Pathology Template

10707 Pacific Street Suite 101 Omaha, NE 68114
Phone: 402-397-7898 Fax: 402-397-8703
Surgical Pathology Report
Wayne R. Markus, M.D., F.C.A.P. David J. Jaskierny, M.D., F.C.A.P
Patient:*
Last NameFirst Name
Date of Birth:*
Date of Procedure:*
MonthDayYear
Date
Age:
Gender*
MaleFemale
Provider*
Location:*
Accession:
Procedure:*

Pathology Review

Sample Size

Diagnosis

Gleaseon

Tumor Size

Tumor Percent

A
Right Lateral Base

B
Right Lateral Mid

C
Right Lateral Apex

D
Right Base

E
Right Mid

F
Right Apex

G
Left Base

H
Left Mid:

I
Left Apex:

J
Left Lateral Base:

K
Left Lateral Mid:

L
Left Lateral Apex:

Comment:
Clinical History and Findings
PSA
4k Score
Examination
This specimen is received in formalin in 12 containers each labeled "Name", "DOB" and the source of the specimen as listed in the diagnoses, all in agreement with the requisition and demographic sheet. Each is inked() and embedded totally in one block. The surgical pathology numbers from the requisition and each cassette match. Gross examination completed by ( ).
Tissue Processing and staining are performed at Uropathology Lab, Urology Health Center 2735 N Clarkson St, Fremont, NE
Microscopic examination and reporting are performed at Adult Pediatric Urology and Urogynecolgy P.C., 10707 Pacific Street, Suite 101, Omaha NE.
Electronically Signed By:
Pathologist
Initials
Add Reporting
Synoptic ReportImmunohistochemistry Report:

	Sample
Histologic type:
Primary Gleason pattern:
Secondary (worse remaining) pattern:
Total Gleason score:
Greatest grade group:
Number of Positive Cores
Total number of cores:
Total linear dimension of carcinoma:
Total length of cores:
Percentage Involvement of all cores
Percentage Involvement of core with the greatest amount of tumor:

Synoptic Report

	Sample
Periprostatic fat involvement:
Seminal vesicle invasion::
Lympho-vascular invasion:
Perineural invasion:
Additional pathologic findings:
AJCC/UICC Stage:

Immunohistochemistry Performed at:
Physicians Laboratory, 4840 F Street, Omaha NE: All controls react appropriately.

Bladder Biopsy
Biopsy
Comment:
Clinical History and Findings
Examination
The specimen is received in formalin in ___ containers labeled “NAME”, “DOB”, and the source of the specimen as listed in the diagnoses, all in agreement with the requisition and demographic sheet. Part A, “___”, consists of ____________. Sections are embedded in one block. Part B, “___”, consists of ____________. Sections are embedded in one block. Part C, “___”, consists of ____________. Sections are embedded in one block. Part D, “___”, consists of ____________. Sections are embedded in one block. Part E, “___”, consists of ____________. Sections are embedded in one block. Gross examination completed by( ).
Tissue Processing and staining are performed at Uropathology Lab, Urology Health Center 2735 N Clarkson St, Fremont, NE
Electronically Signed By:
Pathologist
Initials
Reporting
Synoptic Report

	Report	Sample
P63 and Cytokeratin 5/14 staining basal cells:
P504S (racemase) staining cytoplasm:

10707 Pacific Street Suite 101 Omaha, NE 68114