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Pathology Report

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Healthcare Document Intelligence

The world's best pathology report extraction

Digitize pathology findings with precision. Extract specimen information, gross and microscopic descriptions, diagnostic conclusions, and staging data. Enable rapid clinical decision-making with structured pathology data for oncology and surgical workflows.

pathology-report.pdf


Report date
Mar 22, 2024

Accession number

S24-12345


Patient name

Margaret A. Wilson


Patient dob

1958-02-14


Patient gender

Female


Medical record number

MRN-2024-55678


Ordering physician

Dr. Steven Richards, MD


Ordering physician npi

1593572468


Specimen received date
Mar 20, 2024

Specimen source

Right breast, lumpectomy


Clinical history

56-year-old female with suspicious mass detected on mammogram. BIRADS 4C. Core biopsy positive for invasive ductal carcinoma.


Procedure performed

Lumpectomy with sentinel lymph node biopsy


Procedure cpt

19301


Gross description

Received fresh, labeled 'right breast lumpectomy' is an oriented breast specimen measuring 6.5 x 4.2 x 3.8 cm. Inked margins: superior-blue, inferior-green, medial-black, lateral-orange. Serial sectioning reveals a firm, stellate, tan-white mass measuring 2.1 x 1.8 x 1.5 cm.


Microscopic description

Sections show infiltrating ductal carcinoma, moderately differentiated. Tumor cells arranged in cords and nests with moderate nuclear pleomorphism. Mitotic figures present (8/10 HPF). No lymphovascular invasion identified. Surgical margins negative, closest margin 0.5 cm (inferior).


Diagnosis
2 items
FindingIcd10 code

Invasive ductal carcinoma, moderately differentiated (Grade 2)

C50.911

Sentinel lymph node negative for metastasis (0/2)

C77.3


Tumor staging

Tumor size cm

2.10


Pathologic t stage

pT2


Pathologic n stage

pN0(sn)


Histologic grade

Grade 2 (Nottingham score 6/9)


Margins

Negative, closest 0.5 cm


Biomarkers

Er status

Positive (95%)


Pr status

Positive (80%)


Her2 status

Negative (IHC 1+)


Ki67 index

15%


Pathologist name

Dr. Jennifer Lee, MD


Pathologist npi

1357924680


Electronically signed date
Mar 22, 2024
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Integrations

Connect Pathology Reports across your stack

DocuPipe captures pathology reports from laboratory systems, fax transmissions, or scanned documents. Extract specimen details, diagnostic findings, and staging information, then sync to oncology systems, EHRs, or tumor registries.

Sources
EHR/EMR
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P
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Destinations
EHR/EMR
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P
Practice Management
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