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

Normal and Nearly Normal:

-- No diagnostic abnormality.   

-- Diffuse mild glandular atrophy and focal chronic inflammation.   

-- No high-grade prostatic intraepithelial neoplasia or carcinoma.   

-- No perineural invasion or extraprostatic extension identified.    

Inflammation and Hyperplasis:   

-- Acute and chronic prostatitis with glandular atrophy.   

-- Benign prostatic hypertrophy (BPH), mixed stromal and acinar type.   

-- Focal granulomatous inflammation, consistent with BCG-treatment.   

Neoplastic:   

-- Prostatic adenocarcinoma, Gleason score 7 (= 3 + 4)/10, bilateral  (see Summary Table in Note for tumor extent).   

--  Prostatic adenocarcinoma, Gleason's score 6 (= 3 + 3)/10, present in ___ of ___ biopsy cores, involving approximately ___% of the specimen with maximal single contiguous tumor line length of ___ mm.     

-- No perineural invasion or extraprostatic extension identified.    

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

Clinical scenario:  .       

Prostate, right lobe and left lobe, needle core biopsy:       

-- No significant histologic abnormality.

-- No prostatic intraepithelial neoplasia or carcinoma.

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.    

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

Clinical scenario:  .       

Prostate, right lobe (RA, RLB and RM) and left lobe (LA, LLA, LM and LLM), needle core biopsy:       

-- Focal mild chronic inflammation and glandular atrophy.

-- No prostatic intraepithelial neoplasia or carcinoma.

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.    

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

Clinical scenario:  .       

Prostate, right lobe (RA, RLB and RM) and left lobe (LA, LLA, LM and LLM), needle core biopsy:       

-- Focal prominent acute prostatitis (RA and LA) with glandular atrophy.

-- No prostatic intraepithelial neoplasia or carcinoma.

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.    

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Clinical scenario:  .       

Prostate chips, transurethral resection:     

-- Benign prostatic hypertrophy (___ gm), mixed acinar and stromal type.

-- No high grade prostatic intraepithelial neoplasia or carcinoma.

Slides examined:   H&E   x  12

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:  .       

Prostate, left base, needle core biopsy:     

--  Prostatic adenocarcinoma, Gleason's grade 6 (= 3 + 3)/10, present in ___ of ___ biopsy cores, involving approximately ___% of the specimen with maximal single contiguous tumor line length of ___ mm.

-- No perineural invasion or extracapsular extension identified.

Slides examined:   H&E   x  3

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:          

Prostate, right lobe (RB, RLB and RM) and left lobe (LA, LLA, LM and LLM), needle core biopsies:       

-- Prostatic adenocarcinoma, Gleason's score 7 = (3+4)/10, bilateral  (see table in Note for tumor extent).

-- No perineural invasion or extracapsular extension

Note: The tumor involves:

Slides examined:   H&E   x  12

CPT code:        88305 x  8

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:  59-yo woman with mass lesion; hx/ right breast cancer, s/p lumpectomy 2 years ago; s/p chemoradiation therapy.        

Prostate, right base, needle core biopsies:     

-- Prostatic adenocarcinoma, gleason grade 6 (3 + 3), constituting less than 2% of the biopsy core, with a maximal contiguous tumor line length of 0.4 mm (see Note).

-- No extraprostatic extension or perineural invasion identified.

-- Diagnosis confirmed by immunohistochemical stains.

Note: The adenocarcinoma is present as a single small focus.  In cases similar to this with 0.5-mm cancer of Gleason score less than or equal to 6 on biopsy core, approximately 50% of the corresponding radical prostatectomy specimens contain only very small (<0.1 cc) cancer in a study in which the average number of prostate cores per biopsy was less than seven (7) (ref.)

Reference: Allan RW, Sanderson H, Epstein JI.: Correlation Of Minute (0.5 MM or Less) Focus of Prostate Adenocarcinoma On Needle Biopsy With Radical Prostatectomy Specimen: Role of Prostate Specific Antigen Density. J Urol. 2003 Aug;170(2 Pt 1):370-2.

Editor's comment:

Including such a note in pathology report may prepare the clinician and patient for absence of biopsy-detected carcinoma in the final prostatectomy specimen if such a radical surgery is performed .

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

Clinical scenario:  .       

Prostate, radical prostatectomy:   

-- Prostatic adenocarcinoma, gleason score 7 (3+4) (see Tumor Synopsis).

-- All resection margins are free of  carcinoma.

Note: 02958203.

Slides examined:   H&E   x  12

CPT code:        88309 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:  .       

Prostate chips,transurethral resection:   

-- Prostatic adenocarcinoma, gleason score 7 (3+4), at least 4 mm, constitution <5% of the entire specimen.

-- No extraprostatic extension or seminal vesicle involvement.

Note: 02958203.

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.    

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

Clinical scenario:  .       

Prostate, right base, needle core biopsy:  

-- Focal atypical  glandular proliferation, favor reactive.

Note: In part ___, interpretation limited by small volume of the lesion. Immunohistochemical stains were attempted to further characterize the lesion. However, the additional sections no longer contain the lesion.

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:  .       

Prostate, left apex, needle core biopsy:  

-- One minute microscopic focus of atypical acinar proliferation suspicious but not  diagnostic of prostatic adenocarcinoma (see Note).

       OR

-- Atypical small acinar proliferation, highly suspicious for  adenocarcinoma (see Note).

Note: In part ___, interpretation limited by small volume of the lesion. Immunohistochemical stains were attempted to further characterize the lesion. However, the additional sections no longer contain the lesion.

Slides examined:   H&E   x  X

CPT code:        8830X x  X

Editor's comment:

Wordings included in this example reflect different degree of certainty. In either scenario, reasons of uncertainty should be given (in the Note section).

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

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.