One enduring end-product of all oncologic surgery is the surgical pathology report. It is this document which helps determine a patient's prognosis as well as future therapies, including entrance into or exclusion from standardized or experimental protocols. Although much depends on this report, until recently, there has been surprisingly little attempt at standardization of reporting format for various malignancies. Given the particulars of training programs and individual styles, pathology reports will vary in organization and terminology. Of particular concern, however, is the omission of critical pathologic information, regardless of the format used. This can result in incomplete communication of pathologic information to clinicians which, in turn, can compromise patient care. The problem becomes compounded when all parties utilizing pathology reports are considered. In addition to clinicians, hospital and state tumor registries, central data collection for research and protocols all depend on accurate and complete pathologic information.
An interinstitutional study of 532 laboratories under the auspices of the College of American Pathologists in 1991 analyzed pathologic information derived from nearly 16,000 surgical pathology reports of resected colorectal carcinomas . Somewhat surprisingly, this article represented the first study specifically designed to assess reporting differences amongst surgical pathologists, differences which could result in inadequate communication of pathologic findings to surgeons and oncologists. After analyzing the results, the author discovered that essential parameters such as histologic margin involvement and lymph node status were not routinely incorporated into the final surgical pathology report at a significant number of institutions.
In 1992, citing the multiple goals of increased accuracy, consistency and interinstitutional uniformity, the Association of Directors of Anatomic and Surgical Pathology recommended guidelines for the creation of more complete surgical pathology reports . In addition,