Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Lab Medicine - Pathology
Sample Name: Lung adenocarcinoma Path Report

Description: Probable right upper lobe lung adenocarcinoma. Specimen is received fresh for frozen section, labeled with the patient's identification and "Right upper lobe lung".
(Medical Transcription Sample Report)

CLINICAL HISTORY: Probable right upper lobe lung adenocarcinoma.

SPECIMEN: Lung, right upper lobe resection.

GROSS DESCRIPTION: Specimen is received fresh for frozen section, labeled with the patient's identification and "Right upper lobe lung". It consists of one lobectomy specimen measuring 16.1 x 10.6 x
4.5.cm. The specimen is covered by a smooth, pink-tan and gray pleural surface which is largely unremarkable. Sectioning reveals a round, ill-defined, firm, tan-gray mucoid mass. This mass measures 3.6 x 3.3 x 2.7 cm and is located 3.7 cm from the closest surgical margin and 3.9 cm from the hilum. There is no necrosis or hemorrhage evident. The tumor grossly appears to abut, but not invade through, the visceral pleura, and the overlying pleura is puckered.

FINAL DIAGNOSIS: Right lung, upper lobe, lobectomy: Bronchioloalveolar carcinoma, mucinous type

COMMENT: Right upper lobe, lobectomy.
Tumor type: Bronchioloalveolar carcinoma, mucinous type.
Histologic grade: Well differentiated.
Tumor size (greatest diameter): 3.6 cm.
Blood/lymphatic vessel invasion: Absent.
Perineural invasion: Absent.
Bronchial margin: Negative.
Vascular margin: Negative.
Inked surgical margin: Negative.
Visceral pleura: Not involved.
In situ carcinoma: Absent.
Non-neoplastic lung: Emphysema.
Hilar lymph nodes: Number of positive lymph nodes: 0; Total number of lymph nodes: 1.
P53 immunohistochemical stain is negative in the tumor.

Keywords: lab medicine - pathology, bronchioloalveolar carcinoma, mucinous, mucoid mass, lymph nodes, upper lobe, visceral, bronchioloalveolar, carcinoma, lymph, pleural, margin, tumor, adenocarcinoma, specimen, lobe, lung,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples