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skills/clinical-reports/assets/pathology_report_template.md

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+# Surgical Pathology Report Template
+
+## Patient and Specimen Information
+
+**Patient Name:** [Last, First]  
+**Medical Record Number:** [MRN]  
+**Date of Birth:** [MM/DD/YYYY]  
+**Age:** [years]  
+**Sex:** [M/F]
+
+**Accession Number:** [PathologyAccessionNumber]  
+**Specimen Received:** [Date and time]  
+**Report Date:** [Date]
+
+**Ordering Physician:** [Name]  
+**Clinical Service:** [Department]
+
+---
+
+## Specimen(s) Submitted
+
+**Specimen A:** [Description of specimen]  
+Example: "Skin, left forearm, excisional biopsy"
+
+**Specimen B:** [If multiple specimens]
+
+---
+
+## Clinical History / Indication
+
+[Relevant clinical information provided by clinician]
+
+Example: "72-year-old woman with enlarging pigmented lesion on left forearm. Clinical concern for melanoma. Previous biopsy showed atypical melanocytic proliferation."
+
+---
+
+## Gross Description
+
+**Specimen A labeled "[Specimen label]":**
+
+**Description:**
+- Received [fresh/in formalin]
+- Consists of [specimen type] measuring [dimensions in cm]
+- [External surface description]
+- [Cut surface/sectioning description]
+- [Lesion description if applicable]
+- [Orientation markers if present]
+- [Inking for margins]
+
+**Sampling:**
+- [How specimen was sectioned]
+- [Cassette labeling]
+- [Percent of tissue submitted]
+
+**Example:**
+```
+Specimen A labeled "Skin, left forearm, excisional biopsy":
+Received fresh is an oriented ellipse of skin measuring 3.5 x 1.2 x 0.8 cm with a 
+suture indicating superior. The epidermis contains a 1.1 cm diameter irregularly 
+pigmented lesion located 1.5 cm from superior, 1.2 cm from inferior, 0.8 cm from  
+medial, and 1.2 cm from lateral margins. Inking: superior blue, inferior black, 
+medial green, lateral red, deep yellow. Serially sectioned perpendicular to long 
+axis into 10 slices. Entirely submitted in cassettes A1-A4.
+```
+
+---
+
+## Microscopic Description
+
+[Detailed histological findings]
+
+**Architecture:**
+[Structural patterns observed]
+
+**Cytology:**
+[Cell type, nuclear features, cytoplasm, pleomorphism]
+
+**Special Features:**
+[Necrosis, mitoses, invasion, margins]
+
+**Stains/Immunohistochemistry Results:**
+[Results of special stains or immunostains]
+
+**Example:**
+```
+Sections show skin with an asymmetric melanocytic proliferation composed of 
+epithelioid and spindled melanocytes arranged in irregular nests at the 
+dermoepidermal junction with extension into the papillary and reticular dermis.
+Melanocytes show marked cytologic atypia with nuclear enlargement, hyperchromasia,
+and prominent nucleoli. Mitotic activity is present with 4 mitoses per mm². 
+No ulceration identified. The lesion extends to a Breslow depth of 1.8 mm 
+(Clark level IV). Margins are free of tumor (closest margin: deep, 0.3 cm).
+```
+
+---
+
+## Diagnosis
+
+**Specimen A, Skin, left forearm, excisional biopsy:**
+
+**[DIAGNOSIS IN CAPITAL LETTERS]**
+
+**Example Format:**
+```
+MALIGNANT MELANOMA, SUPERFICIAL SPREADING TYPE
+
+Pathologic features:
+- Breslow thickness: 1.8 mm
+- Clark level: IV
+- Mitotic rate: 4/mm²
+- Ulceration: Absent
+- Margins: Negative for melanoma (closest margin deep, 0.3 cm)
+- Lymphovascular invasion: Not identified
+- Perineural invasion: Not identified
+- Regression: Absent
+- Tumor-infiltrating lymphocytes: Present, non-brisk
+- Microsatellites: Absent
+```
+
+**For Cancer Specimens - Synoptic Format (CAP Protocol):**
+
+```
+SYNOPTIC REPORT FOR [CANCER TYPE]
+
+Procedure: [Type of resection]
+Tumor Site: [Specific location]
+Tumor Size: [Greatest dimension in cm]
+Histologic Type: [WHO classification]
+Histologic Grade: [Grading system and result]
+Depth of Invasion: [Measured in mm if applicable]
+Lymphovascular Invasion: [Present / Not identified]
+Perineural Invasion: [Present / Not identified]
+Margins:
+  - [Margin name]: [Negative/Positive, distance if negative]
+  - [All margins listed]
+Regional Lymph Nodes:
+  - Number examined: [X]
+  - Number with metastasis: [Y]
+  - Extranodal extension: [Present/Absent]
+Pathologic Stage (AJCC 8th edition): [pTNM]
+Additional Findings: [Other relevant findings]
+```
+
+---
+
+## Ancillary Studies
+
+**Immunohistochemistry:**
+
+| Antibody | Result | Interpretation |
+|----------|--------|----------------|
+| [Marker name] | [Positive/Negative, pattern] | [Clinical significance] |
+
+**Example:**
+| Antibody | Result | Interpretation |
+|----------|--------|----------------|
+| S100 | Positive, diffuse | Supports melanocytic lineage |
+| Melan-A | Positive, diffuse | Supports melanocytic lineage |
+| HMB-45 | Positive, patchy | Supports melanoma |
+| Ki-67 | 30% | High proliferative index |
+
+**Molecular/Genetic Testing:**
+[Results of molecular tests if performed]
+- BRAF mutation: [Detected/Not detected]
+- [Other relevant tests]
+
+---
+
+## Comment
+
+[Additional interpretive information, differential diagnosis, recommendations]
+
+**Example:**
+```
+The morphologic and immunohistochemical findings are diagnostic of melanoma. The 
+Breslow thickness of 1.8 mm places this tumor in the T2 category (AJCC 8th edition).
+Sentinel lymph node biopsy is recommended for staging. BRAF mutation testing may be 
+considered for treatment planning. Close clinical follow-up is recommended.
+```
+
+---
+
+## Signature
+
+**Pathologist:**  
+[Name, MD]  
+[Board Certification]  
+[License number]
+
+**Electronically signed:** [Date and time]
+
+**Gross examination by:** [Name, credentials]  
+**Microscopic examination by:** [Name, MD]
+
+---
+
+## Template Notes for Different Specimen Types
+
+### Breast Biopsy
+
+**Key Elements:**
+- Histologic type (invasive ductal, lobular, etc.)
+- Nottingham grade (tubule formation, nuclear grade, mitotic count)
+- Size of invasive component
+- DCIS if present (grade, extent)
+- ER/PR/HER2 status
+- Margins for all components
+- Lymph nodes if present
+
+### Colon Resection
+
+**Key Elements:**
+- Tumor site and size
+- Histologic type and grade
+- Depth of invasion (T stage)
+- Lymph nodes (number positive/total examined)
+- Margins (proximal, distal, radial/circumferential)
+- Lymphovascular and perineural invasion
+- Tumor deposits
+- MSI/MMR status
+
+### Prostate Biopsy/Resection
+
+**Key Elements:**
+- Gleason score (pattern 1 + pattern 2 = total)
+- Grade group (1-5)
+- Percent involvement per core/specimen
+- Extraprostatic extension (if radical prostatectomy)
+- Seminal vesicle invasion
+- Margins
+- Perineural invasion
+
+---
+
+## Frozen Section Report (if applicable)
+
+**Frozen Section Diagnosis:**
+
+**Specimen:** [Description]  
+**Clinical Question:** [Reason for frozen]  
+**Frozen Section Diagnosis:** [Diagnosis given intraoperatively]  
+**Time:** [Time reported]  
+**Pathologist:** [Name]
+
+**Note:** Permanent sections to follow.
+
+**Final Diagnosis:** [State if concordant or discordant with frozen]
+
+