System |
Specimen |
Dx. I |
Dx. II |
Note |
CPT |
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Breast |
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Cardiovascular |
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Gastrointestinal |
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Genitourinary |
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Head & Neck |
CPT code |
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Hepatic/Pancreatic |
CPT code |
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Lymphoid |
CPT code |
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Male Reproductive |
CPT code |
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Mediastinum |
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Neuroendocrine |
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ObGyn |
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Pulmonary |
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Skeleton |
Comments |
CPT code |
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Skin |
Comments |
CPT code |
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Soft Tissue |
Comments |
CPT code |
Breast carcinomas, invasive Gastric carcinomas Pancreatic carcinoma
Cervical carcinomas Lung carcinomas Prostatic carcinoma
Colorectal carcinomas Melanoma Renal carcinomas (excluding TCC)
Endometrial carcinomas Ovarian epithelial carcinomas Urinary bladder carcinomas
Esophageal carcinoma Ovarian germ cell neoplasms
(For a complete list of tumor synoptic form with drop-down features, please visit the Tumor Synopsis website)
Right / Left breast, needle core biopsy at __ o’clock: CPT 88305
Right breast, stereotactic needle core biopsies:
Right / Left breast, excisional biopsy:
Right / Left breast mass, excision: CPT 88305
Right / Left breast, lumpectomy: CPT 88307
Right / Left breast, re-excision: CPT 88307
Right / Left breast, simple / partial mastectomy: CPT 88307
Right / Left breast, radical mastectomy: CPT 88309
Right / Left breast, reduction mammoplasty: CPT 88305
Benign breast tissue with fibrocystic change and microcalcification. No carcinoma or atypical hyperplasia seen.
Fibrocystic changes, including sclerosing adenosis, cysts, and focal areas of usual ductal hyperplasia.
Benign breast tissue with fibrocystic change and focal usual ductal hyperplasia.
Benign breast tissue with fibrocystic changes and microcalcification, no hyperplasia or atypia seen.
Benign breast tissue with focal sclerosing adenosis and microcalcification.
Benign breast tissue with focal fibrosis, no atypical hyperplasia seen.
Fibroadenoma.
Benign breast tissue with changes consistent with hyalinized fibroadenoma
Juvenile papillomatosis.
Focal florid ductal hyperplasia with / without atypia, and associated microcalcification..
Atypical ductal hyperplasia, multifocal, extending to ___ margin(s).
Lobular hyperplasia without atypia associated microcalcification.
Atypical lobular hyperplasia and associated microcalcification.
Infiltrating lobular carcinoma, low nuclear grade, present in all biopsy cores and involving approximately 90% of total tissue volume.
Infiltrating ductal carcinoma, high nuclear grade, with focal comedo necrosis. No amplification of Her-2 gene is identified by Fluorescence in situ hybridization.
Infiltrating and in-situ ductal / lobular carcinoma (__ cm), cribriform / comedo type, low / intermediate / high nuclear grade (Bloom-Richardson nuclear grade __ /3) with angiolymphatic invasion. See attached Tumor Synoptic Report. (See comment for Breast Carcinoma Synopsis.)
Infiltrating ductal / lobular carcinoma, ____ type, Well / moderately / poorly differentiated (Bloom-Richardson score: __ /10 = __ + __ + __ ). See comment for Breast Carcinoma Synopsis.
Infiltrating lobular carcinoma, intermediate nuclear grade (Bloom-Richardson nuclear grade 2), involving 75% of the total tissue volume, with focal in-situ component and terminal ductal involvement.
Invasive lobular carcinoma (__ cm), arising in a background of extensive lobular carcinoma in situ (LCIS). See comment for Breast Carcinoma Synopsis.
Mixed intraductal and infiltrating ductal carcinoma, highs / intermediate / low nuclear grade, with angiolymphatic invasion.
Phyllodes tumor (cystosarcoma phyllodes), __ cm. with heterologous stromal sarcoma (predominantly liposarcoma); no tumor seen on surgical excision margins, see note.
-
Immunohistochemical staining results of estrogen and progesterone receptors, and Her-2/Neu oncoprotein will be issued in a separate report.
Immunohistochemical stains, with adequate controls, show that the majority ( ___ %) of invasive component are negative / strongly positive for estrogen and progesterone receptors, and the majority ( __%) invasive component are negative / positive for HER-2-Neu oncoprotein in membranous pattern
Radiographic film of the specimen is received and correlated with histological findings.
Pending clinical history / special stain / additional levels / decalcification / subspecialty consultation / intradepartmental conference.
- Fluorescence in situ hybridization of cells within paraffin-embedded tissue sections was performed using the FDA-approved Vysis PathVision HER-2 DNA probe kit. The kit consists of two labeled DNA probes. The first one hybridizes to the HER-2/gene and the second hybridizes to the alpha satellite DNA located at the centromere of chromosome 17. Forty interphase nuclei of infiltrating tumor cells were analyzed. There were __ HER-2 signals and __ chromosome 17 signals.
Aortic aneurysm, partial resection: CPT 88305
Abdominal aorta, aneurysm repair:
Aortic valve, valve replacement:
Ascending aorta, partial resection: CPT 88305
Aortic valve, valvectomy: CPT 88305
Aortic valve leaflets, resection:
Right / Left carotid plaque, endarterectomy: CPT 88304
Prosthetic aortic valve, removal CPT 88300
Temporal artery, biopsy: CPT 88305
Mitral valve, valve replacement:
Right ventricle, biopsy:
Thrombus, (site), removal: CPT 88304
Dissecting aneurysm
Marked mural myxoid degeneration, medial necrosis and associated mural hemorrhage consistent with dissecting aneurysm.
Marked atherosclerosis and mural myxoid degeneration (aorta).
Blood and fibrin blots.
Calcified atheromatous plaque.
Atherosclerotic plaque with extensive calcification and fibrosis
Marked atherosclerotic change with atherosclerotic plaque formation fibrosis, calcification and myxoid degeneration.
Calcific atherosclerotic plaques.
Mechanical aortic valve, ball and cage type, for gross examination only.
Bioprosthetic aortic valve.
- Segment of arterial wall with intimal thickening and calcified atheromatous plaque.
Atherosclerotic plaques with fibrosis and calcification.
Focal mild / moderate / severe acute cellular rejection (ISHLT grade __ /3). See note.
Dissecting aortic aneurysm with hemorrhage, fibrin and blood clot and marked mural myxoid degeneration.
Appendix, appendectomy: CPT 88302 (incidental); or 88304
Anal canal, hemorrhoidectomy:
- Cecum, mucosal biopsy: CPT 88305
- Duodenum, mucosal biopsy: CPT 88305
Esophageal-gastric junction, mucosal biopsy: CPT 88305
Esophagus, partial / total esophagectomy: CPT 88309 (tumor) or 88307
Gastric antrum, mucosal biopsy: CPT 88305
Gastric fundus, mucosal biopsy: CPT 88305
Right / Transverse / Left / Sigmoid colon, __ cm, mucosal biopsy: CPT 88305
- Right / Transverse / Left / Sigmoid colon, segmental colectomy: CPT 88309 (tumor) or 88307
- Small intestine / Ileum, segmental resection: CPT 88309 (tumor) or 88307
- Stomach, mucosal biopsy: CPT 88305
- Terminal ileum, cecum and appendix, partial ileocolectomy: CPT 88309 (tumor) or 88307
-
- Rectum, __ cm, mucosal biopsy: CPT 88305
- Stomach, partial /subtotal resection // total gastrectomy: CPT 88309 (tumor) or 88307
-
Acute appendicitis and periappendiceal inflammation. The proximal resection margin is free of / involved by acute inflammation.
Focal acute inflammation. No granuloma or dysplasia seen.
Antral / fundic / pyloric mucosa with hyperplastic changes and mild chronic inflammation. No acute inflammation is present.
Focal / diffuse mild / severe acute gastritis. No H. pylori are identified on Alcian yellow stain. // Microorganism form consistent with H. pylori is identified on Alcian yellow stain.
Antral / fundic / pyloric mucosa with no histologic abnormality. Special stain for Helicobacter pylori is negative.
Antral mucosa with mild chronic inactive gastritis. No dysplasia is identified. Special stain for Helicobacter microorganism is negative.
- Giardiasis, duodenum.
- Gastro-esophageal junction mucosa with mild / moderate / marked chronic / acute gastritis and intestinal metaplasia, consistent with Barrett’s esophagus. No glandular dysplasia is noted. No esophagitis is identified.
- Mild chronic gastritis with very focal activity. No dysplasia seen. Special stain for Helicobacter microorganism is negative
- Benign antral mucosa with mild reactive changes.
- Benign colonic mucosa, no pathological changes identified.
- Idiopathic inflammatory bowel disease, quiescent / minimally active, favoring ulcerative colitis, negative for dysplasia / with polypoid adenomatous (low grade) epithelium; see note.
- Colonic mucosa, with normal limit. // Unremarkable colonic mucosa.
- Colonic mucosa with no histological abnormality identified.
Focal / Diffuse mild / moderate / marked acute inflammation (colitis). No architectural distortion, granuloma or dysplasia seen.
Chronic colitis, quiescent / minimally active / moderately active, no granuloma or dysplasia seen.
Benign colonic mucosa with very focal mild acute inflammation. No significant architecture distortion identified
- Benign colonic mucosa with focal superficial hyperplastic change.
- Lymphocytic colitis. No neutrophilic inflammation, granuloma or dysplasia seen.
- Tubulovillous adenoma, fragmented.
- Adenomatous polyp.
- Fragments of adenomatous colonic epithelium (with focal high grade dysplasia).
- Tubulovillous adenoma(s) (__ cm, __ cm and __ cm), the proximal and distal resection margins are free of the tumor.
- Fragments of adenomatous colonic epithelium with high grade dysplasia and lamina propia invasion with possible vascular invasion suggestive of underlying invasive adenocarcinoma.
-
- Invasive adenocarcinoma (__ cm) of the colon, moderately / poorly differentiated, extending into / through muscularis mucosa / submucosa / muscularis propria into the pericolonic adipose tissue, with no / focal / extensive angiolymphatic invasion. The proximal and distal resection margins are free of tumor. Metastatic adenocarcinoma in __ of __ (__ /__) pericolonic lymph nodes.
- Invasive adenocarcinoma (__ cm) of the colon, moderately / poorly differentiated (see Comment for Synoptic Report).
- Invasive adenocarcinoma (__ cm) of the esophagus, well / moderately / poorly differentiated, extending into / through muscularis mucosa /submucosa /muscularis propria, with no / focal / extensive angiolymphatic invasion. The resection margins are free of tumor (see comment for Synoptic report).
- Invasive gastric adenocarcinoma ( __ cm), well / moderately / poorly differentiated, extending into / through muscularis mucosa / submucosa / muscularis propria, with no / focal / extensive / angiolymphatic invasion, and metastasis to __ of ___ lymph nodes ( __ / __ ). The resection margins are free of tumor. // Tumor present at / -- cm from the closest proximal / distal resection margin.
- Invasive gastric adenocarcinoma (__ cm), well/moderately/poorly differentiated, the resection margins are free of tumor // extending to / present at __ cm from proximal / distal resection margin (see Comment for Synoptic report).
- Carcinoid tumor of ___ (e.g. terminal ileum) (1.5 x 1.0 X 0.7 cm), invading into but not through muscularis propia with lymphovascular invasion. \\ the resection margins are free of tumor. Metastasis to __ of __ (_/__) lymph nodes.
- The histological findings are compatible with the diagnosis of chronic active colitis. The underlying etiology cannot be determined morphologically. Differential diagnosis includes, but is not limited to, idiopathic inflammatory bowel diseases. Clinical correlation is required
Endoscopic report / picture is received and reviewed.
Patient’s previous biopsy (S-01- ___) is reviewed and compared with the current specimen.
Pending clinical history / special stain / additional levels / decalcification / subspecialty consultation / intradepartmental conference.
Case discussed with Dr. ___ (clinician) on __ / __ / __.
Case reviewed with Dr. _____ (pathologist, e.g. Farhood).
Case reviewed at intradepartmental quality assurance conference on __ / __ / __.
- Dr. ___ (clinician) office is notified about the preliminary diagnosis / case status on __ / __ / __ by ____ (pathologist).
-
Case sent to (MD.
- Urinary bladder, mucosal biopsy: CPT 88305
- Bladder, transurethral resection:
- Bladder, dome, biopsy:
- Right / Left kidney, total / partial nephrectomy: CPT 88307
- Right / Left kidney, transplant, biopsy: CPT 88305
Right / Left kidney, explant: CPT 88307 ??
- Right / Left ureter, segmental resections: CPT 88307
- Right / Left ureter, biopsy: CPT 88305
-
-
Renal allograph acute cellular rejection,
- Benign transitional urothelial mucosa and submucosa; no dysplasia seen.
- End-stage kidney with thyroidization of tubules, marked arterial and arteriolar sclerosis.
-
- Oncocytoma (5 cm), extending into renal parenchyma, Girota's fat margin is free of tumor. See note.
- Renal cell carcinoma (___ cm), conventional type/papillary type/chromophobe type (see comment for Synoptic report).
- Renal cell carcinoma ( __ x __ x __ cm), __ type, Fuhrman grade __/4, confined to the kidney, no angiolymphatic invasion identified.
- Renal cell carcinoma, papillary type, with focal clear cell areas, __ cm, confined to the kidney, no angiolymphatic invasion identified. Vascular and ureteral margins are free of tumor.
- Papillary urothelial carcinoma, grade __/3 (papillary urothelial neoplasm of low malignant potential \\ papillary urothelial carcinoma, intermediate/high grade, 1998 ISCP-WHO), no invasion seen. No muscularis propria present.
- Flat urothelial atypia of unknown significance
- Low-grade intraurothelial neoplasia (flat urothelial dysplasia, 1998 ISCP-WHO)
- High-grade intraurothelial neoplasia (carcinoma in situ, 1998 ISCP-WHO).
- Severe dysplasia (carcinoma in situ, 1998 ISCP-WHO).
- Papillary neoplasm of low malignant potential (1998 ISCP-WHO).
- Papillary carcinoma, low-grade (1998 ISCP-WHO).
- Papillary carcinoma, high-graded (with or without marked anaplasia) (1998 ISCP-WHO).
Papillary carcinoma, low-grade with lamina propria invasion (1998 ISCP-WHO). ??
- Papillary carcinoma, high-graded with lamina propria invasion (1998 ISCP-WHO).??
-
- In specimen __, there are focal atypical glands suspicious for adenocarcinoma. However, immunohistochemical stain for high molecular weight keratin reveals the presence of basal cells around the atypical glands. This finding favors benign atrophic changes of the glands.
- Immunohistochemical stain for high molecular weight keratin reveals the absence of basal cells around the atypical glands. This finding confirms the diagnosis of prostatic adenocarcinoma.
- Pending clinical history / special stain / additional levels / decalcification / subspecialty consultation / intradepartmental conference.
- Patient’s previous biopsy (S-01- ___) is reviewed and compared with the current specimen.
- Case discussed with Dr. ___ (clinician) on __ / __ / __.
- Case reviewed with Dr. _____ (pathologist, e.g. Farhood).
Case reviewed at intradepartmental quality assurance conference on __ / __ / __.
- Dr. ___ (clinician) office is notified about the preliminary diagnosis / case status on __ / __ / __ by ____ (pathologist).
-
Case sent to (MD.
- Patient’s previous biopsy (S-01- ___) is reviewed and compared with the current specimen.
- Pending clinical history / special stain / additional levels / decalcification / subspecialty consultation / intradepartmental conference.
- Case discussed with Dr. ___ (clinician) on __ / __ / __.
- Case reviewed with Dr. _____ (pathologist, e.g. Farhood).
- Case reviewed at intradepartmental quality assurance conference on __ / __ / __.
- Dr. ___ (clinician) office is notified about the preliminary diagnosis / case status on __ / __ / __ by ____ (pathologist).
-
Case sent to (MD.
- Sinus content, curettage:
- Right and left tonsils, bilateral tonsillectomy:
- Right/Left tonsil, tonsillectomy:
- Adenoids, excision:
- Left eye, enucleation:
- Skin, left eyelid, blepharoplasty:
-
- Sinonasal mucosa with mild chronic inflammation. Fragments of unremarkable bone and cartilage.
- Benign tonsil tissue with reactive lymphoid hyperplasia. Actinomyces present in crypts.
- Benign adenoid tissue with reactive lymphoid hyperplasia.
- Inflammatory polyp of nose / sinus
- Chronic sinusitis
- Mucocele. No squamous dysplasia or carcinoma seen.
- Hyperplastic follicular nodule consistent with dominant nodule in nodular goiter.
- Multinodular goiter with dominant __ cm hyperplastic nodule with focal ___ features.
- Sinonasal papilloma with inverted features, no dysplasia seen.
- One normocellular parathyroid.
- Pleomorphic adenoma (mixed tumor) ( __ cm), extending to deepen/lateral resection margin. \\ resection margins are free of tumor.
- Mucoepidermoid carcinoma, low /intermediate/high grade, extending to deepen/lateral resection margin. \\ resection margins are free of tumor.
- Medullary thyroid carcinoma, ( __ cm) extending into the peri-thyroidal tissues and focally to the inked surgical resection margin. See note.
Hurtle cell carcinoma, minimally invasive, 2.0 cm. No angiolymphatic invasion identified. Lesion confined to thyroid.
- Adenoid cystic carcinoma, __ cm, extending to superior and deep surface of the specimen, final resection margins negative for tumor; Extensive perineural invasion identified. No lymphovascular invasion seen.
-
- Pending clinical history / special stain / additional levels / decalcification / subspecialty consultation / intradepartmental conference.
- Case discussed with Dr. ___ (clinician) on __ / __ / __.
- Case reviewed with Dr. _____ (pathologist, e.g. Farhood).
- Case reviewed at intradepartmental quality assurance conference on __ / __ / __.
- Dr. ___ (clinician) office is notified about the preliminary diagnosis / case status on __ / __ / __ by ____ (pathologist).
-
Case sent to (MD.
-
- Pancreas and duodenum, Whipple procedure: CPT 88309
- Pancreas, partial pancreactomy: CPT 88309
- Gallbladder, cholecystectomy: CPT88304
- Liver, needle core biopsy: CPT88307
- Donor liver, wedge biopsy: CPT88307
- Native liver, explant:
-
- Chronic cholecystitis and cholilithiasis.
- Chronic cholecystitis and cholesterolosis.
- Biliary cirrhosis with occasional paucity of bile ducts consistent with, but not diagnostic of, primary sclerosing cholangitis.
- Biliary cirrhosis with paucity of bile ducts, (ANA 1:1280); see note.
- Chronic hepatitis, mildly active, consistent with patient’s history of type C hepatitis.
- Chronic hepatitis (grade 2/4) with minimal portal fibrosis (stage 0/4).
- Cirrhosis of liver with chronic active hepatitis compatible with clinical history of type C hepatitis, see note.
- Grade III intrahepatocellular hemosiderin deposition, see note.
- Steatohepatitis, moderately active. No granuloma, viral inclusion or Mallory body identified. No significant portal fibrosis.
- Liver cirrhosis and mild/ moderate/ severe chronic hepatitis (grade __/4, stage 4/4), consistent with patient's clinical history of type C hepatitis (see comment for ref.). - Regenerative liver nodule with focal steatosis. - No carcinoma is identified. - Unremarkable main hepatic biliary tract. - No increased iron deposition. PAS-D stain is negative.
- Moderate centrilobular hepatocytic ballooning and cholestasis and mild acute cholangitis and pericholangitis consistent with ischemic/reperfusion injury. No changes of acute cellular rejection seen.
- Consistent with acute cellular rejection. A minor component of recurrent hepatitis C cannot be excluded.
- Changes consistent with a minimally active hepatitic process.
- Most consistent with recurrent hepatitis (grade ¾, stage 2/4) with possibly superimposed mild acute rejection. Clinical correlation is recommended.
-
- Focal nodular hyperplasia (__ cm), liver.
-
- Invasive pancreatic ductal adenocarcinoma (__ cm), ________ type well/moderately/poorly differentiated, the resection margins are free of tumor (see Comment for Synoptic report).
- Mucinous cystic neoplasm of pancreas (mucinous cystadenoma) (3.0 cm) with ovarian-type stroma.
- Intraductal papillary mucinous neoplasm with low grade dysplasia involving ampulla and large and small pancreatic ducts, present at the shaved pancreatic margin \ the pancreatic resection margins is free of the tumor. No invasive carcinoma identified. Focal chronic pancreatitis.
- Islet cell tumor, low-grade, with cystic degeneration (7 cm), pancreas.
- Hepatocellular carcinoma (3.8 cm), moderate to poorly differentiated, with vascular invasion, margin of resection free of tumor.
- Hepatocellular carcinoma ( __ cm), right / left lobe, predominantly compact pattern with focal pseudoglandular pattern, well / moderately / poorly differentiated (Grade __/III of Edmondson and Steiner) arising in cirrhotic liver, with intrahepatic vascular invasion; hilar vascular and bile duct margins are free of tumor, (see Comment for Tumor Synoptic Report).
-
- Batts KP, Ludwig J.: Chronic hepatitis. An update on terminology and reporting.
Am J Pathol 19:1409-1417, 1995. (Ref. for chronic hepatitis)
- These changes are complex and may represent more than one underlying etiologies. Cholestasis along with foam cell aggregates and particularly bile duct injury are most consistent with chronic rejection, however, biliary obstruction and drug induced injury (less favored) can not be excluded.
- The presence of plasma cells in the infiltrate and central venulitis raise the possibility of de novo autoimmune hepatitis. Correlating serologic studies are indicated.
- Although, in view of the clinical history of hepatic artery thrombosis, ischemic cholangitis is the most plausible diagnosis, a component of recurrent primary sclerosing cholangitis is also strongly suspected.
- Right and left tonsils, bilateral tonsillectomy:
- Right/Left tonsil, tonsillectomy:
- Follicular lymphoma, nodular, predominantly small cleaved cell, grade 1(REAL Classification). See note.
- Benign tonsil tissue with reactive lymphoid hyperplasia. Actinomyces present in the crypts.
- Benign tonsil tissue with reactive lymphoid hyperplasia. No squamous dysplasia seen.
- Atypical lymphoid proliferation, pending flow cytometry and immunohistochemical stains.
-
- Follicular lymphoma, nodular, predominantly small cleaved cell, grade 1(REAL Classification). See note.
- Follicular lymphoma, mixed small and large cell (grade 2), follicular growth pattern, see microscopic description.
- Classic Hodgkin lymphoma, nodular sclerosis type.
- Metastatic squamous cell carcinoma / adenocarcinoma in ___ of ___ lymph nodes with extracapsular extension.
-
- Right / Left testis, orchiectomy: CPT 88309 (tumor) or 88307 (non-neoplastic)
- Right / Left testis, orchiectomy (castration) CPT 88302
- Left testis and spermatic cord, orchiectomy:
- Right / Left testis, needle biopsy: CPT 88307 (tumor) or 88305 (non-neoplastic)
- Prostate, right / left side, needle biopsy:
- Prostate (prostatic chips), transurethral resection CPT 88305
- Prostate, partial resection: CPT 88307
- Prostate, radical prostatectomy: CPT 88309
- Penis, foreskin, circumcision:
- Tunica vaginalis, left, hydrocelectomy:
- Vas deferens, left, vasectomy:
- Urinal bladder, mucosal biopsy: CPT 88305
- Urinary bladder, partial / total cystectomy: CPT 88309
- Mass of urinary bladder, resection: CPT 88305
-
- Benign prostatic tissue with focal glandular atrophy and focal chronic/acute inflammation.
- Benign prostatic tissue with glandular and stromal hypertrophy (benign prostatic hypertrophy).
- Bladder mucosa with marked acute and chronic inflammation and giant cell reaction consistent with patient’s clinical history of BCG treatment, no residual tumor is identified (see comment).
- Benign bladder mucosa with chronic inflammation, no dysplasia seen.
- Benign bladder mucosa with cystitis gladularis / cystica, no dysplasia seen.
-
- Mature teratoma (__ cm), confined to the testis associated with intratubular germ cell neoplasia. No involvement of the rete testes or spermatic cord by tumor. See note.
- Focal atypical glands, favoring atrophy (see comment).
Benign prostatic tissue with focal acute and chronic inflammation and glandular atrophy.
Focal atypical glands suspicious for but not diagnostic of adenocarcinoma.
-
Testicular non-seminomatous germ cell tumor, predominantly yolk sac tumor / embryonal carcinoma / choriocarcinoma, __ cm; resection margins negative for tumor, see note. Intratubular germ cell neoplasia is present.
- Embryonal carcinoma (2.5 cm) with angiolymphatic invasion, focally involving rete testis and invading into but not through tunica albuginea. Intratubal (in-situ) germ cell neoplasm is present. The spermatic cord section margin is free of tumor.
- Mixed germ cell (embryonal carcinoma and yolk sac tumor), 1.5 cm, involving the rete testis, with angiolymphatic invasion. The tunica albuginea is free of tumor. The spermatic cord, including its margin, is free of tumor. Intratubular germ cell neoplasia is identified.
Seminomas, classic type, __ cm, involving rete testis, confined to testis; tunica albuginea, spermatic cord, including its margin, are free of tumor. No vascular invasion is identified. Intratubular germ cell neoplasia is identified.
- Prostatic adenocarcinoma, Gleason Score __ ( __ + __), present in __ of __ biopsy cores, __ mm of combined tumor line length, involving __ % of total tissue volume, with (no) perineural invasion.
- Prostatic adenocarcinoma, Gleason Score __ ( __ + __), __ mm, present in one of __ biopsy cores, involving __ % of total tissue volume, with (no) perineural invasion.
-
- Pancreas and duodenum, Whipple procedure: CPT 88309
- Pancreas, partial pancreactomy: CPT 88309
Thyroid, right / left lobe and isthmus, partial thyroidectomy: CPT 88307
- Thyroid, total thyroidectomy / lobectomy: CPT 88307
- Right / Left adrenal gland, partial/ total adrenectomy: CPT 88307
-
- Multinodular goiter with dominant cellular hyperplastic nodule ( __ cm).
-
- Adrenal pheochromocytoma ( __ cm), completely confined within the adrenal capsule, see note.
- Parathyroid adenoma ( __ cm, __ g).
-
- Papillary thyroid carcinoma (1.5 cm) with extrathyroidal extension and lymphovascular invasion; carcinoma abuts ink margin of resection.
- Papillary thyroid carcinoma ( __ cm), with extension through tumor capsule into perithyroidal soft tissue and present less than __ cm from the inked surgical margin.
- Papillary carcinoma of thyroid (follicular variant) in two small foci ( __ mm and __ mm, respectively), confined to thyroid.
- Olfactory neuroblastoma, focally extending to the tissue edge. See note.
- Medullary thyroid carcinoma, __ cm, extending to extra thyroid soft tissue / confined to thyroid. No angiolymphatic invasion identified.
- Carcinoid tumor of _____ (__ x __ X __ cm), invading into but not through muscularis propia with angiolymphatic invasion. \\ the resection margins are free of tumor. Metastasis to __ of __ (_/__) lymph nodes.
- Endometrium, curettage:
Uterine cervix, biopsy at __ o’clock:
- Uterine cervix, cone biopsy:
- Uterine cervix, LEEP:
Endocervix, biopsy:
- Endocervix, curettage:
- Uterus, cervix, bilateral fallopian tubes and ovaries, TAH-BSO:
Uterus, cervix, left/write/fallopian tube and ovary, TAH-salpingo-oophorectomy:
Right / Left fallopian tubes, segmental salpingectomy:
Right / Left ovary, oophorectomy
Benign inflamed endocervical polyp.
- Benign cervical transitional zone mucosa with chronic inflammation and squamous metaplasia. No HBV change or dysplasia seen.
- Benign ectocervical mucosa with marked chronic inflammation / follicular cervicitis. No HBV change or squamous dysplasia seen.
- Ectocervical mucosa with condyloma, no squamous dysplasia seen.
- Benign inflamed endometrial polyp.
- Benign early / late proliferative phase endometrial, no hyperplasia or atypia seen.
- Benign early / mid / late secretory phase endometrium, day __ - __ (POD __ - __), no hyperplasia or atypia seen.
Benign inactive endometrium, no hyperplasia or atypia seen.
- Benign weekly proliferative endometrium, no hyperplasia or atypia seen.
- Benign disordered proliferative endometrium, no hyperplasia or atypia seen.
- Benign endocervical polyp with immature squamous metaplasia.
- Proliferative endometrium with focal simple hyperplasia with / without atypia. .
- Complex hyperplasia with / without atypia.
- Fragments of benign endometrium, no hyperplasia or atypia seen.
- Benign ovary with corpus luteum and simple cysts.
- Fallopian tube, completely transected, with no histological abnormality identified.
-
- Focal mild / moderate / severe squamous dysplasia (CIN __ /III) and condyloma.
- Ectocervical mucosa with condyloma, no squamous dysplasia identified.
- Ectocervical mucosa with mild chronic inflammation, no HPV change or squamous dysplasia identified.
- Mature cystic teratoma (__ cm) with focal _____ differentiation.
- Leiomyomas with degenerative changes, and adenomyomas, uterine corpus.
Benign endometrial polyp.
Adult granulosa cell tumor ( __ cm), completely encapsulated.
- Ovarian mature cystic teratoma, __ cm, with elements of skin, respiratory epithelium, gastrointestinal epithelium, and smooth muscle, with exuberant granulation tissue and hemosiderin laden macrophages, see note.
- Malignant mixed Müllerian tumor (MMMT) (carcinosarcoma) ( __ cm) with homologous / heterologous components involving fallopian tube, peritubal soft tissue, and ovary.
Endocervical adenocarcinoma in situ (AIS).
Endometrial carcinoma arising in a background of complex hyperplasia with atypia.
Endometrioid carcinoma, superficial non-invasive (exophytic papillary AIS), villoglandular type, involving __ % of anterior / posterior endometrium, confined in uterus.
Endometrial adenocarcinoma, endometrioid type, FIGO grade __, involving __ % of myometrium (see Comment for Tumor Synopsis).
Ovarian serous / mucinous tumor of low malignant potential, __ cm, of the ovary, with focal atypia (see Comment for Tumor Synopsis ).
Ovarian serous / mucinous carcinoma ( __ cm), well / moderately / poorly differentiated, FIGO grade __, with extensive stromal invasion (see Comment for Tumor Synopsis).
Invasive cervical squamous cell carcinoma / adenocarcinoma ( __ cm), well / moderately / poorly differentiated, grade __, extending ___ cm into the cervical wall, with angiolymphatic invasion, present at the resection margins (see Comment for Tumor Synopsis).
-
Bronchus, left main, biopsy:
Lung, left / right upper lobe, lingula, biopsy:
Lung, left upper / lower lobe, lobectomy:
Left / right lower lobe of the lung, transbronchial biopsy
Left / right upper lung, transbronchial biopsy:
Visceral pleura, left side, biopsy:
Left pleura, biopsy:
Unremarkable bronchial mucosa.
Benign unremarkable bronchial mucosa and focally collapsed lung parenchyma with mild interstitial fibrosis and lymphocytic infiltrate.
Benign aerated lung parenchyma with focal hemosiderin-laden macrophages. No granuloma or carcinoma seen.
Mild interstitial fibrosis. No carcinoma is identified.
Marked necrotizing granulomatous pleuritis focally extending into the lung parenchyma. Special stain for mycobacteria is negative.
Non-caseating granulomatous inflammation. Special stain for mycobacteria and fungal microorganisms are negative
Well differentiated neuroendocrine tumor (carcinoid) ( __ cm), extending to bronchial resection margin \\ present at __ cm from the resection margin in. \\ the resection margin is free of tumor. CPT 88309
- Invasive squamous cell carcinoma ( __ cm), well / moderately / poorly differentiated, extending to bronchial resection margin \\ present at __ cm from the resection margin in. \\ the resection margin is free of tumor (see Comment for Tumor Synopsis). CPT 88309
- Invasive adenocarcinoma ( __ cm), ____ type, well / moderately / poorly differentiated, extending to bronchial resection margin \\ present at __ cm from the resection margin in. \\ the resection margin is free of tumor (see Comment for Tumor Synopsis). CPT 88309
- Invasive undifferentiated carcinoma ( __ cm), small cell / large cell type, extending to bronchial resection margin \\ present at __ cm from the resection margin in. \\ the resection margin is free of tumor (see Comment for Tumor Synopsis). CPT 88309
-
- Bone and cartilage, left hip, arthroplasty:
- Bone tumor, left metacarpal, curettage:
- Femoral head, resection:
- Finger, left index, amputation:
- Left / Right leg, BKA (below the knee amputation):
- Left / Right lower extremity, AKA (above the knee amputation):
- Bone and cartilage, left knee, arthroplasty:
-
- Fragments of degenerated fibrocartilage, and perispinal soft tissue.
- Degenerative joint disease (osteoarthritis).
- Geographic hemorrhage and necrosis consistent with avascular necrosis.
- Synovium-lined benign cyst consistent with Baker’s cyst.
- Gangrene without ulcer. Soft tissue resection margins are viable and free of inflammation and necrosis.
- Gangrene with ulcer and marked atherosclerosis with mural calcification and luminal stenosis (80%). The resection margins are viable and free of inflammation and necrosis
-
- Low grade chondrocartilaginous neoplasm (enchondroma), highly fragmented.
- Enchondroma.
- Skin, ____, shave biopsy:
- Skin, ____, punch biopsy:
- Skin, ____, excision:
-
- Fibroepithelial polyp (acrochodon or skin tag), irritated and inflamed.
-
-
- Actinic keratosis
- Compound nevus, melanocytic type.
- Dermal / Compound nevus with neurotization.
- Dermal / Junctional / Compound nevus with focal mild / moderate cytologic atypia, focally pigmented.
- Dermatofibroma
- Eccrine hidrocystoma.
- Follicular infundibular cyst (epidermal inclusion cyst)
- Intradermal nevus, melanocytic type, completely excised.
- Junctional nevus, melanocytic type.
- Juvenile xanthogranuloma
- Papillary hidradenoma.
- Psoriasiform dermatitis
- Pyogenic granuloma
- Sebaceous hyperplasia
- Seborrheic keratosis, pigmented.
- Skin tag (fibroepithelial polyp)
- Skin with scar
- Solar elastosis
- Solar Lentigo
- Spongiotic dermatitis with intracorneal Microabscess (see comment).
- Squamous papilloma
- Superficial and deep perivascular lymphocytic dermatitis
- Superficial perivascular dermatitis with eosinophils
- Basal cell carcinoma, nodular / superficial / morphea type, extending to deep / lateral resection margin. \\ resection margins are free of tumor.
- Invasive squamous carcinoma ( __ cm), well / moderately / poorly differentiated. extending to deepen/lateral resection margin. \\ resection margins are free of tumor.
-
Invasive and tumorgenic malignant melanoma,
- Pilomatrixoma.
-
Mesothelium-lined fibrofatty tissue consistent with hernia sac.
Soft tissue, right inguinal region, herniorrhaphy:
Fibrovascular tissue with reactive mesothelium consistent with hernia sac.
Mature adipose tissue consistent with lipoma.
Lipoma with fat necrosis.
- Nodular Fasciitis.
- Pyogenic granuloma.
- Granular cell tumor, __ cm, margins of excision free of tumor / focally extending to inked resection margin..
- Hemangiopericytoma, Reticulin stain supports the diagnosis.
- Glomus tumor.
- Cavernous Hemangioma.
-
- Dermatofibrosarcoma prutubran, extending to deep/lateral resection margins \\ resection margins are free of tumor.
- Granular cell tumor ( __ cm), extending to deep/lateral resection margins \\ resection margins are free of tumor.
- Capillary hemangioma, extending to inked margin. See note.
- Synovial sarcoma, monophasic / biphasic, grade __/III.
- Malignant peripheral nerve sheath tumor (MPNST), grade __/III.
- Malignant fibrous histiocytoma (MFH) with myxoid features, grade __/III.
-
Specimen Submitted: ___ Lumpectomy. ___ Modified mastectomy.
___ Radical mastectomy ___ Other (specify): _______.
Specimen Dimensions: ____ cm X _____ cm X _____ cm.
Tumor Size/Extent: ____ cm X _____ cm X _____ cm.
Histologic Type: ___ Lobular. ___ Ductal
___ Mucinous ___ Comedo type.
___ Medullary ___ Micropapillary
___ ___ Tubular
___ Other (specify): __________________________________
Histologic Grade: ___ I ___ I I ___ III
Nuclear Grade: ___ I. ___ II. ___ III.
Angiolymphatic Invasion: ___ absent. ___ present
Extensive intraductal Component: ___ absent ___ present
Location of Calcifications (for mammographically detected lesions; include all that apply):
___ invasive cancer. ___ ductal carcinoma in situ. ___ benign breast tissue
Margins of Excision:
Type of evaluation: ___ breadloafed ___ shaved
Invasive Cancer:
___ absent. ___ closest distance to margin. ___ present
Ductal Carcinoma-in-Situ:
___ absent. ___ closest distance to margin. ___ present
Axillary Lymph Nodes:
___ number evaluated. ___ number positive. Size of largest metastasis: ____ cm.
Estrogen Receptor:
Progestrone Receptor:
Her-2/Neu
oncoprotein:
Specimen submitted:
___ Simple ___ Radical ___ Vaginal ___ Hystererectomy ___ BSO
Histologic type:
___ Squamous cell carcinoma ___ Adenocarcinoma
___ Other (specify): _______________
___ No residual tumor identified (Refer to previous specimen # ______)
Grade: ___ I ___ II; ___ III
Tumor diameter (horizontal spread): ___ cm measured on the slides
Depth of invasion: ___ cm
Angiolymphatic invasion: ___ present ___ not identified
Parametrium: ___ Free of tumor ___ Positive for tumor ___ NA
Margins:
Soft tissue margins: ___ Free of tumor ___ Positive for tumor ___ NA
Vaginal cuff: ___ Free of tumor ___ Positive for tumor ___ NA
Other (specify):
Uterus: ___ Free of tumor ___ NA
Tumor involves (specify):
Omentum: ___ Free of tumor ___ Positive for tumor
___ None submitted
Lymph nodes: ___ none submitted
Site # evaluated # positive
_________ ______ ______
_________ ______ ______
_________ ______ ______
_________ ______ ______
Other Extrapelvic Organs (specify): _______________________________
Peritoneal washings: ___ none submitted
Cytology dx (refer to C# ): ___ Negative ___ Atypical
___ Suspicious ___ Positive
Other comments:
Location:
___ Cecum ___ Transverse colon ___ Sigmoid colon
___ Rectum ___ Descending colon ___ Ascending colon ___ Anal canal
Gross type: Polypoid Ulcerative Diffusely infiltrative
Plaque Annular or constricting (including linitis plastica)
Tumor dimension: ___ cm x ___ cm x ____ cm.
Assessment
of the Margins:
Proximal margin: ___ free of tumor. ___ involved by the tumor
Distal margin: ___ free of tumor. ___ involved by the tumor
Radio margin (recta tumors only): ___ free of tumor. ___ involved by the tumor
Proximity to nearest margin: ___ cm
Extent
of involvement:
Obstruction (proximal dilation): ___ No ___ Yes
Perforation of bowel: ___ No ___ Yes
Serosal puckering: ___ No ___ Yes
Mass/nodule in pericolic fat: ___ No ___ Yes, largest = ____ cm.
Presence of mesenteric deposits: ___ No ___ Yes
Histological
type:
- Adenocarcinoma, not otherwise specified. Well differentiated / Moderately differentiated / Poorly differentiated
- Mucinous carcinoma - Signet ring carcinoma - Adenosquamous carcinoma
- Small cell (oat cell) - Undifferentiated carcinoma - Other
Depth
of invasion:
- into submucosa (T1)
- into muscularis propria (T2)
- Through muscularis propria and into submucosa of fat or pericolic perirectal adipose tissue (T3)
- Reaching the serosa or peritoneal surface (T4)
- Into adjacent organs (T4), specify ____________
Angiolymphatic
invasion:
Intramural angiolymphatic invasion: ___ No ___ Yes
Invasion of extramural veins: ___ No ___ Yes
Lymph nodes: Number positive Total number submitted
< 10 cm from tumor __________ ______
> 10 cm from tumor __________ ______
Status of highest mesenteric lymph node (if identified by searching): __________
Tissue
submitted for special investigation:
Other
comments:
Specimen submitted:
______Simple ______Radical ______Hysterectomy ______BSO
Tumor size:
Greatest dimension ___________cm
Histologic type:
_____Endometrioid Adenocarcinoma _____With squamous
differentiation
_____Papillary serous CA _____Clear cell CA
_____Mixed carcinoma (specify types
and %): ___________________
_____Undifferentiated
carcinoma _____Carcinosarcoma
Grade:
_____FIGO Grade: I II III
_____Nuclear Grade (for serous and
clear cell CA only): I II III
_____Grade
of epithelial component (for carcinosarcoma): I II III
Hyperplasia in non-neoplastic endometrium: _____Absent _____Simple _____Complex
Lymphatic/Vascular space invasion: _____Absent _____Present
Depth of myometrial invasion:
_____No myometrial invasion, tumor
limited to endometrium
_____Invasion up to or less than one
half of myometrium
_____Invasion to more than one half
of myometrium
_____10%
_____20% _____30% _____40% _____50% _____75% _____>75% _____of myometrium
Serosa free of tumor: _____Yes _____No
Cervix:
_____Free of tumor
_____Tumor involves endocervical
glands in situ
_____Tumor
invades cervical stroma
Bilateral ovaries and fallopian tubes:
_____Free of tumor
_____Tumor involves _____right ovary _____right
fallopian tube
_____Tumor
involves _____right ovary
_____left fallopian tube
Omentum:
Free
of tumor: _____Yes _____No _____None submitted
Lymph nodes:
_____Pelvic: number evaluated _____; number positive _____; none submitted_____
_____Aortic: number evaluated _____; number positive _____; none submitted_____
Peritoneal
washings: _____none submitted
Cytology
dx (refer to C#__________): _____negative _____atypical _____suspicious _____positive
Comments:
Type of procedure:
___ Local excision:
___ Radical resection (specify type): ____________________________________
Location of tumor:
A. Confined to esophagus: ___ Lower 1/3; ___ Mid 1/3; ___ Upper 1/3 ___ Unknown (for local excisions).
B. Involvement of GEJ: ___ Yes ___ No
Dimensions of tumor: ___ cm.
Esophageal obstruction: ___ Yes ___ No
Esophageal perforation: ___ Yes ___ No
Tumor configuration: ___ Exophytic (fungating);
___ Endophytic (ulcerative); ___ Diffusely infiltrative
Histologic type:
___ Squamous cell ___ Verrucous ___ Adenoid cystic
___ Adenocarcinoma ___ Spindle cell ___ Undifferentiated
___ Adenosquamous ___ Small cell ___ Mucoepidermoid
Histologic grade (for squamous cell and adenocarcinoma only):
___ Well-differentiated ___ Moderately differentiated
___ Poorly differentiated ___ Mucinous (for adenocarcinomas only)
(WD: > 75% differentiated; MD: 26-74% differentiated; PD: < 25% differentiated;
Mucinous neoplasms: > 50% mucinous component).
Depth of invasion:
___ Carcinoma in situ (Tis) ___ Tumor invades muscularis propria (T2)
___ Tumor invades lamina propria (T1a) ___ Tumor invades adventitia (T3)
___ Tumor invades submucosa (T1b) ___ Tumor invades adjacent structures (T4)
Precursor lesion and other related changes:
___ Barrett’s ___ Dysplasia
Lymphatic-vascular invasion: ___ Yes ___ No
Margins of excision:
Proximal: ___ Positive ___ Negative ___ Closest extent: _____ cm.
Distal ___ Positive ___ Negative ___ Closest extent: _____ cm.
Radial (deep) ___ Positive ___ Negative ___ Closest extent: _____ cm.
Regional lymph nodes: ___ Total number ___ Number with metastases
Distant metastases: ___ No. ___ Yes (give site): ___ Cannot assess.
Site of the tumor:
__ Upper 1/3 (cardia & fundus) __ Middle 1/3 (bulk of corpus)
__ Lower 1/3 (pylorus and antrum)
Gross type:
___ Plaque ___ Polypoid ___ Diffuse infiltrative (linitis plastica)
___ Fungating ___ Ulcerated ___ Other (specify): ______________
Dimensions: ___ cm x ___ cm x ___ cm
Distance to resection margins:
___ cm from/ ___ tumor at the proximal margin
___ cm from/ ___ tumor at the distal margin
Histological Type:
___ Adenocarcinoma, NOS, ___ well- ___ moderately ___ poorly-differentiated
___ Papillary adenocarcinoma ___ Tubular adenocarcinoma.
___ Signet ring cell ca (>50%) ___ Mucinous carcinoma (>50%)
___ Adenosquamous carcinoma ___ Small cell carcinoma other, specify
___ Squamous cell carcinoma ___ Undifferentiated carcinoma
___ Other, specify: __________________
Precursor lesion: ___ Absent ___ Present (specify__________________ ).
Pattern of growth: ___ Expansive. ___ Infiltrative.
Depth of invasion: ___ Carcinoma in situ
___ Into lamina propria or submucosa (Ti)
___ Into muscularis propria or subserosa (T2)
___ Through serosa (visceral peritoneum) (T3)
___ Into adjacent structures, i.e. spleen, colon, liver, diaphragm, pancreas, abdominal wall, etc.(T4)
*Intramural extension to the duodenum or esophagus is classified by the depth of greatest invasion in any of these sites including stomach.
Vascular/lymphatic invasion: ___ Yes ___ No
Perineural invasion: ___ Yes ___ No
Lymph node: ___ Total number submitted
___ Number positive within 3 cm of the edge of the primary tumor (Nl)s
___ Number positive > 3 cm from the edge of the primary tumor (N2).
Specifically designated lymph nodes:
Along the ___ left gastric, ___ common hepatic,
___ splenic, or ___ celiac arteries (N2)
Other intra-abdominal lymph nodes (M) , specify: ___________________________
_____________________________________________
Specimen
Submitted:
Site
of the Tumor:
Size
of the Tumor: __ x __ x __
cm
Histological
Type:
Squamous Cell Carcinoma____
Adenocarcinoma: NOS____ Bronchioloalveolar Carcinoma____
Undifferentiated Carcinoma____: Small Cell Type____ Large Cell type____
Other__________________________
Histological
Grade:
Well Differentiated____
Moderately
Differentiated____
Poorly Differentiated____
Surgical
Margins:
Bronchial: Negative____ Positive____
Vascular: Negative____ Positive____
Pleural
Involvement
None____
Tumor invading into but not
through visceral pleura____
Tumor invading through
visceral pleura without involving
parietal pleura____
Tumor invading through
visceral pleura into parietal pleura____
Vascular
Invasion: Absent____ Present____
Lymph
Nodes:
Location: ____ ____ ____ ____
Number Evaluated: ____ ____ ____ ____
Number Positive: ____ ____ ____ ____
Non-Neoplastic
Lung:
No diagnostic abnormalities
recognized____
Bronchopneumonia____
Granulomatous inflammation____
Emphysema____
Other____
Comments:
Anatomic Site:________________________________
Type:_________Superficial Spreading
_________Nodular
_________Lentigo Maligna
_________Other (Specify) _______________________
Greatest Thickness: _________________mm
Radical Growth Phase: ____Absent ____Present
Vertical Growth Phase: ____Absent ____Present
Margins:
Biopsies
____Extending to the tissue edges
____Not extending to the tissue edges in the tissue planes examined
Elliptical Excisions
____Completely excised: measurement to closet
side resection margin: __________mm
____Extending to inked side and deep resection margins
Complete following only if VGPP
Mitoses: ____Absent
____Present, up to _____________per square mm
Tumor infiltrating lymphocytes: ________Absent
________Present, Non-brisk
________Present, Brisk
Precursor Lesion: ____Absent _______Present, specify:
Secondary changes:
Ulceration ____Absent ____Present
Regression ____Absent ____Present
Microsatellites ____Absent ____Present
Other:
Specimen Submitted.
___ Hysterectomy ___ BSO ___ RSO ___ LSO
___ Other specify: __________________
Primary tumor location: ___ Right ovary ___ Left ovary ___ Both ovaries
Histological Type:
___ Papillary serous carcinoma ___ Mucinous adenocarcinoma
___ Endometrioid adenocarcinoma ___ Clear cell adenocarcinoma
___ Undifferentiated carcinoma
___ Serous tumor of borderline (low) malignant potential
___ Mucinous tumor of borderline (low) malignant potential
___ Mullerian ___ Intestinal ___ Other (specify):
Grade: ___ I ___ II ___ III ___ NA
Tumor capsule or ovarian surface:
___ Involved by tumor ___ Not involved by tumor ___ Not identified
Fallopian tubes: ___ Not submitted.
Right: ___ Free of tumor ___ Tumor implants present ___ None submitted
Left: ___ Free of tumor ___ Tumor implants present ___ none submitted
Uterus. ___ Not submitted
Serosa: ___ Free of tumor ___ Tumor Implants on uterine serosa
Endometrium: ___ Free of tumor ___ With tumor (specify): _______________.
Omentum: ___ Free of tumor ___ None submitted
___ Microscopic tumor implants present
___ Macroscopic tumor implants present
Lymph nodes: - ___ none submitted
Site # evaluated # positive
_________ ______ ______
_________ ______ ______
_________ ______ ______
_________ ______ ______
Other extrapelvic organs (specify):
Peritoneal washings: ___none submitted
Cytology dx (refer to C# _____): ___ negative; ___ atypical; ___ suspicious; ___positive
Other comments:
Specimen
Submitted: ____Whipple resection
____Pancreatectomy,
partial
Location Tumor:
head____ body____ tail____
Size of Tumor:____ X____
X____
Histologic Type: Ductal
Adenocarcinoma ____ Other,
Specify: ___________________
Histologic Grade
Well Differentiated____
Moderately
differentiated____
Poorly Differentiated____
Lymph Nodes: Draw line through those not included in
specimen
#total #positive
1. Anterior (ant panc-duod, pyloric) ____ ____
2. Posterior
(post panc-duod, common bile duct) ____ ____
3.
4. Inferior
(inf head and body of pancreas) ____ ____
5. Splenic (tail pancreas, hilus spleen) ____ ____
Vascular invasion: Absent____ Present____
Perineural invasion: Absent____ Present____
Invasion of other organs: Absent____ Present, Specify________________
Surgical margins: Draw line through those that do no apply
Pancreatic: Negative____ Positive____
Duodenal: Negative____ Positive____
Gastric: Negative____ Positive____
Common bile duct: Negative____ Positive____
Comments:
Specimen type: ___ Prostate. ___ Prostate and adnexa
___ Other (specify)
Procedure: ___ Radical prostatectomy. ___ Suprapubic prostatectomy.
___ Other (specify).
Tumor type: ___ Adenocarcinoma. ___ Other (specify):
Tumor histological grade (Gleason grade):
Primary pattern = ___ (1-5); Secondary pattern = ___ (1-5); Total score = ___ (2-10).
Tumor Location: Right: ___ apex. ___ mid. ___ base.
Left: ___ apex. ___ mid. ___ base.
Tumor Amount (radical prostatectomy):
Right: ___ # positive slides; ___ # total slides. Largest size
Left: ___ # positive slides; ___ # total slides. of tumor(measured
Dorsal apex: ___ # positive slides; ___ # total slides. on a single slide):
Ventral apex: ___ # positive slides; ___ # total slides. ________ cm.
Pathologic stage: ___ Confined to prostate. ___ extraprostatic extension to ___________.
Angiolymphatic invasion: ___ Absent. ___ Present.
Perineural extension: ___ Absent. ___ Present within / outside prostate.
Surgical margins: ___ Bladder margin. ___ Apex margin. ___ Capsular margin
Seminal vesicles: ___ Not involved by tumor. ___ Not involved by tumor (left / right)
Lymph nodes: Total number # Positive Size of mets
Right pelvic: __________ ___________ ____________
Right periaortic: __________ ___________ ____________
Left pelvic: __________ ___________ ____________
Left periaortic: __________ ___________ ____________
Specimen Submitted: ___ Partial Nephrectomy ___ Radical Nephrectomy
___ Nephrectomy Other (specify): _______
Adrenal gland: ___ Absent.
___ Present ( ___ positive for tumor. ___ negative for tumor).
Histological Type (refers to AFIP-ATLAS for definition)
A. Renal Cell Carcinomas:
___ Clear cell type ___ Chromophobe type
___ Granular type ___ Collecting duct type
___ Papillary type ___ Sarcomatoid type
B. Other types: ________________________
Nuclear Grade: ___ I; ___ II; ___ III; ___ IV.
Tumor Dimension: ______
cm x ______ cm x ______ cm.
Margins:
A. Inked soft tissue margin: ___ Free of tumor. ___ Positive for tumor.
B. Capsular penetration: ___ Absent. ___ Present.
C. Invasion into perinephric fat: ___ Absent. ___ Present.
D. Renal parenchymal margin (partial nephrectomy only):
___ NA ___ Free of tumor. ___ Positive for tumor.
E. Resection margins:
Venous: ___ NA. ___ Free of tumor. ___ Positive for tumor.
Arterial: ___ NA. ___ Free of tumor. ___ Positive for tumor.
Ureteral ___ NA. ___ Free of tumor. ___ Positive for tumor.
Intrarenal invasion: ___ Absent. ___ Present ( renal artery / renal vein / pelvis).
Lymph nodes: ___ None submitted. ___ # submitted. ___ # positive for tumor.
Goals of the program: This program is designed to help you formulate pathology diagnosis and minimize unnecessary clerical work. It is not designed to make diagnosis for you or help you reach diagnosis. You should make you own diagnosis based upon your observation, use this program only to help formulate your diagnosis (i.e. exact wording and accepted styles). The ultimate goal is to facilitate the routine sign-out process, help resident achieve independence, minimize unnecessary clerical work, and standardize pathology report.
Suggested Utilization: Residents should read the slides and make their own diagnosis first. Then, try to formulate their diagnosis with exact headings and words. As the final step, compare your diagnosis with corresponding diagnosis listed in this program. Pick one (your own or listed one) and put as your final diagnosis.
How to navigate:
Create a temporary notepad by clicking Your Diagnostic Pad
Type the Surgical# of the case you are working on.
Go to the Diagnostic Aids page (by press Alt+Tab, or simply clicking the Diagnostic Aids icon)
Find the organ system and the item you want to look at in the table.
Click the item (which will bring up the full text page for you to review).
Highlight and copy the text that you want to use in your diagnosis.
Go to the temporary notepad (by press Alt+Tab, simply click the notepad icon).
Paste copied text and make necessary modification.
Repeat steps 2-8. When you are done save the temporary notepad for sign-out.
You can also directly paste your diagnosis to Cerner. This is preferred and encouraged. In this case, you should open Cerner and the diagnosis page (under “ATR”) for the case you are working on. Perform the same find / copy function in Diagnostic Aids and switch to Cerner to paste the copied text.