Mark W Becher1. 1. Department of Pathology, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA. markbecher36@gmail.com
Abstract
CONTEXT: Synoptic reporting for central nervous system (CNS) tumors has never been formally addressed, and neuropathologists lack practical templates that they can adapt to their laboratory information system to be compliant with College of American Pathologists (CAP) standards. OBJECTIVES: To provide practical synoptic report templates designed for CNS tumors that allow for easy data extraction and CAP compliance and improve the reporting of CNS tumors. DATA SOURCES: Review of literature and synoptic report format experience in our practice. CONCLUSIONS: Synoptic reporting of required elements is a recently introduced standard for CNS tumors. It is difficult to use a universal non-CNS tumor synoptic report template for CNS tumors because they are heavily weighted to include items not important or required for CNS tumors, such as margins and the TNM classification system. In addition, the CAP CNS protocol, published in 2008, is an immense comprehensive document that is not conducive to simple inclusion in a narrative report. We describe our experience using a synoptic template for CNS tumors that includes all required elements, is tailored to the practice of neuropathology, and can easily be adapted to other laboratory information systems. Because of the multidisciplinary nature of CNS tumor diagnoses, neuropathologists typically collect clinical, demographic, and imaging data on all CNS tumor cases. These data can readily be entered into a primary synoptic report that could replace our standard narrative report.
CONTEXT: Synoptic reporting for central nervous system (CNS) tumors has never been formally addressed, and neuropathologists lack practical templates that they can adapt to their laboratory information system to be compliant with College of American Pathologists (CAP) standards. OBJECTIVES: To provide practical synoptic report templates designed for CNS tumors that allow for easy data extraction and CAP compliance and improve the reporting of CNS tumors. DATA SOURCES: Review of literature and synoptic report format experience in our practice. CONCLUSIONS: Synoptic reporting of required elements is a recently introduced standard for CNS tumors. It is difficult to use a universal non-CNS tumor synoptic report template for CNS tumors because they are heavily weighted to include items not important or required for CNS tumors, such as margins and the TNM classification system. In addition, the CAP CNS protocol, published in 2008, is an immense comprehensive document that is not conducive to simple inclusion in a narrative report. We describe our experience using a synoptic template for CNS tumors that includes all required elements, is tailored to the practice of neuropathology, and can easily be adapted to other laboratory information systems. Because of the multidisciplinary nature of CNS tumor diagnoses, neuropathologists typically collect clinical, demographic, and imaging data on all CNS tumor cases. These data can readily be entered into a primary synoptic report that could replace our standard narrative report.