Diagnosis Wording -- How to formulate final pathology diagnosis ...
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Home --> Diagnosis Wording --> Anus & Rectum (To activate copy function, allow Adobe Flash to ru)
Anus and Rectum: Click sections headings below (in blue) to expand or collapse the content
Diagnostic Headings (i.e. specimen & procedure)
Diagnostic |
Headings |
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Rectum, biopsy: |
Rectum, segmental proctectomy: |
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Rectum, full-thickness biopsy: |
Rectosigmoid colon, segmental colectomy: |
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Anus, biopsy: |
Rectum, proximal circumferential donut, excision: |
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Anus, hemorrhoidectomy: |
Anus and rectum, low anterior resection: |
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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 Nearly Normal:
-- No diagnostic abnormality.
-- No Hirschsprung disease identified in this biopsy.
-- No viral cytopathic change, dysplasia or carcinoma.
-- No colonic / glandular component is present.
Hemorrhoid and Inflammation:
-- Prominent vascular ectasia with thrombosis and congestion, consistent with hemorrhoids .
-- Fistula tract with inflammation, giant cell reaction and fibrosis.
-- Small hemorrhoid.
Hirschsprung Disease:
-- Ganglion cells identified without nerve hypertrophy.
-- Specimen inadequate for evaluation for Hirschsprung disease.
-- Complete aganglionosis and significant nerve hypertrophy, consistent with Hirschsprung disease.
-- Hirschsprung disease with complete aganglionosis and prominent nerve hypertrophy in distal 12-cm segment.
-- Adequate number of ganglion cells present without nerve hypertrophy (see Note).
Neoplastic:
-- Condyloma acuminatum with focal high grade squamous intraepithelial lesion (AIN-2, moderate squamous dysplasia).
-- Neuroendocrine tumor grade-1 (2010 WHO Classification) (carcinoid), 5.5 mm.
-- Invasive squamous cell carcinoma, cloacogenic type, at least 2 mm, in two of three fragments.
-- Invasive squamous cell carcinoma (see Tumor Synopsis).
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Clinical scenario: .
Rectum, biopsy:
-- 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:
Anus, hemorrhoidectomy:
-- Prominent vascular ectasia with thrombosis and congestion, consistent with hemorrhoids
-- Colonic mucosa with reactive glandular atypia.
-- No mucosal erosion, viral cytopathic changes, squamous or glandular epithelial dysplasia.
Slides examined: H&E x X
CPT code: 8830X x X
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Clinical scenario: .
Anus, further designated as "fistula", local excision:
-- Fistula tract with inflammation, giant cell reaction and fibrosis.
-- No skin or mucosal component is present.
Slides examined: H&E x X
CPT code: 8830X x X
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Clinical scenario:
Anus, hemorrhoidectomy:
-- Severe hemorrhoid with thrombi, marked vascular ectasia and stromal hemorrhage.
-- No mucosal erosion, viral cytopathic changes, squamous or glandular epithelial dysplasia.
-- No colonic mucosa is present.
Slides examined: H&E x X
CPT code: 8830X x X
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Clinical scenario: .
Rectum, suction biopsy:
-- Ganglion cells identified without nerve hypertrophy.
-- Diagnosis confirmed by calretinin immunostains and enzyme histochemistry for acetylcholinesterase.
Slides examined: H&E x X
CPT code: 8830X x X
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Clinical scenario:
Rectum, full-thickness biopsy:
-- No Hirschsprung's disease identified in this biopsy.
-- Diagnosis confirmed by calretinin immunostain and enzyme histochemistry for acetylcholinesterase.
-- No colitis or granulomas.
Slides exam: H&E X 2
CPT code: 8830 X 3
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Clinical scenario:
Rectum, biopsy:
-- Specimen inadequate for evaluation for Hirschsprung's disease.
-- Transitional epithelium and skeletal muscle with no diagnostic abnormality.
Slides exam: H&E X 2
CPT code: 8830 X 3
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Clinical scenario:
Rectum, full-thickness biopsy:
-- Complete aganglionosis and significant nerve hypertrophy, consistent with Hirschsprung's disease.
-- Diagnosis supported / confirmed by calretinin immunostain and enzyme histochemistry for acetylcholinesterase.
Slides exam: H&E X 6
CPT code: 88305 X 1, 88342 x 2
Editor's comment:
In Hirschsprung's disease, enzyme histochemistry demonstrates excessive accumulation of acetylcholine esterase (AchE) in nerve fibers in the mucosa while immunohistochemical stain for calretinin reveals no ganglion cells.
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Clinical scenario: .
Rectum, biopsy:
-- Regional aganglionosis and focal nerve hypertrophy, highly suspicious for Hirschsprung's diseas (see Note).
Note: 02958203.
Slides examined: H&E x X
CPT code: 8830X x X
Editor's comment:
Be aware of the normal paucity of ganglion cells within the lowest 3 cm of the rectum! Enzyme histochemistry for Acetylcholinesterase (AChE) can be very helpful. excessive enzyme accumulation characteristic of Hirschsprung's disease
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Clinical scenario: 14-month old girl with constipation. Prior proximal bx negative for Hirschsprung.
Rectum, biopsy:
-- Adequate number of ganglion cells present without nerve hypertrophy (see Note).
Note: The patient's previous biopsy is also reviewed concurrently. Histologic findings in both biopsy specimens are similar and are not compatible with clinical suspicion of Hirschsprung's disease (HD). Although HD may remain a possibility, other causal conditions esp. idiopathic constipation and intestinal neuronal dysplasia should also be considered.
Slides examined: H&E x X
CPT code: 8830X x X
Editor's comment:
Although much less common than HD, idiopathic constipation and intestinal neuronal dysplasia should be considered when adequate number of ganglion cells are identified on repeated biopsy, esp. of a female patient. Raising alternative possibilities can help further clinical workup.
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Clinical scenario: 9-month old girl .
Rectum, full-thickness biopsy:
-- Occasional ganglion cells identified without nerve hypertrophy (see Note).
-- Cannot exclude Hirschsprung's disease (of segment distal from the sampled area).
Note: Ganglion cells are unequivocally identified but the number appears to be significantly reduced. Main differential diagnosis may include transitional zone of colon involved by Hirschsprung's disease and hypoganglionosis. Their distinction cannot be made histologically on a limited sample in this case.
Slides exam: H&E X 2
CPT code: 8830 X 3
Editor's comment:
Distinction between hypoganglionosis and attenuated zone of Hirschsprung's disease is extremely challenge, if possible, based solely on histologic findings in a biopsy. Although gene mutations are detected in up to 50% of patients with Hirschsprung disease, their diagnostic utility is yet to be tested and validated.
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Clinical scenario:
Rectosigmoid colon, re-do transanal pull-through:
-- Sparse ganglion cells and occasional large nerve, consistent with transitional zone (4.5 cm) of Hirschsprung's disease.
-- No Hirschsprung's disease in proximal 3.5 cm segment.
Slides exam: H&E X 2
CPT code: 8830 X 3
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Clinical scenario: .
Rectosigmoid colon, segmental colectomy:
-- Hirschsprung's disease with complete aganglionosis and prominent nerve hypertrophy in distal 12-cm segment.
-- No agangionosis or nerve hypertrophy in proximal 5-cm segment.
-- Constipation-related changes.
Slides exam: H&E X 2
CPT code: 8830 X 3
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Clinical scenario: .
Rectosigmoid colon, segmental proctectomy:
-- Hirschsprung's disease (distal 5.7-cm segment) with complete aganglionosis and prominent nerve hypertrophy.
-- Transitional zone (1.7 cm) with sparse ganglion cells.
-- Disease-free segment (4.5 cm) with proximal resection margin.
-- Diagnoses supported by calretinin immunostain and acetylcholinesterase enzyme histochemistry.
Slides exam: H&E X 2
CPT code: 8830 X 3
Dysplasia and Neoplasm -- Biopsy
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Clinical scenario: .
Anus, biopsy:
-- Condyloma acuminatum with focal high grade squamous intraepithelial lesion (AIN-2, moderate squamous dysplasia), multiple fragments.
-- No carcinoma.
Slides examined: H&E x 2
CPT code: 88305 x 1
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Clinical scenario:
Anus, left anterior quadrant, biopsy:
-- Squamous cell carcinoma in-situ, 2.5 mm in horizontal span on slide, with focal superficial involvement of adnexae, multiple fragments.
-- Prominent human papilloma virus cytopathic changes.
-- No invasive carcinoma identified in this biopsy.
Slides examined: H&E x 2
CPT code: 88305 x 1
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Clinical scenario:
Anus, right anterior, biopsy:
-- Invasive squamous cell carcinoma, well-differentiated, at least 2 mm, in two of three fragments.
-- Depth of stromal invasion cannot be assessed.
Slides examined: H&E x 2
CPT code: 88305 x 1
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Clinical scenario:
Rectum, biopsy:
-- Focally invasive adenocarcinoma, 0.9 mm, arising in a tubulovillous adenoma with high grade glandular dysplasia (see note).
-- Cauterized base margin free of the invasive carcinoma by 1.5 mm.
-- Adenomatous changes present in mucosal edge / margin.
Slides examined: H&E x 2
CPT code: 88305 x 1
Editor's comment:
Given the anatomic site (i.e. rectum), the clinical management of the tumor may depend on the size of the invasive component and the margin status.
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Clinical scenario:
Skin, "perianal lesions", biopsies:
-- Squamous cell carcinoma in situ with superfical involvement of adnexal , extending to peripheral tissue edge, present in both fragments.
-- Human papilloma virus cytopathic changes.
-- No definite invasive squamous cell carcinoma identified in submitted sample.
Slides examined: H&E x 2
CPT code: 88305 x 1
Editor's comment:
This biopsy was performed to map the extent of squamous cell carcinoma in situ in order to determine the next management. Thus, pathology report should specify the number of fragments involved by tumor.
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Clinical scenario:
Rectum, biopsy:
-- Neuroendocrine tumor grade-1 (2010 WHO Classification) (carcinoid), 5.5 mm.
-- No mucosal erosion or colonic epithelial dysplasia.
Slides examined: H&E x 2
CPT code: 88305 x 1
Editor's comment:
Prostatic adenocarcinoma may enter differential diagnosis in male patient when the tumor is extensive and relatively spares mucosa or superficial portion of biopsy. Be aware that neuroendocrine tumor of hindgut often exhibits positive stain for prostatic acidic phosphatase.
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Clinical scenario: 61-year old woman. Perianal red eczematous patches with pruritis.
Anus, biopsy:
-- Extramammary Paget's disease,extending to specimen edges.
-- No dermal (tumor) component is identified.
-- Diagnosis confirmed by immunohistochemical stains.
-- No viral cytopathic changes.
Slides examined: H&E x 2
CPT code: 88305 x 1
Editor's comment:
A close histologic mimicker is malignant melanoma. A short panel of stains can be very helpful.
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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.
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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.