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.