医学病理报告中英文 模板

病理报告是确定相关疾病分型的重要依据,如非小细胞肺癌需根据病理检查确定是鳞癌还是腺癌等。病理报告主要涵盖两个部分:1.样品肉眼观,如肿块大小,颜色等;2.镜下观察,通过放大一定倍数,根据染色情况确定疾病类型。
肉眼检查:
左乳腺癌仿根治术甲标本:30X20X4cm,皮瓣19X7cm,乳头未见异常,外上2点半距乳头5cm可见针吸孔,深面可及肿物2. 8X2. 5X2. 5cm,切面灰白、灰红色,可见粉刺样物,质地硬,边界不清。
淋巴结直径:0.3-2cm。
Macroscopic examination:
The size of sample obtained from modified radical mastectomy for left mammary gland was 30×20×4 cm. The size of skin flap was 19×7 cm. No abnormality was seen in the nipple. Needle aspiration holes were observed in upper outer quadrant at the direction of 2 o’clock 5cm away from the nipple. A lump (2.8×2.5×2.5 cm) was noted in the deep surface. The incisal surface was in a color of grayish white and grey-red, and comedo-like lump was seen with hard texture and vague margins. 
The diameter of lymph node was 0.3-2 cm. 
镜下检查:
如图所示
Endoscopic examination:
Please refer to the following picture. 
病理诊断:
左乳腺外上浸润性导管癌,非特殊型,组织学II级;
乳头(-);外下、内上、内下(-);
区域淋巴结:腋尖0/1;肌间0/0;腋下1/17;
病理学分期:pT2NlaMx;
Pathological diagnosis:
Infiltrating duct carcinoma in upper outer quadrant of left mammary gland, non-special type, histologic grade II. 
No infiltration of cancer cells were noted in nipple, lower outer, upper inner and lower inner quadrant of left mammary gland.
For the metastasis of regional lymph node, no metastasis was noted in apical axilla (0/1), and metastasis was noted in 1 sample (1/17) obtained from armpit. 
Pathological stage: pT2NlaMx

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