영문소견서 샘플(Doctor s medical opinion)

Doctor's medical opinion

(영 문 소 견 서)

 

1. Organ and tissue received

(1) LUS

(2) LUS MESS

(3) mediastinal mass

(4) L/N #5

(5) L/N #10

(6) L/N #12

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2. Pathological Findings an Diagnosis

(1) Gross description

the submitted specimen consistst of a lobe of the lung(#1), a small piece of lung tissue(#2), a solid mass(#3) and several lymph nodes(#4,#5 ). the lung, 17.0x16.0cm, shows dark purple colored pleural surface, and on sectioning there is no grossly identifiable mass lesion in the lung parenchyme, but enlarged lymph nodes are found in the hilar region. these lymph nodes show foci of necrosis. A solid mass, 7.5x6.0cm, shows round to oval shaped and pale brownish smooth slightly nodular external surface. On sectioning the mass shows mulfiple lobulated appearance with pale pinkish cut surface with mulriple foci of necrosis. Many tiny cytic lesions are also found in the lobules

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(2) Microscopic description

Cancer findings
size	1.5x1.5cm	capsular invasion	present(+)	nuclear atypism	moderate
necrosis	present(+)	mitosis	>10/HPF	lymphatic invasion	present(+++)
vein invasion	present(+)	perineural invasion	absent	stage	III
lymph node metastasis		present(12/13), #5:3/3 #10:1/1 #12:8/9

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(3) Immunohistochemistry

CKMNF116 :				positive
EMA :		positive
CD30 :		negative
CD3 :	positive in mature T cells
CD79a :			positive in reactive B cells

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(4) Molecular cytogenetic study

EBV in situ :

negative

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(5) diagnosis

1.combined thymic carcinoma and thyrmoma, thymus, excision 1)thymic carcinoma,undifferentiated 2)thymoma, type A & AB, thymus,excision 2.thymic carcinoma,undifferentiated,metastatic,involving lung,right upper lobe,lobectomy

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(6) Immunogistochemistry

CD56 :	negative
Chromogranin :			negative
Synaptophysin :			negative
PLAP :		negative

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