Introduction

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INTRODUCTION TO DIAGNOSIS WORDING

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Healthcare priority: Standard, Safety, efficacy and cost-effective

General Guidelines

Correct and consistent format: The pathology diagnosis should be listed under “diagnosis” section of a pathology report. It should consist at least of 2 major components—diagnostic heading and the actual diagnosis. The diagnostic heading should include type of specimen, location, and procedure. Examples are given below:

“Uterine cervix, 12 o’clock position, biopsy”

“Intervertebral disc, C4-L1, laminectomy”

“Allograft liver, core needle biopsy (3 weeks post transplantation)”

Diagnosis and key features of the entity: Several key data elements of a pathology diagnosis should be included whenever applicable depending on the nature of the case and the type of specimen examined:

For neoplastic lesions: Type of the tumor, degree of differentiation or grade, the extent of the tumor, invasion (including angiolymphatic invasion), and margins (for resection specimen). Two examples are given below:

“Prostatic adenocarcinoma, Gleason’s score 6 (3+3), present in 1 of 3 biopsy cores, with a maximal single contiguous tumor line length of 0.8cm, with focal perineural invasion.”

“Invasive mammary ductal carcinoma, moderately differentiated, intermediate nuclear grade, present in 3 of 5 fragments of specimen, with a single maximal contiguous tumor line length of 1.1cm, no definite angiolymphatic invasion identified in this biopsy.”

For non-neoplastic lesions: The diagnosis should also include 5 key elements which are: key diagnosis, severity, extent, etiology, and margins, if applicable. Two examples are shown below:

Sigmoid colon, segmental colectomy:

-- Severe acute ischemic colitis, involving mid one-third of the colon, with transmural necrosis and focal perforation, secondary to thrombotic arteriopathy of the mesenteric artery.

-- The resection margins are free of ischemia or inflammation.

Additional comment or note: Sometime it is difficult to be sure that the readers (clinicians) will correctly understand the diagnosis. A note or comment could be very helpful to clarify potential confusion or misunderstanding of the initial diagnosis and to document related aspects in the patient’s care.

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