Diagnosis Wording -- How to formulate final pathology diagnosis ...
|
Home --> Diagnosis Wording --> Ovary & Fallopian Tubes (To activate copy function, allow Adobe Flash to run)
Ovary & Fallopian Tube: Click sections headings below (in blue) to expand or collapse the content
Diagnostic Headings (i.e. specimen & procedure)
Diagnostic |
Headings |
|
|
|
Right fallopian tube, segmental salpingectomy: |
___ ovary, oophorectomy: |
|
|
Left fallopian tube, segmental salpingectomy: |
___ fallopian tube, salpingectomy: |
|
|
Right and left fallopian tubes, salpingectomy: |
Right and left ovary, oophorectomy: |
|
|
___ fallopian tube & ovary, salpingo-oophorectomy: |
|
|
Dx. Menu -- Wording of Common Abnormalities
This subsection lists key diagnostic line for the most common diseases in this organ / system. Copy the relevant line(s) by clicking on the button and paste to your report to construct your own report. |
Normal and Ectopic Pregnancy:
-- No diagnostic abnormality.
-- Complete cross sections of both tubes with no diagnostic abnormality.
-- Ruptured tubal pregnancy with implantation site changes, hemorrhage and immature chorionic villi (products of conception).
Cystic Lesion of the Ovary:
-- Large regressing follicular cyst.
-- Large endometriotic cyste (“chocolate cyst”) with mural fibrosis and old hemorrhages.
-- Endometriosis and a large (27 cm) endometriotic cyst ("chocolate cyst").
-- Mature cystic teratoma (with component of skin, cartilage, bronchial mucosa, brain and intestine).
-- Serous cystadenoma, 16 cm.
Neoplastic:
-- Ovarian endometrioid adenocarcinoma (see Tumor Synopsis).
-- Papillary serous adenocarcinoma, high grade (see Tumor Synopsis).
=============
Clinical scenario:
Right fallopian tube, segmental salpingectomy:
-- Benign simple paratubal cyst.
-- Complete cross section of the fallopian tube with no diagnostic abnormality.
Slides examined: H&E x 1
CPT code: 88302 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:
Right and left fallopian tubes, segmental salpingectomy:
-- Benign simple paratubal cyst, right.
-- Complete cross sections of both tubes with no diagnostic abnormality.
Slides examined: H&E x 2
CPT code: 88302 x 2
=============
Clinical scenario: .
Right fallopian tube and ovary, salpingo-oophorectomy:
-- Benign simple serous cysts.
-- Unremarkable ovarian stroma.
-- Benign simple paratubal cysts.
-- No borderline neoplasm or malignancy.
Slides examined: H&E x 4
CPT code: 88305 x 4
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
Ectopic Pregnancy and Endometriosis
=============
Clinical scenario: .
Right fallopian tube and content, salpingectomy:
-- Intratubal pregnancy with immature chorionic villi, embryonic tissue (products of conception) and hemorrhage.
-- No tubal rupture or hydatiform mole is identified.
Slides examined: H&E x 4
CPT code: 88305 x 4
=============
Clinical scenario: .
Left fallopian tube, salpingectomy:
-- Ruptured tubal pregnancy with implantation site changes, hemorrhage and immature chorionic villi (products of conception).
-- No fetal parts or hydatiform mole is identified.
-- Prominent paratubal hemorrhage, reactive fibrosis and mesothelial reactive hyperplasia.
Slides examined: H&E x 4
CPT code: 88305 x 4
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: .
Left fallopian tube, salpingectomy:
-- Tubal endometriosis with marked old hemorrhage and mural occlusive fibrosis.
-- No active inflammation, borderline neoplasm or malignancy.
Slides examined: H&E x 4
CPT code: 88305 x 4
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:
Right fallopian tube and portion of right ovary, salpingo-oophorectomy:
-- Pseudoxanthomatous salpingitis (pigmentosiss tubae), most likely secondary to endometriosis
-- Ovarian endometriosis
-- No borderline neoplasm or malignancy.
Note: Use this template first. Convert is later into table formats
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.
=============
Clinical scenario:
Right ovarian cyst wall, cystectomy:
-- Large regressing follicular cyst.
-- Hemorrhagic corpus luteal cyst.
-- Large endometriotic cyste (“chocolate cyst”) with mural fibrosis and old hemorrhages.
-- No ovarian borderline neoplasm or malignancy.
Note: Use this template first. Convert is later into table formats
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: .
Left ovary and fallopian tube, salpingo-oophorectomy:
Ovary:
-- A hemorrhagic corpus luteum cyst.
-- Benign simple serous cyst.
-- Cystic follicles.
-- No borderline neoplasm or malignancy.
Fallopian Tube:
-- No diagnostic abnormality.
Slides examined: H&E x 6
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: .
Right ovary and fallopian tube, salpingo-oophorectomy:
-- Ovarian endometriotic cyst (endometriosis with cystic changes).
-- Benign simple paratubal cyst.
-- Unremarkable cross-section of fallopian tube.
-- No borderline neoplasm or malignancy.
=============
Clinical scenario: .
Right ovary, oophorectomy:
-- Endometriosis and a large (27 cm) endometriotic cyst ("chocolate cyst")
-- No borderline neoplasm or malignancy
Note: 02958203.
Slides examined: H&E x 6
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: .
Right ovary and fallopian tube, salpingo-oophorectomy:
Ovary:
-- Mature cystic teratoma (with component of skin, cartilage, bronchial mucosa, brain and intestine).
-- No immature embryonic components, borderline neoplasm or malignancy.
Fallopian tube:
-- No diagnostic abnormality.
=============
Clinical scenario: .
Left ovary and fallopian tube, salpingo-oophorectomy:
Ovary:
-- Serous cystadenoma, 16 cm.
-- No borderline neoplasm or malignancy.
Fallopian tube:
-- No diagnostic abnormality.
=============
Clinical scenario: .
Right ovarian mass, resection:
-- Mucinous cystadenoma (18 cm) with focal stromal pseudoinvasion, multinoculated.
-- No borderline neoplasm or malignancy.
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.
Neoplasms: Borderline and Malignant
=============
Clinical scenario: .
Left ovary and fallopian tube, salpingo-oophorectomy:
-- Ovarian endometrioid adenocarcinoma (See Tumor Synopsis)
-- No carcinoma identified in the attached fallopian tubes.
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.
=============
Clinical scenario:
Right ovary and left ovary, bilateral oophorectomy:
-- Papillary serous carcinoma, high grade (10 mm on the right and 7 mm on the left), multifocal with ovarian stromal invasion, bilateral fallopian tubes and ovaries. (see Tumor Synopsis and Note).
Note: Although the carcinoma involves predominantly the resected omentum, by current WHO classification this tumor is best classified as ovarian papillary serous carcinoma based on the largest size of the tumor in the ovaries.
Editor's comment:
WHO 2010 criteria for peritoneal papillary serous carcinoma: 1) both ovaries normal in size or enlarged due to benign process; 2) peritoneal tumor is smaller than that of ovary; 3) tumor on ovarian surface without stromal invasion and not exceed 5 x 5 mm.
=============
Clinical scenario: .
Left ovary and fallopian tube, salpingo-oophorectomy:
-- Ovarian endometrioid adenocarcinoma (See Tumor Synopsis)
-- No carcinoma identified in the attached fallopian tubes.
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.
=============
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.