Normal and Colon Polyps:

-- No diagnostic abnormality.   

-- Tubular adenoma in three of five microscopic fragments.     

-- Hyperplastic polyps.    

-- Multiple juvenile polyps with focal surface erosion and acute inflammation.    

Colitis:   

-- Moderate chronic active colitis with crypt abscess in all microscopic fragments. 

-- Moderate chronic colitis with focal mild activity in all microscopic fragments.  

-- Acute ischemic colitis with focal mucosal erosion in three of four microscopic fragments. 

Neoplastic:   

-- Invasive adenocarcinoma, moderately differentiated, superficial fragments.    

-- Invasive adenocarcinoma, moderately differentiated,  4.5 cm, pT3N1b (see Tumor Synopsis).    

-- Colorectal neuroendocrine tumor, grade-1 (2010 WHO Classification) (see Tumor Synopsis).    

Note: Final pathology report is faxed to the office of Dr. ___ .     

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

Clinical scenario:  52-year old man. small polyp on endoscopy, biopsied.        

Colon, random mucosal biopsy:  

-- Unremarkable mucosa with small lymphoid aggregates.

-- No diagnostic abnormality.

Slides examined:   H&E   x  1

CPT code:        88305 x  1

Editor's comment:

This endoscopist may not be experienced enough to identify normal mucosal lymphoid aggregates. A phone call about the "polypoid lesion" from him is likely if only "-- No diagnostic abnormality" is in your pathology report. 

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

Clinical scenario:          

Colon, random mucosal biopsy:  

-- Polypoid fragment of colonic mucosa with no diagnostic abnormality.

Slides examined:   H&E   x  1

CPT code:        88305 x  1

  

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

Clinical scenario:  .       

Colon, at ___ cm, biopsy:     

-- Tubular adenoma in three of five microscopic fragments. 

-- No high grade glandular dysplasia or invasive carcinoma identified.

Slides examined:   H&E   x  X

CPT code:        88305 x 1

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

Clinical scenario:  .       

Right colon, biopsy:     

-- Tubulovillous adenoma in all microscopic fragments, superficial biopsy. 

-- No high grade glandular dysplasia or invasive carcinoma identified.

Slides examined:   H&E   x  X

CPT code:        88305 x 1

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

Clinical scenario:  58-year old man. A 2.5-cm polyp in sigmoid, resected.       

Sigmoid colon, excision biopsy (polypectomy):     

-- Tubular adenoma. 

-- No high grade glandular dysplasia or invasive carcinoma identified.

-- No adenomatous change at the inked stalk margin.

Slides examined:   H&E   x  X

CPT code:        88305 x 1

   

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

Clinical scenario:  61-yo man with a rectal mass. r/o cancer.       

Rectum, biopsy:     

-- Adenomatous polyp, multiple superficial fragments (see Note).

-- Cannot exclude an underlying invasive carcinoma.

Note:  Superficial sample of an underlying invasive adenocarcinoma is often indistinguishable from an adenoma. A definitive diagnosis of an underlying "mass" is precluded by the superficial biopsy.  Re-biopsy of the "mass" and  correlation with endoscopic finding and other imaging studies are recommended.

Slides examined:   H&E   x  1

CPT code:        88305 x 1

Editor's comment:

Frequently, the superficial biopsy is not fully representative of the underlying lesion. If an obstructing mass is identified endoscopically, it is more likely than otherwise that the underlying mass is an invasive carcinoma.  Unfortunately, some consider a subcentimeter nodule as "mass" whereas other call a  large mass  "nodule". Thus, a descriptive diagnosis (e.g. adenomatous polyp) rather than adenoma which strictly speaking is a benign tumor should be used. Particular caution must be taken in reporting such findings in the rectum since rectal function may be lost because of resection.

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

Clinical scenario:  64-yo man with .       

Sigmoid colon, polypectomy:     

-- Tubular adenoma with glandular misplacement (see Note).

-- Old hemorrhage and fibrosis, consistent with local trauma.

-- Inked stalk margin is free of adenomatous change by at least 1.5 mm.

-- No high-grade dysplasia or invasive carcinoma identified.

Note: This adenomatous lesion shows extensive glandular component in what appears to be "submucosa".  The key differential diagnosis includes  invasive adenocarcinoma versus misplaced adenomatous glands.  Despite the extent of the submucosal adenomatous gland placement, the glands are surrounded by lamina propria. They are not associated with apparent desmoplastic reaction, single tumor cell or irregular solid tumor nests. In addition, these adenomatous glands are cytologically similar and focally connected to those on the mucosal surface. Old hemorrhage is readily observed. Thus, these features support the diagnosis of tubular adenoma with extensive adenomatous gland misplacement.

Slides examined:   H&E   x  6

CPT code:        88305 x 1

Editor's comment:

The most important differential diagnosis in this setting is invasive adenocarcinoma. Adenoma with misplaced glands is not infrequently misdiagnosed as invasive adenocarcinoma, which often results in unnecessary colectomy.  The distinguishing features are in the Note which is included largely as a reminder if  clinician calls about the case weeks later. 

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

Clinical scenario:  .       

Left colon, biopsy:     

-- Hyperplastic polyp(s).

-- No active inflammation or glandular dysplasia.

Slides examined:   H&E   x  X

CPT code:        88305 x 1

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

Clinical scenario:  .       

Right colon, biopsy:     

-- Most compatible with hyperplastic polyp, partially cauterized/crushed.

Slides examined:   H&E   x  1

CPT code:        88305 x 1

 

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

Clinical scenario:  45-year old man with polyps in ascending colon.        

Ascending Colon, biopsy:     

-- Sessile serrated polyp (see Note).

-- No glandular dysplasia or carcinoma.

Note: Although sessile serrated polyp without dysplasia is primarily nondysplastic, it is associated with the BRAF mutation, and considered to be a precursor to serrated adenomas and adenocarcinoma. The time frame for the progression to adenocarcinoma remains unknown.  The risk stratification and clinical management of such lesions can be found in the guidelines by the US Multi-Society Task Force on Colorectal Cancer (ref.)

Reference:  D. A. Lieberman et al.: Guidelines for Colonoscopy Surveillance After Screening and Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer. GASTROENTEROLOGY 2012;143:844–857.

Editor's comment:

In 2010 WHO classification, "Sessile serrated polyp", even in the absence of histologic features of dysplasia, and 'sessile serrated adenoma" are considered the same . However, adenoma is traditionally dysplasia or histologic presentation of dysplasia. Thus, it is a histologic (i.e. phenotypic) diagnosis. Equating "sessile serrated polyp" in the absence of dysplasia to an adenoma is to replace a phenotypic expression with genotypic predisposition. In addition, sessile serrated polyp with dysplasia is a more advanced lesion than that without dysplasia.

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

Clinical scenario:  59-yo man; rectal mass, likely malignant.       

Rectum, biopsy:     

-- Serrated adenoma, fragmented.

-- Cannot exclude underlying carcinoma (see Note).        

Note: The polypoid adenomatous mucosa exhibit a configuration and crypt changes of an adenoma.  This interpretation, however, may not be compatible with the endoscopic finding of a "mass" and impression of "likely malignant tumor".  Re-biopsy of the "mass" and /or  correlation with endoscopic finding and other imaging studies is necessary for assessing a possible underlying "mass". 

Slides examined:   H&E   x  2

CPT code:        88305 x 1

Editor's comment:

Again, particular caution must be taken in reporting such findings in the rectum since rectal function may be lost because of resection.

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

Clinical scenario:  .       

Sigmoid colon, polypectomy:     

-- Juvenile polyp with surface erosion associated with marked acute and chronic inflammation and granulation tissue formation.

-- No glandular dysplasia or carcinoma.

Slides examined:   H&E   x  X

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:    5-year old boy with multiple colon polyps and elevated calprotectin. r/o IBD.      

Transverse colon and rectum, polypectomy:     

-- Multiple juvenile polyps with surface erosion associated with marked acute and chronic inflammation and granulation tissue formation (see Note).

-- No adenomatous change, prominent adipose component or neural-fibrous proliferation identified.

-- No granuloma or ischemic necrosis.

Note: The prominent acute inflammation associated with granulation tissue secondary to mucosal erosion may contribute to the clinically observed "elevated calprotectin".  All of the identified polyps show typical histological features of juvenile polyp. If extraintestinal manifestation of other associated diseases (e.g. Cowden disease, Peutz-Jehgers syndrome etc.) can be excluded or if the patient has a familial history of juvenile polyp, this case may be best considered a juvenile polyposis coli. Correlation with the family history and other clinical findings is necessary for a definitive diagnosis.

Editor's comment:

The note intends to help differentiate juvenile polyp or juvenile polyposis coli..

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

Clinical scenario:  .       

Sigmoid colon, polypectomy:     

-- Hamartomatous polyp, consistent with Peutz-Jehger polyp.

-- No stromal overgrowth, neural-fibrous component or glandular dysplasia.

Note: Diagnosis of Peutz-Jehger syndrome cannot be made solely on histologic finding of a single polyp. Clinical correlation is required. Up to 48% patient with Peutz-Jehger syndrome develops malignancy.

Slides examined:   H&E   x  X

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:  .       

Sigmoid and descending colon, biopsy:     

-- Moderate chronic active colitis in all microscopic fragments with focal microabscess (see Note).

-- No mucosal erosion, viral cytopathic changes, granuloma or glandular dysplasia.

Note: The active inflammation in the biopsy from different segments of the colon appears to be contiguous (involving all fragments) and with distal accentuation, a pattern compatible with ulcerative colitis although these changes by themselves are not pathognomonic. 

Slides examined:   H&E   x  3

CPT code:        88305 x  1

Editor's comment:

This example is from part of a series of colonic biopsy with colitis. Modify the Note section according to actual findings in other biopsy specimens. 

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

Clinical scenario:  .       

Sigmoid and descending colon, biopsy:     

-- Moderate chronic active colitis, involving all microscopic fragments, compatible with patient's history of ulcerative colitis.

-- No viral cytopathic change, ischemia, granuloma or glandular dysplasia.

Slides examined:   H&E   x  3

CPT code:        88305 x  1

Editor's comment:

This example is from part of a series of colonic biopsy with colitis. Modify the Note section according to actual findings in other biopsy specimens. 

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

Clinical scenario:  34-yo woman. Chronic diarrhea. hx/o UC       

Sigmoid and descending colon, biopsy:     

-- Mild and moderate chronic active colitis with two small epithelioid granulomas, involving four of eight microscopic fragments (see Note).

-- No viral cytopathic change or glandular dysplasia.

Slides examined:   H&E   x  2

CPT code:        88305 x  1

Editor's comment:

This example is from part of a series of colonic biopsy with colitis. Modify the Note section according to actual findings in other biopsy specimens. 

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

Clinical scenario:  .       

Sigmoid and descending colon, biopsy:     

-- Moderate crypt architecture distortion present in all fragments, compatible with inactive (quiescent) chronic colitis.

-- No active inflammation, granuloma or glandular epithelial dysplasia.

Slides examined:   H&E   x  X

CPT code:        88305 x  1

Editor's comment:

This example is from part of a series of colonic biopsy with colitis. Modify the Note section according to actual findings in other biopsy specimens. 

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

Clinical scenario:  .       

Sigmoid and descending colon, biopsy:     

-- Mild to moderate chronic active colitis in all microscopic fragments, etiology uncertain.

-- No viral cytopathic changes, parasitic organisms, granuloma or glandular epithelial dysplasia.

Slides examined:   H&E   x  2

CPT code:        88305 x  1

Editor's comment:

This example is from part of a series of colonic biopsy with colitis. Modify the Note section according to actual findings in other biopsy specimens. 

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

Clinical scenario:  .       

Left colon, segmental colectomy:     

-- Chronic Crohn's colitis with segmental stenosis and multiple inflammatory pseudopolyps.

-- Focal  fistula with pericolonic abscess.

-- No viral cytopathic change, epithelial dysplasia or carcinoma.

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

Clinical scenario:  .       

Terminal ileum and cecum, segmental ileocecectomy:     

-- Moderate to severe chronic active ileocolitis with multiple mucosal erosions, mural inflammation, epithelioid granulomas and focal fibrosis, consistent with active Crohn's disease.

-- One benign reactive lymph node.

-- No inflammation or fibrosis is present at the proximal or distal resection margins.

-- No fistula, pericolonic abscess or pericolonic fibrosis.

-- No epithelial dysplasia or carcinoma.

-- No diagnostic abnormality in the appendix.

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

Clinical scenario:  .       

Rectum, proctectomy:     

-- Patchy, moderate,  active colitis, focally transmural, consistent with chronic Crohn's proctitis. 

-- No mucosal erosion, viral cytopathic change, epithelial dysplasia or carcinoma.

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

Clinical scenario:  .       

Transverse and descending colon, biopsy:     

-- Moderate collagenous colitis.

-- No crypt architectural distortion, significant intraepithelial lymphocytosis or neutrophilic infiltrates.

Slides examined:   H&E   x  2

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: 52-yo female with chronic watery diarrhea for months.  Endoscopy is normal.       

Transverse colon, mucosal biopsy:    # 

-- Lymphocytic colitis (see note).

-- No acute cryptitis, thickened basal lamina, granuloma, crypt architectural distortion or glandular dysplasia

Note: The constellation of diffuse markedly increased intraepithelial lymphocytes (>30 per 100 lining enterocytes), associated enterocyte degeneration in the absence of crypt architectural distortion, along with the clinical findings of chronic watery diarrhea and normal endoscopic finding  is diagnostic of lymphocytic colitis. 

Slides examined:   H&E   x  2

CPT code:        88305 x 1

Editor's comment:

Diagnosis of lymphocytic colitis should also include chronic diarrhea of unknown origin, and normal endoscopic findings.    

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

Clinical scenario:  .       

Descending colon, mucosal biopsy:    # 

-- Highly suggestive of lymphocytic colitis (see note).

-- No acute cryptitis, thickened basal lamina, granuloma, crypt architectural distortion or glandular dysplasia

Note: The constellation of diffuse markedly increased intraepithelial lymphocytes (>30 per 100 lining enterocytes), associated enterocyte degeneration, increased lymphocytic infiltrates in the lamina propria in the absence of crypt architectural distortion  would be consistent with lymphocytic colitis.  Diagnostic criterion for lymphocytic colitis, however, also include chronic diarrhea of unknown origin, and normal endoscopic findings.  Clinical correlation is recommended.

Slides examined:   H&E   x  2

CPT code:        88305 x 1

Editor's comment:

This  text paragraph.    

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

Clinical scenario:  45-yo woman with diarrhea, r/o microscopic colitis.      

Transverse colon, biopsy:     

-- Mild colonic intraepithelial lymphocytosis (10-20 per 100 enterocytes) with focal enterocyte degeneration (see Note).

-- No crypt architectural irregularity, or thickened basal collagen plate, significant neutrophilic infiltrate or cryptitis.

Note: Colonic lymphocytosis is not a distinct diagnostic entity. Although it could represent an early phase or a minor form of lymphocytic colitis. It can occur in a variety of circumstances including gluten-sensitive enteropathy (Celiac disease)-associated colonic change, medication-induced colonic injury, various autoimmune diseases, or merely a nonspecific change.

Slides examined:   H&E   x  1

CPT code:        88305 x  1

Editor's comment:

In pediatric population, it is worthwhile to include additional differential diagnoses such as autoimmune enteropathy, immune deficiency, allergic colitis, and idiopathic IBD.

Ref: Mahajan D et al: Lymphocytic Colitis and Collagenous Colitis: A Review of Clinicopathologic Features and Immunologic Abnormalities. Adv Anat Pathol  Volume 19, Number 1, January 2012).    

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

Clinical scenario: 81-year old woman with acute abdominal pain.       

Colon, splenic flexure, biopsy:     

-- Acute ischemic colitis with focal mucosal erosion in three of four microscopic fragments.

-- No viral cytopathic change, glandular dysplasia or malignancy.

Note: 02958203.

Slides examined:   H&E   x  X

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: 54-yo man with servere diverticular disease .       

Sigmoid colon, segmental colectomy :      

-- Segmental severe ischemic colitis with focal mucosal hemorrhage and prominent vascular congestion, most likely secondary to venous outflow obstruction.

-- Severe mural and extramural reactive fibrosis.

-- No vascular thrombosis or occlusive atherosclerosis.

-- No ischemic changes, fibrosis or inflammation in resection margins (ends).

Note: 02958203.

Slides examined:   H&E   x  8

CPT code:        88307 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:  .       

Sigmoid colon, segmental colectomy :      

-- Diffuse severe ischemic colitis with prominent mucosal congestion and focal hemorrhage, involving entire colonic and appendiceal mucosa, most likely secondary to abdominal compartment syndrome

-- No vascular thrombosis, significant neutrophilic inflammation or abscess

-- Severe ischemic colitis involves the distal colonic margin terminal ileum.

Note: 02958203.

Slides examined:   H&E   x  9

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:        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:  .       

Sigmoid colon, biopsy:     

-- Invasive adenocarcinoma, moderately differentiated, superficial fragments.

-- Depth of invasion cannot be evaluated with this biopsy.

Note: 02958203.

Slides examined:   H&E   x  1

CPT code:        88305 x 1

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

Clinical scenario:  46-year old woman.         

Rectum, polypectomy:      

-- Invasive colorectal adenocarcinoma, well-differentiated, 4 mm in greatest size, arising from an adenoma with high grade glandular dysplasia, pT1.

-- No angiolymphatic invasion identified

-- Mucosal margins are involved by adenomatous change but are free of high-grade dysplasia and carcinoma by > 12 mm.

-- No invasive carcinoma within 1.5 mm from deep resection margin.

Editor's comment:

A synoptic check list can also be used to report such a lesion.

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

Clinical scenario:  .       

Sigmoid colon, segmental colectomy:     

-- Invasive adenocarcinoma, moderately differentiated, ___ cm, pT3N1b  (see Tumor Synopsis)

-- Proximal and distal (end) margins are free of carcinoma or adenomatous change.

-- No metastatic carcinoma in fourteen regional lymph nodes (0/14).

-- No significant histological abnormality in uninvolved colonic mucosa.

Note: 02958203.

Slides examined:   H&E   x  12

CPT code:        88309 x 1

Editor's comment:

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.

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

Clinical scenario:  63-year old man with h/o colon cancer, s/p chemo-radiation.       

Distal sigmoid colon and rectum, low anterior resection s/p neoadjuvant therapy:   

-- Residual invasive adenocarcinoma with treatment effect, at least 3.4 cm in  greatest dimension, (See Note and Tumor Synopsis).

Note: The tumor regression grade is determined to be 2 (minimal response, residual  cancer outgrown by fibrosis) as patchy tumor is present in a background of fibrosis. The scale used is from 0 to 3 with 0 being complete response to 3 being poor response. A grading schema modified for colorectal carcinoma based on the criteria by The  College of American Pathologists (CAP) is used in this case (ref.)

Slides examined:   H&E   x  22

CPT code:        88309 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  2

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  2

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:  .       

Cecum, biopsy:     

-- Submucosal lipoma.

-- Mucosal ganglioneuroma.

-- No glandular dysplasia or malignancy.

--

Note: 02958203.

Slides examined:   H&E   x  2

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  2

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:  .       

Sigmoid colon, segmental colectomy:     

-- Multiple diverticula.

-- No inflammation, fibrosis, ischemia, glandular dysplasia or malignancy.

-- No diverticulum at the resection margins.

-- Six benign reactive lymph nodes (0/6).

Slides examined:   H&E   x  7

CPT code:        883057x  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:   46-yo woman with a colon mass.    

Sigmoid colon, segmental colectomy:     

-- Multiple diverticula with focal severe acute diverticulitis and fistula formation.

-- Mural abscess with multinucleated giant cell reaction secondary to acute diverticulitis.

-- No granuloma, crypt architectural distortion or glandular dysplasia.

-- No inflammation or fibrosis at the proximal and distal resection margins.

-- Four benign reactive lymph nodes (0/4).

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

Clinical scenario:  .       

Organ, site, surgical procedure:     

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

Clinical scenario:  5-year old boy, r/o Hirshsprung's         

Rectum, biopsy:    

-- Submucosal ganglion cells of the meissner plexus are present (see Note)

-- Diagnosis confirmed by immunostain for calretinin (of the ganglion cells).

Note: The biopsy does not contain sufficient muscularis propria for evaluation of the Auerbach plexus.\ \

However, submucosal ganglion cells of Meissner plexus are identified on two of 10 levels of the block.

Slides examined:   H&E   x  2

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.