The Surgical Pathology Report: From the Glass Slide to the Final Diagnosis

ELEMENTS OF A SURGICAL PATHOLOGY REPORT

A pathology report is divided into multiple sections serving different purposes :

• Identifying information:

• Institution identifiers: Name, address, telephone number, FAX number.

• Patient identifiers: Name, date of birth, medical record number, gender.

• Pathology personnel identifiers: Person performing the gross evaluation, pathologist(s) rendering the final diagnosis. If an intraoperative consultation is performed, the additional staff is listed.

• Information specific to the specimen as received:

• Date of the procedure, date that the specimen was received by the pathology department.

• Date that the final report was signed out by the pathologist.

• Name of the clinician(s) submitting the specimen as well as other clinicians caring for the patient.

• Clinical data provided on the requisition form.

• Type of specimen submitted, including a list of all specimens submitted.

• Information specific to the specimen as examined in the pathology department:

• Specimen number: A unique specimen identification number assigned by the pathology department. This number should be located prominently at the top portion of each page of the report for easy identification.

• Gross description: In addition to describing the specimen and how it was labeled, the gross description should include the disposition of all tissue (e.g., saved for electron microscopy, snap-frozen, saved for tumor banking, etc.) and any special techniques used (e.g., decalcification, inking of margins). It should specify whether all or only a part of the specimen has been submitted. This portion of the report should also include other materials received such as specimen radiographs (including a description of the results) or peripheral blood smears.

• Description of tissue submitted for microscopic sections: type of tissue, number of cassettes. Each block of tissue should have a unique identifying number and/or letter.

• Diagnostic field:

• The diagnostic field of the report describes the type or types of pathologic processes present. Important information from the gross examination (e.g., tumor size) is included. The results of special studies are discussed. Discrepancies between intraoperative diagnosis and the final diagnosis are discussed.

• Synoptic reports for invasive cancer and ductal carcinoma in situ: The College of American Pathologists (CAP) has developed synoptic reporting forms (available at www.cap.org ). These reports are used in addition to, or sometimes in lieu of, a separate diagnostic field at some institutions.

• Microscopic description: Provided when appropriate (e.g., unusual tumors or diseases). A microscopic description is not necessary for every specimen if the essential information is provided in the diagnosis.

• Intraoperative consultation: If the specimen was evaluated intraoperatively, the diagnoses rendered are included. This may be in a separate field than the main diagnostic field.

• Note : Standard information included for documentary, billing, or regulatory purposes that is not specific to the patient could cause confusion should it be included in the diagnostic field (see below).

• Standard information:

• There are some types of information that are included in pathology reports for regulatory, billing, or interpretation purposes but do not specifically pertain to the patient (i.e., “boilerplate” text). If this text is included in the diagnostic field, it could potentially be mistaken for diagnostic information or could obscure important diagnostic information. It is better to include it in a different portion of the report. Examples include:

• A statement that the pathologist has examined gross and/or microscopic tissues before rendering the diagnosis.

• A statement that immunoperoxidase studies have Food and Drug Administration approval (or the absence of the need for approval).

• Criteria for positive and negative results for immunohistochemical assays.

• Addendums:

• An addendum can be used to add information after the original report is signed out. This is preferred over revising the original report unless it is critical to change the original report (e.g., if there is diagnostic error).

• Revised (amended) reports:

• A finalized pathology report is part of the patient’s medical record. Unsigning a report involves changing the patient’s medical record and must be approached with great care and caution. All changes made to the original report must be clearly documented.

• Prior surgical and cytologic specimens from the same institution:

• Some reports include a list of prior specimens for the patient. This list can be helpful to correlate with the results for the current specimen.

Diagnostic Headings

Headings need to be as accurate and as informative as possible and should include:

• Organ or tissue

• Site

• Surgical procedure

• Relevant gross descriptors (e.g., length of colon, weight of the spleen)

• Specific designations given by the clinician (e.g., “tissue closest to the margin”)

Usually the headings are based on the label used for the specimen or the gross recognition of the type of specimen. If the type of specimen or type of surgery cannot be recognized, it is generally preferable to discuss the case with the surgeon, as the type of specimen can affect the method of processing it as well as how the specimen should be billed.

Specimen headings using “Specimen labeled” often do not provide useful information on the type of specimen examined. For example, [Specimen labeled “Right Lung”:] could be anything from a transbronchial biopsy to an extrapleural pneumonectomy. This type of heading forces the reader to search for this important information in the gross description.

Examples of appropriate headings:

Colon resectionsRight colectomy (ascending colon and cecum [44 cm], terminal ileum [4 cm], and appendix):

Sigmoid colon (30 cm), resection:

Abdominoperineal resection (rectum [35 cm] and anus [15 cm]):

Breast specimens Left breast, skin-sparing mastectomy and axillary dissection:

Right breast, simple mastectomy:

Left breast, re-excision:

Right breast, radioactive seed localized excision for calcifications marked by a clip:

Left breast, stereotactic core needle biopsy for an irregular mass:

Lung resections Left lung, pneumonectomy:

Right lower lobe of lung, lobectomy:

Right upper lobe of lung, wedge resection:

Prostate specimensProstate, radical prostatectomy (42 g):

Prostate, suprapubic prostatectomy (150 g):

Prostate, transurethral resection (33 g):

Skin specimensSkin of chest, excision:

Skin of right leg, 0.3 cm punch biopsy:

Skin of face, shave biopsy:

Never use a label that may be misleading (e.g., one that may imply an incorrect diagnosis), as someone reading the report may easily mistake a heading for a diagnosis.

Weights should be included when relevant for evaluation or for billing purposes (e.g., spleen, breast reduction mammoplasty, myomectomy).

All separately submitted specimens are given separate diagnoses with separate headings. If multiple specimens have the same name and it is appropriate to combine two or more separately submitted specimens (i.e., they all clearly represent the same type of tissue from the same site and separating the specimens does not provide additional information), this may be indicated in the heading.

MESENTERIC MASS (TWO SPECIMENS):

If frozen sections were performed, they should be incorporated into the heading:

INGUINAL LYMPH NODE (INCLUDING FROZEN SECTION A AND TOUCH PREPARATION A):

Standardized Reporting

Standardized reporting forms are recommended for reporting malignancies. ^, The ones in most common use in the United States and Canada are developed by the CAP (available at www.cap.org ). CAP, The Joint Commission, the National Accreditation for Breast Centers, and the American College of Surgeons Commission on Cancer programs require synoptic reporting based on the required data elements in the CAP protocols. These reports are used in addition to, or sometimes in lieu of, a separate diagnostic field at some institutions.

A synoptic report is a specific type of reporting consisting of a list of elements correlating with defined responses to each element. “Synoptic” comes from the Greek for an overall view of things, a summary or synopsis.

Advantages of standardized reporting include:

• Uniform diagnostic terms, criteria, and style are established for a department or group of pathologists. Additional standard criteria can be included in each report (e.g., the basis of grading systems, definitions, etc.).

• Checklists ensure that important diagnostic and prognostic features are always included. ^, Additional information for AJCC classification and/or grading can be incorporated into a standard form for easy access by the pathologist.

• Facilitates preparing the report by staff and residents.

• Facilitates typing of reports by secretaries, as mnemonics can be used for many sentences or phrases. This can shorten the turnaround time by providing finished reports earlier.

• Important information is easily accessible for clinicians.

• Standardized reports are readily adaptable for computer-based systems and information is readily incorporated into computerized databases. ^,

• Teaching tool—provides important diagnostic features of most common diagnoses for each organ system.

However, unusual or complicated specimens should not be squeezed into a standard format but must be given an appropriate individualized pathology report. Standardized reports need to be flexible enough to allow additional comments for unusual findings.

Disadvantages of standardized reporting include:

• May adversely affect resident training by stifling independent thinking. Residents may become dependent on checklists and templates. Trainees need to recognize that not all pathology findings can be included in multiple-choice formats.

• Pathologists may not be able to reach a consensus on the types of information to be provided or on specific diagnostic criteria for standardized reports.

• Errors may be more difficult to detect with standardized reports.

There is general agreement that the overall advantages of standardized reporting for malignancies outweigh the potential disadvantages. Pathologists should continue to recognize that each specimen and tumor is unique and to include unusual and interesting findings as information added to standardized reports (Promote the note!).

Section 2 includes sign-out checklists for all major tumor types and resections that can be the basis for synoptic reporting. The lists are based on published recommendations (including the CAP protocols) and recommendations by subspecialists.