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

Normal and Nearly Normal:

-- No diagnostic abnormality.   

-- No active inflammation, fibrinoid vegetation or calcification.    

-- No bacterial or fungal organism identified on special stains.   

Cardiac Valves:   

-- Severe atherosclerotic valvulopathy with extensive calcification.   

-- Diffuse moderate myxoid degeneration.   

-- Nodular calcification and fibrosis.   

-- Fibrocalcific aortic stenosis (see Gross Examination).   

--  Marked myxoid degeneration, dystrophic calcification and fibrosis.   

-- Acute necrotizing bacterial endocarditis.   

-- Severe acute inflammation with valve necrosis and thrombus formation.   

Large Vessels:   

-- Severe atherosclerosis with mural plaque formation, calcification and fibrosis consistent with aneurysm.  

-- Mural myxoid degeneration and separation with hemorrhage, consistent with aortic dissection.   

-- Moderate active giant cell arteritis.    

Heart (Pericarcium):   

-- Fibrinous / serofibrinous pericarditis with mild fibrosis.    

-- Metastatic carcinoma, consistent with a ___ origin.    

Heart (Myocardium):   

-- Cardiac myxoma.   

-- Focal mild old interstitial fibrosis.   

-- Moderate eosinophilic myocarditis (see Note).   

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

Clinical scenario:  .       

Left temporal artery, segmental 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. 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  Home page 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 severe aortic valve stenosis.         

Aortic valve, valve replacement:      

-- Severe atherosclerotic valvulopathy with nodular calcification and fibrosis.

-- Fibrocalcific aortic stenosis (see Gross Examination).

-- No fibrinoid vegetation or inflammation.

Slides examined:   H&E   x  X

CPT code:        8830X x  X

Editor's comment:

Gross examination is critical for assessing aortic valvulopathy because histological examination can not determine the type and severity of valvulopathy.  For example, combined length of  free edge leaflets indicates the severity of stenosis while fusion and distortion due to fibrosis are associated with insufficiency.  Gross description should include these findings. 

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

Clinical scenario:          

Aortic valve leaflets, valve replacement:      

-- Severe acute bacterial endocarditis with valve necrosis and thrombus formation.

-- Clusters of Gram-positive cocci in chain identified on special stains.

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:  42-year old woman with mitral valve insufficiency       

Mitral valve leaflets, excision:     

-- Diffuse prominent myxoid degeneration and fibrosis.

-- No active inflammation, fibrinoid vegetation or calcification.

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:          

Chordae tendineae, mitral valve repair:     

-- Mild patchy myxoid degeneration.

-- No active inflammation, fibrin vegetation or calcification.

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:  54-year old man with sepsis.  S/p renal transplant.     

Mitral valve leaflets, excision:     

-- Mild to focally moderate acute inflammation, granulation tissue, and  fibrosis, consistent with treated endocarditis.

-- No fibrinoid vegetation or thrumbus.

-- No bacterial or fungal organisms identified on special stains.

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:  .       

Prosthesis aortic valve, removal:     

-- Hyalinized fibrous tissue with focal calcification and suture material.

--- No active inflammation or fibrinoid vegetation identified.

-- Intact prosthetic valve, ___ type (see Gross Examination).

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:  .       

Prosthesis aortic valve, removal:     

-- Severe acute inflammation and fibrinoid vegetation, consistent with prosthetic valve endocarditis.

-- Intact prosthetic valve, ___ type (see Gross Examination).

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:  62-yo woman with increased ESR; r/o temporal arteritis.        

Right temporal artery, segmental biopsy:     

-- Moderate active giant cell arteritis.

-- No occlusive thrombosis.

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:  67-yo woman; r/o temporal arteritis.        

Right temporal artery, segmental biopsy:      

-- Multifocal mural dystrophic calcification and focal fibrosis (age related changes).

-- No giant cell  arteritis, thrombosis or occlusive arteriopathy.

-- No fragmentation of the vascular elastin on special stain.

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:  63-year old woman.       

Right temporal artery, segmental biopsy:      

-- No giant cell arteritis or any form of inflammation.

-- Focal dystrophic mural calcification (best seen on level 7).

-- Elastin stain reveals no disruption of internal elastic lamina.

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:  .       

Ascending aorta, aneurysm repair:     

-- Diffuse severe atherosclerosis with mural myxoid degenerationmural, fibrosis and dystrophic calcification.

-- No mural hemorrhage or dissection identified.

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:  .       

Abdominal aortic aneurysm, open repair:     

-- Aortic aneurysm with atherosclerotic intimal plaque and mural fibrosis.

-- No aortitis or giant cell granuloma.

-- Fragments of ancient thrombus.

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:  .       

Abdominal aorta, aneurysm repair:     

-- Patchy lymphoplasmacytic infiltrates with multinucleated giant cells, consistent with giant cell aortitis.

-- Diffuse mural degeneration and hyalinized fibrosis. 

-- No mural hemorrhage or dissection identified.

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:  .       

Ascending aorta, aneurysm repair:    # 

-- Moderate active giant cell aortitis with focal acute inflammation and patchy collagen necrosis (necrobiosis)

-- Focal severe mural myxoid degeneration

-- Marked intimal hyperplasia with fibrosis

-- No mural calcification, hemorrhage or dissection

-- No definite atherosclerotic plaque

Note:  The constellation of mural clusters of multinucleated giant cells, lymphoplasmacytic infiltrates, severe medial necrosis with necrobiosis, disruption / destruction of elastic fiber is consistent with the diagnosis of moderate active giant cell aortitis.  Although the increased number of mural IgG4-positive plasma cell and mural fibrosis also raise the possibility of an igg4-associated aortitis, the relationship between the giant cell aortitis and IgG4-associated aortitis remains unclear.  However, the mainstay of treatment for both of these diseases is similar and therefore histological distinction at this stage may not be critical.

Slides examined:   H&E   x  X

CPT code:        8830X x  X

Editor's comment:

Aortic specimen with gian cell aortitis as a product of resection / aneurysm repair  often indicates that the diagnosis is missed clinically. Mild or moderate giant cell aortitis can also easily escape microscopic examination if

IgG4-associated aortitis, the relationship between the giant cell aortitis and IgG4-associated aortitis remains unclear.  However, the mainstay of treatment for both of these diseases is similar and therefore histological distinction at this stage may not be critical..

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

Clinical scenario:  .       

Aortic wall, aneurysm repair:     

--  Severe atherosclerosis with mural plaque formation, calcification and fibrosis consistent with aneurysm (see also Gross Examination).

--  No mural hemorrhage or dissection identified.

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

Clinical scenario:  .       

Ascending aorta, partial excision:     

-- Severe mural myxoid degeneration with mural separation and hematoma (see Gross Examination), consistent with aortic dissection.

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:  .       

Abdominal aorta, partial resection:     

-- Prominent intramural hemorrhage with mural separation, at least 1.7 cm (see Gross Examination), consistent with aortic dissection.

-- Mild intimal degenerative changes.

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:          

Heart, right ventricle, endomyocardial biopsy:     

-- No significant histological abnormality

-- No Amyloid deposition identified on Congo red stain.

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:          

Left ventricle, heart, partial excision:     

-- Focal myocardial scarring with fatty infiltration, hypertrophy and hydropic changes of cardiomyocytes, consistent with chronic ischemic cardiopathy.

-- No acute infarction or myocarditis identified.

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:             

Heart, left ventricle, biopsy:     

-- Changes compatible with clinical finding of restrictive cardiomyopathy, etiology uncertain (see Note).

-- No granuloma, amyloid deposit, giant cell infiltrate or significant inflammation.

-- No acute myocardial infarction or myocarditis.

-- No iron or amyloid material deposits on special stains.

Note: The underlying etiology is not histologically apparent. Main differential diagnoses should include ___.

Slides examined:   H&E   x  X

CPT code:        8830X x  X

Editor's comment:

Restrictive cardiomyopathy is a histologic pattern rather than an etiologic diagnosis.  A wide variety of primary diseases can lead to restrictive cardiomyopathy.  The underlying cause often is not apparent histologically. It is appropriate to perform some routine studies to exclude (or identify) common causes and provide a short list of differential diagnoses based on the combined clinical and morphological findings.

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

Clinical scenario:          

Heart, septum, excisional biopsy:     

-- Focal old myocardial fibrosis, approximately 4 mm in  greatest dimension, probably old infarct.

-- No inflammation, acute myocardial infarct or infiltrative cardiomyopathy.

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:             

Heart, left ventricle, biopsy:     

--  Mild to focally moderate lymphocytic infiltrates associated with myocyte necrosis, consistent with lymphocytic myocarditis (see Note).

-- No viral cytopathic change, giant cells or eosinophils.

-- No acute myocardial infarction.

Note: The underlying etiology is not histologically apparent in this case. In general, viral infection is the most frequent cause.

Slides examined:   H&E   x  X

CPT code:        8830X x  X

Editor's comment:

By the Dallas Criteria,  diagnosis of lymphocytic myocarditis requires lymphocytic infiltrates, myocyte drop-out and exclusion of ischemic necrosis. However, due to low sensitivity and high sampling error rate, a clear-cut diagnosis is often very difficult. Nonetheless, excluding other more distinct and often more ominous disease entities such as (acute necrotizing) eosinophilic myocarditis and giant cell myocarditis can be very helpful.

K. L. Baughman: Diagnosis of Myocarditis -- Death of Dallas Criteria. Circulation. 113: 593-595, 2006.

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

Clinical scenario:          

Pericardium, excisional biopsy: 

-- Benign pericardial mesothelial cyst.

-- No inflammation, significant fibrosis or malignancy.

Slides examined:   H&E   x  2

CPT code:        88305 x  1

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

Clinical scenario:  56-year old woman with pericardial effusion.  H/o breast cancer.      

Pericardium, pericardiectomy:     

-- Metastatic adenocarcinoma, consistent with a breast origin.

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:  77-yo woman with constrictive pericarditis.        

Pericardium, pericardiectomy:     

-- Diffuse fibrosis with focal dystrophic calcification and mild chronic inflammation, compatible with clinical impression of constrictive pericarditis.

-- No acute inflammation, plasma cell infiltrates, granuloma or neoplasm.

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:  72-yo man with chronic renal failure.        

Pericardium, pericardiectomy:     

-- Fibrinous / serofibrinous pericarditis with mild fibrosis.

-- No inflammatory infiltrates, granuloma or neoplasm.

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:          

Pericardium, pericardiectomy:     

-- Benign pericardial (mesothelial) cyst.

-- No inflammation, significant fibrosis 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.   

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

Clinical scenario:          

Pericardium, radical pericardiectomy:     

-- Reactive pericarditis with surface fibrin deposition, hyalinizing fibrosis and prominent chronic inflammation with increased IgG4-positive plasma cells (see note).

-- No (necrotizing) granuloma, atypical epithelioid cells or  malignancy.

-- Special stains for fungal organisms and mycobacteria are negative.

Note: An increased number of IgG4-positive (plasma) cells are present in this specimen. The significance remains unknown. A non-specific reactive process is favored. However, if no other apparent etiology for the "constrictive pericarditis" can be identified clinically, IgG4-related autoimmune etiology should be entertained and further work-up may be warranted.  IgG4-related sclerosing disease is a recently recognized group of diseases. Two histological features characterize this group of diseases in a wide anatomic distribution: a significantly increased number of IgG4-positive plasma cells and fibroproliferative sclerosis. Although rare cases of IgG4-related pericarditis have been reported, consensus for its diagnostic criteria is still lacking.

Slides examined:   H&E   x  X

CPT code:        8830X x  X

Editor's comment:

The following references may be included in the report.

T. Kamisawa and A. Okamoto: IgG4-related sclerosing disease. World J Gastroenterol. 14(25). 3948–3955, 2008.

T. Sugimoto et al.: Constrictive pericarditis as an emerging manifestation of hyper-IgG4 disease.  Int J Cardiol  130(3): e100–e101, 2008.

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

Clinical scenario:  .       

Right atrium, excisional biopsy:     

-- Cardiac myxoma.

-- Surface fibrin deposit.

-- No malignancy.

Slides examined:   H&E   x  X

CPT code:        8830X x  X

Editor's comment:

The tumor often shows chromosomal abnormalities and aneuploidy. It's also positive for a1-antichymotrypsin.  But these tests are rarely needed for the diagnosis.      

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

Clinical scenario:  .       

Right atrium, excisional biopsy:     

-- Papillary fibroelastoma.

-- No inflammation is identified.

-- Diagnosis confirmed by elastic stain.

Slides examined:   H&E   x  X

CPT code:        8830X x  X

Editor's comment:

A main differential diagnosis is myxoma with papillary features (so called "papillary myxoma"). Papillary fibroelastoma is much less common than myxoma. The anatomic location and, if necessary, special stain for elastic fiber can help the distinction. 

A. Agaimy, T. Strecker: Left atrial myxoma with papillary fibroelastoma-like features.  J Clin Exp Pathol. 4(3):307-11, 2011.  

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

Clinical scenario: 13-month old boy.       

Right atrium, excisional biopsy:     

-- Cardiac Rhabdomyoma(s), multiple fragments (see Note).

-- No interstitial fibrosis, inflammation or cytoplasmic vacuolization of myocytes.

Note: It is difficult to determine the number of the lesion in this case due partly to the fragmentation. Multiple rhabdomyomas are  associated with tuberous sclerosis in at least 50% cases.

Slides examined:   H&E   x  X

CPT code:        8830X x  X

Editor's comment:

Cytoplasmic vacuolization can help distinguish from glycogen-storage disease.  Including this in the report serves as a reminder of the differential diagnosis.       

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

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.