Surgical Pathology Report (Complex Resection)

Report Type: Surgical Pathology Report (Complex Resection)

Report Status: [Preliminary / Final / Addendum / Amended]

Patient Name: [Patient name]

MRN: [Medical record number]

Date of Birth: [Date of birth]

Accession Number: [Accession number]

Specimen Part(s): [Part identifiers] (Use consistent naming scheme such as A, B, C or 1, 2, 3 and carry through all sections.)

Facility/Laboratory: [Facility name]

Ordering Clinician: [Clinician name]

Procedure: [Procedure name]

Collection Date: [Collection date]

Report Date: [Report date]

(For any required identifier or date that is unavailable, enter "Not provided.")

Specimens Submitted

(Use consistent Part IDs throughout all sections. Map each container to the specific specimen part. If the container label differs from the requisition, document the discrepancy here and in the Gross Description.)

Part ID	Container Label	Specimen Type/Organ	Anatomic Site (with laterality)	Orientation Markers	Lymph Nodes Included	Special Handling
[Part ID]	[Container label as received]	[Specimen type/organ]	[Anatomic site and laterality]	[Orientation markers, sutures, staples, or anatomic landmarks]	[Yes / No]	[Fresh / Fixed / Biobank / Research / Protect for molecular / Other]
[Part ID]	[Container label as received]	[Specimen type/organ]	[Anatomic site and laterality]	[Orientation markers]	[Yes / No]	[Special handling]

(Add additional rows as needed.)

Clinical Information

(Include only fields for which information was provided; do not fabricate clinical details.)

Preoperative Diagnosis: [Preoperative diagnosis]

Postoperative Diagnosis: [Postoperative diagnosis]

Pertinent History: [Prior malignancy, inflammatory disease, prior procedures, risk factors]

Prior Pathology Reviewed: [Accession numbers and institution]

Neoadjuvant Therapy: [Given / Not given / Unknown] (Include regimen and timing if relevant to staging or response assessment.)

Relevant Imaging Findings: [Summarized findings formally provided to pathology]

(If clinical history is not provided but would materially impact interpretation, state: "Clinical history not provided. Interpretation based on specimen findings.")

Intraoperative Consultation

(Include this section only if an intraoperative consultation occurred; otherwise omit entirely.)

Specimen/Part Evaluated: [Part ID and description]

Type of Consult: [Frozen section / Touch preparation / Gross-only / Other]

Intraoperative Impression: [Intraoperative impression]

Notified: [Person or service notified, date/time]

Limitations: [Sampling, artifact, orientation, or other constraints] (Omit if none.)

Gross Description

(Create a separate subsection for each part. Do not infer or retrofit orientation after sectioning unless certain; document uncertainty explicitly.)

Part [Part ID]: [Specimen type/organ and anatomic site]

[Specimen condition on receipt: fresh vs fixed, intact vs opened/disrupted, container(s) received]

[Overall specimen measurements in three dimensions; weight if appropriate]

[Orientation: how orientation was provided, or state "Unoriented specimen" explicitly]

[Margins identified: name each clinically important margin with anatomic meaning]

• Inking Key:
• [Ink color] = [Margin name]
• [Ink color] = [Margin name]
• [Ink color] = [Margin name]

(Add additional ink assignments as needed.)

Lesion(s): [Number of lesions; location within specimen; size(s) with greatest dimension and additional dimensions; gross appearance; relationship to serosa, capsule, or adjacent structures]

Distances to Margins: [Measured gross distances from lesion(s) to each relevant margin in mm]

Lymph Node Search: [Anatomic areas searched; gross node count; size range] (If no nodes found, state this explicitly.)

Tissue Disposition: [Any tissue submitted for biobank, frozen section, cultures, cytogenetics, molecular studies, or external laboratory] (Omit if none.)

Sampling: [Entirely submitted / Representative sections submitted] (Provide rationale if only partial submission.)

• Block Key:
• [Block ID]: [Anatomic site/structure, orientation if applicable]
• [Block ID]: [Anatomic site/structure, orientation if applicable]
• [Block ID range]: [Anatomic site/structure]

(Ensure each block ID is unique and traceable to an anatomic site. Add additional blocks as needed.)

Part [Part ID]: [Specimen type/organ and anatomic site]

[Specimen condition on receipt]

[Measurements and weight if appropriate]

[Orientation description or "Unoriented specimen"]

[Margin identification]

• Inking Key:
• [Ink color] = [Margin name]

Lesion(s): [Description, size(s), location(s)]

Distances to Margins: [Measured gross distances in mm]

Lymph Node Search: [Areas searched; node count; size range; if none, state explicitly]

Tissue Disposition: [Special studies or external submissions] (Omit if none.)

Sampling: [Entirely submitted / Representative sections submitted]

• Block Key:
• [Block ID]: [Anatomic site/structure]
• [Block ID range]: [Anatomic site/structure]

(Repeat subsection structure for each additional part.)

Microscopic Description

(Include only when it adds interpretive value beyond the Final Diagnosis and Synoptic Report. Use for complex differentials, unusual histology, extensive background disease, or explanations for indeterminate elements. Omit for routine cases. Avoid duplicating synoptic elements verbatim.)

[Focused microscopic findings that clarify diagnostic challenges or limitations]

Final Diagnosis

(List diagnoses by Part in the same order as Specimens Submitted. If an element cannot be determined, state "Cannot be determined" and explain in Microscopic Description or Comment.)

Part [Part ID]: [Organ/site], [Procedure]

• Primary Diagnosis: [Tumor type or non-neoplastic condition]
• Histologic Grade: [Grade] (Omit or state "Not applicable" if grading not indicated.)
• Extent of Invasion: [Depth of invasion and structures involved]
• Margins: [Positive/Involved (specify: invasive tumor vs in situ/dysplasia) / Negative/Uninvolved] (Enumerate each named margin with status and measured distance in mm.)
• Lymph Nodes: [Number examined] examined, [Number involved] involved (Extranodal extension: [Present / Not identified / Cannot be determined])
• Other Significant Findings: [Clinically relevant incidental or background pathology] (Omit if none.)

Part [Part ID]: [Organ/site], [Procedure]

• Primary Diagnosis: [Diagnosis]
• Histologic Grade: [Grade]
• Extent of Invasion: [Extent]
• Margins: [Margin status with distances in mm]
• Lymph Nodes: [Number examined] examined, [Number involved] involved (Extranodal extension: [Present / Not identified / Cannot be determined])
• Other Significant Findings: [Findings]

(Add additional Part subsections as needed.)

Synoptic Report

(Include for primary malignant definitive resections. Use explicit responses; do not leave elements blank. For non-malignant resections, omit this section and ensure Final Diagnosis conveys all necessary elements.)

Element	Response
Procedure / Specimen / Laterality	[Procedure, specimen type, laterality]
Tumor Site	[Anatomic tumor site]
Tumor Focality	[Unifocal / Multifocal / Cannot be determined]
Tumor Size	[Greatest dimension in mm; additional dimensions]
Histologic Type	[Histologic type per WHO classification]
Histologic Grade	[Grade / Not applicable]
Tumor Extent / Depth of Invasion	[Depth of invasion and structures involved]
Lymphovascular Invasion	[Present / Not identified / Cannot be determined]
Perineural Invasion	[Present / Not identified / Cannot be determined]
Tumor Deposits	[Present with site(s) / Not identified / Not applicable]
Margins: Proximal	[Negative with distance in mm / Positive (specify involvement)]
Margins: Distal	[Negative with distance in mm / Positive (specify involvement)]
Margins: Radial/Circumferential	[Negative with distance in mm / Positive (specify involvement)]
Margins: Other Named Margins	[Each margin with status and measured distance]
Closest Margin	[Margin name, distance in mm]
Lymph Nodes Examined (Total)	[Number]
Lymph Nodes Involved (Total)	[Number]
Nodal Stations/Levels	[Stations examined and involved / Not applicable]
Extranodal Extension	[Present / Not identified / Cannot be determined]
Treatment Effect / Regression Score	[Score and description / Not applicable]
Pathologic Stage (pTNM)	pT[stage] pN[stage] pM[Not assessed pathologically / stage if applicable]
Staging System and Version	[AJCC 9th Edition / UICC TNM 9th Edition / FIGO (year)]
Biomarkers	[Results with interpretation / Pending (addendum to follow) / Not performed]
Staging Comments	[Cannot be determined due to (reason) / Deferred pending (test)] (Omit if not applicable.)

Ancillary Studies

(Include when tests were performed or are pending. If performed externally, identify the laboratory. Omit section if no ancillary studies performed.)

Test/Marker	Part/Block	Method	Result	Interpretation	Performing Laboratory	Status
[Test or marker name]	[Part-Block ID]	[IHC / ISH / PCR / NGS / Flow cytometry / Special stain / Microbiology]	[Numeric or qualitative result]	[Positive / Negative / Indeterminate; clinical significance]	[Internal / External laboratory name]	[Final / Pending]

(Add rows for additional tests as needed. For pending tests, note that an addendum will be issued.)

Comment

(Include when needed to document: sampling limitations, labeling discrepancies, correlation requests, prior material reviewed, clinician notification for urgent findings, or reconciliation of intraoperative vs final diagnosis. Omit if not applicable. Do not introduce critical new diagnoses only in this section.)

[Comment text]

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Pathologist: [Pathologist name and credentials]

Electronic Signature: [Signature attestation]

Verification Date/Time: [Date and time of sign-out]