Prostate Gland: Needle Biopsy

Surgical Pathology Cancer Case Summary (Checklist)

Histologic Type

____ Adenocarcinoma (acinar, not otherwise specified)

____ Other (specify): ______________________________

Histologic Grade

Gleason pattern

(If 3 patterns present, use most predominant pattern and worst pattern of remaining 2)

____ Not applicable

____ Cannot be determined

Primary (predominant) pattern

____ Grade 1

____ Grade 2

____ Grade 3

____ Grade 4

____ Grade 5

Secondary (worst remaining) pattern

____ Grade 1

____ Grade 2

____ Grade 3

____ Grade 4

____ Grade 5

Total Gleason score: __________

Tumor Quantitation

Number cores positive: __________

Total number of cores: __________

or

Total number of cores: __________

and

Total linear millimeters of carcinoma: __________ mm

Total linear millimeters of needle core tissue: __________ mm

or

Number cores positive: __________

Total number of cores: __________

and

Proportion (percent) of prostatic tissue involved by tumor: __________ %

and

Total linear millimeters of carcinoma: __________ mm

Total linear millimeters of needle core tissue: __________ mm

^*Proportion (percentage) of prostatic tissue involved by tumor for core with the greatest amount of tumor: __________ %

Periprostatic Fat Invasion (document if identified)

^*____ Not identified

____ Present

Seminal Vesicle Invasion (document if identified)

^*____ Not identified

____ Present

^*Lymph-Vascular Invasion

^*____ Not identified

^*____ Present

^*____ Indeterminate

^*Perineural Invasion

^*____ Not identified

^*____ Present

^*Additional Pathologic Findings (select all that apply)

^*____ None identified

^*____ High-grade prostatic intraepithelial neoplasia (PIN)

^*____ Atypical adenomatous hyperplasia (adenosis)

^*____ Inflammation (specify type): _____________________________

^*____ Other (specify): ______________________________

The Gleason grade and score and tumor extent measures should be documented for each positive specimen (container). The essential information in each specimen could be conveyed with a simple diagnostic line such as, “Adenocarcinoma, Gleason grade 3 + 4 = score of 7, in 1 of 2 cores, involving 20% of needle core tissue, and measuring 4 mm in length.” ^* Data elements with asterisks are not required. However, these elements may be clinically important but are not yet validated or regularly used in patient management. Adapted with permission from College of American Pathologists, “Protocol for the Examination of Specimens from Patients with Carcinoma of the Prostate Gland.” Web posting date October 2009, www.cap.org.

Prostate Gland: Transurethral Prostatic Resection (TUR), Enucleation Specimen (Subtotal Prostatectomy)

Surgical Pathology Cancer Case Summary (Checklist)

Procedure

____ Transurethral prostatic resection

____ Enucleation

____ Other (specify): ______________________________

____ Not specified

Specimen Size

Weight: __________ g

Size (enucleation specimens only: __________ x __________ x __________ cm

Histologic Type

____ Adenocarcinoma (acinar, not otherwise specified)

____ Other (specify): ______________________________

Histologic Grade

Gleason pattern

(If 3 patterns present, use most predominant pattern and worst pattern of remaining 2)

____ Not applicable

____ Cannot be determined

Primary (predominant pattern)

____ Grade 1

____ Grade 2

____ Grade 3

____ Grade 4

____ Grade 5

Secondary (worst remaining) pattern

____ Grade 1

____ Grade 2

____ Grade 3

____ Grade 4

____ Grade 5

Total Gleason score: __________

Tumor Quantitation: TUR Specimens

Proportion (percentage) of prostatic tissue involved by tumor: __________ %

____ Tumor incidental histologic finding in no more than 5% of tissue resected with Gleason score 2 to 6 (cT1a)

____ Tumor incidental histologic finding in more than 5% of tissue resected or Gleason score 7 to 10 (cT1b)

^*Number of positive chips: __________

^*Total number of chips: __________

Tumor Quantitation: Enucleation Specimens

Proportion (percent) of prostatic tissue involved by tumor: __________ %

^*Tumor size (dominant nodule, if present)

^*Greatest dimension: __________ cm

^*Additional dimensions: __________ x __________ cm

Periprostatic Fat Invasion (document if identified)

^*____ Not identified

____ Present

Seminal Vesicle Invasion (document if identified)

^*____ Not identified

____ Present

^*Lymph-Vascular Invasion

^*____ Not identified

^*____ Present

^*____ Indeterminate

^*Perineural Invasion

^*____ Not identified

^*____ Present

^*Additional Pathologic Findings (select all that apply)

^*____ None identified

^*____ High-grade prostatic intraepithelial neoplasia (PIN)

^*____ Atypical adenomatous hyperplasia (adenosis)

^*____ Nodular prostatic hyperplasia

^*____ Inflammation (specify type): ______________________________

^*____ Other (specify): ______________________________

^* Data elements with asterisks are not required. However, these elements may be clinically important but are not yet validated or regularly used in patient management.

Prostate Gland: Radical Prostatectomy

Surgical Pathology Cancer Case Summary (Checklist)

Procedure

____ Radical prostatectomy

____ Other (specify): ______________________________

____ Not specified

Prostate Size

Weight: __________ g

Size: __________ x __________ x __________ cm

Lymph Node Sampling

____ No lymph nodes present

____ Pelvic lymph node dissection

Histologic Type

____ Adenocarcinoma (acinar, not otherwise specified)

____ Prostatic duct adenocarcinoma

____ Mucinous (colloid) adenocarcinoma

____ Signet ring cell carcinoma

____ Adenosquamous carcinoma

____ Small cell carcinoma

____ Sarcomatoid carcinoma

____ Undifferentiated carcinoma, not otherwise specified

____ Other (specify): ______________________________

Histologic Grade

Gleason pattern

(If 3 patterns are present, record the most predominant and second most common patterns; the tertiary pattern should be recorded if higher than the primary and secondary patterns but it is not incorporated into the Gleason score)

____ Not applicable

____ Cannot be determined

Primary pattern

____ Grade 1

____ Grade 2

____ Grade 3

____ Grade 4

____ Grade 5

Secondary pattern

____ Grade 1

____ Grade 2

____ Grade 3

____ Grade 4

____ Grade 5

Tertiary pattern

____ Grade 3

____ Grade 4

____ Grade 5

____ Not applicable

Total Gleason score: __________

Tumor Quantitation

Proportion (percentage) of prostate involved by tumor: __________ %

&/or

Tumor size (dominant nodule, if present)

Greatest dimension: __________ mm

Additional dimensions: __________ x __________ mm

Extraprostatic Extension (select all that apply)

____ Not identified

____ Present

____ Focal

^*Specify site(s): ______________________________

____ Nonfocal (established, extensive)

^*Specify site(s): ______________________________

____ Indeterminate

Seminal Vesicle Invasion (invasion of muscular wall required)

____ Not identified

____ Present

____ No seminal vesicle present

Margins (select all that apply)

____ Cannot be assessed

^*____ Benign glands at surgical margin

____ Margins uninvolved by invasive carcinoma

____ Margin(s) involved by invasive carcinoma

^*____ Unifocal

^*____ Multifocal

____ Apical

____ Bladder neck

____ Lateral

____ Posterolateral (neurovascular bundle)

____ Posterior

____ Other(s) (specify): ______________________________

Treatment Effect on Carcinoma (select all that apply)

____ Not identified

____ Radiation therapy effect present

____ Hormonal therapy effect present

____ Other therapy effect(s) present (specify): ______________________________

Lymph-Vascular Invasion

____ Not identified

____ Present

____ Indeterminate

^*Perineural Invasion

^*____ Not identified

^*____ Present

Pathologic Staging (pTNM)

TNM descriptors (required only if applicable) (select all that apply)

____ m (multiple)

____ r (recurrent)

____ y (post-treatment)

Primary tumor (pT)

____ Not identified

____ pT2: Organ confined

^*____ pT2a: Unilateral, involving 1/2 of 1 slide or less

^*____ pT2b: Unilateral, involving > 1/2 of 1 slide but not both sides

^*____ pT2c: Bilateral disease

pT3: Extraprostatic extension

____ pT3a: Extraprostatic extension or microscopic invasion of bladder neck

____ pT3b: Seminal vesicle invasion

____ pT4: Invasion of rectum, levator muscles, &/or pelvic wall

Note: There is no pathologic T1 classification. Subdivision of pT2 disease is problematic and has not proven to be of prognostic significance.

Regional lymph nodes (pN)

____ pNX: Cannot be assessed

____ pN0: No regional lymph node metastasis

____ pN1: Metastasis in regional lymph node or nodes

Specify

Number examined: __________

Number involved: __________

Diameter of largest lymph node metastasis: __________ mm

Distant metastasis (pM)

____ Not applicable

____ pM1: Distant metastasis

____ pM1a: Nonregional lymph node(s)

____ pM1b: Bone(s)

____ pM1c: Other site(s) with or without bone disease

Note: When > 1 site of metastasis is present, the most advanced category is used. pM1c is most advanced.

^*Additional Pathologic Findings (select all that apply)

^*____ None identified

^*____ High-grade prostatic intraepithelial neoplasia (PIN)

^*____ Inflammation (specify type): ______________________________

^*____ Atypical adenomatous hyperplasia (adenosis)

^*____ Nodular prostatic hyperplasia

^*____ Other (specify): ______________________________

^*Ancillary Studies

^*Specify: ______________________________

^*____ Not performed

^* Data elements with asterisks are not required. However, these elements may be clinically important but are not yet validated or regularly used in patient management.

Anatomic Stage/Prognostic Groups

Group

T

N

M

PSA

Gleason

1

T1a-c

N0

M0

PSA < 10

Gleason ≤ 6

T2a

N0

M0

PSA < 10

Gleason ≤ 6

T1-2a

N0

M0

PSA < 20

Gleason X

IIA

T1a-c

N0

M0

PSA < 20

Gleason 7

T1a-c

N0

M0

PSA ≥ 10 < 20

Gleason ≤ 6

T2a

N0

M0

PSA < 20

Gleason ≤ 7

T2b

N0

M0

PSA < 20

Gleason ≤ 7

T2b

N0

M0

PSA X

Gleason X

IIB

T2c

N0

M0

Any PSA

Any Gleason

T1-2

N0

M0

PSA ≥ 20

Any Gleason

T1-2

N0

M0

Any PSA

Gleason ≥ 8

III

T3a-c

N0

M0

Any PSA

Any Gleason

IV

T4

N0

M0

Any PSA

Any Gleason

Any T

N1

M0

Any PSA

Any Gleason

Any T

Any N

M1

Any PSA

Any Gleason

Note: When either prostate specific antigen (PSA) or Gleason is not available, grouping should be determined by T stage &/or whichever of either the PSA or Gleason is available. Used with the permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, Seventh Edition (2010) published by Springer Science and Business Media LLC, www.springerlink.com.