Protocol for the Examination of Soft Tissue Tumors



Protocol for the Examination of Soft Tissue Tumors





























































































































































































































































Soft Tissue: Biopsy


Surgical Pathology Cancer Case Summary (Checklist)


Procedure



____ Core needle biopsy



____ Incisional biopsy



____ Other (specify): ______________________________



____ Not specified


Tumor Site



____ Specify (if known): ______________________________



____ Not specified


Tumor Size



Greatest dimension: __________ cm



*Additional dimensions: __________ × __________ cm



____ Cannot be determined


Macroscopic Extent of Tumor (select all that apply)



____ Superficial




____ Dermal




____ Subcutaneous/suprafascial



____ Deep




____ Fascial




____ Subfascial




____ Intramuscular




____ Mediastinal




____ Intraabdominal




____ Retroperitoneal




____ Head and neck




____ Other (specify): ______________________________



____ Cannot be determined


Histologic Type (World Health Organization [WHO] Classification of Soft Tissue Tumors)



Specify: ______________________________



____ Cannot be determined


Mitotic Rate



Specify: __________/10 high-power fields (HPF)



(1 HPF × 400 = 0.1734 mm2; x40 objective; most proliferative area)


Necrosis



____ Not identified



____ Present




Extent: __________ %



____ Cannot be determined


Histologic Grade (French Federation of Cancer Centers Sarcoma Group [FNCLCC])



____ Grade 1



____ Grade 2



____ Grade 3



____ Ungraded sarcoma



____ Cannot be determined


Margins (for excisional biopsy only)



____ Cannot be assessed



____ Margins negative for sarcoma




Distance of sarcoma from closest margin: __________ cm




Specify margin: ______________________________




Specify other close (< 2 cm) margin(s): ______________________________



____ Margin(s) positive for sarcoma




Specify margin(s): ______________________________


*Lymph-Vascular Invasion



*____ Not identified



*____ Present



*____ Indeterminate


*Additional Pathologic Findings



*Specify: _____________________________


Ancillary Studies



Immunohistochemistry




Specify: ______________________________




____ Not performed



Cytogenetics




Specify: ______________________________




____ Not performed



Molecular pathology




Specify: ______________________________




____ Not performed


Pre-biopsy Treatment



____ No therapy



____ Chemotherapy performed



____ Radiation therapy performed



____ Therapy performed, type not specified



____ Unknown


Treatment Effect



____ Not identified



____ Present


*Specify percentage of viable tumor: __________ %



____ Cannot be determined


* *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 Tumors of Soft Tissue.” Web posting date October 2009, www.cap.org.


















































































































































































































































































































































Soft Tissue: Resection


Surgical Pathology Case Summary (Checklist)


Procedure



____ Intralesional resection



____ Marginal resection



____ Wide resection



____ Radical resection



____ Other (specify): ______________________________



____ Not specified


Tumor Site



Specify (if known): ______________________________



____ Not specified


Tumor Size



Greatest dimension: __________ cm



*Additional dimensions: __________ × __________ cm



____ Cannot be determined


Macroscopic Extent of Tumor (select all that apply)



____ Superficial




____ Dermal




____ Subcutaneous/suprafascial



____ Deep




____ Fascial




____ Subfascial




____ Intramuscular




____ Mediastinal




____ Intra-abdominal




____ Retroperitoneal




____ Head and neck




____ Other (specify): ______________________________




____ Cannot be determined


Histologic Type (World Health Organization [WHO] Classification of Soft Tissue Tumors)



Specify: ______________________________



____ Cannot be determined


Mitotic Rate



Specify: __________/10 high-power fields (HPF)



(1HPF × 400 = 0.1734 mm2; x40 objective; most proliferative area)


Necrosis



____ Not identified



____ Present




Extent: __________ %


Histologic Grade (French Federation of Cancer Centers Sarcoma Group [FNCLCC])



____ Grade 1



____ Grade 2



____ Grade 3



____ Ungraded sarcoma



____ Cannot be determined


Margins



____ Cannot be assessed



____ Margins negative for sarcoma




Distance of sarcoma from closest margin: __________ cm




Specify margin: ______________________________




Specify other close (< 2 cm) margin(s): ______________________________



____ Margin(s) positive for sarcoma




specify margin(s): ______________________________


*Lymph-Vascular Invasion



*____ Not identified



*____ Present



*____ Indeterminate


Pathologic Staging (pTNM)



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




____ m (multiple)




____ r (recurrent)




____ y (post-treatment)



Primary tumor (pT)




____ pTX: Primary tumor cannot be assessed




____ pT0: No evidence of primary tumor




____ pT1a: Tumor ≤ 5 cm in greatest dimension, superficial tumor




____ pT1b: Tumor ≤ 5 cm in greatest dimension, deep tumor




____ pT2a: Tumor > 5 cm in greatest dimension, superficial tumor




____ pT2b: Tumor > 5 cm in greatest dimension, deep tumor



Regional lymph nodes (pN)




____ pNX: Regional lymph nodes cannot be assessed




____ pN0: No regional lymph node metastasis




____ pN1: Regional lymph node metastasis




Specify: Number examined: __________




Number positive: __________



Distant metastasis (pM)




____ Not applicable




____ pM1: Distant metastasis




*Specify site(s), if known: ______________________________


*Additional Pathologic Findings



*Specify: ______________________________


Ancillary Studies



Immunohistochemistry




Specify: ______________________________




____ Not performed



Cytogenetics




Specify: ______________________________




____ Not performed



Molecular pathology




Specify: ______________________________




____ Not performed


Pre-resection Treatment (select all that apply)



____ No therapy



____ Chemotherapy performed



____ Radiation therapy performed



____ Therapy performed, type not specified



____ Unknown


Treatment Effect



____ Not identified



____ Present


*Specify percentage of viable tumor: __________ %



____ Cannot be determined


* *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 Tumors of Soft Tissue.” Web posting date October 2009, www.cap.org.

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Jul 9, 2016 | Posted by in PATHOLOGY & LABORATORY MEDICINE | Comments Off on Protocol for the Examination of Soft Tissue Tumors
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