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中枢神经系统肿瘤实用神经病理学概要报告。

Practical neuropathology synoptic reporting for central nervous system tumors.

机构信息

Department of Pathology, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA.

出版信息

Arch Pathol Lab Med. 2011 Jun;135(6):789-92. doi: 10.5858/2010-0193-RA.1.

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.

摘要

背景

中枢神经系统(CNS)肿瘤的综合报告从未得到正式解决,神经病理学家缺乏实用模板,无法将其适用于实验室信息系统以符合美国病理学家学院(CAP)的标准。

目的

提供专门设计用于 CNS 肿瘤的实用综合报告模板,便于数据提取和 CAP 合规,并改善 CNS 肿瘤的报告。

资料来源

对文献的回顾和我们实践中的综合报告格式经验。

结论

对所需要素的综合报告是 CNS 肿瘤最近引入的标准。由于 CNS 肿瘤的模板普遍不适用于 CNS 肿瘤,因为它们侧重于包含对 CNS 肿瘤不重要或不需要的项目,例如边缘和 TNM 分类系统。此外,2008 年发布的 CAP CNS 协议是一份庞大的综合文件,不利于简单地纳入叙述性报告。我们描述了我们使用适用于 CNS 肿瘤的综合模板的经验,该模板包括所有必需的要素,适合神经病理学实践,并且可以轻松适用于其他实验室信息系统。由于 CNS 肿瘤诊断的多学科性质,神经病理学家通常会收集所有 CNS 肿瘤病例的临床、人口统计学和影像学数据。这些数据可以方便地输入到主要的综合报告中,该报告可以替代我们的标准叙述报告。

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