Download Proforma for histopathology reporting

Malignant Salivary Gland Neoplasms Proforma
Mandatory questions (i.e. protocol standards) are in bold (e.g. S1.03).
Sex
Family name
Male
Female
Given name(s)
Intersex/indeterminate
Ethnicity
Unknown
Date of birth
Aboriginal/Torres Strait Islander
DD – MM – YYYY
Other ethnicity:
Patient identifiers
e.g. MRN, IHI or NHI (please indicate which)
S1.03
Accession number
DD – MM – YYYY
Requesting doctor - name and contact details
S1.02
Clinical details
Other anatomical site
Type of operation
incisional biopsy
excisional biopsy of minor gland
Laterality of the lesion
resection of submandibular gland
Left
Right
extended resection submandibular gland
(record extent of anantomicalresection)
Clinical history
resection of sublingual gland
+facial nerve sacrifice
- facial nerve sacrifice
superficial parotidectomy
total parotidectomy
Clinical TNM stage
facial nerve preservation
facial nerve sacrifice
extended radical total parotidectomy
(includes resection of parotid gland, facial nerve,
other
neck dissection
Clinical diagnosis or differential diagnosis
masseter muscle, zygoma and mandible)
selective
modified radical
radical
extended radical
Laterality of neck dissection
Left
Right
Date of request
Bilateral
New primary cancer or recurrence
New primary
Recurrence - regional
Recurrence - distant
Details:
Nodal levels included (tick all that apply)
(Record separately for each laterality)
submental (IA)
upper jugular (IIA)
middle jugular (III)
posterior triangle (VA)
submandibular (IB)
Pre-operative or prior radiotherapy administered
upper jugular
(IIB)
Yes
None adminstered
lower jugular (IV)
Details:
posterior triangle (VB)
other nodal tissue
(specify)
Anatomical site of neoplasm
Parotid gland Submandibular gland
Sublingual gland
whole
Minor
salivary gland
superficial lobe
deep lobe
Site(s)
Involvement of adjacent structures
S1.04 Principal clinician
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G1.01
Other relevant details
S2.06
Macro. evidence of extraparenchymal
extension
Absent
Present
Neck dissection
S2.07
Macroscopic findings
S2.01
Specimen labelled as
Absent
Present
Specify type:
selective
modified radical
radical
extended radical
S2.02
Specimen type
(choose all that apply)
Laterality of neck dissection:
Parotid gland - whole
Left
Parotid gland - superficial lobe
length mm
Submandibular gland
Sublingual gland
Minor salivary gland
Bilateral
Dimensions:
Parotid gland - deep lobe
Right
Description
x width
mm
x thickness
mm
(Note: Include for example any anatomical
structures):
Specify sites
Neck dissection
Biopsy incisional
S2.08
Biopsy excisional
MACROSCOPIC LYMPH NODE STATUS
Not received
Biopsy resection
Other (specify)
Received
submental (level IA)
Largest node:
G2.01
S2.03
S2.04
Specimen integrity
submandibular (level IB)
Intact
Fragmented
Largest node:
upper jugular (level IIA)
Specimen received
Fresh
Formalin
Largest node:
upper jugular (level IIB)
Specimen measurements
length mm
x width
mm
x thickness
Largest node:
mm
middle jugular (level III)
S2.05
Description & measurements of lesion
Size
length mm
Site
x width
mm
x thickness
mm
Largest node:
lower jugular (level IV)
Largest node:
(Note: Site should include laterality)
posterior triangle (level VA)
Appearance
Largest node:
posterior triangle (level VB)
Largest node:
Version 0.1 Proforma: Salivary Gland Neoplasms Structured Reporting Protocol 1st Edition
(Note: if bilateral
record for both):
number received
mm
number received
mm
number received
mm
number received
mm
number received
mm
number received
mm
number received
mm
number received
mm
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G2.02
Other macroscopic comments
Site(s) (Choose all that apply)
Skin
Mandible
Ear canal
Facial nerve
Base of skull
S2.09
Pterygoid plates
Block identification key
Carotid artery encasement
Other (specify)
S3.05
Microscopic findings
S3.01
Perineural involvement
Histological tumour type
Acinar cell carcinom
Mucoepidermoid carcinoma
Adenoid cystic carcinoma
S3.06
Not identified
Present
Lymphovascular invasion
Polymorphous low grade adenocarcinoma
Epithelial-myoepithelial carcinoma
Not identified
Present
Clear cell adenocarcinoma, NOS
Basal cell adenocarcinoma
Sebaceous carcinoma
S3.07
Sebaceous lymphadenocarcinoma
SURGICAL MARGIN STATUS
Margin 1
(specify)
Cystadenocarcinoma
Low-grade cribiform cystadenocarcinoma
Mucinous adenocarcinoma
Involved
Not involved
Oncocytic
carcinoma
Distance to
tumour Salivary duct carcinoma
Adenocarcinoma, NOS
Margin 2
Myoepithelial carcinoma
(specify)
Carcinoma ex pleomorphic adenoma
Carcinosarcoma, NOS
Metastasizing pleomorphic adenoma
Involved
Not involved
Squamous cell carcinoma
Distance to
tumour Small cell carcinoma
Large cell carcinoma
Lymphoepithelial
carcinoma
(specify)
HISTOLOGICAL GRADE
Grading system:
Involved
Not involved
Distance to
tumour Grade/score:
S3.08
S3.04
x width
mm
x thickness
mm
Involvement of adjacent structures
(Note: if bilateral
record for both):
Total number of nodes
Tumour size
length mm
mm
Cervical lymph node
status
submental (level IA)
S3.03
mm
Margin 3
Sialoblastoma
S3.02
mm
Not applicable
Absent
Present
Number of involved nodes
submandibular (level IB)
Total number of nodes
Number of involved nodes
List sites
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S3.08
Lymph node status (cont.)
Distance from closest perinodal surgical
margins
upper jugular (level IIA)
mm
Total number of nodes
Number of involved nodes
Permeation of perinodal lymphatics
Absent
upper jugular (level IIB)
Total number of nodes
Present
G3.01
Number of involved nodes
Other microscopic comments
middle jugular (level III)
Total number of nodes
Number of involved nodes
Ancillary test findings
lower jugular (level IV)
S4.01
Total number of nodes
Number of involved nodes
IMMUNOHISTOCHEMICAL STAINS
No
Pending
Yes
Complete details:
posterior triangle (level VA)
Positive Abs
Total number of nodes
Negative Abs
Number of involved nodes
Equivocal Abs
posterior triangle (level VB)
Interpretation
Total number of nodes
Number of involved nodes
Largest metastastic deposit
Clinical significance
Location
Dimensions
length mm
S4.02
x width
mm
x thickness
mm
Extracapsular spread
Absent
Present
Pending
Yes
Complete details:
Performing laboratory
Extent of invasion from nodal capsule:
IN-SITU HYBRIDISATION
No
Result
mm
Number of nodes with extracapsular spread:
If 1, record the no.
of foci /tongues
Conclusion
Structures involved in extracapsular spread:
Person responsible for reporting
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S4.03
S5.01 Stage & stage group##
CYTOGENETICS
No
Pending
Yes
Primary Tumour (T)
Complete details:
Performing laboratory
Result
TX
Primary tumour cannot be assessed
T0
No evidence of primary tumour
T1
Tumour 2 cm or less in greatest dimension without
extraparenchymal extension*
T2
Tumour more than 2 cm but not more than 4 cm in
greatest dimension without extraparenchymal extension*
T3
Tumour more than 4 cm and/or tumour having
extraparenchymal extension*
T4a
Moderately advanced disease. Tumour invades skin,
mandible, ear canal, and/or facial nerve
T4b
Very advanced disease. Tumour invades skull base and/or
pterygoid plates and/or encases carotid artery
Notes: Extraparenchymal extension is clinical or macroscopic
evidence of invasion of soft tissues. Microscopic evidence
alone does not constitute extraparenchymal extension for
classification purposes.
Conclusion
Regional Lymph Nodes (N)
Person responsible for reporting
Synthesis and overview
S5.01
AJCC Tumour stage (see opposite)
T
N
M
NX
Regional lymph nodes cannot be assessed
N0
No regional lymph node metastasis
N1
Metastasis in a single ipsilateral lymph node, 3 cm or less
in greatest dimension
N2
Metastasis in a single ipsilateral lymph node, more than 3
cm but not more than 6 cm in greatest dimension, or in
multiple ipsilateral lymph nodes, none more than 6 cm in
greatest dimension, or in bilateral or contralateral lymph
nodes, none more than 6 cm in greatest dimension
N2a
Metastasis in a single ipsilateral lymph node, more than 3
cm but not more than 6 cm in greatest dimension
N2b
Metastasis in multiple ipsilateral lymph nodes, none more
than 6 cm in greatest dimension
N2c
Metastasis in bilateral or contralateral lymph nodes, none
more than 6 cm in greatest dimension
N3
Metastasis in a lymph node, more than 6 cm in greatest
dimension
Distant Metastasis (M)
S5.02
G5.01
G5.02
Stage Grouping
Year of publication and edition of
cancer staging system
No distant metastasis
M1
Distant metastasis
Anatomic Stage/Prognostic Groups
Diagnostic summary
Include: Type of operation; Anatomical site/
laterality; Tumour type; Histological grade;
Tumour dimensions; Extraglandular extension
of tumour; LVI; Perineural invasion; Involved or
close margins with measurements; Type of neck
dissection (if present); Presence or absence of
metastatic tumour in lymph nodes and level of
involved nodes; Presence or absence of extracapsular spread of tumour; Ki-67 index; Tumour
stage.
M0 Stage I
T1
N0 M0
Stage IVA
T1
N2
M0
Stage II
T2
N0 M0
T2
N2
M0
Stage III
T3
N0 M0
T3
N2
M0
T1
N1 M0
T4a
N2
M0
T2
N1 M0
Stage IVB
Any T
N3
M0
T3
N1 M0
Stage IVA T4a
N0 M0
N1 M0
##
T4a
Stage IVC
T4b
Any N
M0
Any T
Any N
M1
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
.
Other relevant comments
Worksheet prepared by:
On:
DD – MM – YYYY
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