Case 5
Reproductive Pathology
Radiology Images
Surgical Pathology Report 12-17
Radiology Images:
CT scan 12-12:
CT scan 2-12 with autopsy correlation:
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
|
|
|
|
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+ |
||||
|
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 |
|
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 |
-- |
|
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 |
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.
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. "
- 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
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
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
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.