| | The Importance of Synoptic Pathology ReportsThe information included in the pathology reports is the source of information for clinicians to make critical treatment decisions. It is imperative, therefore, that the information presented is clear, concise, and accurate. Pathologists are notorious for being detailed oriented, a feature well appreciated by our colleagues over the years. However, all those details must be clearly summarized and logically presented. It is in the diagnostic or synoptic template where all the information included in the body of the report is condensed. These templates also serve as a guide to the pathologist by having a checklist of the important items that must be included in every report. The importance of the pathology information in treatment decisions has been accepted for decades, whereas the adoption of synoptic templates has taken many years. Memorial Care pathologists started using a breast cancer synoptic template for diagnosis in 1993 at the request of the breast cancer treatment team to improve accuracy and completeness of the reports. Although we received a very positive response from clinicians, our pathologist colleagues felt that it was excessive. Today, however, it is the standard of care in our organization and is currently used for multiple organ types.
The art of reporting pathology findings has evolved over the years from very elegant macroscopic descriptions and microscopic dissertations regarding the histopathologic and pathophysiologic aspects of the disease process ending in a succinct diagnostic line to extremely practical reports where the microscopic description has been replaced by a standard phrase: “A microscopic examination has been performed.” I personally believe there is still a need for microscopic descriptions to explain certain details that can not be covered in the diagnosis summary.
Over the years, pathologists have taken pride on the individualization of reports. These reports, although very nice and sometimes entertaining reading, were not necessarily helpful for patient care decision-making. Rather, it was an opportunity to demonstrate the wealth of histologic detail the pathologists had accumulated. The detailed pathology report was of more use to pathologists than to clinicians, particularly when working with pathologists-in-training because each case is a training opportunity. Most of that information, however, was of little use to clinicians for patient care. The treating team had to extract the relevant information themselves.
Establishing checklists has become beneficial for pathologists as well as for clinicians because now pathologists are forced to comment positively or negatively on the presence or absence of different features, both at the macroscopic and the microscopic levels. These are also helpful in standardizing terminology. This allows for better analysis of the data. These checklists are available in different forms and from different organizations.3, 4, 5, 6, 7, 8 The most comprehensive and updated checklist is published by the College of American Pathologists9 which can be found in the organization’s Web site (http://www.cap.org). The checklists can be downloaded free of charge. These protocols are voluntary at this time. They are constantly being updated. These checklists include clinical information plus macroscopic and microscopic items that need to be in the report. They also include detailed explanations regarding the different data elements such as the precise protocol to arrive at the combined histologic grade most commonly used today, the Nottingham combined histologic grade. The checklists should be the basis for the summary content, which includes all the important information for prognosis and treatment.
As much as we want to believe that all of our pathology reports are complete, if a guideline or protocol is not used, there is always room for errors, mostly of omission. The most accurate mechanism to determine whether pathology reports are always (100%) complete is not to have the pathologists review them, but to have a medical oncologist, a surgeon, or a radiation oncologist do an audit of several randomly selected reports. There is no doubt that they will find data elements missing when a guideline is not used. In a 1997 article, Dr. Nakhleh and coworkers10 reported in a multi-institutional Q-Probe study a disparity between what clinicians desired and what the pathologists were reporting. There was an underreporting of diagnostic items in the pathology report such as tumor size being omitted in 20% and margin status omitted in 10% of cases. They learned that the reporting of diagnostic items was higher in those organizations that used checklists. MemorialCare pathologists started using breast cancer synoptic templates in 1993.2
The Pathology Report  This is the document that will be used to determine staging, treatment, and prognosis. Most significant treatment decisions are based on the pathology report. The importance of the pathology information has been well accepted1; it is the format of the information that we are discussing here. No surgeon will perform a cancer operation without a pathologic diagnosis of cancer. No surgeon will re-excise a margin without a pathology report indicating that the edge of the excision was involved by tumor. The magnitude of the surgical intervention is based on the pathology report details. No radiation oncologist will ignore an axilla when the pathology report indicates extranodal extension of the tumor. The extent of the radiation therapy is based on the information provided in the pathology report. No medical oncologist will treat with adjuvant chemotherapy a patient with noninvasive carcinoma. The oncologic decision to use SERMS or Trastuzumab is based on the information included in the pathology report. It is the pathology report that dictates management and prognosis by detailing the disease process. Every clinician involved in the care of a patient will use this report to counsel the patient regarding prognosis based on the nodal status, the size of the invasive carcinoma, etc. In addition, the pathology report becomes a significant source of information for the tumor registries and for databases across the world. Finally, the pathology report should be a document that patients understand.11 Translating the different terms into understandable lay language is important for those patients who plan to actively participate in their treatment planning. Increasingly, particularly in interdisciplinary comprehensive breast programs, the pathologists are personally speaking with newly diagnosed breast cancer patients and are often involved in community outreach. Pathology Report Components The pathology report begins with the demographic information that assures proper identification and no margin for error. It is extremely important for patients to know that the diagnosis of cancer rendered by the pathologist is actually their cancer. Since most patients have no idea what a pathologist does or the details of the anatomic pathology laboratory operation, they need to be assured that most laboratories in the United States are accredited by the College of American Pathologists (CAP) and follow the College guidelines, and that there are quality improvement programs in most laboratories that make the operation very safe. The next portion of the pathology report is the clinical and surgical information. These items include prior diagnosis (usually by biopsy), laterality of the disease, clinical symptoms (eg, nipple discharge), manner by which the lesion was identified (eg, mammography, palpation, etc.), the preoperative diagnosis from the radiologists’ and surgeons’ information, and the type of surgical procedure being performed. All of this information is important to the pathologist who is acting as a consultant on behalf of the patient. A pathologist in the year 2006 cannot and should not work in a vacuum. If the radiologist found calcifications, the pathologist must have this knowledge to properly process the tissue removed from the patient. If the radiologist found two tumors, the pathologist must have this information. It is a misconception that the pathologist has “the ultimate specimen” and will see any and everything that is present. Although the pathology workup is extensive and detailed, it may vary depending on the information provided. A partial breast excision prompted by a mammographically identified lesion, such as calcifications or a mass, must be x-rayed immediately after removal. The specimen has to be x-rayed in two views to evaluate all margins and assure that the lesion has been removed. This is done by the radiologist who communicates the information to the surgeon while the patient remains in the operating suite. The decision to re-x-ray the slices after the tissue has been cut rests with the individual pathologist. If no lesion or biopsy site is identified but the tissue will be submitted in its entirety for microscopic examination, there is no mandatory need to x-ray the slices. If the pathologist identifies the area of biopsy by recognizing the radiologic marker (clip or collagen marker), the need for re-x-ray of the slices can be obviated as long as the area of cancer is examined thoroughly. The re-x-ray of the tissue slices is extremely helpful when the pathologist cannot see the area of concern and the excision will only be sampled partially (ie, mastectomy or large excision). Although this practice has not gained universal acceptance because it is cumbersome to send biopsy or mastectomy slices to the mammography suite or main x-ray department, it helps the pathologist pinpoint the areas of concern (ie, calcifications) and allows for highly selective examination usually resulting in a decrease in the number of blocks required to reach a diagnosis. Many laboratories have decided to do the x-ray of the tissue slices themselves using equipment such as the Faxitron® radiography system obviating the transport of tissue from department to department. A partial breast excision submitted with a diagnosis of DCIS with calcifications has to be x-rayed to assure that the lesion in question has been, in fact, removed. The pathologist may decide to x-ray the specimen again after slicing the tissue to better localize the area of calcifications. On the other hand, a partial breast excision for a palpable “mass” that was discovered by physical examination does not necessarily need to be x-rayed after removal. The next component of the pathology report is the macroscopic description, also known as the “Gross” description. The size of the specimen received is important when we compare it with the size of the tumor and obtain a mental image of the amount of normal tissue removed around the tumor. An excision that measures 3 cm in largest dimension and harbors a 2-cm invasive tumor indicates that the margins are not generous. Under the best of circumstances, the cancer will be exactly in the center of the specimen and therefore the margins are at best 5 mm on either side. Most often, however, the tumor is not exactly in the center. If the specimen is received in one piece, we are able to assess the margins of excision with a certain degree of accuracy. If a specimen is submitted in pieces or if it has been cut before arriving to the laboratory, we are unlikely to be able to comment on the margins of excision. The orientation of the specimen and the inking protocol should always be dictated in the body of the report in a way that will allow any pathologist to reconstruct the specimen at a later date. The following description indicates a specimen that can never be reconstructed: “received fresh is a partial breast excision measuring 6 cm in greatest dimension. It is sectioned and representative tissue is submitted in 5 cassettes.” On the other hand, with the proper inking and sectioning protocol dictated any pathologist can determine the extent of a lesion and the relationship of such to the margins of excision of the following lesion: “the specimen is received fresh with a wire localization and measures 6 × 4 × 4 (Med-Lat × Sup-Inf × Ant-Post). It is cut into 12 slices from medial (slice 1) to lateral (slice 12). The specimen is entirely submitted in 24 blocks with each slice in 2 blocks (ie, slice 1: cassettes 1 and 2; slice 2: cassettes 3 and 4; etc.). If a tumor is identified, it must be described as to size, location within the excision or mastectomy specimen, texture and proximity to margins. This article does not cover every detail since these can be studied in the referenced articles. Another important part of this section is the key to cassettes where we can map the specimen submitted. The use of a “work form”2 is beneficial where drawings can be made of each slice of tissue and the sections submitted from each one. The microscopic description has become extinct in many institutions. I personally believe the microscopic description is an opportunity to discuss certain features that cannot be covered in detail in the diagnostic template and that can be used to clarify some of the findings. There does not have to be a detailed scientific discussion of the histopathologic findings associated with the lesion, but rather it is an opportunity to convey selective findings to the treating team. For example, with DCIS and extent of disease, the diagnostic template would state 3 cm DCIS, whereas the microscopic description could include: “The extent of DCIS has been estimated at 3 cm (DCIS in slices 4 through 9, each slice 0.5 cm thick).”2 Likewise, the status of close margins can be discussed in more detail. The “Comments” section, usually after the diagnostic template, is used to cover information items that pathologists want to emphasize to the clinicians and that may be overlooked in the body of the report or the diagnostic template. In summary, the diagnostic template or Synoptic report (Tables 1 and 2) is the culmination of the processing of a biopsy or excised specimen. It is simply the summary of all those items incorporated in the pathology report. It is here where everything, every item, every detail, every prognostic piece will be incorporated. It is this synoptic report that the treating team will use to determine the course of further treatment; that will serve as a guide to discuss prognosis with patients and family members; that the tumor registrars will use to extract information; that nurses will use to understand the stage of the disease of their patients as they administer treatments; and that the patients will use to understand their disease. Also the use of synoptic reports will allow the recording of uniform and consistent data elements, which will result in a more reliable system for analysis of the information. Although patients should be able to understand this summary, the pathologist should keep in mind that it is primarily a tool for the treating team.
 | ANATOMIC SITE: | Breast, side, Quadrant, o’clock, etc. | |
| SIZE OF SPECIMEN: | ____________ X ____________ X ____________ cm. (In centimeters) | |
| SIZE OF TUMOR: | ____________ X ____________ X ____________ cm. | |
| HISTOLOGIC TYPE: | Invasive ____________ carcinoma. | |
| HISTOLOGIC GRADE: | Specific grade (____________/9 MBR Scale of 3-9/9) | |
| | ____________/3 -Tubules | |
| | ____________/3 -Nuclear grade | |
| | ____________/3 -Mitosis | |
| NECROSIS (in invasive): | Present or not present | |
| IN SITU CARCINOMA: | Present or not, uni or multifocal. | |
|  Type of CIS: | Histologic type and pattern of growth. | |
| Nuclear grade: | Low, intermediate or high. | |
| Necrosis: | Present or not. | |
| Percentage: | ____________% | |
| Extent: | ____________ cm | |
| MARGINS OF RESECTION: | Negative or positive (invasive or in situ) | |
| Closest margin: | Invasive tumor ____________ mm from ____________ margin (in millimeters) | |
| | DCIS ____________ mm from ____________ margin (in millimeters) | |
| LYMPHATIC INVASION: | Present or absent. | |
| SKIN INVOLVEMENT: | N/A or Present/absent | |
| NIPPLE INVOLVEMENT: | N/A or present/absent | |
| MICROCALCIFICATION: | Present or absent and where (i.e.: in DCIS) | |
| BACKGROUND: | Proliferative breast disease, atypical ductal hyperplasia, atypical lobular hyperplasia, etc. | |
| PROGNOSTIC MARKERS: | See addendum report. | |
| LYMPH NODES: | Positive or negative and total count (____________/____________) | |
| Sentinel lymph node: | Positive or negative and count (____________/____________), H&E/IHC | |
| Non-sentinel lymph node: | Positive or negative and count (____________/____________), H&E/IHC | |
| TNM CLASSIFICATION: | T____________, N____________, M____________ | | | | |
| ANATOMIC SITE: | Breast, side, Quadrant, o’clock, etc. | |
| (Ca++, mass, distortion) | For ____________ (reason, if known) | |
| SIZE OF SPECIMEN: | ____________ X ____________ X ____________ cm. (In centimeters) | |
| HISTOLOGIC TYPE: | Ductal carcinoma in situ | |
| Type of CIS | Histologic type and pattern of growth. | |
| Nuclear grade/CIS | Low, intermediate or high nuclear grade | |
| Necrosis | Yes or no | |
| SIZE OF LESION: | In centimeters (see below)* | |
| MICROCALCIFICATIONS: | Present or not and where (i.e.: in DCIS) | |
| MARGINS OF RESECTION: | Positive or negative | |
| Distance to edge: | <1mm, 1-9mm, >9mm | |
| LYMPH NODES: | None available, or ____________ benign lymph nodes (____________/____________) | |
| Sentinel lymph node: | Positive or negative and count (____________/____________), H&E/IHC | |
| Non-sentinel lymph node: | Positive or negative and count (____________/____________), H&E/IHC | |
| TNM CLASSIFICATION: | Tis, N____________, M____________ | | | | |
I encourage all breast programs, regardless of size and programmatic scope, to work with the diagnostic and treatment team to develop a synoptic pathology report—to be used for all breast specimens and to be followed by all pathologists involved in breast pathology.1 References 1.
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Memorial Care Breast Center at Orange Coast, Fountain Valley, CA.  Address reprint requests to Julio A. Ibarra, MD, Memorial Care Breast Center at Orange Coast, 9920 Talbert Ave., Fountain Valley, CA 92708.
PII: S1092-4450(06)00011-1 doi:10.1053/j.sembd.2006.03.010 © 2005 Elsevier Inc. All rights reserved. | |
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