Cancer Synoptic Report (Lung Resection)

Report Header

Patient Name: [Patient name]

Medical Record Number: [Medical record number]

Accession Number: [Accession number]

Date of Collection: [Date of specimen collection]

Date of Report: [Date of report]

Ordering Provider: [Ordering provider name and credentials]

Pathologist: [Pathologist name and credentials]

Cancer Synoptic Report – Lung Resection

(Use element–response pairs with each element on its own line. Core elements must always be present with a valid response including "Not applicable," "Not identified," "Cannot be determined" with brief reason, or "Not specified." Include conditional elements only when relevant. Do not infer laterality, procedure type, margin designation, or lymph node station without explicit documentation.)

Specimen

Procedure: [wedge resection / segmentectomy / lobectomy / sleeve lobectomy / bilobectomy / pneumonectomy / other: specify]

Specimen Laterality: [right / left / not specified]

Synchronous Primary Tumors: [present / not identified / cannot be determined] (Include only if multiple primaries are present or suspected; specify number and sites in Comments.)

Tumor

Tumor Focality: [single focus / separate tumor nodules (same lobe) / separate tumor nodules (different ipsilateral lobe) / multifocal pattern / pneumonic-type adenocarcinoma / other: specify]

Tumor Site (lobe): [right upper lobe / right middle lobe / right lower lobe / left upper lobe / left lower lobe / other: specify / not specified] (For multifocal disease, list all applicable lobes or detail in Comments.)

Invasive Tumor Size (cm): [measurement in cm] (For adenocarcinoma with lepidic component, record invasive non-lepidic size only.)

Total Tumor Size (cm): [measurement in cm] (Include only when lepidic component is present; otherwise "Not applicable.")

Histologic Type (WHO classification): [WHO histologic type and subtype]

Histologic Grade: [well differentiated / moderately differentiated / poorly differentiated / not applicable]

Spread Through Air Spaces (STAS): [present / not identified / cannot be determined]

Visceral Pleural Invasion (VPI): [present / not identified / cannot be determined]

PL Category: [PL0 / PL1 / PL2 / PL3 / not applicable / cannot be determined] (Include only if VPI assessment permits category assignment.)

Direct Invasion of Adjacent Structures: [present / not identified / cannot be determined]

Structures Involved: [structure(s) specified] (Include only if direct invasion is present.)

Lymphovascular Invasion (LVI): [present / not identified / cannot be determined]

Neoadjuvant Therapy Administered: [yes / no / not specified]

Treatment Effect in Tumor Bed: [complete response / near complete response / partial response / no definite response / cannot be determined] (Include only if neoadjuvant therapy was given.)

Percent Residual Viable Tumor: [percentage] (Include only if neoadjuvant therapy was given.)

Margins

Margin Status for Invasive Tumor: [negative / positive / cannot be determined]

Closest Margin: [bronchial / vascular / parenchymal / staple line / chest wall / soft tissue / pleural / other: specify] (Include only if all margins are negative.)

Distance to Closest Negative Margin (cm): [distance in cm] (Include only if margin status is negative and distance is measurable.)

Positive Margin(s) Involved: [bronchial / vascular / parenchymal / staple line / chest wall / soft tissue / pleural / other: specify] (Include only if margin status is positive.)

Carcinoma in Situ / Lepidic Component at Margin: [present / not identified / cannot be determined]

Margin(s) with CIS/Lepidic Component: [specify margin(s)] (Include only if CIS/lepidic component is present at a margin.)

Regional Lymph Nodes

Overall Nodal Status: [tumor present in regional lymph nodes / no tumor identified / cannot be determined]

Total Number of Lymph Nodes Examined: [number] (Use "at least [number]" if nodes are fragmented; explain in Comments.)

Number of Lymph Nodes with Tumor: [number] (Use "at least [number]" if fragmentation precludes exact count.)

Nodal Stations Examined (IASLC): [list station numbers with laterality, e.g., 4R, 7, 10L]

Nodal Stations Involved (IASLC): [list station numbers with laterality / not identified]

Extranodal Extension (ENE): [present / not identified / cannot be determined] (Include only if tumor is present in lymph nodes.)

Distant Metastasis

Pathologically Confirmed Distant Metastasis: [present / not identified / not applicable / cannot be determined]

Metastatic Site(s): [contralateral lung nodules / pleural nodules / pericardial nodules / malignant pleural effusion (cytology confirmed) / malignant pericardial effusion (cytology confirmed) / extrathoracic metastasis: specify site(s)] (Include only if metastasis is present.)

Pathologic Stage Classification

Staging System: AJCC 9th edition (effective January 2025)

Applicable Modifiers: [none / y (post-neoadjuvant) / r (recurrent) / m (multiple)] (Select all that apply.)

pT Category: [pT category]

pN Category: [pN category]

pM Category: [pM category / cannot be determined from submitted specimens] (Assign pM only when metastasis is pathologically confirmed.)

(Final pathologic stage is established by the managing physician using all available clinical, radiologic, and pathologic information.)

Additional Findings

Non-neoplastic Findings: [atypical adenomatous hyperplasia / tumorlets / granulomatous inflammation / post-obstructive changes / fibrosis / emphysema / other: specify / none identified] (List all that apply.)

Special Studies

Biomarker Testing Status: [reported separately / pending (addendum to follow) / not performed / performed at outside institution]

Comments

[Clarifications and explanatory notes] (Use to explain "cannot be determined" responses; document tumor size measurement method if relevant; rationale for multiplicity categorization; lymph node counting limitations; pending study details; and any other pertinent clarifications.)