Synoptic Reporting in Anatomic Pathology - s3.amazonaws.com

49 Pages·2014·10.99 MB·English

by  John H. Sinard

Synoptic Reporting in Anatomic
Pathology: What, Why, and How?
(9028)
John H. Sinard, MD, PhD
John H. Sinard, MD, PhD

Yale University School of Medicine
Department of Pathology

Yale University School of Medicine
www.ascp.org/ascp2014
Speaker Disclosure

In the past 12 months, I have NOT had a significant
financial interest or other relationship with the
manufacturer(s) of the product(s) or provider(s) of the
service(s) that will be discussed in my presentation.
Special thanks to Paul Valenstein for the first several slides
(from a previous talk we did together)
Outline

• General concepts related to reporting

• Definition of synoptic reporting

• “Requirements” related to synoptic reporting

• Options for Implementing synoptic reporting

John H. Sinard, MD, PhD
Newspaper Formatting

By far the most important consideration in formatting a
newspaper to direct the readers attention is spacing

•  Readers love and crave white space

•  Layout strategies to increase white space:

§ Headings and sub-headings

§ Indents

§ Block quotations

§ Bullet and number lists

§ Figures, tables, and illustrations
BREAST (LEFT): FATTY, WITH MILDLY PROLIFERATIVE FIBROCYSTIC
CHANGES, AND A SINGLE (1 MM) FOCUS OF HIGH GRADE DUCTAL
CARCINOMA IN SITU, COMEDO-TYPE, 4 MM FROM THE MARGIN OF THE
SPECIMEN. NO INVASIVE CARCINOMA. ESTROGEN RECEPTORS
ORDERED.

BREAST (LEFT): DUCTAL CARCINOMA IN SITU

Size: 1 mm

Histologic type: Comedo

Histologic grade: High grade

Specimen margin: 4 mm free

Calcifications: Present in in-situ component

Non-neoplastic breast: Proliferative fibrocystic disease

Estrogen receptors: To be performed and reported later
A. PROSTATE, RIGHT BASE: ATROPHY AND CHRONIC INFLAMMATION. NO
NEOPLASM IDENTIFIED.

  B. PROSTATE, RIGHT MID: ACUTE AND CHRONIC INFLAMMATION. NO NEOPLASM
IDENTIFIED.

  C. PROSTATE, RIGHT APEX: ATROPHY. NO NEOPLASM IDENTIFIED.

  D. PROSTATE, LEFT BASE: ADENOCARCINOMA, CONVENTIONAL TYPE, GLEASON
3+4=7, SIZE = 7 MM, PERINEURAL INVASION PRESENT.

  E. PROSTATE, LEFT MID: SINGLE FOCUS OF ADENOCARCINOMA, CONVENTIONAL
TYPE, GLEASON 3+3=6, SIZE = 2 MM.

  F. PROSTATE, LEFT APEX: ATROPHY AND CHRONIC INFLAMMATION. NO
NEOPLASM IDENTIFIED.

PROSTATE: ADENOCARCINOMA

Malignant locations: left base, left mid

Benign locations: left apex, right base, right mid, right apex

Gleason score: 3 + 4 = 7

Maximum dimension: 7 mm (left base)

Histologic type: conventional prostatic adenocarcinoma

Perineural invasion is present
Consistency in Position Is Important

• Anchors expectations about content

• Speeds information transfer

• Prevents confusion
Memorize the following digits…

1 1 7 7 6 9 1 1 1 9 8 4

1 1776 911 1984

117 769 111 984

Short term memory can hold 7 +/- 2 pieces of information.
Lasts 5 sec to few minutes, and is subject to interference.

Chunking allows more information to be absorbed / retained.

Grouping unfamiliar terms obscures facts.
Summary of Underlying Themes

•  Structured display with inverted pyramid to focus
attention

•  White space / tables / lists to facilitate understanding

•  Consistent structure for rapid assimilation

•  Grouping of information into discrete, absorbable units

John H. Sinard, MD, PhD
Synoptic Reporting

•  What is it?

§ The term has been used to refer to both a style of reporting,
and to some of the tools available to help generate this style of
reporting

•  Synoptic Reporting

§ A style of reporting in which the data is summarized as a list of
previously defined data elements

§ Probably helps assure report completeness

§ May improve communication of pertinent findings

§ Controversial: some feel it is too restrictive to adequately
communicate the subtle features of a particular case

John H. Sinard, MD, PhD