10.2 Pathology Reporting, CAP Cancer Protocols & Electronic Pathology (CoC Standard 5.1)
Key Takeaways
A surgical pathology report typically contains clinical history, gross description, microscopic description, final diagnosis, a synoptic (CAP) summary, comments, addenda and ancillary study results.
The Solid Tumor Rules say to use the more specific histology when the final diagnosis and the synoptic report disagree; the CAP protocol itself is used only when neither is available. STORE ranks lymph node counts as final diagnosis, synoptic report, microscopic, then gross.
CAP cancer protocols list core and conditional data elements to be reported in "diagnostic parameter pair" format (element followed by its response), grouped together in one place in the report.
CoC Standard 5.1 requires an annual clinician audit of at least 20 eligible resection reports from at least three disease sites, confirming that at least 90% use CAP synoptic format with all core elements.
Eligible reports are definitive resections of invasive primary cancers and DCIS, and resections after neoadjuvant therapy with residual tumor; biopsies, cytology and resections with no residual tumor are not required to use the protocol.
Why pathology reporting is a separate topic
Most reportable cancers are microscopically confirmed, and the pathology report supplies the codes that matter most: histology and behavior, grade, tumor size and extension, margins, lymph nodes, lymphovascular invasion and many SSDIs. The ODS outline lists "pathology reporting" in Domain 3 and names CAP among the organizations in Domain 2.
Anatomy of a surgical pathology report
| Section | Contents | Registry use |
|---|---|---|
| Specimen and clinical information | Procedure, laterality, clinical history | Confirms the site, laterality, and whether neoadjuvant therapy was given |
| Gross description | What the pathologist saw and measured: size, cut surfaces, margin distances, node count | Tumor size when the microscopic size is not given; lowest priority for node counts |
| Microscopic description | Histologic findings | Supports the histology and extent |
| Final diagnosis | The pathologist's conclusion | Primary source for histology and behavior |
| Synoptic report or CAP summary | Structured list of core elements | Often the most specific source for histology, grade, margins, lymph nodes and pTNM |
| Comment | Differential diagnosis, reasoning | Context; watch for ambiguous terms |
| Addendum or amended report | New or corrected information (IHC, molecular results, revised diagnosis) | Update the abstract |
| Consultation report | Outside expert review | For grade, the Grade Manual says to record the consult result when it differs from the original |
Which part to trust when parts disagree
- Histology: the Solid Tumor Rules say that when the final diagnosis and the synoptic report differ, use the document with the more specific histology, which is usually the synoptic report. Use the CAP protocol only when a final diagnosis or synoptic report is not available. Each site module also gives its own priority order for pathology, cytology, imaging and physician documentation. Tissue pathology always comes first.
- Regional lymph node counts: STORE's priority is final diagnosis → synoptic report (CAP protocol or checklist) → microscopic → gross.
- Grade: the Grade Manual's priority is synoptic report (including the CAP protocol) → final diagnosis → physician statement.
- Neoadjuvant therapy: code histology from the diagnosis made before neoadjuvant therapy, because treatment can change the tumor's appearance.
The CAP Cancer Protocols
The College of American Pathologists (CAP) publishes cancer protocols (templates) for each site and procedure. They define:
- Core elements, which must be reported whether or not they apply, and conditional elements, which are reported only when applicable.
- "Diagnostic parameter pair" format: each element is followed by its response (for example, "Margins: negative for invasive carcinoma").
- Layout: each pair on its own line or in a table, with all core elements together in one location.
Typical core elements for a resection include the procedure, tumor site, histologic type, histologic grade, tumor size, extent of invasion, margins, lymphovascular invasion, regional lymph nodes (number examined and number with metastasis), and a pathologic stage classification. Biomarker results are often reported in separate CAP biomarker templates.
The pathologist's pTNM in the synoptic report is valuable, but the registry's AJCC stage is assigned by applying AJCC rules to all the information in the pathologic time frame. That may add information the pathologist did not have, such as a biopsy-proven distant metastasis.
CoC Standard 5.1: College of American Pathologists Synoptic Reporting
| Requirement | Detail |
|---|---|
| Annual internal audit | Confirms that at least 90% of eligible cancer pathology reports use CAP synoptic format with all core elements |
| Sample | At least 20 surgical resection cases from at least three different disease sites |
| Auditor | A clinician; a pathologist is recommended but not required |
| Reporting | Results are presented to the cancer committee in the same calendar year and documented in the minutes |
| Below 90% | An action plan to find and remove the barriers |
Eligible reports:
- Definitive surgical resections of primary invasive malignancies and of DCIS.
- Definitive surgical resections after neoadjuvant therapy when residual tumor remains.
Not required to use the CAP protocol:
- Definitive resections with no residual tumor.
- Additional procedures after the definitive resection (for example, re-excision of positive margins, or later node biopsy or resection).
- Diagnostic biopsies, cytology or other diagnostic procedures done before definitive surgery.
- Resections for recurrent tumor.
- In situ carcinomas other than DCIS.
- Special studies such as biomarker or prognostic testing.
Electronic pathology (e-path) reporting
- Pathology laboratories send structured results electronically in HL7 messages, following NAACCR's standard for pathology laboratory electronic reporting (Standards for Cancer Registries, Volume V). CAP's electronic Cancer Checklists (eCC) let pathologists capture synoptic data discretely.
- Hospital registries use e-path feeds for casefinding. Automated keyword screening flags reports that a registrar then reviews, because "negative for carcinoma" also contains the word "carcinoma."
- Central registries receive e-path directly from independent and hospital laboratories. This improves completeness and timeliness, especially for cases diagnosed outside hospitals. Pathology-only reports may be collected (Class of Case 43 where required) and followed back to physicians.
Reading a synoptic report: example
Colon, right hemicolectomy. Histologic type: adenocarcinoma. Grade: G2 (moderately differentiated). Tumor size: 4.8 cm. Extent: invades through the muscularis propria into pericolonic tissue. Margins: all negative. LVI: present. Regional nodes: 2 of 17 involved. Tumor deposits: not identified. pTNM: pT3 pN1b.
The registrar codes adenocarcinoma 8140/3; Grade Pathological 2 (following the Grade Manual colorectal table); Regional Nodes Examined 17 and Positive 02; Tumor Deposits 00. The AJCC pathologic stage is assigned after confirming the M category from the whole record, for example cM0 from imaging.
Under CoC Standard 5.1, which pathology report must be included in the population audited for CAP synoptic format?
A definitive colectomy for invasive adenocarcinoma with no neoadjuvant therapy
A re-excision of a positive lumpectomy margin
A core needle biopsy that first diagnosed invasive breast carcinoma
A resection after neoadjuvant chemotherapy showing no residual tumor
The final diagnosis on a mastectomy report lists "12 lymph nodes, 2 positive," but the gross description says 14 nodes were submitted. Which count should the registrar use for Regional Lymph Nodes Examined?
12, because STORE's priority for node counts is final diagnosis, then synoptic report, then microscopic, then gross
14, because the gross description records what was physically submitted
13, the average of the two counts
99, because the report is internally inconsistent
A cancer program's CoC Standard 5.1 audit reviews 24 eligible resection reports from four disease sites; 20 contain every CAP core element in synoptic format. What is the result?
Compliant, because at least 20 cases were reviewed
Not compliant, because 20 of 24 is 83%, below the 90% requirement, so an action plan is needed
Compliant, because at least three disease sites were included
Not compliant, because the audit must include at least 50 cases
Sections you finish are checked off in the contents.