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Pathology Reports Nicole Draper, MD. Information in a Surgical Pathology Report – Patient...
Transcript of Pathology Reports Nicole Draper, MD. Information in a Surgical Pathology Report – Patient...
Pathology Reports
Nicole Draper, MD
Information in a Surgical Pathology Report
– Patient information: Name, birth date, biopsy date.– Accession number: for example S13-1297– Gross description: Color, weight, and size of tissue as seen
by the naked eye. Lesions identified.– Microscopic description: How the tissue sections look
under the microscope and comparison with normal cells.– Diagnosis: May be general or very specific.– Tumor or lesion size: Measured in centimeters.– Margins:
• Positive : abnormal cells are found at the edge of the material removed.• Negative: no abnormal cells are found at the outer edge.• Close: usually within 1mm.
– Other information: Samples sent for other tests or a second opinion, TNM staging
http://www.jkjpathology.com/doctors/reports.htm
Sometimes importantinformation about theseverity of disease or prognostic factors are found in the comment or microscopic description.
Special stains, IHC or othertest modalities in additionto microscopic analysis of H&E stained slides
http://jmmultiplemyeloma.blogspot.com/2012/04/bone-marrow-surgical-pathology-report.html
The gross description caninform you how much tissue was evaluated.
Breast Cancer Reporting Guidlines• http://link.springer.com/article/10.1007%2FS1
2094-010-0478-8
Breast Cancer pTNMStandardized reporting makes finding desired information easier
http://blog.mtuitive.com/mTuitive-Blog/bid/243736/5-Quality-Measures-Pathology-Synoptic-Reporting-Captures
Skin Cancer
Negative margins are very important in skin cancers.Ink is typically used to definitively determine all margins.
Bone Tumor
IHC studies for antigen expression to determine likely origin of neoplastic cells
Brain Tumor
Molecular testing for mutations is becoming more important for diagnosis, prognosis and determining treatment options for many neoplasms.
Brain Tumor
Quick diagnosis by frozen sectionwhile the patient is still in the OR so surgeons can decide next step
Information in a Clinical Pathology Report
• Reference ranges of test values• Goal values for treatment• Specimen collection and handling needs• Limitations of a test• Interpretation of test results– Single tests– Multiple tests that are considered together to
make a diagnosis
TM Antibody Report
Negative antibody screen about 2 months ago
Positive antibody screen now after RBC transfusion 2 months ago
The “c” indicates a comment/interpretation of the test result
Coagulation Testing Interpretation
An overall interpretation of the combination of results of all of these single tests
LMW Heparin not therapeutic ornot drawn at the appropriate 4 hrs