=============

Normal and Nearly Normal:

-- No diagnostic abnormality.   

-- One small benign reactive lymph node.    

Inflammation and Non-neoplastic Lesions:   

-- Moderate acute appendicitis largely confined within the appendix.    

-- Severe suppurative acute appendicitis, focally transmural without perforation.    

-- Diffuse suppurative acute appendicitis with mural abscess  and severe periappendiceal acute inflammation.   

-- Marked periappendiceal  acute inflammation with abscess.  

-- Moderate appendicitis with multiple non-necrotizing granulomas, etiology uncertain (see Note).  

-- Moderate granulomatous appendicitis, favor sarcoidosis.  

Neoplastic:   

-- Appendiceal mucinous neoplasm with low-grade glandular dysplasia and extensive mucosal erosion, luminal mucous retention and associated inflammatory reactive changes (see Note).   

-- Appendiceal neuroendocrine tumor, grade-1, 0.7 cm in greatest dimesion,  limited to appendix, distal appendix.   

-- Appendiceal (tubular) adenoma.  

-- One small benign reactive lymph node.    

=============

Clinical scenario:          

Appendix, appendectomy:     

-- No diagnostic abnormality (see Note).

Note: Specimen is submitted entirely for histologic examination.  Multiple additional levels of the tissue blocks are examined.

Slides examined:   H&E   x  4

CPT code:        88305 x  1

Editor's comment:

This example include typical structural components and format that are used widely -- Diagnosis Heading, Main diagnosis, applicable Note or Comment (e.g. stain results), Slides examined and CPT codes. For diagnosis with complex attributes (e.g. of resected malignant tumor), a synoptic report  (or "Checklis") must be included to comply with ACoS mandates. To prepare "Synoptic Report" with an on-line tool, go to  Home page and click on Tumor Reporting. It usually takes less than 30% of the time required by routine dictation method.

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Clinical scenario:          

Appendix, appendectomy:     

-- Luminal fecalith.

-- No inflammation, granuloma or periappendiceal fibrosis.

Slides examined:   H&E   x  4

CPT code:        88304 x  1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.    

=============

Clinical scenario:          

Appendix, appendectomy:     

-- Fecalith and  mucosal atrophy suggestive of proximal obstruction.

-- Prominent reactive follicular lymphoid hyperplasia.

-- No inflammation, granuloma or fibrosis.

Slides examined:   H&E   x  4

CPT code:        88304 x  1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.    

=============

Clinical scenario:          

Appendix, appendectomy:     

-- Moderate acute appendicitis largely confined within the appendix.

-- Minimal periappendiceal acute inflammation.

-- One small benign reactive lymph node.

-- No inflammation is noted in the proximal resection margin.

Slides exam:         H&E X  2 

CPT code:        88304 X  1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.

=============

Clinical scenario:  .       

Appendix, appendectomy:     

-- Severe suppurative acute appendicitis, focally transmural.

-- Diffuse periappendiceal acute inflammation with abscess.

-- No perforation is identified 

-- No inflammation is noted in the proximal resection margin.

Slides exam:         H&E X  2 

CPT code:        88304 X  1

Editor's comment:

"Transmural" indicates that the inflammation involves entire thinckness of the appendiceal wall -- severity / extent of the disease. "Perforation" indicates open communication of appendiceal lumen to abdominal cavity -- complication of the disease.

=============

Clinical scenario:  .       

Appendix, appendectomy:      

-- Moderate necrotizing granulomatous appendicitis of mycobacterial infection.

-- Mycobacteria are identified by acid-fast and immunohistochemical stains.

-- Transmural acute inflammation with prominent periappendiceal acute inflammation and abscess formation.

-- No acute inflammation at the proximal resection margin.

Note: 02958203.

Slides exam:         H&E X  2 

CPT code:        88304 X  1, 88342 x 1, 88332 x 2

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.    

=============

Clinical scenario:  .       

Appendix, appendectomy:      

-- Moderate appendicitis with multiple non-necrotizing granulomas, etiology uncertain (see Note).

-- No fungal organism, actinomyces or mycobacteria on special stains.

-- No significant periappendiceal acute inflammation.

-- No acute inflammation at the proximal resection margin.

Note: The etiology underlying observed granulomatous inflammation is not histologically apparent.  Main differential diagnosis includes sarcoidosis, Crohn's colitis, infection (esp. by mycobacteria), and local foreign body reaction. Although sarcoidosis is somewhat favored, other listed causes cannot be entirely excluded.

Slides exam:         H&E X  2 

CPT code:        88304 X  1, 88342 x 1, 88332 x 2

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.    

=============

Clinical scenario:  29-year woman.  Acute appendicitis.       

Appendix, appendectomy: 

-- Prominent endometriosis with fibrosis and reactive appendiceal fibromuscular hypertrophy.

-- Moderate acute appendicitis, limited to mucosa and submucosa, proximal segment. 

--- No products of conception, granuloma or neoplasm.

Slides examined:   H&E   x  2

CPT code:        88304 x  1

Editor's comment:

Appendiceal endometriosis is often an "incidental" finding in appendix resected for appendicitis. Keeping this in mind may help avoid unnecessary further work-up studies such as over-sampling, immunostains.    

=============

Clinical scenario:  .       

Appendix, appendectomy: 

-- Appendiceal diverticula with acute inflammation and periappendiceal fibrosis (see Gross Description).

-- No mucinous neoplasm.

Slides examined:   H&E   x  3

CPT code:        88305 x  1

Editor's comment:

Appendiceal diverticulitis is often misdiagnosed as appendicitis or mucinous neoplasm microscopically. A good gross examination is important.     

=============

Clinical scenario:  50-year old woman. enlarged appendix.      

Appendix, appendectomy: 

-- Appendiceal mucocele with focal mucin extravasation to submucosa, distal portion.

-- No extramural mucin extravasation or perforation.

-- No glandular displasia or carcinoma.

-- No mucinous change in proximal 1.1 cm of the appendix.

Slides examined:   H&E   x  5

CPT code:        8830X x  X

Editor's comment:

The key differential diagnosis should include cystadenoma / cystadenocarcinoma, esp. for cases with mural mucin extravasation. Typical mucocele with flat and atrophic epithelial lining, proximal obstruction, minimal or no inflammation is only occasionally encountered. It is prudent to submit entire specimen for histologic examination, esp. those with micropapillae and mural mucin extravasation.

=============

Clinical scenario:  54-year old man     

Appendix, appendectomy: 

-- Low-grade mucinous cystadenoma.

-- No mural or extramural mucin extravasation.

-- No mucinous neoplastic change in the proximal 1.5 cm of appendix.

Slides examined:   H&E   x  X

CPT code:        8830X x  X

Editor's comment:

The most important differential diagnosis is cystadenocarcinoma. The specimen should be submitted entirely for histologic examination.

=============

Clinical scenario:   Middle-aged woman; no prior history of peritoneal disease.       

Terminal ileum, cecum and appendix, segmental ileocolectomys:     

-- Appendiceal mucinous cystadenoma with low-grade glandular dysplasia and extensive mucosal erosion, luminal mucous retention and associated inflammatory reactive changes (see Note).

-- No stromal invasion, mural mucin pool or mucinous deposit in periappendiceal fat.

-- No significant histological abnormality in the cecum and terminal ileum.

-- No metastatic carcinoma in twenty-four regional lymph nodes (0/24).

Note: Multiple additional levels of selected sample blocks are examined to confirm the absence of mucin extraversation beyond muscularis mucosae. No mucinous deposit is found in the examined periappendiceal fat. In the absence of invasion of muscularis propria and mural mucin pool, this mucinous neoplasm is best classified as appendiceal mucinous cystadenoma. The appendix is entirely submitted. Immunohistochemical stains confirm the absence of mural invasion by tumor cells.

Slides exam:         H&E X  8 

CPT code:        88307 X  1

Editor's comment:

Complete submission and examination of the mucinous lesion are required before rendering this (benign) diagnosis.

=============

Clinical scenario:    42-yo woman with incidental finding of abnormal appendix during removal of right ovary.      

Appendix, appendectomy:      

-- Appendiceal mucinous cystadenocarcinoma, low-grade, with prominent cellular mural mucin pools in submucosa (see Note)

-- No mucinous deposit in periappendiceal fat.

-- No tumor cells or mucin pool at proximal resection margin

-- No metastatic carcinoma in one small periappendiceal lymph node (0/1).

Note: Although the tumor shows low-grade glandular dysplasia, presence of mucin pools with dysplastic cells in the submucosa  indicate that this is a cystadenocarcinoma by current AJCC and WHO definition.

References: J. Misdraji: Appendiceal Mucinous Neoplasms: Controversial Issues. Archives of Pathology & Laboratory Medicine. 134(6):864-870, 2010.

Slides exam:         H&E X  10 

CPT code:        88307 X  1

Editor's comment:

This histological diagnosis will leads to ileocolectomy whereas cystadenoma may not.

=============

Clinical scenario:  .       

Appendix, appendectomy:     

-- Neuroendocrine tumor, grade 1 (2010 WHO / ENETS Classification) (see Tumor Synopsis)

Note: 0412866 (to be completed).

Slides examined:   H&E   x  X

CPT code:        8830X x  X

Editor's comment:

This single-line key Dx plus a Tumor Synopsis fully complies with AJCC mandate. An alternative paragraphic format should be avoided for three reasons. First, a Tumor synopsis should be used (anyway). Repeating tumor attributes in diagnosis section is prone to errors of inconsistency if changes need to be made.  Second, there are too many tumor attributes to fit in a short paragraph. Third, AJCC also mandates a structured format for reporting (i.e. Tumor Synopsis).    

=============

Clinical scenario:  .                          Delete this one / used only for making Synopsis    

Appendix, appendectomy:     

-- Neuroendocrine tumor, grade 2 (2010 WHO / ENETS classification), 1.1 cm, extending to muscularis propria and is 1 mm from serosal surface (see Tumor Synopsis).

-- No  mesoappenix involvement, angiolymphatic invasion or perineural invasion by tumor.  

-- No tumor at the resection  margins. 

-- Pathologic stage*

Slides examined:   H&E   x  X

CPT code:        8830X x  X

Editor's comment:

This paragraphic format should be avoided for three reasons. First, a Tumor synopsis should be used. Repeating tumor attributes in diagnosis section is prone to errors of inconsistency if changes need to be made.  Second, there are too many tumor attributes to fit in a short paragraph. Third, AJCC also mandates a structured format for reporting (i.e. Tumor Synopsis). See Editor's Comment for previous example. paragraph.    

=============

Clinical scenario:  .       

Appendix, appendectomy:     

-- A small neuroendocrine tumor, grade  1 (WHO 2010 / ENETS classification), 1.5 mm, confirmed by immunostains, incidental finding (see Tumor Synopsis).

-- Mild to moderate acute appendicitis, largely confined in the  mucosa and submucosa.

-- No significant periappendiceal inflammation.

-- The proximal and radial resection margins are free of the  tumor and acute inflammation.

Slides examined:   H&E   x  X

CPT code:        8830X x  X

Editor's comment:

This paragraphic format should be avoided for three reasons. First, a Tumor synopsis should be used. Repeating tumor attributes in diagnosis section is prone to errors of inconsistency if changes need to be made.  Second, there are too many tumor attributes to fit in a short paragraph. Third, AJCC also mandates a structured format for reporting (i.e. Tumor Synopsis). See Editor's Comment for previous example. paragraph.    

=============

Clinical scenario:          

Appendix, appendectomy:     

-- Appendiceal (tubular) adenoma (see Note).

-- Severe suppurative acute appendicitis, focally transmural  without perforation.

-- Focal mild periappendiceal acute inflammation.

-- No significant luminal mucinous content or mural / extramural mucin identified.

Note: The adenoma involves approximately 66% of appendiceal mucosa and appears to extend to the proximal (end margin). There is no high-grade glandular dysplasia. The specimen is entirely submitted fro histological examination.

Slides exam:         H&E X  4 

CPT code:        88305 X  1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.

=============

Clinical scenario:  .       

Organ, site, surgical procedure:     

-- Dx Heading above font = 04Heading; Style = 04DxHeadings.

--

Note: 02958203.

Slides examined:   H&E   x  X

CPT code:        8830X x  X

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.