Lung Cancer - Structured Pathology Reporting database

Structured Reporting of Lung Cancer using a standard protocol re-constructed in FileMaker database is used to record answer data for 74 questions in 6 groups. Data is recorded for patient identification, observations about the clinical specimen, macroscopic and microscopic findings of the lung specimen, results for ancillary tests and tumour classification. The completed data is reported as print or PDF output.

Patient identification data

Family Name, Given Name, Gender, Date Of Birth, Patient Identifiers, Date of Request, Path Accession No., Req dr name, Req dr phone, Req Dr contacted.

Clinical details data

Relevant clinical information, Principal clinician, Nature of the resection, (other details), Site and laterality of tumour, Results of previous cytological investigations or biopsies, Details of any previous treatment of the current tumour, Details of previous cancer diagnosis, Risk factors for lung cancer (including smoking history, ethnicity and asbestos exposure), Clinical tumour stage, Other relevant information and comments.

Macroscopic findings data

Specimen type, (Other details), Nature and site of blocks, Tumour site, Tumour location, Number of tumours, Maximum tumour diameter, Extent of direct spread of tumour, Description of pleura overlying a peripheral tumour, Distance of tumour from the bronchial resection margin, Number, Site, Non-neoplastic lung, Other relevant information and comments.

Microscopic findings data

Histological tumour type, (typical|atypical), Other tumour type, Histological grade, Visceral pleural invasion, Vessel invasion, Artery, Vein, Lymphatic, Perineural invasion, Bronchial resection margin, Microscopic clearance, (Involved margin), (if invasive), Vascular resection margin, Nature of involvement:, Other surgical margins (lung), Specify:, Direct involvement of contiguous structures, (Margin), Specify margin:, Clearance from margin:, In situ carcinoma, Lymph node involvement by tumour, Number involved:, Site of involved nodes:, Lymph node replacement, Extracapsular extension, Non-neoplastic lung, Other relevant information and comments.

Ancillary test findings data

Immunohistochemical stains, Molecular pathology testing.

Synthesis and Overview

pT - Primary Tumour, pN - Regional Lymph Nodes, pM - Distant Metastasis, Residual tumour status, Completeness of surgical resection, Diagnostic summary, Overarching comment.