4.1 General Cancer Report Structure

The pathology cancer report follows a general structure.  The synoptic report is a summation of the required diagnostic and prognostic data elements identified in each of the following steps:

1. Case.  A case is defined as a review of all tissue excised from the patient during a single surgery.  (Note: in many surgeries, multiple organs or portions of organs are excised.  Each excised organ, or portion of an organ, is considered a "Part".)
   
   
2. Gross Description.  Each tissue part excised is visually described by the pathologist as received from the surgeon/surgical suite.  Information documented includes what organ, or portion of organ, the part consists of, the overall appearance, weight and size.  The Gross Description is a non-microscopic assessment of the tissue to be microscopically examined.
   
   
3. Microscopic examination.  This section of the pathology report is performed and recorded after each part is prepared for microscopic examination.  Preparation includes dissecting portions of each part; fixing the tissue in formalin which stops tissue metabolism and degradation; embedding the tissue in paraffin wax; microtome (very, very thinly slicing portions) of the paraffin-embedded tissue; mounting microtome tissue onto glass slides; staining of mounted tissue using prescribed diagnostic staining techniques, primarily hematoxylin and eosin.
   
   Upon tissue preparation, tissue specimens are examined using light microscopy.  The pathologist assesses each slide and determines the notable presence and absence of normal and diseased portions of the tissue.  The report may consist of a textual review of each part or a summative enumeration of observations.  
   
   
4. Additional studies.  In this section, additional diagnostic and/or prognostic information is described.  This may include review of immunohistochemically stained tissue, cytogenetic examinations, or gene sequencing results.
   
   
5. The synoptic report.  One or more tissue parts examined are considered diagnostic and representative of the case in toto.  If the case results in a diagnosis of cancer, a synoptic protocol is completed for the case.  Usual practice is to associate the protocol to a single part as submitted that is considered representative of the entire case and supplement the protocol summation with notable components from other parts.  For example, a colon resection will consist of portions of colon and lymph nodes.  Each portion of colon and the lymph nodes are treated as different parts.  Thus, a colon cancer diagnosis will be rendered and associated with a colon part, and the presence of lymphatic involvement will be based on lymph node parts but included in the overall cancer report associated with the colon part. 
   
   Reporting protocols are specific to the primary organ system (anatomic location) of the malignant neoplasm.  The specific aspects of the neoplasm to be assessed and the acceptable observations are enumerated within each protocol.  Types of necessary observations follow common concept modeling, but terminology binding is unique to each protocol. Terminology bindings for College of American Pathologists (CAP) and International Collaboration on Cancer Reporting (ICCR)-based reporting protocols are available from each organization. 

The diagram below shows the pathology cancer report high-level information model in UML format