Following are general notes on reporting in pathology.
Selection and trimming
From the stage of selection and trimming, a histopathology report should preferably include:
- Patient identification and/or sample number
- Type of tissue sample as described on container
- Specimen chronology, often A, B, C, etc., at least where there are multiple specimens from the same case. With multiple specimens, preferably write out the chronology for all of them first, so that you don't miss reporting any of them later.
- Specimen type and/or surgery type, such as "appendix, appendectomy", for clarification. This is not necessary at all departments.
- Findings. This is not always necessary, but should be included if the diagnosis is uncertain. One systematic approach is to describe findings from largest to smallest ones. For example, a description of a tumor can start with the demarcation of the tumor, followed by texture, cell shapes, nucleus shapes and chromatin appearance.
- Diagnosis or most probable diagnoses.
- In case of malignancy or suspected malignancy:
- Depth or most distant invasion of malignant findings. Depending on location, it may need to exclude important pathways, such as vascular, neural and/or through capsules or other layers.
- Whether the resection is radical or not.
Factors supporting a relatively more comprehensive report, particularly in the inclusion of negated findings:
- Lack of explanation from existing evidence. For example, an inflamed appendix that fits the medical history does not need detailed mention of harmless incidental findings.
- Double-reading: If your report is likely to undergo double reading by another pathologist before sign-out, it needs to be more detailed, because the doctor who will do the double-reading then knows that you have looked at those locations.
- Highly suspected locations, such as given from the referral.
- Defensive precautions, which appears to be more common among doctors in the Unites States compared to for example Europe.
Multiple instances of the same type of pathology (such as lung nodules) can often simply be reported as such, at least with a particular mention of the largest or the most severe example thereof.
Where findings are made, general statements of clearing a region should still be given, such as: "There is a 18.0 cm curvilinear well-healed thin scar in the left thorax. Otherwise, there are no puncture marks or healed surgical scars on the torso." The main exception is for aspects that are barely worth mentioning, in which case the description of the finding may imply that the aspect has been considered in general.
The same word used describing the certainty of findings can refer various probabilities, differing between pathologists as well as clinical situations. The following is a suggestion of words, in an attempt to sort them from most to least probable:
|(non-lethal condition) cannot be excluded|
|(lethal condition) cannot be excluded|
For findings and diagnoses, is preferable to write "negative for..." rather than "no..." to emphasize the possibility of false negative findings.
For cancers, generally include a synoptic report, such as per College of American Pathologists (CAP) protocols at cap.org/protocols-and-guidelines. However, synoptic reports are generally not needed for tumor metastases.
Whenever possible, give numerical quantities of sizes, rather than descriptions that are subjective (such as "small" or "large") or variable (such as "apple-sized").
The information contained in the reporting sections in Patholines assume that the clinician has requested the exam for the topic of the article at hand, but should be tailored to any particular questions or requests by the clinician. Any relevant findings beyond the issues or questions raised by the clinician should also be mentioned.
The most important findings can be moved to near the top of the report if feasible, but doctors performing subsequent double-reading may prefer a consistent anatomic order.
If a certain grammatical rule has a risk of making the report less clear to the reader, ignore it.
Restrict acronyms/abbreviations to those who are certainly well known among all doctors, such as "cm".[notes 2]
Generally describe what can be seen rather than processes (such as preferring "an abundance of" rather than "proliferation of").
- Patholines:Editorial guidelines, contains guidelines on how to write reporting guidelines in Patholines.
- For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
- Acronyms/abbreviations increase reading speed only if the reader is familiar with the abbreviated terms:
- A "lateral" margin may be interpreted as opposite to the "medial margin"
- . An Example of a Melanoma Pathology Report. Melanoma Foundation. Retrieved on 2019-09-24.
- Studdert D. M.; Mello M. M.; Sage W. M.; DesRoches C. M.; Peugh J.; Zapert K.; Brennan T. A. (2005). "Defensive medicine among high-risk specialist physicians in a volatile malpractice environment ". JAMA 293 (21): 2609–2617. doi:10.1001/jama.293.21.2609. PMID 15928282.
- Steurer J.; Held U.; Schmidt M.; Gigerenzer G.; Tag B.; Bachmann L. M. (2009). "Legal concerns trigger PSA testing ". Journal of Evaluation in Clinical Practice 15 (2): 390–392. doi:10.1111/j.1365-2753.2008.01024.x. PMID 19335502.
- David Slater, Paul Barrett. Standards and datasets for reporting cancers - Dataset for histopathological reporting of primary cutaneous basal cell carcinoma. The Royal College of Pathologists. February 2019