Case 5

Reproductive Pathology

 

Radiology Images

CXR 12-12

CT scan 12-12

Barium Enema 2-3

CXR 2-12

CT scan 2-12

 

Laboratory Data on Admission

Laboratory Trends

Liver Function Tests

Microbiology

 

History and Physical

Colonoscopy Report

Operative Reports 12-17

            12-18

12-29

1-3

Surgical Pathology Report 12-17

Death Summary 2-12

Autopsy Report 2-13

 

 

Radiology Images:

 

Chest X-ray 12-12:

 

CT scan 12-12:

 

 

 

 

 

Barium enema 2-3:

 

 

Chest X-ray 2-12:

 

CT scan 2-12 with autopsy correlation:

 

 

 

 

 

 

 

 

 

 

 

 

Clinical Labs 12-11-03

CBC

Name

Result/Unit

 

Ref Interval

WHITE BLOOD CELL COUNT

18.27 K/uL

H

3.20-10.60

RED BLOOD CELL COUNT

5.28 M/uL

 

3.88-5.46

HEMOGLOBIN

14.2 g/dL

 

12.1-15.9

HEMATOCRIT

43.3 %

 

34.3-46.6

MEAN CORPUSCULAR VOLUME

82.0 fL

 

77.8-94.0

MEAN CORPUSCULAR HEMOGLOBIN

27.0 pg

 

26.5-32.6

MEAN CORPUSCULAR HGB CONC

32.9 g/dL

 

32.7-36.9

RED CELL DISTRIBUTION WIDTH

14.7 %

H

10.8-14.1

PLATELETS

506 K/uL

H

177-406

MEAN PLATELET VOLUME

7.6 fL

 

5.9-9.8

POLYMORPHONUCLEAR

75 %

 

44-76

LYMPHOCYTE

14 %

L

15-43

MONOCYTE

6 %

 

2-8

EOSINOPHIL

5 %

 

0-6

PLATELET ESTIMATE

ADEQUATE

 

NORMAL

MICROCYTOSIS

1+

A

 

Name

Result/Unit

 

Ref Interval

SODIUM

130 mmol/L

L

136-144

POTASSIUM

2.8 mmol/L

LL

3.3-5.0

CHLORIDE

90 mmol/L

L

98-107

CARBON DIOXIDE

35 mmol/L

H

22-29

UREA NITROGEN

3 mg/dL

L

6-22

CREATININE, SERUM - mg/dL

0.5 mg/dL

L

0.7-1.2

GLUCOSE

137 mg/dL

H

64-128

ANION GAP

5 mmol/L

L

8-14

CALCIUM, SERUM OR PLASMA

8.1 mg/dL

L

8.4-10.2

Name

Result/Unit

 

Ref Interval

ALBUMIN

2.9 g/dL

L

3.5-4.6

BILIRUBIN, TOTAL

0.4 mg/dL

 

0.2-1.3

ALKALINE PHOSPHATASE

266 U/L

H

38-126

ASPARTATE AMINOTRANSFERASE

32 U/L

 

14-50

ALANINE AMINOTRANSFERASE

24 U/L

 

9-52

BILIRUBIN, DIRECT

0.3 mg/dL

 

0.0-0.4

TOTAL PROTEIN

6.4 g/dL

 

6.3-8.2

Name

Result/Unit

 

Ref Interval

CANCER ANTIGEN 125

841 U/mL

H

0-35

Name

Result/Unit

 

Ref Interval

CARCINOEMBRYONIC Ag

14.8 ng/mL

H

0.0-3.0

 

 

Respiratory Culture 2-7

 

Name

Result

 

GRAM STAIN

1+ GRAM POSITIVE COCCI IN CLUSTERS

 

GRAM STAIN

1+ GRAM NEGATIVE RODS

 

GRAM STAIN

NO WBCS SEEN

 

GRAM STAIN

SPECIMEN ACCEPTABLE, <25 EPITHELIAL CELLS / LPF

 

FINAL REPORT

3+ PSEUDOMONAS AERUGINOSA

 

FINAL REPORT

2+ METHICILLIN RESISTANT STAPH AUREUS (MRSA)

 

FINAL REPORT

2+ NORMAL FLORA ISOLATED

 

FINAL REPORT

See Comments

Name

Value

Result

 

AMIKACIN

2.0000

SUSCEPT

 

AZTREONAM

8.0000

SUSCEPT

 

CEFEPIME

2.0000

SUSCEPT

 

CEFTAZIDIME

2.0000

SUSCEPT

 

CIPROFLOXACIN

<= 0.12

SUSCEPT

 

GENTAMICIN

1.0000

SUSCEPT

 

IMIPENEM

1.0000

SUSCEPT

 

MEROPENEM

0.5000

SUSCEPT

 

PIPERACILLIN

8.0000

SUSCEPT

 

TICARCILLIN/CLAVULINIC ACID

32/2

SUSCEPT

 

TOBRAMYCIN

0.5000

SUSCEPT

 

Name

Result

 

mecA GENE

PRESENT

 

 

Blood Culture 2-7

Name

Result

FINAL REPORT

CULTURE POSITIVE.

FINAL REPORT

COAGULASE NEGATIVE STAPHYLOCOCCUS SPECIES (CoNS)

Name

Result

FINAL REPORT

NO GROWTH

 

 

Lab Trends

Date

Hct

Na

K

BUN

Creat

Creat

PT

INR

PTT

WBC

PLT

02/12/04 04:00 AM

--

136

4.8

79

1.1

--

--

--

--

--

--

02/12/04 04:00 AM

26.7

--

--

--

--

--

--

--

38.37

283

--

02/11/04 04:00 AM

--

136

4.4

69

0.8

--

--

--

--

--

--

02/11/04 04:00 AM

27.8

--

--

--

--

--

--

--

38.83

278

--

02/10/04 03:50 AM

--

138

3.5

64

0.9

--

--

--

--

--

--

02/10/04 03:50 AM

30.1

--

--

--

--

--

--

--

31.16

323 1

--

02/09/04 04:00 AM

--

133

4.0

68

0.9

--

--

--

--

--

--

02/09/04 04:00 AM

26.9

--

--

--

--

--

--

--

28.95

343

--

02/08/04 04:00 AM

--

134

4.4

67

0.9

--

--

--

--

--

--

02/08/04 04:00 AM

23.9

--

--

--

--

--

--

--

27.57

371

--

02/07/04 04:00 AM

--

134

4.4

52

1.2

--

--

--

--

--

--

02/07/04 04:00 AM

24.2

--

--

--

--

--

--

--

27.73

360

--

02/06/04 08:45 AM

--

--

--

--

--

16.0

--

--

--

--

--

02/06/04 08:45 AM

--

--

--

--

--

--

--

37

--

--

--

02/06/04 04:00 AM

--

135

3.9

43

0.6

--

--

--

--

--

--

02/06/04 04:00 AM

29.4

--

--

--

--

--

--

--

23.50

392

--

02/05/04 04:00 AM

--

136

4.0

40

0.6

--

--

--

--

--

--

02/05/04 04:00 AM

26.1

--

--

--

--

--

--

--

25.47

391

--

02/04/04 04:00 AM

--

135

4.2

36

0.6

--

--

--

--

--

--

02/04/04 04:00 AM

27.1

--

--

--

--

--

--

--

26.12

384

--

02/03/04 06:00 PM

--

--

4.8

--

--

--

--

--

--

--

--

02/03/04 06:05 AM

--

135

5.5

35

0.5

--

--

--

--

--

--

02/03/04 06:05 AM

27.3

--

--

--

--

--

--

--

28.95

385

--

02/02/04 04:20 AM

--

137

5.2

34

0.5

--

--

--

--

--

--

02/02/04 04:20 AM

26.2

--

--

--

--

--

--

--

26.56

373

--

02/01/04 04:50 AM

--

135

4.8

32

0.5

--

--

--

--

--

--

02/01/04 04:50 AM

26.4

--

--

--

--

--

--

--

26.27

368

--

01/31/04 04:00 AM

--

140

4.4

33

0.5

--

--

--

--

--

--

01/31/04 04:00 AM

26.1

--

--

--

--

--

--

--

24.33

301

--

01/30/04 04:00 AM

--

140

4.4

32

0.4

--

--

--

--

--

--

01/30/04 04:00 AM

25.8

--

--

--

--

--

--

--

22.38

331

--

01/29/04 04:00 AM

--

140

4.3

30

0.4

--

--

--

--

--

--

01/29/04 04:00 AM

25.9

--

--

--

--

--

--

--

20.67

348

--

01/28/04 04:05 AM

--

136

3.5

31

0.4

--

--

--

--

--

--

01/28/04 04:05 AM

26.3

--

--

--

--

--

--

--

21.08

354

--

 

Hepatic Functions

Date

Alk phos

AST/SGOT

ALT/SGPT

T Bili

D Bili

T Prot

ALBUMIN

02/12/04 04:00 AM

457

47

39

8.3

8.1

6.4

2.1

01/28/04 12:20 PM

561

27

27

4.0

3.5

6.2

2.1

12/31/03 04:00 AM

176

44

53

5.7

5.1

5.1

1.7

12/24/03 04:00 AM

160

65

80

7.9

7.5

4.3

1.8

12/22/03 04:00 AM

116

147

114

10.4

9.8

4.4

2.0

12/20/03 08:30 AM

112

265

177

10.3

9.4

4.5

2.4

12/19/03 03:00 AM

120

1018

293

14.9

12.7

4.6

2.2

12/11/03 08:26 PM

266

32

24

0.4

0.3

6.4

2.9

 

 

Colonoscopy Report

 

Procedure:      Colonoscopy
Indications:    Contrast enema suggestive of colonic obstruction.
Medicines:      General anesthesia
Complications:  No immediate complications

Procedure:  H \T\ P was performed prior to procedure. After obtaining
            informed consent, the colonoscope was passed under direct
            vision. Throughout the procedure, the patient's blood
            pressure, pulse, and oxygen saturations were monitored
            continuously. The Colonoscope was introduced through the
            anus and advanced to the ileum. The quality of the prep
            was poor with formed stool throughout the left colon and
            liquid stool in the right colon.

Findings:       A segmental area of the ileum was congested and
            erythematous. No site of narrowing was seen. Stool was found
            in the entire colon. There was evidence of previous
            colo-colonic anastomosis in the descending colon. Suture
            material was visible. There was no evidence of stenosis seen
            and the colonoscope was easily passed throughout the colon.
Impression: - Congested mucosa in the ileum.
            - Colonic stool in the entire colon.
            - Colo-colonic anastomosis in the descending colon.
Recommend:  - Return to ICU.
            - Carefully restart tube feeds with low residue formula.
            Schedule stool softener and osmotic laxative and use PRN
            enemas if constipation persists.
            -Consider small bowel enteroclysis if signs of mechanical
            obstruction occur.

 

 

History and Physical 12-11-03

 

REASON FOR ADMISSION: Probable small bowel obstruction and pelvic mass.

HISTORY OF PRESENT ILLNESS: This is a 65-year-old gravida 4,para
4-0-0-4 female who was transferred from an outside Hospital and referred
by her Family Practice physician, secondary to a pelvic mass
and probable small bowel obstruction.

The patient reported an approximately three-day history of increasing
abdominal distention. Likewise, during that time period, she had
experienced no bowel movement. She had minimal flatus during that time.
Initially, the patient was seen by her primary care physician who
prescribed laxatives as well as Fleets enema and magnesium citrate;
however, these had no effect. The patient continued to develop
increasing distention; likewise, was unable to tolerate the magnesium
citrate orally and vomited. She has had continued nausea and vomiting
throughout this time period and has been able to tolerate nearly no oral
input.

The patient does describe some difficulty breathing secondary to the
abdominal distention, as well as a significant amount of abdominal pain
secondary to the pressure. She denies any fever or chills; likewise,
denies any other associated symptoms. She did note some burning at the
time of placement of a Foley catheter; however, she feels she has had no
urinary symptoms prior to this time. The patient was evaluated at the
outside Emergency Department where she was found to have a
urinary tract infection.

Likewise, lab work was drawn and showed a sodium of 130, potassium 3.0,
and chloride of 88, all low values. Likewise, a white blood count was
found to be 17. Liver functions were normal; otherwise, hematocrit was
45, platelets 474. Urine again was positive for nitrites, bacteria,
white blood cells, as well as mucus. With these findings, a CT scan was
likewise performed, which showed a pelvic mass. Abdominal films were
consistent with an ileus, and the patient was transported.

The patient's family describes the patient having decreased appetite over
the past several months; however, they have not noted any abdominal
distention. The patient has noted minimal weight loss during the past
several months, and otherwise denies any changes in clothing or any other
abdominal discomfort or pain. The patient reports no history of
hormone-replacement therapy. She states that her last pelvic examination
and ultrasound were approximately 1-1/2 years ago, at which time no
evidence of a mass or other abnormalities were noted.

PAST MEDICAL HISTORY: Chronic pain in the hips, back, and neck;
hypothyroidism; hypertension; hypercholesterolemia. PAST SURGICAL
HISTORY: Hip, neck, and back surgery, carpal tunnel surgery,
cholecystectomy, appendectomy, bilateral tubal ligation. Past
Gynecologic History: Menarche at age 16 with last menstrual period
during the last calendar year. No history of treatment for abnormal Pap
smears, with only suspicious Pap smears always being normal with
followup. No history of hormone replacement therapy. Oral contraceptive
use for a short time during reproductive years.
No history of pelvic

infections otherwise noted. Past Obstetrical History: Gravida 4, para
4-0-0-4 with four normal spontaneous vaginal deliveries.

CURRENT MEDICATIONS: Synthroid 0.01 mg p.o. q.d., morphine 100 mg q.h.s.
plus 130 mg q.a.m. and 100 mg q.d. at 2 p.m., Zoloft 60 mg p.o. q.d.

ALLERGIES: No known drug allergies.

SOCIAL HISTORY: The patient is married. Denies any tobacco, alcohol, or
drug use.


REVIEW OF SYSTEMS: Negative, except those symptoms noted above. The
patient reports normal bowel movements prior to above-noted symptoms.
Normal urination, and no other associated symptoms.

PHYSICAL EXAMINATION:
VITAL SIGNS: Afebrile, vital signs stable with oxygenation ranging
          between 85% to 95%.
HEENT: Within normal limits. No thyromegaly. No lymphadenopathy.
CHEST: Clear to auscultation bilaterally.
CARDIOVASCULAR: Regular rate and rhythm. No murmur, rub, or gallop.
ABDOMEN: Moderately distended, diffusely tender, no bowel sounds present, tympanitic to percussion.
EXTREMITIES: No cyanosis, clubbing, or edema, nontender.
GU: Deferred until clinic being opened.

LABORATORY DATA: From outside lab include white blood count of 17,
hematocrit 45.3, platelets 474, 85% PMNs. Sodium 130, potassium 3.0,
chloride 88, bicarbonate 30, BUN 5, creatinine 0.5, glucose 216, calcium
8.6, AST 35, ALT 21, total protein 6.9, albumin 2.9, alkaline phosphatase
303. Urinalysis: Positive nitrites, bacteria, white blood cells, and
mucus.

Radiology exams from the outside show KUB with mild nonspecific ileus.
Chest x-ray with mild CHF and abdominal CT with ovarian mass and ascites.
Otherwise, descriptions not given.

ASSESSMENT:
This is a 65-year-old gravida 4, para 4 female with an approximately
three-day history of increasing abdominal distention with probable small
bowel obstruction. Likewise, she is noted to have a pelvic or abdominal
mass per CT evaluation. Otherwise, the patient appears stable at present
time. The patient does likewise have a urinary tract infection with an
elevated white blood count.

PLAN:
1. Small bowel obstruction. We will continue patient n.p.o., hydrating
with IV fluids. We will likewise consider an NG tube placement should
the patient experience any further distention or nausea and vomiting. We
will review abdominal films for evaluation of ileus versus small bowel
obstruction.

2. Pelvic mass. Minimal report from CT evaluation outside. We
will have films reviewed by Radiology here for further
evaluation of pelvic or abdominal mass. Likewise, we will obtain a CA
125 and a CEA for evaluation of possible ovarian versus GI cancer.
Likewise, we will take the patient to GYN Clinic tomorrow for
pelvic examination for further evaluation.

3. Urinary tract infection. We will place the patient on Levaquin for
treatment of urinary tract infection. Likewise, we will follow up
urinary cultures.

4. Fluids, electrolytes, and nutrition. Electrolytes are somewhat
depleted. We will replace the potassium with both a K rider as well as
IV fluids containing potassium chloride. The patient will be given
D-5-1/2 NS with 20 mEq of potassium chloride at 125 cc/hr in addition to
the K rider
. Likewise, we will follow blood glucose closely secondary to

elevated levels at the outside hospital.

5. We would anticipate further development of plan pending radiologic
evaluation with patient probably requiring surgical evaluation and
staging of abdominal and/or pelvic masses. We would anticipate keeping
the patient on antibiotics until urinary tract infection has been treated
prior to proceeding to the operating room.

 

 

Operation Report     12/17/02

PREOPERATIVE DIAGNOSIS:       A 65-year-old female, gravida 4, para 4,
               with a complex pelvic mass, multiple
               abdominal masses, and an ileus versus small
               bowel obstruction.
POSTOPERATIVE DIAGNOSIS:      A 65-year-old female, gravida 4, para 4,
               with a complex pelvic mass, multiple
               abdominal masses, and an ileus versus small
               bowel obstruction, with metastatic
               carcinoma by frozen pathology.

OPERATION PERFORMED:     Exploratory laparotomy with supracervical
               hysterectomy, bilateral salpingo-oophorectomy, omentectomy, partial
               transverse and descending colon resection,
               with primary reanastomosis and debulking of
               tumor.

ANESTHESIA:              General endotracheal.

ESTIMATED BLOOD LOSS: 600 cc. FLUIDS: 5900 cc LR and 1750 cc albumin.
URINE OUTPUT: 150 cc.

FINDINGS: Approximately 6 liters of straw colored ascites. A dense
tumor noted caking the omentum. Also dense tumor rinds along the
bilateral pericolic gutters and slightly onto the anterior peritoneum.

A dense tumor rind noted along the pelvic peritoneum. The uterus was noted

to be densely adhered to the anterior cul-de-sac with apparent tumor rind.

The left ovary was noted to be approximately 4 by 6 cm and cystic in nature.

The right ovary appeared normal.

There was likewise noted to be a large volume of stool throughout the
colon, no obvious point of obstruction, however the small bowel and
sigmoid colon were densely adhered within the pelvis. Miliary nodules

of tumor were noted on the diaphragm and along the posterior peritoneum.

The patient was noted to be optimally debulked of tumor to approximately

3-4 mm of tumor remaining in the abdominal cavity.

PROCEDURE: After ensuring informed consent, the patient was taken to

the operating room where general anesthesia was administered. The patient
was then prepped and draped in the usual sterile fashion.

A vertical midline incision was then made using a scalpel. It was
carried through to the layer of the fascia which was scored using the
scalpel. This incision was extended both superiorly and inferiorly along
the length of the incision. The peritoneum was then identified and
entered sharply using a scalpel, at which time ascitic fluid was noted to
emerge through the peritoneal incision.   Again approximately 6 liters of
straw colored ascites was drained. Some of this fluid was collected as a
specimen for peritoneal washings.

With the ascites drained from the abdominal cavity, the peritoneal
incision was extended both superiorly and inferiorly for the length of
the incision with good visualization of bowel and bladder. The
peritoneal cavity was then explored manually with the above-noted
findings. The liver margin did feel smooth other than some small
nodularity along the falciform ligament. The Balfour retractor was
applied to the incision for greater visualization.

Attention was then turned to the pelvis where adhesiolysis was performed
in attempts at freeing the bowel as well as identification of the pelvic
structures. At this point the left ovary was elevated by dissection of
adhesions and tumor rind, and was noted to be maintained by only a single
pedicle with blood vessels passing through this pedicle. This pedicle
was clamped, cut, and the ovary removed and sent as frozen section to
pathology.

Further dissection was made both manually and with sharp dissection of
the tumor rind and adhesions within the pelvis for freeing of the bowel.
With this freed and greater visualization obtained, the decision was made
to proceed with omentectomy. The omentum was identified and dissected
free of the transverse colon and stomach with individual pedicles being
crossclamped using 8 inch clamps and tied with silk ties for hemostasis.
The omentum was thus dissected free and excised from the abdominal cavity
and collected as a specimen.

Slight omental remnants in both the splenic flexure and hepatic flexures
were then further dissected and removed for complete omentectomy and
complete debulking of tumor mass. Attention was then turned for removal
of the tumor caking or rind within the left pericolic gutter. This was
accomplished both with sharp dissection and Bovie cautery. The tumor
rind was excised. Likewise at this point the decision was made for bowel
resection at the splenic flexure both secondary to tumor involvement, as
well as difficult dissection from tumor.

The approximately midportion of the transverse colon was then identified
and crossclamped using the GIA stapler and transected likewise.
Approximately one-half of the distance along the descending colon was
likewise dissected free and crossclamped using the GIA stapler and
transected. The distal portion of the transverse colon and the proximal
portion of the descending colon were then dissected free and excised from
the abdominal cavity and collected as a specimen.

Attention was further turned to debulking of the tumor. The right
pericolic rind was likewise dissected using both sharp and Bovie cautery
dissection and collected as a specimen. Attention was then further
turned to the pelvis where extensive lysis of adhesions was performed for
visualization of and identification of the right tube and ovary. This
was accomplished by entering the lateral peritoneum sharply, and
identifying
both the infundibulopelvic ligament as well as well round

ligament.

The infundibulopelvic ligament was crossclamped and suture-ligated prior
to transection with excellent hemostasis noted. The ovary and tube were
excised from the pelvis. The left infundibulopelvic ligament was
likewise identified and suture-ligated. The ureter was visualized
bilaterally during the entire pelvic portion of the procedure. The
uterus was then identified again as densely adherent to the anterior
peritoneum. It went in the anterior cul-de-sac.

This was dissected free from the anterior cul-de-sac and bladder.
Following dissection the uterus was grasped, elevated, and the uterine
vessels skeletonized, crossclamped, transected, and suture-ligated.
Additional clamps were placed in a descending fashion along the lower
uterine segment. However secondary both to dense adhesions as well as to
tumor involvement within the pelvis, the decision was made for a
supracervical hysterectomy.


The cervix was then transected and the uterus excised from the pelvis.
Apical stitches were placed on the cervix for hemostasis. Excellent
hemostasis was noted. Likewise the surface of the transected cervix was
cauterized using Bovie cautery. The CUSA was then used for further
dissection of tumor within the pelvic cavity including the tumor rind, as
well as throughout the abdominal cavity.

With all tumor appropriately reduced, the attention was again turned to
the bowel for reanastomosis. The angles of the bowel staple lines were
cut for placement of the stapler. At this point soft stool spillage was
noted and extensive irrigation was performed. Secondary to bowel edema
difficulty was noted in bringing the two stapled ends of the bowel
together. As such further mobilization was performed up the transverse
colon as far at the hepatic flexure for greater mobilization and
reapproximation of the two bowel segments.

The falciform ligament was likewise transected and tumor debulking
performed in that region. The two segments of bowel were brought
together and were anastomosed using the stapler. Reinforcing stitches
were placed at the apices as well as at the inferior aspect of the
communicating anastomosis between the two segments using silk sutures.
Excellent reapproximation was noted with excellent hemostasis, and no
further stool spillage.

Again copious irrigation was performed throughout the abdominal cavity
secondary to stool spillage. Further hemostasis was obtained throughout
the abdominal cavity using Bovie cautery. With excellent hemostasis
noted the decision was made for completion of the procedure. Two JP
drains were placed, one within the pelvis, and one in the left pericolic
gutter approximating the bowel reanastomosis. These were brought through
the skin and tied using a silk suture.

The fascia was then closed with two running #1 PDS sutures and tied in
the midpoint. The subcutaneous tissues were again copiously irrigated
with sterile saline. Hemostasis was obtained with Bovie cautery. The
skin was closed with staples. All instrument, sponge, and sharp counts
were correct times two. The patient tolerated the procedure well and was
taken to recovery in stable condition following extubation within the OR.

Drains: A Foley to down drain. A pelvic JP drain and abdominal JP drain
to bulk suction. The specimens were as noted above. The condition was
stable to recovery.

 

 

Operation Report    12/18/03

PREOPERATIVE DIAGNOSIS:       Recurrent abdominal compartment syndrome.
POSTOPERATIVE DIAGNOSIS:      Same.

OPERATION PERFORMED:     1.   Removal of Vac-Pak dressing with
                         opening of Velcro mesh to release
                         abdominal compartment syndrome.
                          2.   Re-closure of abdomen with vacuum pack
                         dressing.

 

Operation Report    12/18/03

 

PREOPERATIVE DIAGNOSIS:       Abdominal compartment syndrome.
POSTOPERATIVE DIAGNOSIS:      Same.


OPERATION PERFORMED:     1. Exploratory laparotomy with
                         decompression of abdominal compartment
                         syndrome.
                         2. Velcro mesh closure of abdomen.

 

 

Operation Report    12/29/03

 

PREOPERATIVE DIAGNOSIS:       1. Metastatic ovarian cancer.
               2. Status post-ovarian cancer resection
                   with debulking and partial colectomy.
               3. Status post-abdominal compartment
                   syndrome.
               4. Possible intra-abdominal abscess.


POSTOPERATIVE DIAGNOSIS:      1. Metastatic ovarian cancer.
               2. Status post-ovarian cancer resection
                   with debulking and partial colectomy.
               3. Status post-abdominal compartment
                   syndrome.
               4. Uninfected appearing intra-abdominal
                   fluid.



Operation Report    1/3/04

 

PREOPERATIVE DIAGNOSIS:       Open abdomen status post abdominal
                              compartment syndrome.
POSTOPERATIVE DIAGNOSIS:      Same.

OPERATIONS PERFORMED:         1. Removal of Velcro mesh closure of
                              abdomen.
                              2. Abdominal closure with Dexon mesh.
                              3. Debridement of skin and soft tissue off
                              anterior abdominal wall.


Surgical Pathology Report 12-17-03

 
SP CLINICAL HISTORY

Pelvic mass.

SP GROSS DESCRIPTION

Received are 13 containers labeled with the patient's name and medical record
number.
Container one is received with fresh tissue for frozen section labeled "left
adnexa" and contains a 37.7 gram, 8.3 x 7.0 x 4.9 cm specimen. Sectioning
reveals a large cystic space with a small portion of rubbery white tissue. The
adnexal surface is inked black. Fallopian tube not identified. Cassette
code: frozen section is resubmitted in cassette 1FA. Representative sections
are submitted in cassettes 1A-1F.
Container two is received with fresh tissue for frozen section labeled
"omentum" and contains a 43.3 x 11.7 x 2.4 cm specimen of omentum. It
specimen has multiple firm nodules over the surface. Frozen section is
resubmitted for permanent sections in cassette 2FA. Representative sections
are submitted in five cassettes, 2A-2E.
Container three is received with formalin labeled "left gutteral nodule" and
contains a 5.5 x 2.5 x 0.6 cm fibrofatty specimen that has a firm red-tan
surface with several white nodules (0.5 cm in greatest diameter).
Representative sections are submitted in two cassettes, 3A and 3B.
Container four is received with formalin labeled "transverse colon nodules"
and contains a 3.5 x 2.0 x 0.7 cm tan to brown rubbery tissue fragment that
has a light tan to yellow nodular cut surface. Representative sections are
submitted in three cassettes, 4A-4C.
Container five is received with formalin labeled "left gutteral nodule #2" and
contains a 4.5 x 2.5 x 1.3 cm fibrofatty tissue with a firm white to pink cut
surface. Representative sections are submitted in three cassettes, 5A-5C.
Container six is received with formalin labeled "colon epiploica" and contains
two red-brown fragments of fatty tissue measuring 3.0 x 2.1 x 0.5 cm and 2.7 x
1.7 x 1.0 cm. Sectioning reveals a homogeneous, yellow, lobulated cut
surface. Representative sections are submitted in three cassettes, 6A-6C.
Container seven is received with formalin labeled "partial end descending
colon" and contains an unoriented portion of bowel measuring 20.5 cm in length
x 7.4 cm in circumference with a maximal wall thickness of 0.3 cm. The
serosal surface is tan to brown with areas of firm, hemorrhagic epiploic
nodules (0.5 cm to 3.0 cm in greatest diameter). The mucosal surface is light
tan to yellow with areas of mucosal flattening. Perforation or areas of
ulceration are not identified. Lymph nodes are not identified. Cassette
code: 7A-7C - surgical margin; 7D-7I - representative section of nodules; 7J -
representative section of bowel.
Container eight is received with formalin labeled "supra colic omentum" and
contains several pieces of fragmented fatty tissue with a firm tan to brown,
hemorrhagic, nodular surface. The tissues measure 6.0 x 4.0 x 0.6 cm in
aggregate. The cut surface is yellow-tan and lobulated. Representative
sections are submitted in three cassettes, 8A-8C.
Container nine is received with formalin labeled "lesser curvature omentum"
and contains a 3.5 x 2.1 x 0.8 cm fibrofatty tissue fragment with a
hemorrhagic surface. The cut surface is tan-yellow and lobulated.
Representative sections are submitted in two cassettes, 9A and 9B.
Container 10 is received with formalin labeled "right gutter nodule" and
contains four fibrofatty tissue fragments ranging in size from 3.0 x 2.4 x 1.5
cm to 4.6 x 3.6 x 3.1 cm. Sectioning of the largest fragment reveals a firm
white to red cut surface. Representative sections are submitted in five
cassettes, 10A-10E.
Container 11 is received with formalin labeled "left pelvic sidewall" and
contains a 4.0 x 2.4 x 0.4 cm specimen with a smooth, shiny peritoneal surface
with a white to black cauterized surgical margin. Sectioning reveals a yellow
lobulated to firm white cut surface. The surgical margin is inked black.
Representative sections are submitted in two cassettes, 11A and 11B.
Container 12 is received with formalin labeled "uterus, right ovarian tube"
and contains a uterus with an amputated cervix and attached right ovary and
fallopian tube. The 75.7 gram uterus has a light tan to red rough serosal
surface and is 5.5 cm from cornu to cornu, 4.0 cm from anterior to posterior,
and 6.5 cm from fundus to amputated portion of cervix. Five leiomyomas are
identified (1.5 to 0.9 cm in greatest diameter). The cut surface of all the
leiomyomas are firm white and whorled. The myometrium is up to 1.0 cm thick
and otherwise is tan to pink. The light tan to hemorrhagic endometrium
measures 2.6 cm from cornu to cornu x 2.2 cm and up to 0.2 cm thick. The
light tan to pink cerebriform ovary measures 3.0 x 2.0 x 1.4 cm with a purple
adhesed fallopian tube measuring approximately 5.6 cm in length x 0.6 cm in
diameter. The cut surface of the ovary shows a cystic cavity filled with
slightly thick, clear fluid. The cavity is 1.0 x 0.6 x 0.8 cm. Ovary is
inked black. Cassette code: 12A - right ovary and right fallopian tube; 12B -
right ovary; 12C-12G - representative sections of uterus.
Container 13 is received with formalin labeled "anterior peritoneum" and
contains a 3.5 x 2.6 x 0.8 cm soft tissue fragment with a smooth glistening
white to red surface. The specimen is sectioned and representative portions
are submitted in cassette 13A.
 

SP FROZEN SECTION DIAGNOSIS

Frozen section diagnoses
1FA - "Mucinous neoplasm of at least borderline malignant potential".
2FA - "Consistent with metastatic carcinoma".

SP DIAGNOSIS

1. "LEFT ADNEXA, RESECTION":
- CONSISTENT WITH MUCINOUS PAPILLARY CYSTOADENOCARCINOMA.
- TUMOR IS SEEN PRACTICALLY REPLACING THE ENTIRE OVARY.
- TUMOR MAXIMUM GROSS DIAMETER OF ABOUT 8.0 CM
- NO DEFINITIVE FALLOPIAN TUBE IDENTIFIED
- TUMOR IS SEEN TOUCHING THE INKED MARGIN OF RESECTION IN SEVERAL SECTIONS

2. "OMENTUM, PARTIAL RESECTION":
- METASTATIC ADENOCARCINOMA

3. "LEFT GUTTERAL NODULE, BIOPSY":
- METASTATIC ADENOCARCINOMA

4. "TRANSVERSE COLON NODULES, BIOPSY":
- METASTATIC ADENOCARCINOMA

5. "LEFT GUTTERAL NODULE #2, BIOPSY":
- METASTATIC ADENOCARCINOMA

6. "COLON, APPENDIX EPIPLOICA, BIOPSY":
- METASTATIC ADENOCARCINOMA

7. "DESCENDING COLON, PARTIAL RESECTION":
- METASTATIC ADENOCARCINOMA INFILTRATING THOUGH OUT THE ENTIRE SEROSAL
SURFACE OF THE BOWEL
- METASTATIC ADENOCARCINOMA IS SEEN CLOSELY APPROACHING THE MUSCULAR LAYER
OF THE BOWEL WITHOUT DEFINITIVE INVASION INTO IT (SLIDE 7I)
- ONE OF THE MARGINS OF RESECTION NEGATIVE FOR NEOPLASM
- CONTRALATERAL MARGIN OF RESECTION SHOWING METASTATIC CARCINOMA IN THE
SEROSA OF SURFACE (SLIDES 7B AND 7C)

8. SUPRA COLIC OMENTUM, PARTIAL RESECTION:
- METASTATIC ADENOCARCINOMA

9. "LEFT CURVATURE, OMENTUM, PARTIAL RESECTION":
- METASTATIC ADENOCARCINOMA

10. "RIGHT GUTTER NODULE":
- METASTATIC ADENOCARCINOMA

11. "LEFT PELVIC SIDE WALL":
- METASTATIC ADENOCARCINOMA

12. "UTERUS, RIGHT OVARY AND TUBE, HYSTERECTOMY AND SALPINGO-OOPHORECTOMY":
- OVARY SHOWING MUCINOUS PAPILLARY CYSTOADENOCARCINOMA
- TUMOR, MAXIMUM DIAMETER IN THE GLASS SLIDE OF ABOUT 1.4 CM
- TUMOR IS SEEN TOUCHING THE INKED SEROSAL SURFACE OF THE OVARY
- FALLOPIAN TUBE SHOWING NO SIGNIFICANT PATHOLOGY
- TUMOR IS SEEN IN SOFT TISSUE SURROUNDING FALLOPIAN TUBE WITHOUT
DEFINITIVE INVASION INTO THE WALL OF THE TUBE
- ENDOMETRIUM SHOWING INACTIVE/BASALIS ENDOMETRIUM
- MYOMETRIUM SHOWING LEIOMYOMATA (LARGEST LEIOMYOMA MEASURING ABOUT 1.5
CM)
- MYOMETRIUM SHOWING METASTATIC ADENOCARCINOMA WITH FOCAL EVIDENCE OF
LYMPHOVASCULAR INVASION (SLIDE 12G)

13. ANTERIOR PERITONEAL, BIOPSY:
- METASTATIC ADENOCARCINOMA

 

 

Death Summary 2-12-04


REASON FOR DEATH:
Cardiopulmonary arrest secondary to multiorgan dysfunction secondary to
stage IIIC ovarian adenocarcinoma.

HOSPITAL COURSE: The patient was a 66-year-old white female who
was taken to the operating room by the Gynecology Oncology Service
approximately two months ago secondary to ovarian adenocarcinoma. She
underwent total abdominal hysterectomy and bilateral
salpingo-oophorectomy. After the operation, she developed abdominal
compartment syndrome and General Surgery was consulted.

She had since been in the surgical intensive care unit and had
experienced a lingering course over the past two months marked by failure
to wean from the respirator, multiple infectious complications, failure
to tolerate any enteral feeding, and, most significantly, she had missed
the opportunity to undergo chemotherapy for her advanced stage disease.
Most recently, she had developed a right lower lobe pneumonia and had
increasing respiratory difficulties as well as a septic clinical picture.

After an extensive discussion with the family regarding the prognosis and
the futility of the situation, the decision was made to withdraw support.
With the family at the bedside, the patient's ventilator settings were
turned to minimal support. She was placed on a morphine and Versed drip.
She quickly expired. Time of death was 1300 hours. The family consented
to an autopsy request.

 

 

Autopsy Report 2-13-04

 
AU CASE INFORMATION

SEX: F AGE: 66 RESTRICTIONS: No restrictions
CONSENT: Consent obtained from the husband

AUTOPSY CAUSE OF DEATH: Sepsis
DUE TO: Stage IV ovarian adenocarcinoma
OTHER CONDITIONS: Bronchopneumonia.

AU CLINICAL DIAGNOSIS

CLINICAL HISTORY:
1. Hypothyroidism
2. Hypertension
3.
Hypercholesterolemia
4.
Hip, neck and back surgery

5. Carpal tunnel surgery
6.
Cholecystectomy
7.
Appendectomy
8.
Bilateral tubal ligation
9.
Stage IIIc ovarian adenocarcinoma 12/17/02

10. Supracervical hysterectomy, 12/17/02
11.
Bilateral salpingo-oophorectomy 12/17/02
12.
Omentectomy 12/17/02
13.
Partial transverse and descending colon resection 12/17/02
14.
Abdominal compartment syndrome 12/18/03.


AU FINAL DIAGNOSIS

I. Sepsis
  A. Sputum culture positive for Pseudomonas aeruginosa and methicillin
  resistant Staphylococcus aureus 2/7/04
  B. Blood cultures positive for coagulase negative Staphylococcus species
  2/7/04
  C. Abscess in apex of right upper lung lobe 2.5 x 2.5 x 1.9 cm, GMS and
  Gram stain negative.
  D. Hemorrhagic right adrenal gland
  E. Foci of ischemia and necrotic small bowel
  F. Congested liver.
  G. Splenitis.
II. Bronchopneumonia with foci of lipoid pneumonia.
  A. Erythematous bronchi
  B. Mottled lungs bilaterally with consolidations in the inferior segment
  of the left upper lobe and entire left lower lobe
  C. Loculated fluid in left lower lobe 5.0 x 4.0 x 3.5 cm with necrosis
  D. Pleural effusions, left 10 cc mucoid, right 600 cc serous
  E. Moderate pleural adhesions
  F. Right lung bulla 4.0 x 5.0 cm
III.
Stage IV ovarian adenocarcinoma

  A. Status post supracervical hysterectomy, bilateral
  salpingo-oophorectomy, omentectomy, partial transverse and descending
  colon resection and tumor debulking
  B. 22.0 x 14.0 cm midline abdominal surgical incision with a Vac-Pack
  dressing
  C. Metastases
    1. Abdominal carcinomatosis with entrapment of abdominal and pelvic
    viscera.

    2. Multiple mesenteric nodules and mesenteric lymph nodes with
    extracapsular extension of tumor.
    3. Focal invasion of large and small bowel into the submucosa.
    4. Tumor identified in fibrotic tissue surrounding spleen and liver.
    5. Right abdominal wall necrotic, cystic mass 18.0 x 7.8 x 3.2 cm, GMS
    stain negative.
    6. Diaphragm, right.
    7. Left lower lung lobe 5.0 x 4.0 x 3.5 cm
    8. Microscopic foci of tumor in all lobes of the lungs, liver, and
    left adrenal gland.

  D. Status post tracheostomy placement
  E. Biliary tree obstruction with jaundice, total bilirubin 8.3 mg/dL.
IV. Atherosclerosis
  A. Moderate-severe atherosclerosis of the descending aorta.

  B. Minimal atherosclerosis of the left main coronary artery, left
  anterior descending artery, circumflex artery and right coronary
  artery consisting of lipid plaques involving 10% of the vessels.
  C. Remote myocardial infarct of the left ventricle.
V. Incidental findings:
  A. Multinodular right thyroid lobe.
  B. Left lobe of thyroid not identified.
  C. Small sacral decubitus ulcer, 0.4 x 0.4 cm.

AU CASE SUMMARY

The decedent was a 66-year-old Caucasian woman, transferred from an outside
Hospital on December 11, 2003 secondary to a pelvic mass and
probable small bowel obstruction. Prior to admission the patient reported a
three day history of increasing abdominal distention, no bowel movements and
minimal flatus. Fleets enemas and oral magnesium citrate were not
effective. The decedent developed nausea and vomiting and eventually was not
able to tolerate any oral input. The patient reported no significant weight
loss. Her last pelvic examination and ultrasound were approximately 1.5 years
ago at which time there was no evidence of a mass or other abnormalities. On
December 17, 2003 the patient underwent an exploratory laparotomy with
supracervical hysterectomy, bilateral salpingo-oophorectomy, omentectomy,
partial transverse and descending colon resection with primary re-anastomosis
and debulking of tumor. Metastatic carcinoma was diagnosed by frozen
section. The final surgical pathology report identified ovarian
adenocarcinoma with metastases to the omentum, a left gutteral nodule,
transverse colon, descending colon, left pelvic sidewall, and uterus. On
December 18, 2003 the decedent developed abdominal compartment syndrome and
was taken to the operating room for removal of the Vac-Pack dressing and
opening of the Velcro mesh to release the abdominal pressure. On December 29,
2003 a CT scan was suggestive of an intra-abdominal abscess, and the patient
was taken to the operating room for exploratory surgery. Intra-abdominal fluid
was not infected. On January 3, 2004 the Velcro mesh was removed and her
abdomen was closed. She also underwent debridement of skin and soft tissue of
the anterior abdominal wall. During her stay in the surgical intensive care
unit, she failed to be weaned from the respirator, developed infectious
complications and could not tolerate tube feedings. She did not receive
chemotherapy. Chest x-rays demonstrated a left lower lobe consolidation and
right
lower lobe pneumonia. After extensive discussion with the family,

support was withdrawn. The time of death was 13:00 hours on February 12,
2004.

At autopsy the decedent appears the stated age of 66 years and is status post supracervical hysterectomy, bilaterally salpingo-oophorectomy, omentectomy, partial transverse and descending colon resection and tumor debulking. A 22.0 x 14.0 cm midline abdominal surgical incision with a VAC-pack dressing is present. The decedent has abdominal carcinomatoses with entrapment of the abdominal and pelvic viscera. Numerous metastases are identified. There are multiple mesenteric nodules and mesenteric lymph nodes with extracapsular extension of the tumor. There are multiple areas of the large and small bowel tumor metastases extending from the serosa through the submucosal layers. Tumor is identified in fibrotic tissue surrounding the spleen and liver with extension of the tumor into the right diaphragm. What was initially thought to be a right abdominal wall abscess (18.0 x 7.8 x 3.2 cm) microscopically shows extensive metastatic ovarian adenocarcinoma. GMS stain is negative.
Loculated fluid in the left lower lung lobe (5.0 x 4.0 x 3.5 cm with necrosis) microscopically demonstrates numerous foci of metastatic adenocarcinoma. Microscopic foci of tumor is seen in all lobes of the lung, liver, and left adrenal gland. The patient is jaundiced and biliary tree obstruction is seen microscopically. Areas of central venous fibrosis and necrosis is seen in the liver. The biliary tree is likely obstructed by tumor and the central vein stasis could be related to heart failure or compression of the inferior vena cava by tumor. The decedent is also status post tracheostomy placement.
Bronchopneumonia with foci of lipoid pneumonia are seen microscopically. The bronchi are erythematous and the lungs are mottled bilaterally with consolidations in the inferior segment of the left upper lobe and entire left lower lobe. The areas of lipoid pneumonia may have resulted from obstruction or aspiration of mineral oil. A 600 cc serous pleural effusion is seen on the right side and a 10 cc mucoid pleural effusion is seen on the left. There are moderate pleural adhesions and a right lung bulla 4.0 x 5.0 cm. Consistent with the patient's history of sepsis, an abscess is seen in the apex of the right upper lung lobe 2.5 x 2.5 x 1.9 cm. GMS and gram stain are negative.
The right adrenal gland is hemorrhagic and there are foci of ischemic and necrotic small bowel. The liver is congested and splenitis is seen microscopically. Moderate to severe atherosclerosis is seen in the descending aorta. Minimal atherosclerosis of the left main coronary artery, left anterior descending artery, circumflex artery and right coronary artery consisting of lipid plaques involving 10% of the vessels are identified. A remote myocardial infarct is seen in the left ventricle. Incidental findings include a multinodular area in the right thyroid lobe. The left lobe of the thyroid is not identified. A 0.4 x 0.4 cm sacral decubitus ulcer is identified.

 

The autopsy cause of death is sepsis in a 66 year old female with stage IV ovarian adenocarcinoma, who recently underwent abdominal surgery for resection and debulking of the tumor.

Ovarian cancer is the fourth leading cause of cancer mortality in women after
cancer of the lung, breast, and colorectum. The lifetime risk of developing
ovarian cancer for the general population ranges from 1.4 to 1.6%. One in
seventy women will be diagnosed with ovarian cancer and 70% of these women
present with advanced stage disease. The five year survival rate for advanced
stage disease is 25.1% for stage III and 11.1% for stage IV. There are a
number of genetic, environmental and reproductive factors that influence an
individual's risk for developing ovarian cancer. 80% of cases of ovarian
cancer are sporadic, with approximately 10% being genetically determined.
Women with a history of infertility, nulliparity or few pregnancies are at a
higher risk for developing ovarian cancer. Multiparous women or women with a
history of oral contraceptive use have a decreased risk for developing ovarian
cancer. A diet high in saturated fat has also been linked to development of
ovarian carcinoma. 48% of all cases of ovarian cancer occur in women greater
than 65 years of age.
Sepsis refers to the systemic response to a serious infection. Patients
usually manifest fever, tachycardia, tachypnea, leukocytosis and a localized
site of infection. Microbiologic cultures from the blood or infection site
are frequently, although not always, positive. The incidence of sepsis has
been rising since the 1930's. Reasons include increased use of invasive
devices such as intravascular catheters, widespread use of cytotoxic
immunosuppressive drug therapies for cancer and transplantation, an increased
life span of patients with cancer and diabetes who are prone to develop sepsis
and an increase in infections due to antibiotic resistant organisms. The
precise incidence of sepsis is not known because this is not a reportable
entity. A reasonable annual estimate for the United States is 400,000 bouts
of sepsis and 100,000 deaths from sepsis per year.


REFERENCES:
Abeloff: Clinical Oncology, 2nd ed., cc 2000 Churchill Livingstone Inc.,
pp344-346.
Goldman: Cecil Textbook of Medicine, 21st ed., cc 2000 W.B. Saunders Co.,
pp507-509.
Cotran: Robbins Pathologic Basis of Disease, 6th ed., cc 1999 W.B. Saunders
Co., pp1067.

AU GROSS DESCRIPTION

EXTERNAL EXAMINATION: A duly executed permit for autopsy is received from
the husband and the body is identified by toe-tag.

The body length is 163 cm crown to heel and 70 cm crown to rump. The
body is that of a normally developed Caucasian female who appears to be the
stated age of 66 years. The body habitus is obese. The head circumference
is 49 cm, the head is normal in size and the shape is symmetric. Hair
distribution is normal and the texture is normal. Scalp hair is brown-gray and
10.0 cm in length. The face is unremarkable. The eyes show scleral icterus.
The irides are blue and the right pupil is 0.5 cm in diameter and the left
pupil is 0.4 cm in diameter. The ears are unremarkable. The nose is normal. A
nasogastric tube is present. The upper molars are absent. A 0.7 cm
ulceration
is present on the upper right lip. A tracheostomy site is present

in the neck. The skin is jaundiced and shows 1+ dependent livor. Needle marks
are present in the left and right antecubital fossae and dorsum of the left
hand. A 0.4 x 0.4 cm decubitus ulcer is present over the sacrum. A 22.0 x
14.0 cm midline surgical incision is present over the abdomen with a Vac-Pak
dressing. 2.5 cm and 1.0 cm incisional scars are present in the left upper
quadrant. A 2.0 cm incisional scar and 23.0 cm incisional scar are present in
the right lower quadrant. A 0.4 cm puckered scar is present under the left
clavicle. A triple lumen Intravenous access line is present beneath the left
clavicle. ID tags are present around the left wrist and the right great toe.
The chest circumference is 115 cm and the chest is symmetric. The breasts are
normal on palpation. The abdominal circumference is 119.5 cm and the abdomen
is distended. The back is normal. The external genitalia are normal for female
sex. A Foley catheter is present. The lower extremities are edematous with
taught shiny skin. Hair is present over the legs.
CENTRAL NERVOUS SYSTEM: A bitemporal incision is performed and the calvarium
is removed. The scalp is normal. The skull is of average thickness. The middle
ears are not examined. The dura is normal. The meninges are normal. The
cerebral vessels show no atherosclerosis. The convolutions show normal gyri
and sulci. The brain and spinal cord are saved for neuropathologic
examination.
After formalin fixation, the brain and spinal cord are examined at the
Neuropathology Conference. External examination shows minimal atherosclerosis in the Circle of Willis. No areas
of softening or discoloration are seen. No evidence of edema is noted. The
brainstem and cerebellum appear normal. The spinal cord is normal.
THORACIC CAVITY: A "Y" incision is made. The subcutaneous fat measures 3.5 cm
at the level of the nipples. Organ situs in the thorax is normal. The pleural
surfaces show fibrinous adhesions. The pleural cavities contain 600 cc of
serous fluid on the right and 10 cc of thick mucus on the left. The
mediastinum is clear.
ABDOMINAL CAVITY: A midline incision is made. The diaphragmatic dome heights
are between the 6th and 7th rib on the right and at the fifth rib on the left.
The abdomen has extensive carcinomatosis and adhesions. The peritoneal
surfaces show extensive adhesions and the peritoneal cavity is clear. An 18.0
x 7.8 x 3.2 cm abscess runs along the right anterior abdominal wall. There
are numerous metastatic nodules in the mesentery. The organs are completely
surrounded by tumor and adherent in one mass. The entire organ block is
removed by the Rokitansky method and serially sectioned from the trachea to
the bladder. Weights of organs were not obtained.
CARDIOVASCULAR SYSTEM The heart weighs 470 grams. The pericardial cavity
contains 5 cc of serous fluid. The heart chambers are not dilated. The right
ventricular thickness is 0.4 cm and the length is 9.0 cm. The left ventricular
thickness is 1.3 cm and the length is 7.2 cm. The atrial appendages are
clear. The foramen ovale is closed. The myocardium is firm and is brown with
no fibrosis. The endocardium is thin and translucent. The trabeculae carneae
and papillary muscles are normal. The chordae tendineae are normal. The heart
valves are thin and pliable. The heart valve ring circumferences are 11.2 cm
tricuspid, 8.6 cm pulmonic, 9.7 cm mitral, and 8.5 cm aortic. The coronary
arteries show a right dominant pattern with 10% atherosclerosis of all
branches and no narrowing. Thrombosis of no branches is found. The aorta is
not elastic and shows moderate to severe atherosclerosis in the arch and
descending aorta. The major branches are clear. The venae cavae are clear and
the leg veins milk freely. An adherent non-occlusive thrombus is identified
in the descending aorta.
RESPIRATORY TRACT: The larynx shows erythema. The trachea shows erythema. The
mainstem bronchi are erythematous. The pleural surfaces show fibrous
adhesions. The lungs are inflated with formalin prior to sectioning. The
pulmonary parenchyma shows posterior congestion. On sectioning the parenchyma
shows consolidation in the lower portion of the left upper lobe and entire
left lower lobe. All lobes show mottled consolidation. Tumor masses are not
seen. Granulomas are not identified. An area of loculated fluid is identified
in the left lower lobe (5.0 x 4.0 x 3.5 cm). A 2.5 x 2.5 x 1.8 cm abscess is
identified in the right upper lobe. The cut surfaces of the lungs are dark
red-brown and they exude no fluid. Anthracotic pigmentation is not marked.
The bronchi show erythematous mucosa. The pulmonary arteries do not have
pre-mortem thromboemboli. The pulmonary veins are clear.
GASTROINTESTINAL TRACT: The esophagus is clear. The stomach contains 50 cc
of dark green fluid. The gastric mucosa is erythematous. The small
intestine shows foci of infarction and ischemia. The appendix is surgically
absent. The large intestine shows necrosis and ischemia. The bowel contents
consist of a moderate amount of soft brown stool. The mesenteric arteries and
veins are normal.
PANCREAS: The pancreas is the usual size, firm, tan with normal
architecture.
HEPATOBILIARY SYSTEM: The liver is surrounded by firm white tissue. The
hepatic parenchyma is soft and has a nutmeg appearance. Cirrhosis is not
present. Tumor masses are not identified. The portal vein is clear. The
gallbladder is surgically absent.
SPLEEN AND LYMPHATIC SYSTEM: The spleen is soft. No tumor masses are
identified. The spleen is surrounded by firm white tissue. There are no
accessory spleens found.
URINARY SYSTEM: The cortical surfaces of the kidneys are pale red and
smooth. There are no scars. The cut surfaces are pale red with cortices that
are 0.8 cm in thickness. Corticomedullary demarcations are good. The medullae
are red. There are no cysts present. The bladder is the usual size with a
thin wall and smooth mucosa throughout. A catheter is present.
FEMALE GENITAL SYSTEM: The cervix is not identified. The uterus, fallopian
tubes and ovaries are surgically absent.
ENDOCRINE ORGANS: The pituitary is the usual size, shape, color, consistency,
and rests in the sella Turcica. The thyroid has one lobe (right) and on
sectioning, the parenchyma is red-brown with multiple nodules. No parathyroid
glands are identified. The right adrenal gland is hemorrhagic and the left
adrenal gland is normal with the usual appearance.
MUSCULOSKELETAL SYSTEM: The body and extremities are symmetric. The skeletal
muscles are red-brown and there is no evidence for muscle wasting. Bone
deformities are not present. Cardiopulmonary resuscitation was not performed.
The joints are not examined. The vertebral bone marrow is red and the
vertebral bone is normal in consistency.

CASSETTE SUBMISSION:
A - right ventricle
B - septum
C - left ventricle
D - left ventricle
E - pituitary
F - thrombus from descending aorta
G - thyroid, parathyroid
H - right upper lobe
I - right middle lobe
J - right lower lobe
K - left upper lobe
L - left lower lobe
M - abscess left upper lobe
N - fluid loculation from left lower lobe
O - firm tissue around liver
P - left kidney
P - Decal, vertebra
Q - right kidney
R - liver
S - spleen
T - right adrenal, large bowel, small bowel
U - left adrenal, mesentery
V - abdominal wall abscess

AU MICROSCOPIC DESCRIPTION

HEART: Sections of the right ventricle show a minute focus of wavy fibers. A
minute focus of interstitial hemorrhage is seen in the septum. Interstitial
fibrosis, myocytes with large box-car nuclei, and pigmented macrophages are
seen in the left ventricle.
PITUITARY: Sections of pituitary show cells with deeply eosinophilic to clear
cytoplasm with round nuclei and salt and pepper chromatin. Cells with pink
fibrillary cytoplasm with round to spindle shaped nuclei and salt and pepper
chromatin are also seen.
THROMBUS: Sections of the thrombus from the descending aorta show numerous red
blood cells and pink fibrillar material. There is no evidence of
recannulization and no lines of Zahn.
THYROID: Sections of the thyroid show follicles of various sizes with pink
colloid and cuboidal cells with round nuclei. A section of parathyroid is
identified.
LUNG: Sections of the lung show alveolar wall congestion. Pink proteinaceous
material is seen in the alveolar space with foci of hemorrhage into the
alveolar space. There are foci of acute inflammatory cells and vacuolated
foamy macrophages. Malignant cells with pink cytoplasm, oval nuclei and
prominent nucleoli are seen forming glands.
LEFT UPPER LOBE ABSCESS, LUNG: Sections of the abscess show spindled cells in
a fibrous matrix, hemorrhage, acute inflammatory cells and pink proteinaceous
material in the alveolar space. Bacterial and fungal stains are negative. No
malignant cells are seen.
LEFT LOWER LOBE FLUID LOCULATION: Sections of the left lower lobe fluid
loculation show malignant cells with pink cytoplasm, oval nuclei with
prominent nucleoli forming a glandular and cribriform pattern.
FIBROTIC TISSUE AROUND LIVER: Sections of the fibrotic tissue surrounding the
liver show morphologically normal skeletal muscle. Malignant cells with ovoid
nuclei, prominent nucleoli and pink cytoplasm are forming glands in a
background of pink fibrillar material with small spindled cells. Mucin
production is identified. These glands are seen infiltrating the diaphragm
and liver.
KIDNEY: Sections of the kidney show normal architecture and focal sclerosed
glomeruli. There is moderate autolysis.
MARROW: Sections of expressed marrow from a rib and cross sections of the
vertebra show 60% cellularity and adequate megakaryocytes. The myeloid to
erythroid ration is 5:1 and trilineage hematopoiesis with maturation is
identified. The trabecular bone is slightly thinned.
LIVER: Sections of the liver show extensive autolysis and bile plugging.
Microscopic foci of malignant cells with ovoid nuclei and prominent nucleoli
forming glands are seen. Macrovesicular steatosis and congestion with areas
of fibrosis and necrosis is most prominent in zone 3.
SPLEEN: Sections of the spleen show normal architecture with acute
inflammatory cells and plasma cells.
ADRENALS: Sections of the adrenals show extensive autolysis. A microscopic
focus of malignant cells with ovoid nuclei and prominent nucleoli forming
glands are seen in the left adrenals.
MESENTERY: Sections of the mesentery show mature adipocytes and areas of
chronic inflammation with cells with pink cytoplasm, oval nuclei and prominent
nucleoli forming glands. These cells are seen involving the lymph node and
extend beyond the lymph node capsule.
BOWEL: Sections of the bowel show acute and chronic inflammatory cells in the
bowel wall. Cells with ovoid nuclei and prominent nucleoli forming glands are
seen involving the serosa through submucosal layers.
ABDOMINAL WALL ABSCESS: Sections of the abdominal wall abscess show
unremarkable skeletal muscle, mature adipocytes and cuboidal cells with
vacuolated cytoplasm forming glands. The round to ovoid nuclei have prominent
nucleoli. These cells are in a background of pink material and spindled
cells. GMS stain is negative.