Cancer Synoptic Report (Prostatectomy)

Patient Name: [Patient full name]

MRN: [Medical record number]

Date of Birth: [DOB]

Accession Number: [Accession ID]

Procedure Date: [Date of radical prostatectomy]

Report Date: [Date of report sign-out]

Surgeon: [Surgeon name and credentials]

Pathologist: [Pathologist name and credentials]

Institution: [Institution or laboratory name]

Clinical Information

Clinical indication: [Indication]

Prior prostate cancer treatment: [No known presurgical therapy / Type and timing of therapy] (Use "No known presurgical therapy" only when confirmed)

Prior biopsy Gleason/Grade Group: [Grade Group and Gleason score / Not provided]

Pre-procedure PSA: [Value with units / Not provided]

Specimen

Procedure type: [Radical prostatectomy; note approach if specified]

Specimen components received: [Prostate; seminal vesicles with presence/completeness; lymph node specimens with laterality and sites if submitted]

Prostate weight: [Weight in grams] (Omit if not recorded)

Prostate dimensions: [Three dimensions in cm] (Omit if not recorded)

Primary Diagnosis

[Narrative summary including: specimen and tumor type; WHO/ISUP Grade Group with Gleason score; EPE status; seminal vesicle invasion status; margin status; lymph node status with counts if applicable; pTNM stage] (Limit to 1–3 lines)

Synoptic Cancer Report

(Use element: response format with one element per line. Use standardized responses: "Not identified," "Present," "Cannot be determined," or "Not applicable." Do not leave required oncologic elements blank.)

Tumor

Histologic Type: [Tumor type; note variants or mixed components with approximate percentages if present]

Gleason Score: [Primary pattern + Secondary pattern = Total / Not applicable] (If not applicable, explain in Comments)

WHO/ISUP Grade Group: [1 / 2 / 3 / 4 / 5 / Not applicable]

Tertiary Pattern 5 (<5%): [Not identified / Present] (Include only when applicable)

Percent Pattern 4: [Percent value / Not applicable] (Report for Gleason 7 tumors when assessed)

Intraductal Carcinoma (IDC-P): [Not identified / Present]

IDC-P Incorporated into Grade: [Yes / No] (Document institutional practice)

Invasive Cribriform Pattern: [Not identified / Present / Cannot be determined]

Tumor Quantitation

Percent of Prostate Involved: [Estimated percent or range]

Dominant Nodule Size: [Greatest dimension in mm / Dominant nodule not designated]

Dominant Nodule Location: [Laterality, zone, level] (Include only if dominant nodule designated)

Extent of Disease

Extraprostatic Extension (EPE): [Not identified / Present, focal / Present, nonfocal / Cannot be determined] (Do not count apical skeletal muscle involvement alone as EPE)

EPE Location(s): [Anatomic locations using standard descriptors] (Include only if EPE present)

Bladder Neck Invasion (microscopic): [Not identified / Present / Cannot be determined / Not applicable] (A positive bladder neck margin does not equal bladder neck invasion)

Seminal Vesicle Invasion: [Not identified / Present / Not applicable] (Requires invasion into muscular wall; intraprostatic SV involvement does not qualify)

SVI Laterality: [Right / Left / Bilateral] (Include only if SVI present)

Lymphovascular Invasion: [Not identified / Present / Cannot be determined]

Perineural Invasion: [Not identified / Present] (Optional; include if routinely reported)

Margins

Margin Status: [Negative for invasive carcinoma / Positive for invasive carcinoma / Cannot be assessed] (Positive only when tumor contacts inked surface)

Positive Margin Location(s): [Anatomic locations] (Include only if margins positive)

Positive Margin Focality: [Unifocal / Multifocal] (Include only if margins positive)

Extent of Positive Margin: [Linear measurement in mm / Limited / Non-limited] (Include only if margins positive)

Gleason Pattern at Positive Margin: [Highest pattern present] (Include only if margins positive)

Margin Positive in Area of EPE: [Yes / No / Cannot be determined] (Include only if margins positive)

Regional Lymph Nodes

Lymph Node Status: [No nodes submitted / Negative for tumor / Positive for tumor]

Number Examined: [Total count / At least N if fragmented] (Include only if nodes submitted)

Number Positive: [Count] (Include only if nodes submitted)

Sites Involved: [Nodal stations and laterality] (Include only if positive)

Size of Largest Metastasis: [Measurement] (Include only if positive and measured)

Extranodal Extension: [Not identified / Present / Cannot be determined] (Include only if positive)

Pathologic Stage (AJCC 8th Edition)

Prefix: [None / y] (Use y only if post-neoadjuvant therapy)

pT Category: [pT2 / pT3a / pT3b / pT4]

pN Category: [pNX / pN0 / pN1] (Use pNX if no nodes submitted; do not assign pN0 without nodal examination)

pM Category: [Not applicable / pM1] (Include only if distant metastasis pathologically confirmed in specimen)

Comments

[Clarifications as needed] (Use to explain "Cannot be determined" responses, complex margin scenarios, capsular incision effects, multifocal grading decisions, specimen limitations, or treatment effect. Avoid restating synoptic findings. Omit section if no comments needed.)

Additional Findings

[High-grade PIN; chronic inflammation; benign prostatic hyperplasia; other incidental findings] (Optional section; include only if part of institutional practice; omit entirely if no additional findings)