Diagnosis Wording -- How to formulate final pathology diagnosis ...
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Breast: Click sections headings below (in blue) to expand or collapse the content
Diagnostic Headings (i.e. specimen & procedure)
Diagnostic |
Headings |
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Left breast, core biopsy: |
Left breast, upper outer quadrant, stereotactic biopsy: |
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Right breast, ___ o'clock, core biopsy: |
Right breast, partial mastectomy: |
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Left breast, local excision: |
Right breast, simple mastectomy: |
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Right breast, excisional biopsy: |
Left breast with axillary content, radical mastectomy: |
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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 atypical hyperplasia or carcinoma.
-- Diffuse mild collagenous stromal fibrosis.
-- Benign skin with cicartix.
Epithelial lesions -- Non-neoplastic:
-- Fibrocystic changes with apocrine metaplasia and multiple microcalcifications.
-- Hyalinized fibroadnoma with microcalcification.
-- Small hyalinized fibroadenoma.
-- Fibrocystic disease with focal apocrine metaplasia.
-- Focal sclerosing adenosis.
-- Microcalcifications in benign ductal-lobular units.
Stromal Lesions -- Non-neoplastic:
-- Prominent stromal hyalinizing fibrosis.
-- Focal pseudoangiomatous stromal hyperplasia (PASH).
-- A small radial scar, 3 mm.
Neoplastic -- Benign:
-- Intraductal papilloma with usual hyperplasia in all four biopsy cores, 2.0 mm in greatest linear length, extending to the edge of biopsy cores.
-- Small hyalinized fibroadenoma.
-- Focal atypical lobular hyperplasia.
Neoplastic Malignant:
-- Invasive mammary ____ carcinoma, nuclear grade ____, present in ____ of ____ biopsy cores, constituting ____% of the biopsy material, with a maximal contiguous tumor line length of ____ mm.
-- Ductal carcinoma in-situ, high nuclear grade with commedo necrosis and microcalcifications (see Tumor Synopsis).
-- Invasive ductal carcinoma (___ mm), Bloom-Richardson grade ___, pT___ N___ Mx (see Tumor Synopsis).
-- Malignant phyllodes tumor (see Tumor Synopsis).
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Clinical scenario: 43-year old woman with calcifications at 1:00.
Left breast, upper outer quadrant, stereotactic core biopsy:
-- Focal fibrocystic disease with focal apocrine metaplasia (see Note).
-- No atypical hyperplasia or carcinoma.
Note: The attached radiographic film of the specimen is also reviewed. The findings on the radiographic films and the histologic slides for both parts are correlated.
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: 43-year old woman with calcifications at 1:00.
Left breast, reduction mammoplasty (___ g):
-- Focal fibrocystic disease and usual ductal hyperplasia.
-- No diagnostic abnormality in the skin.
-- No atypical hyperplasia or carcinoma.
Slides examined: H&E x 5
CPT code: 88305 x 1
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Clinical scenario: 58-year old female with high density area.
Left breast, upper outer quadrant, stereotactic core biopsy:
-- Diffuse stromal hyalinizing fibrosis, 6 mm measured on slide.
-- No atypical hyperplasia or carcinoma.
Slides exam: H&E X 15
CPT code: 88305 x 1
Editor's comment:
Approximately 25% of women have so call "dense breast" which is very difficult to evaluate on mammogramm (ref). Microscopically, the breast tissue shows diffuse prominent stromal fibrous component with high fibrous to fat and fibrous to epithelial unit ratio. Reporting as "No significant abnormality" often elicit phone call from radiologists.
Fibrocystic Changes and Other Common Benign Lesions
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Clinical scenario: 43-year old woman with calcifications at 1:00.
Left breast, upper outer quadrant, stereotactic core biopsy:
-- Fibrocystic disease with focal apocrine metaplasia.
-- Sclerosing adenosis / complex adenosis.
-- Small hyalinized fibroadenoma
-- Microcalcifications in benign ductal-lobular units (see Note).
-- No atypical hyperplasia or carcinoma.
Note: The attached radiographic film of the specimen is also reviewed. The findings on the radiographic films and the histologic slides are correlated
Slides examined: H&E x 15
CPT code: 88305 x 1
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Clinical scenario:
Left / Right breast, excisional biopsy:
-- Fibrocystic changes with prominent apocrine metaplasia
-- Usual ductal hyperplasia
-- Blunt ductal adenosis and sclerosing adenosis.
-- No (residual) radial scar or lobular carcinoma.
-- No atypical ductal hyperplasia or carcinoma.
Slides examined: H&E x 15
CPT code: 88305 x 1
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Clinical scenario:
Left / Right breast, core biopsy:
-- Adenosis with columnar cell change (see Note).
-- Fibrocystic changes with apocrine metaplasia.
-- No atypical epithelial hyperplasia or carcinoma.
Note: Correlation with subsequent excisional biopsy findings (SP-16-xxxx, dated ____ ) indicates that the abnormal epithelial proliferation in this specimen is best classified as columnar cell change in adenosis. There is no atypical epithelial hyperplasia or carcinoma.
Slides examined: H&E x 15
CPT code: 88305 x 1
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Clinical scenario: 59-yo woman with mass lesion; hx/ right breast cancer, s/p lumpectomy 2 years ago; s/p chemoradiation therapy.
Right breast, lumpectomy:
-- Fat necrosis with dystrophic calcification, multinucleated giant cell reaction and fibrosis.
-- Multiple histiocytic-rich granulomatous nodules (see note).
-- No atypical hyperplasia or carcinoma identified.
Note: The exact cause of the granulomatous nodules is not histologically apparent. Reaction to fat necrosis is a common scenario. Given the patient's clinical history of "breast cancer", so called "pseudoneoplastic proliferation of histiocytes" may also be a cause (ref) if the patient received treatment with Taxol. Special stains for fungus and mycobacteria are negative although the result does not entirely exclude infection. In any case, there is no atypical hyperplasia or carcinoma in the examined specimen.
Reference:
Lemos LB, Qu Z, et al.: Pseudoneoplastic proliferation of histiocytes with paclitaxel-induced ultrastructural changes in a mastectomy specimen. Ann Diagn Pathol. 8(5):299-304, 2004.
Editor's comment:
This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.
Fibroadenoma and Benign Phyllodes Tumor
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Clinical scenario: 21-year old woman with a 3-cm mass, r/o FA vs sarcoma.
Left breast, core biopsy:
-- Fibroepithelial lesion in four of five cores, most likely a fibroadnoma (see Note)
-- No overt malignant features is noted.
Slides examined: H&E x 15
CPT code: 88305 x 1
Editor's comment:
The degree of certainty of the diagnosis may depend on the biopsy sample, histologic features and personal experiences, etc. The diagnosis may read "consistent with...", "probably ...", etc . A note may be added to specify why uncertainty remains.
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Clinical scenario: 19-year old woman with a 3-cm mass, r/o FA .
Left breast, local excision:
-- Cellular fibroadnoma (28 mm) with focal changes consistent with prior biopsy site.
-- All margins are free of the tumor by at least 2 mm.
-- No atypical hyperplasia or malignancy.
Slides examined: H&E x 12
CPT code: 88307 x 1
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Clinical scenario: 47-year old woman with a recurrent breast mass. hx/o phyllodes tumor on recent biopsy.
Right breast, partial mastectomy:
-- Hypercellular fibroepithelial neoplasm, consistent with a low-grade phyllodes tumor (see Note).
-- No atypical epithelial hyperplasia or carcinoma.
Slides examined: H&E x 12
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.
Intraductal Papilloary Neoplasms
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Clinical scenario:
Right breast, 8 o'clock, stereotactic core biopsy:
-- Intraductal papilloma with usual hyperplasia in all four biopsy cores, 2.0 mm in greatest contiguous linear length, extending to the edge of biopsy cores.
-- No atypical hyperplasia or carcinoma.
Slides examined: H&E x 12
CPT code: 88307 x 1
Editor's comment:
Increasingly, intraductal papilloma is managed by local complete excision. Report of findings in core biopsy and excision is expected to include quantative tumor attributes to guide the further clinical management.
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Clinical scenario:
Right breast, stereotactic core biopsy:
-- Intraductal papilloma (2 mm), completely excised in the plane of examined sections.
-- Fibrocystic changes, focal usual ductal hyperplasia and microscopic calcifications, corresponding to the specimen radiograph
-- No atypical hyperplasia or carcinoma.
Slides examined: H&E x 12
CPT code: 88305 x 1
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Clinical scenario: 46-year old woman, s/p local excision for intraductal papilloma
Left breast, 2:30, core biopsy:
-- Previous procedure site changes (benign cystic change, extensive hyalinized fibrosis and multinucleated giant cell reaction).
-- No residual papilloma, atypical hyperplasia or carcinoma identified.
Note: The attached radiographic film of the specimen is also reviewed. The findings on the radiographic films and the histologic slides for both parts are correlated.
Editor's comment:
In general, it is not necessary to specify what the previous procedure site changes are.
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Clinical scenario: .
Left breast, 11 o'clock, core biopsy:
-- Solid papillary carcinoma, nuclear grade 1, present in all biopsy cores, constituting 75% of specimen, at least 7 mm (see note).
-- No tumor calcification.
-- No definite invasive component is identified.
-- Hormonal receptor studies are requested on block A2.
Slides examined: H&E x 15
CPT code: 88305 x 1
Editor's comment:
The presence of smooth mucle myosin p63 cells around tumor nodule shown by immunohistochemical stain is considered features support the diagnosis of solid papillary carcinoma.
Ductal and Lobular Hyperplasia
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Clinical scenario: 44-year old woman with a breast mass.
Left breast, core biopsy:
-- Usual ductal hyperplasia, fibrocystic changes and focal sclerosing adenosis (see Note).
-- Multiple microcalcifications (calcium oxylates), corresponding to those identified in attached radiographic film.
-- No atypical hyperplasia or carcinoma (in this biopsy).
Note: sections reveals benign breast tissue predominantly composed of cellular and fibrotic parenchyma (>80%), with a linear length of 7 mm. Depending on the size of the clinically identified "mass", the histological findings may or may not be representative of the "mass".
Slides examined: H&E x 9
CPT code: 88305 x 1
Editor's comment:
The term "mass" and "nodule" are used clinically with a bewildering range: some refer a 0.5 cm nodule as a "mass" whereas others call a 5-cm solid lesion as a "nodule". In this setting, it is highly advised NOT to assume that biopsy findings are representative or not representative of the underlining lesion. It is best to leave that judgment to clinicians.
Atypical Ductal and Lobular Hyperplasia
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Clinical scenario:
Left breast, upper outer quadrant, stereotactic core biopsy:
-- Focal atypical lobular hyperplasia.
-- Prominent stromal hyalinizing fibrosis.
-- Microcalcifications in benign ductal-lobular units (see Note).
-- No carcinoma or atypical ductal hyperplasia.
Note: The attached radiographic film of the specimen is also reviewed. The findings on the radiographic films and the histologic slides for both parts are correlated.
Slides examined: H&E x 12
CPT code: 88307 x 1
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Clinical scenario:
Left breast, upper outer quadrant, core biopsy:
-- Ductal carcinoma in-situ (DCIS), nuclear grade 2, solid and cribriform pattern with focal comedo necrosis, present in ____ of ____ biopsy cores, constituting ____% of the biopsy material, with a maximal contiguous tumor line length of ____ mm.
-- No invasive carcinoma or tumor microcalcification.
-- ER and PR studies requested on block A2; results to be reported separately.
Slides examined: H&E x 12
CPT code: 88307 x 1
Editor's comment:
Compared to the synoptic format (see next example), this one takes much less time to dictate once getting used to it and especially speech recognition technology is used. In practice, either one is sufficient.
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Clinical scenario:
Left breast, upper outer quadrant, core biopsy:
-- Ductal carcinoma in-situ, high grade with commedo necrosis and microcalcifications (see Tumor Synopsis).
-- No invasive carcinoma is identified.
Tumor Synopsis (Ductal carcinoma in-situ)
Specimen designation: |
Left breast , UOQ |
Surgical procedure: |
Core biopsy |
Histological type: |
Ductal carcinoma in-situ |
Nuclear grade: |
Intermediate (grade-2) |
Number of cores involved: |
4 |
Maximal tumor line length: |
8 mm |
Relative tumor volume: |
75% of the specimen |
Tumor calcification: |
Present |
Receptor studies: |
Ordered on A2 |
Note: Dr. ___ is notified about the above diagnosis on 03/12/2016.
Slides examined: H&E x 12
CPT code: 88305 x 1
Editor's comment:
This synoptic format may be a little more time-consuming than the paragraphical one (see last example) because of longer time required for dictation and transcription.
Invasive Carcinomas -- Ductal or Lobular
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Clinical scenario:
Left breast, upper outer quadrant, core biopsy:
-- Invasive mammary ____ carcinoma, Bloom-Richardson grade ____, present in ____ of ____ biopsy cores, constituting ____% of the biopsy material, with a maximal contiguous tumor line length of ____ mm.
-- Ductal carcinoma in-situ, multifocal, nuclear grade 1, predominantly solid and cribriform pattern with focal comedo necrosis.
-- No tumor necrosis, microcalcification or angiolymphatic invasion is identified.
-- ER, PR and her-2/neu studies requested on block A2; results to be reported separately.
Note: Dr. ___ is notified about the above diagnosis on 03/12/2016.
Slides examined: H&E x 9
CPT code: 88305 x 1
Editor's comment:
This template includes key quantitative tumor attributes. Compared to synoptic format (see next example), this paragraphical format take less time to dictate and transcribe, especially when speech recognition technology is used routinely.
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Clinical scenario:
Left breast, 3:00 o'clock, core biopsy:
-- Invasive ductal carcinoma (see Tumor Synopsis).
-- Ductal carcinoma in-situ, nuclear grade 1, cribriform pattern, adjacent to invasive carcinoma.
Tumor Synopsis
Histologic type: Invasive ductal carcinoma
Main histologic type: NOS
Histologic grade: Grade 2 (moderately differentiated)
Number of cores involved: 4
Maximum length of invasive carcinoma: 0.8 cm
In-situ carcinoma: Present
Calcifications in tumor: Present
Receptor studies ordered: yes
Block used for receptor studies: block A2.
Note: Dr. ___ is notified about the above diagnosis on 03/12/2016.
Slides examined: H&E x 12
CPT code: 88305 x 1
Editor's comment:
This synoptic format may be a little more time-consuming than the paragraphical one (see example above) because of longer time for dictation and transcription. 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: 53-year old woman, recent core biopsy with invasive ductal carcinoma.
Left breast with axillary content, mastectomy:
-- Invasive ductal carcinoma (9.0 mm), Bloom-Richardson grade 2, pT1b N1a Mx (see Tumor Synopsis).
-- Ductal carcinoma in-situ, extensive
-- No angiolymphatic invasion
-- All resections margins are free of tumor by at lease 4 mm (inferior)
-- Metastatic ductal carcinoma (3.0 mm) in one of four lymph nodes (1/4)
Tumor Synopsis
(Complete list of tumor attributes here)
(Please refer to AJCC manual, CAP protocol or Web-based Tumor Reporting System)
Note: Dr. ___ is notified about the above diagnosis on 03/12/2016.
Slides examined: H&E x 12
CPT code: 88307 x 1
Editor's comment:
In addition to a complete Tumor Synopsis, this example for mastectomy specimen selectively lists some key tumor attributes in the top diagnosis section. Given the increasingly expanding Tumor Synopsis, it may be desirable to list some key attributes in the top diagnosis section. However, repeating the same attributes in different sections is prone to inconsistency/discrepancy when changes are made. Whether to do so and what to include in the top list are largely of personal preference and institutional culture. 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: 46-yo woman with a breast mass; hx/o phyllodes tumor on recent biopsy.
Right breast, partial mastectomy:
-- Malignant phyllodes tumor (see Tumor Synopsis).
-- No atypical epithelial hyperplasia or carcinoma.
Note: Currently, there is no recommended reporting standard and tumor staging schema for this tumor in AJCC manual.
Tumor Synopsis (Breast Phyllodes Tumor)
Specimen designation: |
Right breast mass |
Surgical procedure: |
Partial mastectomy |
Tumor site: |
Anterior/superior portion |
Tumor focality: |
Unifocal |
Tumor size: |
42 mm |
Histological type: |
Malignant phyllodes tumor |
Infiltrative growth: |
Present |
Tumor cellularity: |
High cellularity |
Differentiation / grade: |
interdediate |
Mitotic rate: |
2.3 / 10 high-power fields (40 fields counted) |
Tumor necrosis: |
Focally present, approximately 5% of the tumor |
Heterologous sarcomatoid component: |
Absent |
Angiolymphatic invasion: |
Absent |
Resection margins: |
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Superior: |
Negative by 2.0 mm |
Inferior: |
Negative by > 5.0 mm |
Anterior: |
Negative by 2.0 mm |
Posterior: |
Negative by > 5 mm |
Medial: |
Negative by > 5 mm |
Lateral: |
Negative by > 5 mm |
Pathological Stage |
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Slides examined: H&E x 12
CPT code: 88307 x 1
Editor's comment:
Currently, there is no well accepted data set for reporting malignant phyllodes tumor. This suggested example of synopsis comes from our web-based Tumor reporting System. 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.