Hodgkin Lymphoma: Biopsy, Resection

Surgical Pathology Cancer Case Summary (Checklist)

Specimen (select all that apply)

____ Lymph node(s)

____ Other (specify): ______________________________

____ Not specified

Procedure

____ Biopsy

____ Resection

____ Other (specify): ______________________________

____ Not specified

Tumor Site (select all that apply)

____ Lymph node(s), site not specified

____ Lymph node(s)

Specify site(s): ______________________________

____ Other tissue(s) or organ(s) (specify): ______________________________

____ Not specified

Histologic Type (based on 2008 WHO classification)

____ Hodgkin lymphoma, histologic subtype cannot be determined

____ Classical Hodgkin lymphoma, histologic subtype cannot be determined

____ Nodular lymphocyte predominant Hodgkin lymphoma

____ Nodular sclerosis classical Hodgkin lymphoma

____ Mixed cellularity classical Hodgkin lymphoma

____ Lymphocyte-rich classical Hodgkin lymphoma

____ Lymphocyte-depleted classical Hodgkin lymphoma

*Pathologic Extent of Tumor (select all that apply)

*____ Involvement of a single lymph node region

*Specify sites: ______________________________

*____ Involvement of ≥ 2 lymph node regions on same side of diaphragm

*Specify sites: ______________________________

*____ Involvement of lymph node regions on both sides of diaphragm

*Specify sites: ______________________________

*____ Spleen involvement

*____ Liver involvement

*____ Bone marrow involvement

*____ Other site involvement

*Specify site(s): ______________________________

*Additional Pathologic Findings

*Specify: ______________________________

Immunophenotyping (immunohistochemistry)

____ Performed, see separate report: ______________________________

____ Performed

Specify method(s) and results: ______________________________

____ Not performed

*Clinical Prognostic Factors and Indices (select all that apply)

*____ International Prognostic Score (IPS) (specify): __________

*____ B symptoms present

*____ Other (specify): ______________________________

Adapted with permission from College of American Pathologists, “Protocol for the Examination of Specimens from Patients with Hodgkin Lymphoma.” Web posting date October 2009, www.cap.org.