4.9.11

Minimal Reporting Guidelines for the Treatment of Cancer Patients



Minimal Reporting Guidelines for the  Treatment of Cancer Patients 

As laboratory physicians, our contribution to patient care is knowledge:  this is the starting point from which all informed therapeutic intervention proceeds.  How that knowledge is obtained and communicated is the art and science of our profession.  These minimal diagnostic guidelines are designed  to be used as an aid, not a constraint, in that process.  The guidelines are presented in a specific format out of necessity, but any format that effectively communicates the necessary information in a given pathology  report is valid.  Furthermore, it is accepted that not all of the information specified by these guidelines  may be available at the time of diagnosis.  Specific examples may include estrogen receptor or C-ERB B2  status of breast tumours or adequate information for meaningful pathologic staging.  A lack of this  information should not prevent the timely release of a final diagnosis in any case.  It is assumed that the  pathologist will provide all pertinent information that is available, either at the time of initial diagnosis, or  further along in the course of the patient’s care.


Minimal Reporting Guidelines – Breast Carcinoma

Microscopic Diagnosis  
(Right/Left) Breast, (core biopsy, wire local. biopsy, lumpectomy, mastectomy specimen)  
  a)  Invasive carcinoma, histologic type  
  b)  Greatest linear tumour dimension (define gross or microscopic measurement) of invasive
carcinoma, specify, if multifocal   
  c)  Extent (% of total tumour volume) type and grade, (low, intermed., high) of intraductal
component (w/wo comedonecrosis)  
  d)  Histologic grade of invasive carcinoma (Nottingham modification, Bloom and Richardson)      
      Nuclear grade  -  low = 1
        -  intermediate = 2
        -  high = 3
      Mitotic rate*  -  <4/sq mm = 1 (low)
        -  4-7/sq mm = 2 (intermediate)
        -  >7/sq mm = 3 (high)
      Tubule formation  -  >75% = high = 1
        -  10-75% = intermediate = 2
        -  <10% = low = 3

      Add points for each feature to obtain total score
        3-5 points = well differentiated
        6-7 points = moderately differentiated
        8-9 points = poorly differentiated

  e)  Venous or lymphatic space invasion (identified/not identified); specify if multiple vessels
involved; (specify if dermal lymphatics are involved)

  f)  Surgical Margins (positive/negative, indeterminate; site specific, focal or extensive, closest
approach of invasive/in-situ tumour to margins in mm)

  g)  Lymph node status (x of y lymph nodes positive for metastatic carcinoma, size of largest
metastasis, with/wo extranodal tumour spread).  Note 2002 changes to TNM staging for
microscopic lymph node metastasis.

  h)  Involvement of skin, nipple, or skeletal muscle by invasive carcinoma (present/absent)

  i)  Index microcalcifications present (if seen in specimen radiograph)

  j)  Status of background breast tissue (atypical hyperplasia, benign mass forming lesions)

  k)  Status of estrogen receptors (all invasive CAs)
Status of progesterone receptors (all ER negative tumours)
Status of Her 2-neu expression (all metastatic positive CAs)
Report should indicate tissue block suitable for immunohistochemical prognostic markers. 
Cut off for ER/PR is 5% of tumour cell nuclei staining.  Her2-neu expression should be
reported as negative, equivocal (1+ to 2+), or positive (3+).  All equivocal Her2-neu
immunostaining should be referred for FISH analysis.

  L )  pTNM tumour stage





Minimal Reporting Guidelines – Melanoma

Microscopic Diagnosis

Skin of (site), (biopsy/excision)  
  a)  Positive for invasive malignant melanoma, (histologic type)  
  b)  Clark’s Level 
      II   –  papillary dermis invasion
      III   –  fills papillary dermis, abuts retic. dermis
      IV  –  into reticular dermis
      V   –  into subcutis

  c)  Breslow Depth (mm, from granular layer)

  d)  Ulceration (present/absent)

  e)  Dermal Satellitosis (present/absent)

  f)  Mitotic figures/square mm

  g)  Vascular space invasion (present/absent)

  h)  Margins of excision (positive/negative, closest approach in mm)

  i)  Lymph node status (if applicable)

Minimal Reporting Guidelines – Soft Tissue Sarcoma

Microscopic Diagnosis

Soft tissue of (site), (resection/biopsy)

  a)  Sarcoma type

  b)  Tumour size (3 dimensions)

  c)  Tumour grade (Trojani system)

    Differentiation score – 
      Close resemblance to adult tissue  1
      Tumour type clearly recognized  2
      Undifferentiated sarcoma  3

    Necrosis score –
      None  0
      <50%  1
      >50%  2
     Mitotic score –
      0-9  per 10 hpf  1
      10-19  per 10 hpf  2
      20 or more  per 10 hpf  3

    Total score – 
      2,3  =  Grade 1
      4,5   =  Grade 2
      6,7,8  =  Grade 3

  *  NOTE:  Alveolar and embryonal rhabdomyosarcoma, neuroblastoma, Ewing’s sarcoma
and PNET are, by definition, high grade sarcomas.

  d)  Vascular space invasion (present/absent)

  e)  Surgical resection margin
  i)  positive/<2 cm from margin/>2 cm from margin
  ii)  nearest margin location (sup/inf/med/lat, ant/post)
  iii)  composition of nearest margin (muscle, vessel, fascia, skin, etc.)
  



Minimal Reporting Guidelines – Laryngeal Carcinoma

Microscopic Diagnosis

Larynx, radical resection

  a)  Positive for invasive squamous cell carcinoma (histologic subtype, if applicable)

  b)  Tumour site

  c)  Tumour size

  d)  Tumour grade (well, moderately, poorly differentiated)

  e)  Direct tumour extension (commissure, ventricle, false cords, subglottis)

  f)  Depth of invasion

  g)  Vascular space invasion

  h)  Perineural invasion

  i)  In-situ component (present/absent)

  j)  Surgical margins and distance from margins

  k)  Lymph node status (Site specific:  submandibular; upper jugular; mid jugular; lower jugular;
posterior cervical; juxtathyroid; paratracheal.  Size of largest metastasis and extranodal
tumour spread should be mentioned.)

  l)  pTNM tumour stage






 Minimal Reporting Guidelines – Thyroid Carcinoma

Microscopic Diagnosis

Thyroid, (right/left lobe or total) resection

  a)  Positive for (papillary/follicular/medullary/other) carcinoma

  b)  Tumour location (or locations if multicentric)

  c)  Greatest linear tumour dimension

  d)  Encapsulation (complete/incomplete/absent); w/wo invasion

  e)  Extrathyroidal extension (present/absent, include measurement)

  f)  Vascular space invasion

  g)  Surgical margins (if positive, include measurement)

  h)  Lymph node status (ipsilateral, midline, bilateral, mediastinal)

  i)  Status of non-neoplastic thyroid (thyroiditis, nodular hyperplasia)

  j)  pTNM tumour stage  


Minimal Reporting Guidelines – Lung Carcinoma  

Microscopic Diagnosis  

Lung, (lobectomy, pneumonectomy, side)  
  a)  Histologic tumour type (small cell/non small cell/other)

  b)  Greatest single tumour dimension  

  c)  Location –  <2 cm from bronchial resection margin

      >2 cm from bronchial resection margin  

  d)  Bronchial margin pos/neg  

  e)  Pleural involvement (into visceral pleura, through pleura, extension into chest wall)  

  f)  Lymphangitic spread (present/absent)  

  g)  Direct venous invasion

  h)  Lymph node involvement (Subdivide ipsilateral peribronchial/hilar nodes from
extrapulmonary mediastinal/subcarinal nodes.  Direct extension counts as lymph node
involvement.)

  i)  Lung parenchyma away from tumour

  j)  pTNM tumour stage




    
Minimal Reporting Guidelines – Upper Gastrointestinal and Ileocolic

Microscopic Diagnosis

Esophagus/Stomach/Duodenum/Small Bowel/Colon Resection

  a)  Positive for (well, moderately, poorly) differentiated carcinoma (specify type)

  b)  Longitudinal tumour dimension; polypoid, semicircumferential, circumferential lesion

  c)  Depth of invasion (submucosa, muscularis propria, perivisceral adipose tissue, peritonealized
serosa, extension into adjacent organs) measure the depth of extension beyond the muscularis
propria in mm.

  d)  Surgical margins (proximal, distal, radial; distance to radial margins in mm.)  Direct tumour
extension within 1 mm or a positive lymph node at the radial resection margin is considered a
positive margin.

  e)  Venous space invasion (present/absent)

  f)  Lymph node status *(x of y lymph nodes positive for metastatic carcinoma).  Any mesenteric
tumour deposit with a rounded contour counts as a replaced lymph node.  Stellate deposits are
defined as angiolymphatic tumour spread.

  g)  Perforation (present/absent)

  h)  Status of non-carcinomatous mucosa (Barrett’s mucosa, gastritis, multifocal dysplasia).

  i)  pTNM tumour stage.


* A minimum of 12 lymph nodes are required to accurately predict pNO stage. 


Minimal Reporting Guidelines – Rectum

Microscopic Diagnosis

Rectum, resection

  a)  Positive for (well, moderately, poorly) differentiated adenocarcinoma (if specific subtype,
define).

  b)  Tumour site (anterior, posterior, left, right; above or below peritoneal reflection).

  c)  Longitudinal tumour dimension and fraction of rectal circumference involved by tumour.

  d)  Depth of invasion (submucosa, muscularis propria, perirectal adipose tissue, peritonealized
serosa, adjacent structures).  Measure distance of tumour extension beyond muscularis
propria in mm.

  e)  Surgical margins (proximal, distal, radial).  Measure closest approach of tumour to radial
margin in mm. (Direct tumour extension within 1 mm or a positive lymph node at the radial
margins are defined as a positive margin).

  f)  Completeness of mesorectal excision specimen (essentially complete with minimal
defects/incomplete with exposure of rectal muscularis propria).

  g)  Venous space invasion (present/absent).

  h)  Lymph node status *(x of y lymph nodes positive for metastatic carcinoma).  Any mesenteric
tumour deposit with a rounded contour counts as a replaced lymph node.  Stellate deposits are
defined as angiolymphatic tumour spread.

  i)  Perforation (present/absent).

  j)  Status of noncarcinomatous mucosa (adenomas, CIBD, multifocal dysplasia).

  k)  pTNM tumour stage.


* A minimum of 12 lymph nodes are required to accurately predict pNO stage.



Minimal Reporting Guidelines – Pancreatic/Biliary Carcinoma

Microscopic Diagnosis

Pancreas/common bile duct, total/subtotal resection

  a)  Positive for carcinoma of (tumour site:  common bile duct, ampulla, pancreatic head, etc.)

  b)  Tumour size (significant discrepancies between gross and microscopic estimates are
common.  Unless microscopic growth is confluent, the gross estimate is preferred.)

  c)  Tumour subtype (solid, cystic, papillary, tubular, signet -ring cell, acinic cell, neuroendocrine)

  d)  Tumour grade (well, moderately, poorly differentiated)

  e)  In situ component (present/absent)

  f)  Vascular space invasion (present/absent)

  g)  Perineural invasion (present/absent)

  h)  Direct tumour extension (ie., duodenum, bile ducts, peripancreatic tissue, stomach, spleen,
bowel, large vascular channel)

  i)  Surgical margins:  radial, ductal (if subtotal pancreatectomy or CBD resection)

  j)  Lymph node status:  separate regional (peripancreatic, hepatic artery, peripyloric, celiac,
mesenteric, periaortic) lymph nodes from distant metastases

  k)  Status of non-neoplastic pancreas/bile ducts (pancreatitis, gallstones, sclerosing cholangitis)

  l)  pTNM tumour stage

  


Minimal Reporting Guidelines – Cervical Carcinoma

Microscopic Diagnosis

Cervix, cone excision or Uterus, resection

  a)  Cervical tumour cell type

  b)  Grade of invasive carcinoma

  c)  In situ component (present/absent)

  d)  Depth and breadth of invasive component

  e)  Vascular space invasion (present/absent)

  f)  Extension beyond cervix (parametrium, pelvic wall, vagina, bladder)

  g)  Resection margins (ectocervical, endocervical, deep; with closest approach in mm; define if
mucosal margin is positive for in situ or invasive disease)

  h)  Lymph node status

  i)  FIGO tumour stage



Minimal Reporting Guidelines – Vulva (non-melanoma)

Microscopic Diagnosis

Vulva, (simple/radical) resection

  a)  Vulvar tumour cell type

  b)  Tumour grade (well, moderately, poorly differentiated)

  c)  Depth of invasion and overall tumour size

  d)  Vascular space invasion (present/absent)

  e)  In-situ component (present/absent)

  f)  Extension to extra-vulvar sites (mention if present)

  g)  Surgical margins (peripheral, deep, vaginal; define if positive for in situ or invasive disease).

  h)  Lymph node status

  i)  Status of non-neoplastic mucosa (condyloma)

  j)  FIGO tumour stage


Minimal Reporting Guidelines – Endometrial Carcinoma

Microscopic Diagnosis

Uterus (tubes, ovaries), resection (curettings)

  a)  Positive for (endometrioid, papillary serous, clear cell, etc.) adenocarcinoma

  b)  FIGO tumour grade – 
      1   -  5% or less solid growth
      2   -  6-50% solid growth
      3   -    more than 50% solid growth
    (Morular growth excluded.  High grade nuclei raises tumour grade by 1.  Serous and clear
cell carcinomas are almost always grade 3.)

  c)  Myometrial invasion (none, inner ½ of myometrium, outer ½ of myometrium).  (If possible,
measure maximum depth of invasion and thickness of uninvolved myometrium at this site.)

  d)  Vascular space invasion

  e)  Cervical involvement (absent, noninvasive, invasive)

  f)  Extrauterine spread (bladder, bowel)

  g)  Status of non-carcinomatous endometrium

  h)  Lymph node status (if submitted)

  i)  FIGO tumour stage



Minimal Reporting Guidelines – Ovarian Carcinoma

Microscopic Diagnosis

(Right/left/bilateral/TAHBSO) Ovary, resection

  a)  Positive for (endometrioid, serous, mucinous) adenocarcinoma. 
    (Borderline tumours are reported using the same guidelines.)

  b)  Tumour Grade (Invasive carcinoma only, Silverberg)

    Nuclear score  -  1, 2, 3

    Mitotic score  -  <10  per 10 hpf = 1
        10-24  per 10 hpf = 2
        25 or more  per 10 hpf = 3

    Architecture score  -  glandular  =  1
        papillary  =  2
        solid  =  3

    Total score:     3-5  =  Grade 1
        6-7  =  Grade 2
        8-9  =  Grade 3

  c)  Ovarian surface involvement (present/absent)

  d)  Tumour capsule intact/ruptured

  e)  Tumour involvement unilateral/bilateral 

  f)  Extraovarian spread (define sites of implants, invasive or non-invasive; size of implants

  g)  Status of peritoneal washings (if known)

  h)  Lymph node status (if submitted)

  i)  FIGO tumour stage


Minimal Reporting Guidelines – Penis for Squamous Carcinoma

Microscopic Diagnosis

Penis, resection

  a)  Positive for invasive squamous cell carcinoma

  b)  Tumour site (urethra, foreskin, glans, shaft)

  c)  Tumour grade (well, moderately, poorly differentiated, or verrucous)

  d)  Tumour extension:  subepithelial connective tissue, tunica albuginea, corpus spongiosum,
corpus cavernosum, urethra

  e)  Vascular space invasion (present/absent)

  f)  In situ component (present/absent/extent, multifocal)

  g)  Surgical margins:  urethra, corpora, skin; define if positive for in situ or invasive disease

  h)  Lymph node status

  i)  Status of non-neoplastic epithelium (condyloma, inflammatory process)

  j)  pTNM tumour stage


Minimal Reporting Guidelines – Testis for Germ Cell Tumour

Microscopic Diagnosis

(Right/Left) Testis, radical orchidectomy

  a)  Positive for (germ cell tumour type)

  b)  Tumour size

  c)  Tumour extension (limited to seminiferous tissues, extension into rete testis/tunica
albuginea/epididymis or spermatic cord)

  d)  Vascular space invasion (present/absent, non-seminomatous GCT only)

  e)  Estimated percent of different germ cell components (mixed GCT only)

  f)  Surgical margins (peritesticular, adnexal structures, spermatic cord)

  g)  Status of lymph nodes (if submitted)

  h)  Status of non-neoplastic testis: spermatogenesis, intratubular germ cell neoplasm

  i)  pTNM tumour stage



Minimal Reporting Guidelines – Radical Prostatectomy for Prostatic Carcinoma

Microscopic Diagnosis

Prostate, radical resection

  a)  Positive for prostatic adenocarcinoma

  b)  Gleason primary and secondary grades and total score (omit if treatment effect evident)

  c)  Sites involved (peripheral/transitional zone; single or both lobes; apex, mid or bladder base)

  d)  Greatest single tumour dimension

  e)  Estimated percent of gland involvement

  f)  Tumour extension:  limited to gland, periprostatic fat, seminal vesicles

  g)  Vascular space invasion

  h)  Surgical margins:  peripheral, apex, bladder neck (define:  mm, involvement, type of tissue
involved – capsule/soft tissue)

  i)  Lymph node status (x of y positive, site specific)

  j)  Status of non-malignant prostate (PIN)

  k)  Status of prostatic urothelium (if abnormal)

  l)  pTNM tumour stage



Minimal Reporting Guidelines – Prostate Needle Biopsies

Microscopic Diagnosis

Prostate, needle biopsy (or biopsies xN)

  a)  Positive for prostatic adenocarcinoma

  b)  Gleason primary and secondary grade and score

  c)  Number of and location of cores involved (if multiple at one site)

  d)  Greatest single linear tumour dimension (confluent growth)

  e)  Vascular space invasion (present/not identified)

  f)  Extraprostatic fat involvement (present/not identified)

  g)  High Grade PIN (report if present only)

* NOTE:  Use these same criteria for reporting TUPR specimens.  Substitute number of chips involved
(eg., 4 of 20 chips positive) for linear tumour dimension.  Report prostatic urothelium and
seminal vesicle status, if present.


Gleason Grading (omit if treatment effect evident)

  1)  Single, separate uniform glands closely packed, with definite edge.

  2)  Single, separate uniform glands loosely packed, with irregular edge.

  3)  Single, separate, scattered glands (very small or uniform) or smoothly circumscribed
papillary/cribriform masses.

  4)  Fused glands with ragged infiltration, with or without large pale cells (hypernephroid).

  5)  Solid masses with any necrosis (comedocarcinoma) or anaplastic raggedly infiltrating.

Gleason Score 

  Predominant pattern plus the worst of any additional patterns.
  If only one pattern is seen, the grade is doubled to arrive at score.

  

Minimal Reporting Guidelines – Bladder Carcinoma

Microscopic Diagnosis

Urinary Bladder (transurethral resection/radical cystectomy or cystoprostatectomy)

  a)  Positive for urothelial carcinoma (subtype, invasive/noninvasive)

  b)  Tumour site(s) (single or multifocal)

  c)  Tumour size

  d)  Tumour depth of invasion (lamina propria, submucosa, inner or outer half of muscularis
propria, extravesicle)*

  e)  Involvement of ureters, urethra, prostate or seminal vesicles

  f)  Vascular space invasion (present/absent)

  g)  Histologic grade of invasive component (1,2,3)

  h)  High grade flat carcinoma in situ (present/absent)

  i)  Surgical margins
      i)  ureters
      ii)  urethra
      iii)  perivesical 
      iv)  periprostatic

  j)  Lymph node status (if submitted)

  k)  Prostate Gland (as per prostatectomy guidelines)

  l)  pTNM tumour stage



 * NOTE:  Report should delineate, where possible, invasion into bladder lamina propria versus
submucosa.


  
Minimal Reporting Guidelines – Renal Carcinoma

Microscopic Diagnosis

(Right/Left) Kidney, (segmental, simple, radical) resection

  a)  Positive for renal  cell carcinoma, histologic subtype

  b)  Tumour site(s) (pole, mid region, capsule, multiple)

  c)  Tumour size

  d)  Nuclear grade (Fuhrman)

      Grade 1:  round nuclei: nucleoli visible only at x 400 magnification
      Grade 2:  slightly irregular nuclei; nucleoli visible at x 200 magnification
      Grade 3:  irregular nuclei; nucleoli visible at x 100 magnification
      Grade 4:  enlarged pleomorphic nuclei or giant cells

  e)  Tumour extension (capsular perforation, renal pelvis, adrenal, renal vein, IVC)

  f)  Surgical margins (perinephric, hilar vascular, ureteric)

  g)  Lymph node status (if submitted)

  h)  Status of non-malignant renal tissue

  i)  pTNM tumour stage




GROSS AND MICROSCOPIC NOTES ON PATHOLOGY REPORTING OF EXCISIONAL BREAST BIOPSIES OR MASTECTOMY SPECIMENS


REPORT

  a)  Specimen
·  3 dimensional size and nature of specimen perimeter (ie.,specify if fragmented)

  b)  Invasive carcinoma

    i)  Size in mm
·  re-evaluate maximum exact size of apparent T1 or T2 invasive carcinoma (exclude
size of DCIS if it is major part of tumour nodule) microscopically
·  note critical invasive carcinoma size threshold for node negative cases: <20 mm
versus > 21 mm for chemo, Grade III duct < 10 versus > 10 mm for chemo, and
potentially at 5 and 10 mm thresholds for necessity of node dissection

    ii)  Type
·  duct, lobular, mixed, and other variants

    iii)  Grade
·  I-III/III Nottingham modification of Bloom and Richardson scoring system
·  architecture – tubule; nuclear grade; mitosis
·  record overall average for tubula r differentiation, but highest (even focal) nuclear
grade and mitotic rate; ie., consider grade heterogeneity

    iv)  Single or multifocal 
·  specify details for each focus

    v)  Margin status
·  exact distance in mm (eg., touching inked margin, <1 mm, 1 – 2 mm, 2 – 5 mm, >5
mm or indeterminate)
·  amount of invasive carcinoma at margin (eg., transected, focal microscopic,
number of mm and sections with close/positive margins)
·  exact location of all positive and close (<5 mm) margins composition of margin,
eg., breast parenchyma, fascia, skeletal muscle, skin, etc.

    vi)  Peritumoral lymphatic and vascular invasion
·  record only if definite lymphatic invasion, as may lead to chemotherapy for node
negative T1 carcinoma.
·  comment if lymphatic invasion is extensive (multiple vessels involved)
·  perineural invasion is of lesser importance unless a large nerve is involved near the
margin
·  true peritumoral venous invasion is rare
    
    vii)  Skin or skeletal muscle involvement

    viii)  ER, PR & HER2 (see latter)

  c)  Ductal Carcinoma In-Situ

·  size, grade and distance to closest margins (0 – 10 mm) are important treatment
parameters for cases with DCIS only (re:  Van Nuys Prognostic System)

    i)  Size
·  15, 25, 40 and 50 mm size thresholds for DCIS potentially clinically important.
·  often DCIS size can only be evaluated by summing up thickness of sequentially
submitted blocks

    ii)  Nuclear Grade (I – III) +/- necrosis

    iii)  Type
·  cribriform, solid, micropapillary, other

  d)  ADH, ALH and LCIS

·  Comment about extent
·  Relationship to margin generally not pertinent
·  Differentiate solid DCIS from LCIS at margins

  e)  Lymph Nodes

    i)  Number
·  exact number obtained and number positive

    ii)  Size of positive nodes
·  maximal size of largest metastatic carcinoma deposit (not just size of enlarged
node)

    iii)  Extranodal  soft tissue extension (comment if focal or extensive)

    iv)  Perinodal lymphatic or venous invasion
  

  
RECOMMENDATIONS FOR OPTIMAL HANDLING
OF COLORECTAL CARCINOMA SPECIMENS


GROSS SPECIMEN HANDLING

1)  For rectal resection specimens, identify the peritoneal reflection for orientation.  This well be
located at the anterior superior aspect of the rectum.  Ink all nonperitonealized radial rectal margins. 
For colonic specimens, locate the mesenteric resection margin, where the surgeon’s knife has cut
through the mesentery to remove it from the abdomen, and ink this nonperitonealized surface.

2)  Open and rinse the bowel (starting at the proximal end for rectal specimens, and from both ends for
colonic specimens) but stop when the scissors reach the tumour.  Do not longitudinally transect the
tumour.  Leave the tumour intact and fix the partially opened specimen for 48 hours.

3)  After fixation, slice the bowel through the area of the tumour involvement in radial sections (like a
sausage) at 5 mm intervals.

4)  Examination of these slices should allow measurement of the circumference of the bowel involved
by tumour, gross assessment of the radial margin, and identification of the minimum 12 pericolic or
perirectal lymph nodes.

  HINT:  Reportedly, most of the lymph nodes will be found at the outer edge of the specimen.

5)  Lymph nodes should be submitted for histology in their entirety (bisect them if they are big, but try
to be accurate on the count.  The radial resection margin of a total mesorectal excision should be
sampled in three tissue blocks (one should suffice for the mesenteric root of a colonic specimen) at
the site of closest approach by tumour.  Proximal and distal resection margins only require
sampling if closer than 3 cm to the tumour, in the fixed state.


NOTES ON MICROSCOPIC REPORTING

1)  Radial resection margins and depth of invasion are separate criteria with different clinical
implications.  Extension of a cecal carcinoma to the mesenteric resection margin without extension
to the peritonealized serosal surface is a T3 lesion with residual disease.  Involvement of the serosa
is T4 disease but is considered completely excised.

2)  Tumour at the serosal surface with an inflammatory response is the same as tumour on the serosal
surface (identical clinical implications).
  

3)  If we can’t find 12 lymph nodes, we are obliged to go back to the bottle and look for more.  This
recommendation is based upon validated studies indicating that a minimum of 12 lymph nodes is
required in order to accurately stage a patient as n0.  If less than 12 nodes are examined, and the
pathologist diagnoses the case as negative for node metastasis, there is a significant   chance that
the pathologist is wrong.  However,  if the surgeon has not provided an adequate mesenteric pedicle,
we will not find many nodes.  It is advisable to provide a 1 dimension assessment of the width of
the mesentery, along with the length of the specimen, in the gross description.  This measuresment
is likely to prevent arguments about who’s dissection (the pathologist’s or the surgeon’s) was
inadequate.  Reporting on more than 15 lymph nodes provides no additional information.



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List of all the posts

Interesting Case

Clinical History:

53 years male,History of hypertension and tachycardia,MRI abdomen:-Left adrenal mass:- size 5.8 cm Right renal mass:- size-3.0cm Microscopic examination of the renal mass showed vascular tumor with diffuse sheets of clear cells having Fuhrman grade III nuclei. There was no evidence of necrosis within the tumor. There was no evidence of extraparenchymal invasion.
Gross examination of the left adrenal gland revealed cortically centered, solid and multinodular mass measuring 6.5 x 6.0 x 5.0 cm and weighing 122 grams. The tumor was encapsulated but showed evidence of extraparenchymal penetration. The tumor had golden brown cut surface with areas of hemorrhage and necrosis. The partial nephrectomy showed 3.0cm x 3.0cm x 3.0 cm yellow solid mass which did not invade into the perinephric adipose tissue.
Microscopically, the adrenal mass had predominant diffuse sheets and focal trabecular arrangements. The former pattern was present in about third of tumor. The cells had clear cytoplasm and round to ovoid nuclei with conspicuous nucleoli. Mitotic rate was 9/50 HPF and included atypical forms. Gross necrosis and capsular invasion were documented microscopically. There was no evidence of lymphovascular invasion. Considering the above mentioned features, a Weiss histopathologic score2 of 7/9 was applied.



Discussion:

The differential diagnosis included Renal Cell Carcinoma (RCC) with contralateral adrenal metastasis, Adrenocortical carcinoma (ACC) with contralateral renal metastasis, synchronous RCC and ACC or synchronous RCC and adrenocortical adenoma. A panel of immunohistochemical stains was performed to sort out the diagnosis. Adrenal tumor demonstrated strong Vimentin positivity and is negative for CK7, CK20, E1/AE3, EMA, Synaptophysin and S100.Renal cell carcinoma was positive for CK7, AE1/AE3, EMA (weak) and Vimentin. It was negative for CK20, Synaptophysin and S100. The difference of immunoprofile between the two tumors documented that they originated from two different primaries.

Final Diagnosis:

The diagnosis of synchronous RCC and ACC rather than metastasis influences the prognosis.

Prognosis:

The longest disease free interval after removal of contralateral adrenal metastasis was 12.1 years8 and the longest crude survival was 14.3 years. In contrast non metastazing RCC has an excellent prognosis if no metastasis developed.