250 lines
6.5 KiB
Markdown
250 lines
6.5 KiB
Markdown
# Surgical Pathology Report Template
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## Patient and Specimen Information
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**Patient Name:** [Last, First]
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**Medical Record Number:** [MRN]
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**Date of Birth:** [MM/DD/YYYY]
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**Age:** [years]
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**Sex:** [M/F]
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**Accession Number:** [PathologyAccessionNumber]
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**Specimen Received:** [Date and time]
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**Report Date:** [Date]
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**Ordering Physician:** [Name]
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**Clinical Service:** [Department]
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---
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## Specimen(s) Submitted
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**Specimen A:** [Description of specimen]
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Example: "Skin, left forearm, excisional biopsy"
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**Specimen B:** [If multiple specimens]
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---
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## Clinical History / Indication
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[Relevant clinical information provided by clinician]
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Example: "72-year-old woman with enlarging pigmented lesion on left forearm. Clinical concern for melanoma. Previous biopsy showed atypical melanocytic proliferation."
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---
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## Gross Description
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**Specimen A labeled "[Specimen label]":**
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**Description:**
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- Received [fresh/in formalin]
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- Consists of [specimen type] measuring [dimensions in cm]
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- [External surface description]
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- [Cut surface/sectioning description]
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- [Lesion description if applicable]
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- [Orientation markers if present]
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- [Inking for margins]
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**Sampling:**
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- [How specimen was sectioned]
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- [Cassette labeling]
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- [Percent of tissue submitted]
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**Example:**
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```
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Specimen A labeled "Skin, left forearm, excisional biopsy":
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Received fresh is an oriented ellipse of skin measuring 3.5 x 1.2 x 0.8 cm with a
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suture indicating superior. The epidermis contains a 1.1 cm diameter irregularly
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pigmented lesion located 1.5 cm from superior, 1.2 cm from inferior, 0.8 cm from
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medial, and 1.2 cm from lateral margins. Inking: superior blue, inferior black,
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medial green, lateral red, deep yellow. Serially sectioned perpendicular to long
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axis into 10 slices. Entirely submitted in cassettes A1-A4.
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```
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---
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## Microscopic Description
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[Detailed histological findings]
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**Architecture:**
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[Structural patterns observed]
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**Cytology:**
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[Cell type, nuclear features, cytoplasm, pleomorphism]
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**Special Features:**
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[Necrosis, mitoses, invasion, margins]
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**Stains/Immunohistochemistry Results:**
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[Results of special stains or immunostains]
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**Example:**
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```
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Sections show skin with an asymmetric melanocytic proliferation composed of
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epithelioid and spindled melanocytes arranged in irregular nests at the
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dermoepidermal junction with extension into the papillary and reticular dermis.
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Melanocytes show marked cytologic atypia with nuclear enlargement, hyperchromasia,
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and prominent nucleoli. Mitotic activity is present with 4 mitoses per mm².
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No ulceration identified. The lesion extends to a Breslow depth of 1.8 mm
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(Clark level IV). Margins are free of tumor (closest margin: deep, 0.3 cm).
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```
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---
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## Diagnosis
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**Specimen A, Skin, left forearm, excisional biopsy:**
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**[DIAGNOSIS IN CAPITAL LETTERS]**
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**Example Format:**
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```
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MALIGNANT MELANOMA, SUPERFICIAL SPREADING TYPE
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Pathologic features:
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- Breslow thickness: 1.8 mm
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- Clark level: IV
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- Mitotic rate: 4/mm²
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- Ulceration: Absent
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- Margins: Negative for melanoma (closest margin deep, 0.3 cm)
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- Lymphovascular invasion: Not identified
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- Perineural invasion: Not identified
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- Regression: Absent
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- Tumor-infiltrating lymphocytes: Present, non-brisk
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- Microsatellites: Absent
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```
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**For Cancer Specimens - Synoptic Format (CAP Protocol):**
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```
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SYNOPTIC REPORT FOR [CANCER TYPE]
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Procedure: [Type of resection]
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Tumor Site: [Specific location]
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Tumor Size: [Greatest dimension in cm]
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Histologic Type: [WHO classification]
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Histologic Grade: [Grading system and result]
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Depth of Invasion: [Measured in mm if applicable]
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Lymphovascular Invasion: [Present / Not identified]
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Perineural Invasion: [Present / Not identified]
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Margins:
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- [Margin name]: [Negative/Positive, distance if negative]
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- [All margins listed]
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Regional Lymph Nodes:
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- Number examined: [X]
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- Number with metastasis: [Y]
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- Extranodal extension: [Present/Absent]
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Pathologic Stage (AJCC 8th edition): [pTNM]
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Additional Findings: [Other relevant findings]
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```
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---
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## Ancillary Studies
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**Immunohistochemistry:**
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| Antibody | Result | Interpretation |
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|----------|--------|----------------|
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| [Marker name] | [Positive/Negative, pattern] | [Clinical significance] |
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**Example:**
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| Antibody | Result | Interpretation |
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|----------|--------|----------------|
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| S100 | Positive, diffuse | Supports melanocytic lineage |
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| Melan-A | Positive, diffuse | Supports melanocytic lineage |
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| HMB-45 | Positive, patchy | Supports melanoma |
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| Ki-67 | 30% | High proliferative index |
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**Molecular/Genetic Testing:**
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[Results of molecular tests if performed]
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- BRAF mutation: [Detected/Not detected]
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- [Other relevant tests]
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---
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## Comment
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[Additional interpretive information, differential diagnosis, recommendations]
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**Example:**
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```
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The morphologic and immunohistochemical findings are diagnostic of melanoma. The
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Breslow thickness of 1.8 mm places this tumor in the T2 category (AJCC 8th edition).
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Sentinel lymph node biopsy is recommended for staging. BRAF mutation testing may be
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considered for treatment planning. Close clinical follow-up is recommended.
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```
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---
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## Signature
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**Pathologist:**
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[Name, MD]
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[Board Certification]
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[License number]
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**Electronically signed:** [Date and time]
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**Gross examination by:** [Name, credentials]
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**Microscopic examination by:** [Name, MD]
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---
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## Template Notes for Different Specimen Types
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### Breast Biopsy
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**Key Elements:**
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- Histologic type (invasive ductal, lobular, etc.)
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- Nottingham grade (tubule formation, nuclear grade, mitotic count)
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- Size of invasive component
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- DCIS if present (grade, extent)
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- ER/PR/HER2 status
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- Margins for all components
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- Lymph nodes if present
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### Colon Resection
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**Key Elements:**
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- Tumor site and size
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- Histologic type and grade
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- Depth of invasion (T stage)
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- Lymph nodes (number positive/total examined)
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- Margins (proximal, distal, radial/circumferential)
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- Lymphovascular and perineural invasion
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- Tumor deposits
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- MSI/MMR status
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### Prostate Biopsy/Resection
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**Key Elements:**
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- Gleason score (pattern 1 + pattern 2 = total)
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- Grade group (1-5)
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- Percent involvement per core/specimen
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- Extraprostatic extension (if radical prostatectomy)
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- Seminal vesicle invasion
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- Margins
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- Perineural invasion
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---
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## Frozen Section Report (if applicable)
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**Frozen Section Diagnosis:**
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**Specimen:** [Description]
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**Clinical Question:** [Reason for frozen]
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**Frozen Section Diagnosis:** [Diagnosis given intraoperatively]
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**Time:** [Time reported]
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**Pathologist:** [Name]
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**Note:** Permanent sections to follow.
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**Final Diagnosis:** [State if concordant or discordant with frozen]
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