Medical Pathology Report Form

Basic Report Information

Patient Name

Specimen Number

Age

Gender

Male Female

Ref By

Received Date

Date Reported

Nature of Specimen

Report Status

Clinical Data

Gross Description

Microscopic Description

Diagnosis

Sections from Lt. Larger nodule show a malignant tumor formed dominantly of follicles with focal papillae lined by malignant epithelial cells that have washed-out nuclei with occasional nuclear grooving. These tumor follicles and papillae are surrounded by fibrosis. There is mild anaplasia and mitosis. The smaller detected nodule in the left lobe shows a benign tumor composed of small follicular formations lined by active follicular cells with a small amount of colloid in the majority of follicles. Separating stroma is delicate and vascular. No evidence of vascular invasion or panmural capsular infiltration. The rest of the thyroid tissue shows nodular colloid hyperplasia with gross cystic change. Two reactive lymph nodes were detected adjacent to the isthmus, negative for metastasis. <h4>Tumor Summary:</h4><ul><li>Type & grade: Papillary thyroid carcinoma, low grade.</li><li>Tumor site: Lt. lobe.</li><li>Tumor size: 1.2x0.8x0.7 cm.</li><li>Thyroid capsule: Not infiltrated. </li><li>Lymphovascular invasion: Absent.</li><li>Perineural permeation: Absent. </li><li>Lymph nodes (peri-isthmic): Negative (0/2)</li><li>TNM Stage: pT1N0Mx.</li><li>Associated thyroid disease: Microfollicular adenoma + Nodular colloid hyperplasia with gross cystic change.</li></ul>

Image Width (px)

Image Height (px)

Image Position

Template

المسافة الفارغة من أعلى الصفحة عند عدم استخدام قالب Header Space (mm)

Generate PDF