Pathology Report

Pathology

Two of the main types of specimens received in pathology from ovarian cancer staging procedures are

  1. Bodily fluids for cytopathology [e.g., abdominal fluid (ascites), peritoneal washings]

-and-

  1. Organs & resected tissue for surgical pathology (e.g., ovaries & fallopian tubes, lymph nodes)

Cytopathology

Cytopathology Report Mock Example

Cytology Report, ascites

Name: Jane Doe
Age: 62
Sex: Female
Procedure Date: 01/01/2018

CYTOPATHOLOGY SERVICE

Specimen labeled: Abdominal fluid

Gross: Cloudy yellow, 500 mL, non-bloody

Microscopic evaluation: Cellular preparation of isolated cells and papillary clusters that include large, round cells with pleomorphic nuclei, prominent nucleoli, large vacuoles, and psammoma bodies. Cell block is positive for PAX-8 and WT1 by immunohistochemistry. The entire specimen is submitted for processing

Specimen Adequacy: Adequate for evaluation

Diagnosis:

  1. Positive for malignant cells (see comment)

Comment: These findings are suggestive of a Mullerian malignancy.  Clinical and radiologic correlation is recommended.

Clinical Hx: Ascites, abdominal pain, rule out malignant

Surgical Pathology Report

Following are key components of a surgical pathology report for a primary ovarian, fallopian tube, or peritoneal cancer.

Surgical pathology report elements:

  • Procedure
  • Specimen Integrity (by applicable organ)
    Capsule/serosa intact, ruptured, fragmented, other
    • Right ovary
    • Left ovary
    • Right fallopian tube
    • Left fallopian tube
  • Tumor Site
  • Surface Involvement (where applicable)
    Present, absent, cannot be determined
    • Ovarian
    • Fallopian tube
  • Tumor Size
    • Greatest dimension (cm)
    • Additional dimensions (cm) (optional)
  • Histologic Type
  • Histologic Grade (if applicable)
  • Implants (if applicable)
    Not sampled, not identified, present
  • Other Organ/Tissue Involvement (if applicable)
  • Largest Extrapelvic Peritoneal Focus (if applicable)
  • Fluid
    • Peritoneal/Ascitic
    • Pleural (optional)
  • Treatment Effect (if applicable)
  • Regional Lymph Nodes (numbers)
    • Nodes with metastasis >10 mm
    • Nodes with metastasis ≤10 mm
    • Nodes with isolated tumor cells, ≤0.2 mm (if no metastases >0.2 mm)
    • Size of largest metastatic deposit
    • Location of largest metastatic deposit
    • Total nodes examined
  • Pathological Stage (pTNM, AJCC 8th Edition)
    • TNM descriptors (if applicable)
      • m – multiple primaries
      • r – recurrent
      • y – post-treatment

Updated: June 8, 2018