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Clinical scenario:          

Organ name, subsite, procedure:     

-- Source files should be: Font Times New Roman 11

Note: Use this template first. Convert is later into table formats as shown in the Design section

Slides exam:         H&E X  2 

CPT code:        8830 X  3

Editor's comment:

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.

Normal and Nearly Normal:

-- No diagnostic abnormality.   

-- Moderate non-specific chronic duodenitis, favor reactive.   

-- Focal moderate peptic duodenitis with gastric metaplasia and acute inflammation.   

-- Active gluten-sensitive enteropathy (Celiac sprue), Marsh-Oberhuber classification 3b.   

Inflammation:   

-- Chronic pancreatitis with prominent acinar atrophy and extensive fibrosis.   

-- Sclerosing pancreatitis with Ig-G4-positive plasma cells, consistent with autoimmune .   

-- Intestinal Giadiasis with multiple luminal clusters of trophozites.   

-- Severe cytomegalovirus esophagitis with mucosal erosion and granulation tissue.   

-- Duodenal infection by mycobacterium avium intracellulare in sheet, confirmed by Ziehl - Neelsen stain.   

Cystic Lesions:  

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Neoplastic:   

-- Pancreatic ductal adenocarcinoma (2.5 cm), moderately differentiated (see Tumor Synopsis and Note).   

-- Intraductal papillary mucinous neoplasm (IPMN) with low-grade dysplasia in branch duct, gastric type.   

-- Pancreatic neuroendocrine tumor, grade-2 (2010 WHO Classification) (see Tumor Synopsis and Note).   

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Clinical scenario: 57-year old man with a mass in pancreatic head. R/O malignancy.       

Pancreatic head "mass", transduodenal biopsy:   

-- Benign pancreatic and duodenal tissue.

-- No inflammation, glandular dysplasia or carcinoma (see Note).

Note:  Sections reveal unremarkable duodenal mucosa and two small fragments of unremarkable  pancreatic acini and an islet.  No histological abnormality is identified.  The histological features  of this biopsy do not seem to be compatible with the clinical finding of an "mass".  Re-biopsy  of the "mass" should be considered if also clinically indicated.

Slides examined:   H&E   x  3

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:  .       

Organ, site, surgical procedure:     

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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:     

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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:  .       

Duodenum and pancreas, pylorus-preserving pancreaticoduodenectomy: 

Pancreas: 

-- Invasive pancreatic ductal carcinoma, mucinous type, arising from an extensive intraductal  papillary mucinous neoplasm (IPMN) (see Tumor Synopsis and Note) .

-- Extensive IPMN in pancreatic main branch ducts with focal extrapancreatic extension.

Ampulla of vater: 

-- Pancreatic ductal carcinoma superficial spreading along the epithelium of ampulla of vater.

-- Focal invasive ductal carcinoma, >4 mm from the os.

Duodenum:

-- Pancreatic ductal carcinoma in muscularis propria and submucosa.

-- No mucosal intestinal dysplasia or carcinoma.

Note: There is extensive low-grade intraductal papillary mucinous neoplasm (IPMN) throughout the sampled portion of the pancreas that appears to involve predominantly the main branch ducts with  "extrapancreatic extension".  Focal high-grade dysplasia in IPMN is identified and is associated with  unequivocal invasive moderately differentiated mucinous adenocarcinoma. The invasive carcinoma  extends to muscularis propria of the duodenum.

The high-grade epithelial dysplasia (carcinoma in situ) also shows the surface spread to the ampulla of  Vater towards the duodenum, best seen in block , but not reach the os of the ampulla or the surface of   intestinal mucosa although the invasive tumor involves the ampulla of Vater near pancreas.  

          TUMOR SYNOPSIS 

Specimen Identification

Specimen & procedure: Duodenum and proximal pancreas, pylorus-preserving Pancreaticoduodenectomy.

Tumor Attributes

Tumor site: Predominantly in the pancreatic head.

Tumor size: Approximately ___ mm.

Histologic type: Pancreatic ductal carcinoma, mucinous type.

Histologic grade:  Well-differentiated and moderately differentiated (grade ___).

Microscopic tumor extension: Tumor extends to Ampulla of Vater and duodenal submucosa.

Lymph-vascular invasion: Present.

Perineural invasion: Present.

Treatment effect: Not applicable.

Final Margins 

Nearest margin: Posterior margin.

Distance from specified margin to tumor: ___ mm.

Proximal margin (duodenal): Negative.

Distal margin (distal duodenal): Negative.

Superior mesenteric artery margin: Negative.

Common bile duct margin: Negative.

-- Carcinoma in situ/high-grade dysplasia at margin: Absent.

Pancreatic parenchymal resection margin: Negative.

-- Carcinoma in situ/high-grade dysplasia at margin: Absent.

Inked surface of portal vein bed: Negative.

Other margin(s): N/A.

Lymph Nodes 

Regional lymph nodes (involved/examined): ___/___, ___ mm in greatest extent, with focal extranodal extension.

Pathologic stage: pT___ N__ M(Not applicable)

Slides examined:   H&E   x  22

CPT code:        88309 x  1

Editor's comment:

By the 8th edition of AJCC cancer staging manual, tumor size segregates pT2 from pT3. Extrapancreatic extension of tumor is no longer as the segregator.   

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Clinical scenario:  .       

Organ, site, surgical procedure:     

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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:     

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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.

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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.    

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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.