Non-Hodgkin Lymphoma/Lymphoid Neoplasms: 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): ______________________________

____ Not specified

Histologic Type

____ Histologic type cannot be assessed

Precursor lymphoid neoplasms

____ B lymphoblastic leukemia/lymphoma, not otherwise specified (NOS)#

____ B lymphoblastic leukemia/lymphoma with t(9;22)(q34;q11.2); BCR-ABL1

____ B lymphoblastic leukemia/lymphoma with t(v;11q23); MLL rearranged

____ B lymphoblastic leukemia/lymphoma with t(12;21)(p13;q22); TEL-AML1 (ETV6-RUNX1)

____ B lymphoblastic leukemia/lymphoma with hyperdiploidy

____ B lymphoblastic leukemia/lymphoma with hypodiploidy (hypodiploid acute lymphoblastic leukemia/lymphoma [ALL])

____ B lymphoblastic leukemia/lymphoma with t(5;14)(q31;q32); IL3-IGH

____ B lymphoblastic leukemia/lymphoma with t(1;19)(q23;p13.3); E2A-PBX1 (TCF3-PBX1)

____ T lymphoblastic leukemia/lymphoma

Mature B-cell neoplasms

____ B-cell lymphoma, subtype cannot be determined (Note: Not a category within the WHO classification)

____ Chronic lymphocytic leukemia/small lymphocytic lymphoma

____ B-cell prolymphocytic leukemia

____ Splenic B-cell marginal zone lymphoma

____ Hairy cell leukemia

____ Splenic B-cell lymphoma/leukemia, unclassifiable†

____ Splenic diffuse red pulp small B-cell lymphoma†

____ Hairy cell leukemia-variant†

____ Lymphoplasmacytic lymphoma

____ Gamma heavy chain disease

____ Alpha heavy chain disease

____ Plasma cell myeloma

____ Solitary plasmacytoma of bone

____ Extraosseous plasmacytoma

____ Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma)

____ Nodal marginal zone lymphoma

____ Pediatric nodal marginal zone lymphoma†

____ Follicular lymphoma

____ Pediatric follicular lymphoma†

____ Primary intestinal follicular lymphoma†

____ Primary cutaneous follicle center lymphoma

____ Primary cutaneous follicle center lymphoma

____ Mantle cell lymphoma

____ Diffuse large B-cell lymphoma (DLBCL), NOS

____ T-cell/histiocyte-rich large B-cell lymphoma

____ Primary DLBCL of central nervous system (CNS)

____ Primary cutaneous DLBCL, leg type

____ Epstein-Barr virus (EBV) positive DLBCL of the elderly†

____ DLBCL associated with chronic inflammation

____ Lymphomatoid granulomatosis

____ Primary mediastinal (thymic) large B-cell lymphoma

____ Intravascular large B-cell lymphoma

____ Anaplastic lymphoma kinase (ALK) positive large B-cell lymphoma

____ Plasmablastic lymphoma

____ Large B-cell lymphoma arising in HHV8-associated multicentric Castleman disease

____ Primary effusion lymphoma

____ Burkitt lymphoma

____ B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma and Burkitt lymphoma

____ Other (specify): ______________________________

Mature T- and NK-cell neoplasms

____ T-cell lymphoma, subtype cannot be determined (Note: Not a category within the WHO classification)

____ T-cell prolymphocytic leukemia

____ T-cell large granular lymphocytic leukemia

____ Chronic lymphoproliferative disorder of NK cells†

____ Aggressive NK-cell leukemia

____ Systemic EBV positive T-cell lymphoproliferative disease of childhood

____ Hydroa vacciniforme-like lymphoma

____ Adult T-cell leukemia/lymphoma

____ Extranodal NK/T-cell lymphoma, nasal type

____ Enteropathy-associated T-cell lymphoma

____ Hepatosplenic T-cell lymphoma

____ Subcutaneous panniculitis-like T-cell lymphoma

____ Primary cutaneous anaplastic large cell lymphoma

____ Lymphomatoid papulosis

____ Primary cutaneous gamma-delta T-cell lymphoma

____ Primary cutaneous CD8 positive aggressive epidermotropic cytotoxic T-cell lymphoma†

____ Peripheral T-cell lymphoma, NOS

____ Angioimmunoblastic T-cell lymphoma

____ Anaplastic large cell lymphoma, ALK positive

____ Anaplastic large cell lymphoma, ALK negative†

____ Other (specify): ______________________________

Histiocytic and dendritic cell neoplasms

____ Histiocytic sarcoma

____ Langerhans cell histiocytosis

____ Langerhans cell sarcoma

____ Interdigitating dendritic cell sarcoma

____ Fibroblastic reticular cell tumor†

____ Indeterminate dendritic cell tumor†

____ Disseminated juvenile xanthogranuloma

Post-transplant lymphoproliferative disorders (PTLD)##

Early lesions

____ Plasmacytic hyperplasia

____ Infectious mononucleosis-like PTLD

____ Polymorphic PTLD

____ Monomorphic PTLD (B- and T/NK cell types)

Specify subtype: _____________________________

____ Classical Hodgkin lymphoma type PTLD###

*Pathologic Extent of Tumor (select all that apply)

*____ Involvement of a single lymph node region

*Specify site: _____________________________

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

*Specify site: _____________________________

*____ Spleen involvement

*____ Liver involvement

*____ Bone marrow involvement

*____ Other site involvement

*Specify site(s): _____________________________

*Additional Pathologic Findings

*Specify: _____________________________

Immunophenotyping (Flow Cytometry &/or Immunohistochemistry)

____ Performed, see separate report: _____________________________

____ Performed

*Specify method(s) and results: _____________________________

*____ Not performed

*Cytogenetic Studies

____ Performed, see separate report: ____________________________

____ Performed

*Specify method(s) and results: _____________________________

*____ Not performed

*Molecular Genetic Studies

____ Performed, see separate report: ____________________________

____ Performed

*Specify method(s) and results: _____________________________

*____ Not performed

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

*____ International Prognostic Index (IPI) (specify): __________

*____ Follicular Lymphoma International Prognostic Index (FLIPI) (specify): __________

*____ B symptoms present

*____ Other (specify): ______________________________

† Denotes provisional entities in the 2008 WHO classification.

# An initial diagnosis of “B lymphoblastic leukemia/lymphoma, NOS” may need to be given before the cytogenetic results are available.

## These disorders are listed for completeness, but not all of them represent frank lymphomas.

### Classical Hodgkin lymphoma type PTLD can be reported using either this protocol or the separate College of American Pathologists protocol for Hodgkin lymphoma. Adapted with permission from College of American Pathologists, “Protocol for the Examination of Specimens from Patients with Non-Hodgkin Lymphoma/Lymphoid Neoplasms.” Web posting date June 2010, www.cap.org.