR DYSPLASIA IDENTIFIED.
 
2. STOMACH, CARDIA, NODULE, BIOPSY:
CARDIA TYPE MUCOSA WITH MILD CHRONIC INFLAMMATION AND FOVEOLAR HYPERPLASIA
NO HELICOBACTER PYLORI IDENTIFIED ON IMMUNOSTAIN
NO INTESTINAL METAPLASIA (ALCIAN BLUE/PAS) OR DYSPLASIA IDENTIFIED
 
 
SPECIMEN 1. EG JUNCTION, BIOPSY:

1. SQUAMO-COLUMNAR (CARDIA-OXYNTIC TYPE) MUCOSA WITH CHRONIC ACTIVE INFLAMMATION.
2. NO  FUNGAL ORGANISMS OR BARRETT'S SPECIALIZED COLUMNAR EPITHELIUM (INTESTINAL METAPLASIA) IDENTIFIED (ALCIAN BLUE/PAS STAIN EXAMINED).
3. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
SPECIMEN 2. CECUM POLYP, BIOPSY:

1. FRAGMENTS OF TUBULAR ADENOMA.
2. NO EVIDENCE OF HIGH-GRADE DYSPLASIA OR MALIGNANCY.

 
STOMACH, BIOPSY:

1. HELICOBACTER PYLORI CHRONIC ACTIVE GASTRITIS, MODERATE.
2. NUMEROUS HELICOBACTER PYLORI ORGANISMS PRESENT ON IMMUNOSTAIN.

1. NEGATIVE FOR INTESTINAL METAPLASIA (ALCIAN BLUE/PAS STAIN EXAMINED)
2. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
 
SPECIMEN 1.  GASTRIC BX:

1. REACTIVE GASTROPATHY AND MILD CHRONIC GASTRITIS.

1. FOCAL INTESTINAL METAPLASIA (ALCIAN BLUE/PAS STAIN EXAMINED).

1. NO HELICOBACTER PYLORI ORGANISMS DETECTED ON IMMUNOSTAIN.
2. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
SPECIMEN 2.  GASTRIC POLYP, BIOPSY:

1. FOVEOLAR HYPERPLASIA.
2. NEGATIVE FOR INTESTINAL METAPLASIA (ALCIAN BLUE/PAS STAIN EXAMINED)
3. NO HELICOBACTER PYLORI ORGANISMS DETECTED ON IMMUNOSTAIN.
4. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
SPECIMEN 3.  DUODENAL POLYP, BIOPSY:

1. PROMINENT BRUNNER GLANDS.
2. FOCAL GASTRIC FOVEOLAR METAPLASIA SUGGESTIVE OF PEPTIC TYPE INJURY. (ALCIAN BLUE/PAS STAIN EXAMINED).
3. NO EVIDENCE OF GIARDIASIS, CELIA SPRUE OR WHIPPLE'S DISEASE.
4. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
SPECIMEN 4.  GE JUNCTION, BX:

1. COLUMNAR MUCOSA (CARDIA-OXYNTIC TYPE) WITH CHRONIC INFLAMMATION
2. FOCAL MULTILAYERED EPITHELIUM (See comment).
3. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
cz
SPECIMEN 1.
DUODENUM, BIOPSIES:
UNREMARKABLE SMALL INTESTINAL MUCOSA.
No evidence of celiac sprue or gastric foveolar metaplasia (Alcian Blue/PAS stain examined).
 
SPECIMEN 2.
STOMACH, BIOPSIES:
HELICOBACTER PYLORI CHRONIC ACTIVE GASTRITIS.
No intestinal metaplasia identified (Alcian Blue/PAS stain examined).
Helicobacter pylori organisms identified on HP immunohistochemical stain and Giemsa stain.
 
SPECIMEN 3.
EG JUNCTION, BIOPSIES:
MILD REFLUX PATTERN ESOPHAGITIS.
No fungal organisms or Barrett's specialized columnar epithelium (intestinal metaplasia) identified (Alcian Blue/PAS stain examined).
 
 
 
SPECIMEN 1.  ANTRUM, BIOPSY:

1. HELICOBACTER PYLORI CHRONIC ACTIVE GASTRITIS, MODERATE.
2. NUMEROUS HELICOBACTER PYLORI ORGANISMS PRESENT ON IMMUNOSTAIN.

1. NEGATIVE FOR INTESTINAL METAPLASIA (ALCIAN BLUE/PAS STAIN EXAMINED)
2. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
SPECIMEN 2.  ESOPHAGUS, BIOPSY:

1. SQUAMOUS MUCOSA WITH FEATURES SUGGESTIVE OF REFLUX ESOPHAGITIS.
2. COLUMNAR (CARDIA-OXYNTIC TYPE) MUCOSA WITH CHRONIC INFLAMMATION.
3. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
SPECIMEN 3.  ASCENDING COLON POLYPS, BIOPSIES:

1. FRAGMENTS OF TUBULAR ADENOMA(S).
2. NO EVIDENCE OF HIGH-GRADE DYSPLASIA OR MALIGNANCY.

 
 
 
 
INTERPRETATION:  Zaremba  RS17-01857
 
SPECIMEN 1:  SMALL INTESTINE, BIOPSY.
a.  SMALL INTESTINAL MUCOSA WITH INTRAEPITHELIAL LYMPHOCYTOSIS (SEE COMMENT).
b.  NO EVIDENCE OF GASTRIC FOVEOLAR METAPLASIA (ALCIAN BLUE/PAS STAIN).
c.  NO DYSPLASIA OR MALIGNANCY IDENTIFIED.
 
SPECIMEN 2:  STOMACH, ANTRUM, BIOPSY.
a.  ANTRAL MUCOSA WITH CHANGES CONSISTENT WITH MILD REACTIVE/CHEMICAL GASTROPATHY.
b.  NO INTESTINAL METAPLASIA (ALCIAN BLUE/PAS) OR DYSPLASIA IDENTIFIED.
c.  NO HELICOBACTER PYLORI ORGANISMS IDENTIFIED (HP IMMUNOSTAIN).
 
SPECIMEN 3:  ESOPHAGUS, BIOPSY.
a.  JUNCTIONAL MUCOSA WITH MILD ACTIVE INFLAMMATION, CONSISTENT WITH GASTROESOPHAGEAL REFLUX DISEASE.
b.  NO FUNGAL ORGANISMS OR INTESTINAL METAPLASIA (ALCIAN BLUE/PAS) IDENTIFIED.
 
COMMENT:
Specimen 1, labeled small intestine biopsy, the histologic section show intraepithelial lymphocytosis, especially near the villous tips, with overall preservation of the villous architecture.  This finding may be seen in the wide variety of conditions, particularly treated or clinically latent celiac sprue, non-steroidal anti-inflammatory drug use, and infection (including helicobacter).  In addition, lymphocytic colitis, stasis/bacterial overgrowth, and systemic autoimmune disease should also be considered.  Correlation with the clinical and laboratory findings, including anti-gluten serology, may be useful to distinguish between these different causes.
 
Clinical Diagnosis/History:
Z98.4 BARIATRIC SURGERY STATUS
 
 
INTERPRETATION:
GASTRO-JEJUNUM ANASTOMOSIS, BIOPSY.
a.  OXYNTIC-TYPE MUCOSA WITH GASTRIC FOVEOLAR HYPERPLASIA AND REACTIVE CHANGES, COMPATIBLE WITH ANASTOMOTIC CHANGES.
b.  NO INTESTINAL METAPLASIA (ALCIAN BLUE/PAS), DYSPLASIA OR MALIGNANCY IDENTIFIED.
c.  NO HELICOBACTER PYLORI ORGANISMS IDENTIFIED ON HP IMMUNOHISTOCHEMICAL STAIN.
 
 
SPECIMEN 2:  ESOPHAGUS, BIOPSY.
a.  SQUAMOUS MUCOSA WITH NO SIGNIFICANT HISTOPATHOLOGIC CHANGES.
b.  DETACHED FRAGMENT OF CARDIA-TYPE GASTRIC MUCOSA WITH MILD REACTIVE CHANGES.
c.  NO FUNGAL ORGANISMS OR INTESTINAL METAPLASIA (ALCIAN BLUE/PAS) IDENTIFIED.
 
 
INTERPRETATION:
 
SPECIMEN 1.  GASTRIC POLYP BX X5:

1. POLYPOID FOVEOLAR HYPERPLASIA.
2. NEGATIVE FOR INTESTINAL METAPLASIA (ALCIAN BLUE/PAS STAIN EXAMINED)
3. NO HELICOBACTER PYLORI ORGANISMS DETECTED ON IMMUNOSTAIN.
4. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
SPECIMEN 2.  RANDOM GASTRIC BX X2:

1. MILD FOVEOLAR HYPERPLASIA.
2. NEGATIVE FOR INTESTINAL METAPLASIA (ALCIAN BLUE/PAS STAIN EXAMINED)
3. NO HELICOBACTER PYLORI ORGANISMS DETECTED ON IMMUNOSTAIN.
4. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
SPECIMEN 3.  DISTAL ESOPHAGUS BX X2:

1. SQUAMOUS MUCOSA WITH REACTIVE/REPARATIVE CHANGES.
2. ATTACHED GASTRIC (CARDIA-FUNDUS TYPE) MUCOSA WITH MILD CHRONIC INFLAMMATION.
3. NO  FUNGAL ORGANISMS OR BARRETT'S SPECIALIZED COLUMNAR EPITHELIUM (INTESTINAL METAPLASIA) IDENTIFIED (ALCIAN BLUE/PAS STAIN EXAMINED).
4. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
SPECIMEN 4.  MIDDLE ESOPHAGUS BX X3:

1. SQUAMOUS EPITHELIUM WITH CONGESTION.
2. NO INCREASE IN INTRAEPITHELIAL EOSINOPHILS (0/hpf).
3. NO  FUNGAL ORGANISMS OR BARRETT'S SPECIALIZED COLUMNAR EPITHELIUM (INTESTINAL METAPLASIA) IDENTIFIED (ALCIAN BLUE/PAS STAIN EXAMINED).
4. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
 
 
SPECIMEN 1.  DUODENUM, BX X 4:

1. UNREMARKABLE SMALL INTESTINAL MUCOSA.
2. NO EVIDENCE OF GIARDIASIS, CELIA SPRUE OR WHIPPLE'S DISEASE.
3. NO EVIDENCE OF GASTRIC FOVEOLAR METAPLASIA (ALCIAN BLUE/PAS STAIN).
4. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
SPECIMEN 2.  RANDOM GASTRIC BX X2:

1. ANTRAL-OXYNTIC MUCOSA WITH VERY MILD CHRONIC GASTRITIS.
2. NO HELICOBACTER PYLORI IDENTIFIED ON IMMUNOSTAIN.
3. NO INTESTINAL METAPLASIA (ALCIAN BLUE/PAS) IDENTIFIED.
4. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
The histologic pattern of inflammation is suggestive of H. pylori infection, but H. pylori organisms are not seen.  The absence of identifiable H. pylori may be due to inadequate sampling or previous treatment with antibiotics or PPI therapy.  Clinical correlation is recommended.
 
No viral inclusions were identified on H&E sections.  Immunostain for CMV is pending and will be reported in an addendum.
 
No submucosal tissue is represented in the biopsy specimen.  The possibility of a clinically significant lesion in the submucosa or deeper layers of the gastrointestinal wall therefore cannot be excluded.  Correlation with endoscopic observations and/or findings on imaging studies is recommended.
 
 
SPECIMEN 1.  LABELLED “EG JUNCTION, BX X2”:

1. ANTRAL-OXYNTIC MUCOSA WITH MINIMAL CHRONIC GASTRITIS AND REACTIVE CHANGES
2. NO INTESTINAL METAPLASIA (ALCIAN BLUE/PAS) OR DYSPLASIA IDENTIFIED.

 
SPECIMEN 2.  LABELLED “GASTRIC BX X3”:

1. COLUMNAR MUCOSA (CARDIA-OXYNTIC TYPE) WITH FOCAL INTESTINAL METAPLASIA.(ALCIAN BLUE/PAS STAIN EXAMINED) AND MILD CHRONIC INFLAMMATION (See comment).
2. SQUAMOUS MUCOSA WITH FEATURES SUGGESTIVE OF REFLUX ESOPHAGITIS.
3. NO HELICOBACTER PYLORI IDENTIFIED ON IMMUNOSTAIN.
4. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
COMMENT: The specimens appear switched.  The diagnosis for specimen “A” reflects that of specimen “B” and vice versa.
The presence of intestinal metaplasia in biopsies from the GE junction may represent either short segment Barrett esophagus or intestinal metaplasia of the gastric cardia.  Correlation with endoscopic findings and exact site of procurement of biopsies is recommended.
Helicobacter pylori immunostain is pending.  The results will be reported in an addendum report to follow.
The upper GI endoscopy report was unavailable for review at this time.
 
 

 
STOMACH, SLEEVE RESECTION:

1. NO SIGNIFICANT HISTOPATHOLOGIC CHANGES.
2. NEGATIVE FOR INTESTINAL METAPLASIA (ALCIAN BLUE/PAS STAIN EXAMINED)
3. NO HELICOBACTER PYLORI IDENTIFIED ON IMMUNOSTAIN.
4. MORBID OBESITY, CLINICALLY.
5. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
 
 
 
HISTOCHEMICAL STAINS:
Alcian Blue/PAS x2.
 
IMMUNOHISTOCHEMICAL STAINS:
Helicobacter pylori immunostain x1.
 
Immunohistochemical stain for H. pylori organisms was technically performed at Mid Valley Pathology (2300 West Pike Blvd ste 103B Weslaco TX 78596, CLIA# 45D2119325) and interpreted at Knapp Medical Center Dept Pathology (1401 East 8th Street, Weslaco, TX, CLIA#45D0503943). Stain controls are adequate.

 
BLADDER STONE, REMOVAL:
A. MULTIPLE CALCULI FRAGMENTS (gross diagnosis, see comment)
B. URINARY RETENTION, FREQUENT BLADDER INFECTION, CLINICALLY
 
 
BLADDER CALCULUS, REMOVAL:

1. SINGLE STONE FRAGMENT (gross diagnosis, see comment)
2. URETHRAL STONE, MEATAL STRICTURE, CLINICALLY

 
COMMENT:
The specimen will be submitted to a special reference laboratory for crystallographic analysis.  A separate report will follow.
 
 
LEFT URETERAL CALCULUS, REMOVAL:
MULTIPLE CALCULI FRAGMENTS (gross diagnosis, see comment)
 
COMMENT:
The specimen will be submitted to a special reference laboratory for crystallographic analysis.  A separate report will follow.
 
LEFT URETERAL STONE, REMOVAL:
MULTIPLE CALCULI FRAGMENTS (gross diagnosis, see comment)
 
COMMENT:
The specimen will be submitted to a special reference laboratory for crystallographic analysis.  A separate report will follow.
 
 
LEFT URETERAL STONE FRAGMENTS, REMOVAL:

1. MULTIPLE CALCULI FRAGMENTS (gross diagnosis, see comment)
2. LEFT OBSTRUCTING URETERAL CALCULUS, HYDRONEPHROSIS, CLINICALLY.

 
COMMENT:
The specimen will be submitted to a special reference laboratory for crystallographic analysis.  A separate report will follow.
 
 
 
SPECIMEN 1. RIGHT URETERAL STENT, REMOVAL:
URETERAL STENT (GROSS EXAM ONLY).
 
SPECIMEN 2. RIGHT URETERAL STONE, REMOVAL:
SINGLE CALCULUS FRAGMENT (gross diagnosis, see comment)
 
COMMENT:
The second specimen will be submitted to a special reference laboratory for crystallographic analysis.  A separate report will follow.
 
 
RIGHT URETERAL STONE, REMOVAL:
SINGLE CALCULUS FRAGMENT (gross diagnosis, see comment)
 
COMMENT:
The specimen will be submitted to a special reference laboratory for crystallographic analysis.  A separate report will follow.
 
LEFT KIDNEY, CORE BIOPSIES:
FOUR KIDNEY CORE BIOPSIES (1.5 CM IN GREATEST DIMENSION) (see gross description and comment).
 
COMMENT:
This case was submitted to Nephrocor Laboratories for expert consultation.  Please see the scanned separate report.
 
 
RIGHT KNEE EXPLANT, REMOVAL.
PLASTIC ORTHOPEDIC SURGICAL HARDWARE (gross exam only).
 
COMMENT:  Right knee acute post-op wound infection, clinically.
 
 
BATTERY, REMOVAL:
MEDTRONIC INTERSTIM BATTERY, (Gross exam only).
  
LEFT URETERAL STENT, REMOVAL:

1. URETERAL STENT (GROSS DIAGNOSIS).
2. LEFT URETERAL STRICTURE - HYDRONEPHROSIS CLINICALLY.

 
SPECIMEN 1.
RIGHT URETERAL STENT, EXPLANTATION:
URETERAL STENT (GROSS DIAGNOSIS).
 
SPECIMEN 2.              
LEFT URETERAL STENT, EXPLANTATION:
URETERAL STENT (GROSS DIAGNOSIS).
 
 

 
 

RIGHT FOOT, TRANSMETATARSAL AMPUTATION:

1. STATUS POST PREVIOUS AMPUTATION OF THIRD TOE.
2. GANGRENE
3. SOFT TISSUE SURGICAL MARGINS -  VIABLE TISSUE.
4. BONE SURGICAL MARGINS -  NEGATIVE FOR OSTEOMYELITIS.
5. NO EVIDENCE OF MALIGNANCY.

 
LEFT FOOT, TRANSMETATARSAL AMPUTATION:

1. STATUS POST PREVIOUS AMPUTATION OF FIRST TOE.
2. GANGRENE.
3. FOCAL ACUTE OSTEOMYELITIS.
4. SOFT TISSUE SURGICAL MARGINS -  VIABLE TISSUE.
5. BONE SURGICAL MARGINS -  NEGATIVE FOR OSTEOMYELITIS.
6. NO EVIDENCE OF MALIGNANCY.

 
 
3RD TOE, LEFT FOOT, AMPUTATION:

1. ACUTE INFLAMMATION WITH ABSCESS.
2. FOCAL NECROSIS.
3. BONE -  NO EVIDENCE OF OSTEOMYELITIS.
4. SOFT TISSUE SURGICAL MARGINS -  VIABLE TISSUE.
5. NO EVIDENCE OF MALIGNANCY.

 
 
RIGHT 4TH AND  5TH TOES, AMPUTATION:

1. GANGRENE WITH ABSCESS.
2. BONE -  NO EVIDENCE OF OSTEOMYELITIS.
3. SOFT TISSUE SURGICAL MARGINS -  VIABLE AND NECROTIC TISSUE.
4. NO EVIDENCE OF MALIGNANCY.

 
 
 
 
LEFT 2ND, 3RD, 4TH AND  5TH TOES, AMPUTATION:

1. GANGRENE WITH ULCER.
2. BONE -  NO EVIDENCE OF OSTEOMYELITIS.
3. SOFT TISSUE SURGICAL MARGINS -  VIABLE TISSUE.
4. NO EVIDENCE OF MALIGNANCY.

 
 
LEFT GREAT TOE, AMPUTATION:

1. GANGRENE WITH ABSCESS.

1. ACUTE AND CHRONIC OSTEOMYELITIS, MARGINS APPEAR FREE.

1. SOFT TISSUE SURGICAL MARGINS -  VIABLE TISSUE.
2. NO EVIDENCE OF MALIGNANCY.

 
 
RIGHT GREAT TOE, AMPUTATION:

1. GANGRENE.

1. CHRONIC OSTEOMYELITIS, MARGINS FREE.

1. SOFT TISSUE SURGICAL MARGINS -  VIABLE TISSUE.
2. NO EVIDENCE OF MALIGNANCY.

 
 
RIGHT 3RD TOE, AMPUTATION:

1. GANGRENE.

1. ACUTE OSTEOMYELITIS, MARGINS FREE.

1. SOFT TISSUE SURGICAL MARGINS -  VIABLE TISSUE.
2. NO EVIDENCE OF MALIGNANCY.

 
RIGHT LEG, ABOVE KNEE AMPUTATION:

1. GANGRENE WITH ULCER.
2. BONE -  NO EVIDENCE OF OSTEOMYELITIS.
3. SOFT TISSUE SURGICAL MARGINS -  VIABLE TISSUE.
4. MAJOR BLOOD VESSELS -  CALCIFIC ARTERIOSCLEROSIS.
5. NO EVIDENCE OF MALIGNANCY.

 
 
RIGHT LOWER EXTREMITY, BELOW THE KNEE AMPUTATION:

1. GANGRENE WITH ULCER AND ABSCESS.
2. BONE -  NO EVIDENCE OF OSTEOMYELITIS.
3. SOFT TISSUE SURGICAL MARGINS -  VIABLE TISSUE.
4. MAJOR BLOOD VESSELS -  CALCIFIC ARTERIOSCLEROSIS.
5. NO EVIDENCE OF MALIGNANCY.

 
 
LEFT LEG, BELOW KNEE AMPUTATION.

1. STATUS POST PREVIOUS TRANSMETATARSAL AMPUTATION.
2. GANGRENE AT PREVIOUS AMPUTATION SITE.
3. SOFT TISSUE SURGICAL MARGINS -  VIABLE TISSUE.
4. MAJOR BLOOD VESSELS -  CALCIFIC ARTERIOSCLEROSIS.
5. NO EVIDENCE OF MALIGNANCY.

 
 
 
LEFT FOOT, BELOW KNEE AMPUTATION.

1. STATUS POST PREVIOUS TRANSMETATARSAL AMPUTATION OF 2ND, 3RD, 4TH AND 5TH TOES.
2. GANGRENE AT PREVIOUS AMPUTATION SITE.
3. SOFT TISSUE SURGICAL MARGINS -  VIABLE TISSUE.
4. MAJOR BLOOD VESSELS -  CALCIFIC ARTERIOSCLEROSIS.
5. NO EVIDENCE OF MALIGNANCY.

 
 
LEFT FOOT WOUND, DEBRIDEMENT:

1. POLYPOID FIBROADIPOSE TISSUE WITH ISCHEMIC NECROSIS, CONGESTION, FRESH HEMORRHAGE AND ACUTE INFLAMMATION.
2. NO EVIDENCE OF MALIGNANCY.

 
 
RIGHT FOOT NECROTIC TISSUE, DEBRIDEMENT:

1. SKIN AND SUBCUTANEOUS TISSUE WITH NECROSIS AND ACUTE INFLAMMATION.
2. BONE -  NO EVIDENCE OF OSTEOMYELITIS.
3. NO DIAGNOSTIC EVIDENCE OF MALIGNANCY.

 

 
SPECIMEN 1.  ANTERIOR VAGINAL WALL, EXCISION:

1. UNREMARKABLE VAGINAL TISSUE.
2. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
SPECIMEN 2.  POSTERIOR VAGINAL WALL, EXCISION:

1. UNREMARKABLE VAGINAL TISSUE.
2. NO EVIDENCE OF DYSPLASIA OR MALIGNANCY.

 
 
COMMENT:
Cystocele, rectocele, clinically.
 
 
 
 
 

 
MICROSCOPIC:
There are 8 Diff-Quick stained touch imprints made from 8 CT-guided needle core biopsy passes examined on-site.  2 PAP stained slides are prepared for later microscopic examination.  The needle biopsy fragments are submitted as surgical biopsy S17-2557.  There is no cell block made.
 
There are 3 Diff-Quick stained touch imprints made from 3 needle core biopsy passes examined on-site.  The needle biopsy fragments are submitted as surgical biopsy S17-1671.  There is no cell block made.
 
INTERPRETATION:
SPECIMENS 1 AND 2.
SPUTUM, CYTOLOGY:
NEGATIVE FOR MALIGNANT CELLS.
FEW MIXED INFLAMMATORY CELLS WITH NO SIGNIFICANT INCREASE IN EOSINOPHILS (LESS THAN 1%).
NO DEFINITIVE MORPHOLOGIC EVIDENCE OF MYCOBACTERIAL ORGANISMS ON AFB STAIN.
NO DEFINITIVE EVIDENCE OF PNEUMOCYSTIS JIROVECI OR OTHER FUNGAL ORGANISMS ON GMS STAIN.
 
COMMENT:
Please correlate clinically and with final laboratory studies. Moderate numbers of squamous epithelial cells and partially viable vegetable material from oral contamination are present in this sample.
 
GROSS:
1/15/2016 RR/klm
The specimen is received in two separate containers, fresh, labeled with the patient's name, Robert Klase, the patient's ID#, and "Sputum for cytology". Each container shows 5 mL of light green cloudy mucus fluid. Two cytospin preparations are performed and Papanicolaou stained. One cell block is performed (two H&E slides). Both blocks undergo AFB and GMS stains.
 
MICROSCOPIC:
1/15/2016 RR/klm
 
The cytologic features of cytospin preparations on both specimens reveal similar morphology. The cytospins are suboptimal since most of the tissue fell off the slides and reveals few cellular components. The cell block preparation displays mild numbers of mixed inflammatory cells containing neutrophils and mature appearing lymphocytes predominately with a rare eosinophil identified in 40 high power fields, accounting for less than 1% of inflammatory cells identified. For the most part, the tissue comprises mucoid debris, mature appearing squamous epithelial cells, and few macrophages. There are also partially viable vegetable particles. Based on these specimen preparations there is no diagnostic evidence of a separate population of malignant cells.
 
 
 
INTERPRETATION:
Sputum, cytology interpretation–
Negative for malignant cells.
Eosinophil count – 2.5% (see comment).
Neutrophils count – 50% (see comment).
Few fungal organisms morphologically consistent with Candida sp.
 
COMMENT:
The sample is limited by cellularity but adequate for evaluation due to presence of macrophages. Due to specimen cellularity, counts were performed over 200 cells and could not be performed at the recommended 400 non-epithelial cells at 400X HPF (high power field).
Eosinophils – 5 eosinophils /200 non-epithelial cells – 2.5%
Neutrophils – 100 neutrophils /200 non-epithelial cells – 50%
 
According to some studies, sputum eosinophil count less than 1%, 1–3%, and greater than 3% may have different therapeutic approach.
References:
Green R, Brightling CE, McKenna S, et al. Asthma exacerbations and sputum eosinophil counts: a randomized controlled trial. Lancet 2002; 360: 1715–21.
Jayaram L, Parameswaran K, Sears MR, et al. Induced sputum cell counts: their usefulness in clinical practice. Eur Respir J 2000; 16: 150-158.
 
GROSS:
12/10/10 RAR/RAR
 
Received is 1 mL of white turbid fluid for cytologic evaluation, labeled with the patient’s name, ID# and as "sputum for eosinophil and neutrophil count".  Two routine cytospin slides, one stained with PAP and one with Wright-Giemsa. One cell block with two levels is also prepared from this specimen.
 
MICROSCOPIC:
12/10/10 RAR/RAR
 
Cytospin slides demonstrate an adequate sputum sample due to presence of numerous macrophages, although is limited by cellularity. Mature squamous epithelial cells as well as neutrophils, few lymphocytes and eosinophils are also identified. Eosinophils and neutrophil count is performed over 200 non-epithelial cells at 400X HPF (high power field). Eosinophils – 5 eosinophils /200 non-epithelial cells – 2.5%. Neutrophils – 100 neutrophils /200 non-epithelial cells – 50%. Few fungal organisms morphologically consistent with Candida sp. No evidence of malignancy is seen.
 
Gross Dictation: Rosemary A Recavarren, MD, Pathologist, 12/10/2010 8:23:21 PM
Final Review: Rosemary A Recavarren, MD, Pathologist, 12/10/2010 8:24:00 PM
Final: Rosemary A Recavarren, MD, Pathologist, 12/10/2010 8:24:00 PM
 
 
SPUTUM, CYTOLOGY:
NEGATIVE FOR MALIGNANT CELLS. LIMITED SAMPLE. See comment.
NO DEFINITIVE MORPHOLOGIC EVIDENCE OF MYCOBACTERIAL ORGANISMS ON AFB STAIN.
NO EVIDENCE OF PNEUMOCYSTIS JIROVECI OR OTHER FUNGAL ORGANISMS ON GMS STAIN.
 
COMMENT:  This specimen shows presence of macrophages; however, it is contaminated by mature squamous epithelial cells, likely from oral contamination. Please correlate clinically and with final laboratory studies.
 
 
 
MICROSCOPIC:
3/42016 CMZ/CMZ
The cytologic features of cytospin preparations reveal predominately a background of mucus with occasional scattered macrophages and mature squamous epithelial cells. The cell block preparation is scanty, but reveals debris with macrophages. The background is of mucus and mature squamous epithelial cells likely from oral contamination. No definitive morphologic evidence of organisms are seen on AFB and GMS stains. Stain controls are adequate.  Based on this specimen preparation, there is no definitive evidence of a separate population of malignant cells.
 
SPECIAL STAINS:
3/4/2016 CMZ/CMZ
AFB:  No definitive evidence of acid fast organisms seen.
GMS:  No definitive evidence of fungal organisms.
 
 
 
SPUTUM, CELL BLOCK AND CYTOSPIN PREPARATIONS, CYTOLOGY:

1. NO MALIGNANT CELL DETECTED.
2. NO ACID-FAST BACILLI DETECTED (AFB STAIN ON CELL BLOCK EXAMINED).
3. NO PNEUMOCYSTIS JIROVECI OR OTHER FUNGAL ORGANISMS DETECTED (GMS STAIN ON CELL BLOCK EXAMINED).
4. SCATTERED GRAM POSITIVE BACTERIA PRESENT (GRAM STAIN ON CELL BLOCK EXAMINED.

 
COMMENT:  This specimen shows presence of macrophages; however, it is contaminated by mature squamous epithelial cells, likely from oral contamination. Please correlate clinically and with final laboratory studies.
 
 
 
 
 
 
 
SPECIMEN ADEQUACY:
Satisfactory.
 
MICROSCOPIC:
There are two H&E stained slides prepared from one cell block and two Pap stained cytospin preparations examined microscopically. 
 
HISTOCHEMICAL STAINS:
AFB stain (on cell block - with appropriate control) – no acid-fast bacilli detected.
 
GMS stain (on cell block – with appropriate control) – no fungal organisms or pneumocystis jiroveci organisms detected.
 
Gram stain (on cell block – with appropriate control) – No bacteria detected.
 
Final Diagnosis performed by
Alberto Gonzalez, MD
Pathologist
Electronically signed 12/14/2017 12:58:19PM
 
 

 
 
 
 
RIGHT PLEURAL EFFUSION, CELL BLOCK AND CYTOSPIN PREPARATIONS, CYTOLOGY:

1. NO MALIGNANT CELLS DETECTED.
2. MODERATE NUMBERS OF MIXED INFLAMMATORY CELLS, PREDOMINANTLY LYMPHOID WITH FEW ADMIXED NEUTROPHILS.
3. REACTIVE-APPEARING MESOTHELIAL CELLS AND MACROPHAGES.
4. BACKGROUND BLOOD.

 
 
RIGHT PLEURAL FLUID, CELL BLOCK AND CYTOSPIN PREPARATIONS, CYTOLOGY:

1. NO MALIGNANT CELLS DETECTED.
2. FEW INFLAMMATORY CELLS.
3. REACTIVE-APPEARING MESOTHELIAL CELLS AND MACROPHAGES.
4. FEW RED BLOOD CELLS.

 
 
 
PLEURAL EFFUSION, RIGHT, CYTOLOGY:
            - NEGATIVE FOR MALIGNANT CELLS
            - REACTIVE APPEARING MESOTHELIAL CELLS AND MACROPHAGES
            - BACKGROUND FIBRINOUS/PROTEINACEOUS DEBRIS, BLOOD AND MIXED INFLAMMATION
 
 
 
 
 
LEFT PLEURAL EFFUSION, CELL BLOCK AND CYTOSPIN PREPARATIONS, CYTOLOGY:

1. NO MALIGNANT CELLS DETECTED.
2. MODERATE NUMBERS OF MIXED INFLAMMATORY CELLS, PREDOMINANTLY LYMPHOID WITH FEW ADMIXED NEUTROPHILS.
3. REACTIVE-APPEARING MESOTHELIAL CELLS AND MACROPHAGES.
4. BACKGROUND BLOOD.  

 
 
SPECIMEN ADEQUACY:
The specimen is satisfactory.
 
MICROSCOPIC:
There are two H&E stained slides prepared from one cell block and two Pap stained cytospin preparations examined microscopically.  There are inflammatory cells, benign appearing mesothelial cells and red blood cells.  There are no malignant cells detected.
 
 
 
INTERPRETATION:
PLEURAL EFFUSION, RIGHT, CYTOLOGY:
a.     NEGATIVE FOR MALIGNANT CELLS.
b.     MINIMAL NUMBERS OF MIXED INFLAMMATORY CELLS AND MACROPHAGES.
c.     BACKGROUND FIBRINOUS/PROTEINACEOUS DEBRIS.
 
COMMENT:
The history indicates a recurring right pleural effusion over the last several months.  Multiple prior evaluations by both routine and immuno-marker studies have revealed no evidence of malignant tumor therein.  No routine morphologic evidence to suggest either epithelial or hematologic malignancy is found here.  Requested flow-cytometry results will be reported separately.
 
 
COMMENT:
There is no evidence of a separate population of epithelial malignant cells, based on morphology and non-reactive MOC31 and BerEP4 immunostains. Please correlate the results clinically.
 
 
 
MICROSCOPIC:
Few loose clusters and isolated overall bland appearing cells with modest abundant eosinophilic cytoplasm and small non hyperchromatic nuclei without prominent nucleoli are seen, in a background of fibrinous/proteinaceous debris with mild mixed inflammatory cells with lymphocytic predominance.
 
IMMUNOHISTOCHEMICAL STAINS:
MOC31 – Negative within cell clusters and isolated cells. Stain controls adequate.
BErEP4 – Negative within cell clusters and isolated cells. Stain controls adequate.
Mesothelin – Negative within cell clusters and isolated cells. Stain controls adequate.
 
Immunohistochemical stains were technically performed at Mid-Valley Pathology, PLLC (2300 West Pike Blvd, Suite 103-B, Weslaco, TX 78596) and interpreted at Knapp Medical Center Dept Pathology (1401 East 8th Street, Weslaco, TX, CLIA#45D0503943). Stain controls are adequate.
 

 
 
 
INTERPRETATION:
 
LEFT THORACENTESIS FLUID, CELL BLOCK AND CYTOSPIN PREPARATIONS, CYTOLOGY:

1. NO MALIGNANT CELLS DETECTED.
2. MODERATE NUMBERS OF MIXED INFLAMMATORY CELLS.
3. MESOTHELIAL CELLS AND MACROPHAGES.

 
COMMENT:
Pneumonia, fever, confusion, diabetes, clinically.
 
 
 
 
 
 
SPECIMEN ADEQUACY:
Specimen is adequate.
 
MICROSCOPIC:
There are two H&E stained slides prepared from one cell block and two Pap stained cytospin preparations examined microscopically.  There are inflammatory cells, benign appearing mesothelial cells and few red blood cells.  There are no malignant cells detected.
 
 
HISTOCHEMICAL STAINS:
AFB stain (on cell block - with appropriate control) – no acid-fast bacilli detected.
 
GMS stain (on cell block – with appropriate control) – no fungal organisms or pneumocystis jiroveci organisms detected.
 
Gram stain (on cell block – with appropriate control) – No bacteria detected.
 
HISTOCHEMICAL STAINS:
AFB x 1,   GMS x 1,    Gram stain x 1.
 
Breast Marker Studies Fixation (CAP/ASCO requirement)
Cold ischemic time < 1 hour: Yes
10% neutral buffered formalin: Yes
Fixation duration >6 and <72 hours: Yes
Collection time:
Fixation and Processing Protocol
Type of fixative: 10% neutral buffered formalin
Collection time: 10/15/15; 1100 am
Cold Ischemia time: 0
Duration in fixative: >6 - < 72 hours.
Thirteen lymph nodes, no tumor present (0/13)
Comment: This biopsy may not be representative of the remainder of the breast lesion, and
should be interpreted along with clinical and radiologic findings. As with any lesion where
limited material is evaluated, follow-up is recommended.
Rare atypical cell clusters, not diagnostic of malignancy
However, these results should be used with caution since there is only limited specimen
available for evaluation. If clinically indicated, repeat biopsy with procurement of additional
tissue for morphologic examination and ancillary studies, such as flow cytometry and cultures,
may be warranted.
The sample size, orientation, and tangential sectioning make conclusive assessment difficult.
The tumor in the biopsy is consistent with… However, insuffiecient tumor is present to verify
with immunohistochemistry.. Clinical correlation is recommended.
It does not express an immunoprofile that is characteristic of a unique body site or organ.
There is no immunohistochemical support for a… . For treatment purposes, this neoplasm is
classified as an adenocarcinoma of unknown origin.
The lack of a connection to the epidermis could be due to sampling or to the possibility of a
metastatic lesion. An adnexal tumor with squamous differentiation was also considered but
the morphology of the lesion does not support this.
Although there is no immunohistochemical support for… the morphology is compatible with…
Morphologically compatible with…
NOTE: According to the Bethesda system for thyroid cytopathology, the diagnosis of
suspicious for follicular neoplasm implies a risk of malignancy at 15 - 30%. The usual
management for the majority of these lesions is surgical lobectomy as clinically indicated.
Correlation with clinical, serologic, genetic and radiologic findings is
recommended.
Immunohistochemical stains were technically performed at Clarient Lab (31 Columbia
Aliso Viejo, CA 92656) and interpreted at Knapp Medical Center dept pathology (1401
East 8th Street, Weslaco, TX, CLIA#45D0503943). Stain controls are adequate. Fixative/
Length fixation time: 10% Neutral Buffered Formalin / 6-72 hrs. Please refer to
immunostain report, case # AS15-49318.

The presence of these cells does not explain clinical suspicion for a submucosal nodule.
Please correlate clinically in order to determine the next step in this patient’s management.
The codes documented in this report are preliminary and upon coder review may be revised
to meet current compliance requirements.
RAPID ONSITE EVALUATION (ROSE)
Left thyroid mass, fine needle aspiration adequacy: Suspicious for a follicular neoplasm.
Three passes were performed by radiologist, Dr. DeCandia. Three Diff-Quik stained smears
are evaluated on site. Three alcohol fixed smears are prepared. Tissue is submitted for Afirma
GEC in two separate passes. Tissue for cell block is obtained.
Left thyroid mass biopsy, ultrasound guided core biopsies: Suspicious for a follicular
neoplasm. Two separate passes are performed by radiologist. Two Diff-Quik stained touch
imprints are evaluated on site. Two alcohol fixed touch preps are performed. Tissue cores are
entirely submitted to surgical case S15-1758-1A.
Adequacy reported to Dr. DeCandia by Dr. Recavarren on 09/14/2015.
Specimen 2.
Stomach, biopsy:
Chronic inactive gastritis, mild.
Intestinal metaplasia present, extensive.
No definitive Helicobacter pylori organisms on Giemsa stain. Immunostain pending. See
comment.
No definitive evidence of dysplasia or infiltrating malignancy.
COMMENT: Immunostain for H. pylori is pending on gastric biopsies and will follow in an
addendum.
Specimen 3.
Stomach, antrum and body, biopsies:
Chronic inactive gastritis, mild.
Antral mucosa with surface mucin regenerative type atypia consistent with healing
erosion.
No definitive evidence of Helicobacter pylori organisms on Giemsa stain. Immunostain
pending.
No definitive evidence of intestinal metaplasia, dysplasia, or infiltrating carcinoma.
The touch imprint performed on specimen 3 reveals predominately macrophages of possible
cyst contents. However, no significant numbers of ductal epithelial cells to further assess this
specimen. Hence, it is best classified as nondiagnostic for cytologic evaluation of this clinical
breast nodule.
The cytologic features of specimen 4 reveals fibrinous granular debris with no significant
cellular population, hence this specimen is best classified as possible cyst contents and
nondiagnostic for evaluation of this clinical breast lesion.
The cytologic features of specimen 5 reveal a markedly hypocellular specimen containing a
rare cluster of benign appearing ductal epithelial cells and macrophages. Based on this
limited specimen preparation, there is no diagnostic evidence of a separate population of
malignant cells.

RAPID ONSITE EVALUATION:
Specimen 1.
Left breast cyst of 2.5 cm:
Apocrine cells present. Cyst contents. 3 mL of light yellow fluid are obtained by one pass
aspiration by radiologist. One Diff-Quik stain smear is evaluated on site. One alcohol fixed
smear is prepared. Tissue for one cell block is obtained.
Specimen 2, 3, and 4.
Left breast cyst, 2.3 cm, 1.8 cm, and #4 at 5 o’clock, fine needle aspiration:
Proteinaceous material. Nondiagnostic. Consistent with cyst contents. Less than 2 mL of light
yellow fluid is obtained after one pass at each of these sites. One Diff-Quik stain smear is
evaluated on site for each pass. One alcohol fixed smear is prepared. Tissue is obtained for
cell block preparation in alcohol fixative.
Adequacy reported to Dr. DeCandia by Dr. Recavarren on 09/29/2015.
The cytologic features of specimen 1 reveal few small sheets and clusters of benign
appearing ductal epithelial cells with apocrine metaplasia. The background contains fibrinous/
proteinaceous debris. The cell block is noncontributory. There is no definitive evidence of a
separate population of malignant cells. The specimen is markedly hypocellular.
The specimen is markedly hypocellular and only a rare cluster of small ductal epithelial cells is
identified of 2 to 4 cells. The remainder background is of light proteinaceous debris. The cell
block is noncontributory. Based on this specimen preparations this specimen is best classified
as nondiagnostic for cytologic evaluation due to hypocellularity.
The cytologic features of the smears, both Diff-Quik and Pap, and cell block preparation
reveals similar morphology. They contain proteinaceous debris predominately. The specimen
is acellular. Based on this specimen preparations there is no significant numbers of epithelial
fragments. Based on this specimen preparations this site is best classified as nondiagnostic
for cytologic evaluation and consistent with cyst contents only.
The specimen collection time is 09/29/2015, time of specimen collection 01:50, for a total
fixation time between 6 and 72 hours
INTERPRETATION:
Thyroid, right, mid posterior, needle biopsy:
Histologic changes consistent with lymphocytic thyroiditis. See comment.
COMMENT:
Please correlate with the accompanying cytology and aspirate, our case # C15-614, which
under the Bethesda System for Reporting Thyroid Cytology falls within Category 2
(benign) and is consistent with lymphocytic (Hashimoto) thyroiditis in the proper clinical
context. Within this diagnostic category, even though it is given a benign designation, the risk
of malignancy is still between 0 to 3% indicating clinical followup on this patient.
Specimens 1 and 2.
Thyroid, right lobe, ultrasound-guided FNA and touch imprints of cores, cytology:
Nondiagnostic, cyst fluid only (Bethesda system category I). See comment.
Specimens 3 and 4.
Thyroid, left lobe (midportion), ultrasound-guided FNA and touch imprints of cores,
cytology:
FOLLICULAR LESION OF UNDETERMINED SIGNIFICANCE (BETHESDA SYSTEM
CATEGORY III). SEE COMMENT.
COMMENT:
1-2. The fine needle aspiration specimen consists of peripheral blood with scattered
pigmented macrophages/histiocytes. The aspirate clot section shows rare clusters of benignappearing
follicles without overt cytoarchitectural features of papillary thyroid carcinoma. The
results should be interpreted in correlation with clinical and imaging studies. Please also refer
to core biopsy of this site on case S15-2290 (right thyroid biopsy). Careful clinical follow up is
recommended. Due to these results, AFIRMA GEC ® test will not be pursued on this
specimen.
According to the Bethesda system for thyroid cytopathology, the risk of malignancy for this
category is 0 - 3%. Management of benign thyroid nodules varies among practitioners and
institutions. Because the false-negative rate for cytologically benign thyroid nodules may be
as high as 5%, careful clinical follow-up of these nodules is required. As with other nodules,
they may be reaspirated or surgically removed if significant growth occurs or worrisome
changes (such as irregular margins and central hypervascularization) are noted by
ultrasound.
3-4. The fine needle aspiration specimen for part two shows bland appearing follicular cells
with areas of architectural atypia within a background of abundant inspisated colloid. No
definitive nuclear features of papillary thyroid carcinoma are identified. The main differential
diagnoses include hyperplastic/adenomatoid thyroid nodule and follicular adenoma.
According to the Bethesda system for thyroid cytopathology, the risk of malignancy for
follicular lesions of undetermined significance category is 5 – 15%. The management of
follicular lesions with no rapid growth or enlargement includes follow-up with re-biopsy after an
appropriate interval of observation, although in specific clinical settings other management
options may be more appropriate.
If re-biopsy of the same nodule is clinically indicated, an interval of at least 6 – 8 weeks is
recommended to reduce needle track-induced atypical cellular changes in cytology
specimens. Due to these results, AFIRMA GEC ® test will be pursued on this specimen.
ADDENDUM:

Please note that these findings are intended for use, in conjunction with and not in lieu of
current standard diagnostic procedures, as an aide for initial diagnosis of bladder carcinoma
in patient’s with hematuria and subsequent monitoring for tumor recurrence in patient’s with
previously diagnosed bladder cancer.
have been requested and will be reported separately. If positive, this would confirm a
diagnosis of mycosis fungoides. If negative, the sample should still be considered atypical
and the patient followed closely. Clinical correlation is recommended.
COMMENT:
Please refer to the concurrent surgical pathology case S15-2335 for a more definitive
histologic interpretation in this case and results of ancillary studies.
“GATA3 expression is most often seen in breast, urothelial, and pancreaticobiliary
adenocarcinomas. p63 is negative, making a urothelial primary less likely. Mesothelin and
MUC5 are negative in neoplastic cells, making a pancreaticobiliary primary less likely. This
leaves a breast primary as the favored primary.”
COMMENT:
The carcinoma invades into the lamina propria in these superficial biopsies.
There appears to be adequate tissue in block 1A to perform gastric HER2 analysis by
immunohistochemistry and fluorescent in-situ hybridization (FISH). . The results of these ancillary studies will be
reported separately.