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Example Synoptic Report – anal sac adenocarcinoma
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This report generator has not been peer reviewed - if used for diagnostic purposes, pathologists should review the information and use at their own risk.
Signalment
Relevant Clinical History
Samples Submitted
Left anal sac
Right anal sac
Internal iliac lymph node
Unspecified lymph node
Other lymph node (specify)
Other lymph node
Sample Measurements (cm)
Tumor Measurements (cm)
Gross Description
Sample inked?
Yes, by submitter
Yes, by laboratory
No (representative sections)
Histologic subtype
Solid subtype
Other subtype with < 50% solid component
Other subtype lacking solid component
Neoplasia at Margin?
Present
Absent
Histologic Tumor Free Distance - deep (mm)
Histologic Tumor Free Distance - peripheral (mm)
Tissue Barriers
Capsule
Other
Other Tissue Barrier(s)
Peripheral Infiltration
None
1 focus of infiltration
2 or more foci of infiltration
Peripheral infiltration is defined as neoplastic aggregates found separated from the main nodule within the peripheral connective tissue and/or muscle. From:
Pradel et al. 2018
Tissues Infiltrated
Peripheral connective tissue
Perirectal musculature
Other
Other Tissue(s) Infiltrated
Lymphovascular Invasion
Not identified
Equivocal
Present
Lymphovascular Invasion Criteria Detected
Thrombus adherent to intravascular tumor
Tumor cells invading through a vessel wall and endothelium
Neoplastic cells within a space lined by lymphatic or blood vascular endothelium
Neoplastic cells in a structure confirmed to be a lymphatic or blood vessel by the use of IHC markers
Necrosis
None
Present
Estimated % Necrosis
Mitotic Count per 2.37mm2
Pleomorphism
Low - Less than 25% of cells with anisocytosis and/or anisokaryosis
Moderate - 25 - 75% of cells with anisocytosis and/or anisokaryosis
Marked - Greater than 75% of cells with anisocyosis or anisokaryosis
Per
Skorupski et al. 2018
Nuclear Pleomorphism
Low - Less than 5% of cells with nuclei 2x larger than adjacent cells
Moderate - 5-10% of cells with 2x larger nuclei
Marked - More than 10% of cells with 2x larger nuclei
Per
Pradel et al. 2018
Lymph Node Metastasis
No
Yes
Lymph Nodes Submitted
Lymph Nodes With Metastasis
Organ Metastasis
Not evaluated
Not detected
Present
Organs With Metastasis
E-cadherin Expression
Less than 75%
75% or more
See
Polton et al. 2007
and
Skorupski et al. 2018
Microscopic Description
Morphologic Diagnosis
Comments
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