完整的细针穿刺病理报告除患者姓名、性别、年龄外,应包括以下内容:穿刺部位、穿刺方法、细胞形态学描述、辅助检查结果、最后诊断及备注。
根据细针穿刺的结果,诊断可以分为无法诊断、阴性结果、存在不典型细胞、良性肿瘤、怀疑恶性肿瘤及恶性肿瘤。良性肿瘤、怀疑恶性肿瘤及恶性肿瘤的诊断还应尽可能进一步说明肿瘤具体的类型。即使对于不典型细胞也尽量对细胞的类型进行区别,如不典型鳞状上皮细胞、不典型淋巴细胞等。
对于能明确诊断的良性或恶性肿瘤应尽量采用组织病理学的术语,以方便与临床医生交流及与组织病理学检查结果的比较。对于一些在细胞学上无法区分的病变可以使用一个较为笼统的术语。比如细胞学上甲状腺滤泡肿瘤包括了组织学上的结节性甲状腺肿、甲状腺滤泡腺瘤、甲状腺滤泡腺癌及部分甲状腺滤泡型乳头状癌,因为这些病变在细胞形态学上不易区别。
在备注中可以说明细针穿刺样本的质量、肿瘤的鉴别诊断及对临床医生的建议。建议中可包括是否需要重新穿刺和是否需要做组织学活检。对于缺乏临床信息的样本,在作出诊断时也应提示临床医生需结合临床作出判断。有效地与临床医生交流是一项重要工作,通过交流可以使病理医生和临床医生在对具体病例的诊断上达成一致。
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