Sentinel Lymph Node Mapping-Pathology Protocol in Breast Cancer.

Sentinel Lymph Node Mapping-Pathology Protocol.

Sentinel lymph node mapping is now performed on selected patients who opt for conservative surgery to treat their breast cancer.
The procedure involves the surgical identification of those axillary lymph nodes that theoretically would be the first ‘‘sentinel’’ nodes to receive the lymphatic drainage from the breast harboring the invasive cancer. If these nodes are pathologically negative, the patient is spared the morbidity associated with a standard axillary node dissection.

Surgical identification is based on the peritumoral injection of radioactive solutions and/or colored dyes. The surgeon then massages the breast to facilitate permeation of the solution into the lymphatic system. Several hours after the injection, the patient is taken to the operating room, where the surgeon uses a radioactive counter to locate the ‘‘hot’’ lymph node. If a colored dye has been used, visual inspection of the axilla usually identifies the sentinel lymph node. Usually, the pathologist receives 1 to 3 lymph nodes for evaluation.

Some centers use cytologic imprints, either with or without frozen section evaluation,at the time of surgery to determine whether the sentinel node is involved by metastatic tumor. If the imprintsare positive, then the surgeon proceeds to an axillary node dissection. Other hospitals submit their sentinel lymph node biopsies for routine processing without intraoperative consultation.
Once the specimen is received in the pathology laboratory, the pathologist must carefully dissect out all the nodes and record the number and sizes. If it is technically feasible, each node should be serially sectioned at 2- to 3-mm intervals, parallel to the long axis, and entirely submitted for evaluation. One hematoxylineosin–stained section should be cut from each block for light microscopy. Additional unstained levels may also be requested at the time of sectioning, in the event that immunohistochemical analysis of the node will be required to confirm the diagnosis of metastatic disease. Although some studies advocate using immunohistochemistry on all histologically negative lymph nodes, the current College of American Pathologists guidelines state that this procedure is not the standard of care for pathologic evaluation of sentinel lymph nodes in patients with invasive breast cancer.

Metastasis and prognosisMacrometastases (>2 mm) have a clear influence on prognosis
Micrometastases (>0.2 mm, < or =" 2">
References:
Cserni G. Evaluation of sentinel lymph nodes in breast cancer. Histopathology 2005;46:697–702.
Weaver DL. Pathological evaluation of sentinel lymph nodes in breast cancer: a practical academic perspective from America. Histopathology 2005;46:702–6.
Bobrow L, Pinder S. Histopathology and the SLN. In: Sentinel lymph node biopsy handbook—NEW START. London: RoyalCollege of Surgeons of England; 2004. p. 88–94.

Errors in Surgical Pathology

Errors in Anatomic Pathology
Extracts of the interview with Dr. Stephen Raab, Professor of Pathology, Vice-Chair for Quality and Director of Anatomic Pathology at the University of Colorado, Denver.
Q: How many errors have been reported to date ?

Dr. Raab: There are now more than 25,000 errors in the database.

Q: What are some area for quality improvement in anatomic pathology?
Dr. Raab: Quality improvement is more effective if there are simultaneous efforts to improve quality in specimen collection, laboratory processing, and pathologist interpretation, rather than just focusing on error in pathology interpretation.

Q: Error detection is critical to quality improvement. How are errors usually detected in anatomic pathology?
Dr. Raab: The two most common methods of error detection are cytologic-histologic correlation and secondary review of previously reported cases.

Q: What kind of errors do these methods detect?
Dr. Raab: They detect many different errors including mislabeled specimens, suboptimal specimens -for example a cytology or histology specimen that fails to sample the cancerous area of a mass-, and errors in interpretation by a pathologist.

Q: What is your general approach to interventions to decrease errors in anatomic pathology?
Dr. Raab: Enhanced communication. Disconnection between pathologists and direct care providers is a significant latent source of errors in pathology. When pathologists communicate more frequently with care providers, the quality of the pathologist's work improves because both the clinician and pathologist are better informed about the patients.
some examples of enhanced communication between pathologists and care providers are as follows:
1) Pathologists calling their diagnosis directly to the physician caring for the patient,
2) Increasing the number of conferences at the multiple-headed scope with both pathologists and care providers present,
3) Having the pathologist physically present when a different physician collects a fine needle aspirate.
4) The specimen collector, who is often a direct care provider or radiologist, receives immediate feedback from the pathologist regarding the adequacy of the specimen.
Using a checklist in the gynecologist office to maximize the likelihood of an adequate specimen.

Q: Besides increased communication, what other interventions do you favor regarding decreasing errors in pathologist interpretation?
Dr Raab: The key to decreasing errors in pathologist interpretation of an adequate specimen is standardization. Standardization is basically an agreement that work is going to be done a certain way. It requires that standards be developed at a national or international level, than adhered to by each pathology practice. To achieve standardization, the pathologists in the practice must work together as a group and apply methods such as:
1) Reviewing a sampling of each other's cases
2) Meeting frequently around the multiple-headed scope to decide cases by a consensus-building process.
Practices dominated by individualists or egotists tend to resist change and have trouble standardizing. Unfortunately, many practicing pathologists strongly resist standardization.

Q: What is the "Big Dog" effect ?
Dr. Raab: At many institutions, there is a dominant senior pathologist, the Big Dog, who becomes the gold standard of anatomic pathology. The other pathologists follow the diagnostic beliefs of the Big Dog, and defer to the Big Dog on difficult cases and in the analysis of the cause of an error.

Q: What are the problems caused by Big Dogs?
Dr. Raab: There is a poor agreement between Big Dogs from different institutions in their interpretation of a particular case. This makes it hard to achieve standardization regarding a diagnosis. In addition, Big Dogs agree poorly regarding their assessment of the causes of an error. This hinders quality improvement, since judgments regarding root causes of an error provide a guide for the choice of interventions.

References:
1. Raab SS et al. Patient safety in anatomic pathology: measuring discrepancy frequencies and causes. Arch Pathol Lab Med. 2005;129:459-466.
2. Raab SS et al. Errors in thyroid gland fine-needle aspiration. Am J Clin Pathol. 2006;125:873-882.

Importance of Tissue fixation in Cancer management

“Do you want a quick result, or the right result?”

There is always a pressure on the laboratory (and the pathologist) to turn specimens around quickly, so that decisions can be relayed to anxious and expectant patients.

Proper specimen handling and preparationhas been under-appreciated by clinicians and pathologists alike.How preanalytical variables such as tissue handing and tissue fixation have the potential to significantly and adversely affect the accurate assessment of therapeutic targets such as ER/Her2neu in tumor specimens.,must be understood properly.

Following are the Consensus Recommendations on Estrogen Receptor Testing in Breast Cancer By Immunohistochemistry by Members of the Standardization Ad-Hoc Consensus Committee.

1. As soon as they are available from the operating room, breast specimens with a known cancer, or a suspicion of cancer, should be oriented, inked, carefully sectioned at 0.5 to 1 cm intervals and placed in the appropriate volume of fixative with gauze pads or paper towels in between slices to assist with the penetration of fixative into all areas of the tissue.


2. In addition,if gross tumor is easily identifiable, the pathologist (or pathology assistant) should remove a 2-mm thick sample of tumor, together with a 2-mm thick sample of benign tissue and place both into the same cassette at the time of the initial evaluation, thus ensuring that normal breast elements are available as appropriate internal tissue controls for subsequent breast marker testing.


3. Breast core biopsies should be fixed and processed in an identical manner to excision specimens.


4. Only 10% aqueous phosphate-buffered 4% formaldehyde pH 7.0-7.4 (10% phosphate-buffered formalin) should be used as the fixative for breast tissue samples.


5. Minimum fixation times of at least 8 hours optimally 24 to 48 hours, not to extend to more than 72 hours are recommended for all laboratories accepting breast tissue samples.

There is a misconception that smaller biopsy samples will fix more quickly than larger resection specimens and therefore require less time in formalin. It is true that formalin will penetrate smaller samples more quickly than larger samples, but actual fixation is a chemical reaction that takes time.Penetration time of formalin is of little importance than the chemical reaction time .For example, a single layer of cells is penetrated by formalin extremely rapidly, however the chemical reaction requires 24 hours to complete. A 4-mm thick slice of tissue is fully penetrated within an hour and requires 25 hours for the chemical reaction to complete.

Having a record of the fixation time for each breast tissue sample is expected to prove valuable for interpreting and troubleshooting aberrant and/or unexpected ER results.One such example would be when an ER IHC assay is found to be negative in a well-differentiated cancer such as a tubular carcinoma or a classic lobular carcinoma. This result would be unexpected, and having access to the details on tissue fixation, such as a long delay before the initiation of fixation or short fixation time in formalin would be valuable in interpreting the validity of the unexpected results for such a patient.

Reference:

Consensus Recommendations on Estrogen Receptor Testing in Breast Cancer By Immunohistochemistry;Hadi Yaziji et al.Apllied immunohistochem Mol.Vol16,Dec.2008

Measuring size of DCIS

Measuring Size (Extent) of DCIS

Although not required for pT classification or stage assignment, the size (extent) of DCIS is an important factor in patient management. Although a precise measurement is often not possible, an estimate of the extent of DCIS is clinically important.

Size /Extent of Ductal Carcinoma In Situ (DCIS) and Clinical Significance
DCIS Size/ Extent
Up to 2 cm:Breast conservation with wide negative margins can be achieved in most women.
>2-4 cmWide negative margins may be difficult to achieve in some women with breast-conserving surgery.

>4 cm
Breast conservation with wide negative margins may be impossible to achieve in some women.
There is a possibility of undetected areas of invasion if the area involved by DCIS is not completely examined. Lymph node sampling may be recommended.

Methods to measure DCIS:
DCIS in One Block:
The area involved by DCIS can be measured from a single slide, if DCIS is present in only one block. If separate foci are present on the same slide, the largest distance between foci should be reported. This method will underestimate the extent of DCIS when multiple blocks are involved, and should not be used in such cases.
DCIS in multiple blocks in case of Serial Sequential Sampling:

The entire specimen is blocked out in such a way that the location of each block can be determined. The extent of the DCIS can be calculated by using a diagram of the specimen, the thickness of the slices, and the location of the involved blocks. This method is recommended for all excisions likely to harbor DCIS or with previously diagnosed DCIS (eg, by diagnosis on a prior core needle biopsy).

DCIS in case of Nonsequential Sampling:

Multiplying the number of blocks involved by DCIS by the approximate width of a tissue section gives an estimate of the extent. ( multiplying by 0.4 cm is recommended,which is size of tissue thickness)

Specimen sampling to measure size of DCIS:

For specimens with a known diagnosis of DCIS (eg, by prior core needle biopsy) it is highly recommended that the entire specimen is examined using serial sequential sampling to exclude the possibility of invasion, to completely evaluate the margins, and to aid in determining extent.If an entire excisional specimen or grossly evident lesion is not examined microscopically, it is helpful to note the approximate percentage of the specimen or lesion that has been examined.

References:

1. Silverstein MJ, Poller D, Craig P, et al. A prognostic index for ductal carcinoma in situ of the breast. Cancer. 1996;77:2267-2274.
2. Grin A, Horne G, Ennis M, O’Malley FP. Measuring extent of DCIS in breast excision specimens: a comparison of four methods. Arch Pathol Lab Med. 2009;133:31-37.
3. Dadmanesh F, Fan X, Dastane A, Amin MB, Bose S. Comparative analysis of size estimation by mapping and counting number of blocks with DCIS in breast excision specimens. Arch Pathol Lab Med. 2009;133:26-30.

4. ww.cap.org

HER2/neu Marker in Breast Cancer

Quality Management Requirements for HER2/neu Marker in Breast Cancer
Recommendations of the HER2/neu Advisory Committee,Ontario,Canada

The testing laboratory must have an established immunohistochemistry program with sufficient volume to maintain technical/professional knowledge and skill. (The UK guidelines recommend performance of 250 IHC and, if applicable, 100 FISH tests per year1). For Ontario, we recommend a minimum of 20 HER2/neu IHC tests per month or 240 HER2/neu tests per year.

The laboratory must have a quality assurance improvement program that provides for the required quality control and uses quality indicators to determine whether performance is meeting the quality standard.

At least one pathologist from each centre, involved in the reading and interpretation of
immunohistochemical preparations in situ hybridization for HER2/neu, must complete appropriate training.

Quality Assurance Requirements - To be read in conjunction with the Testing Algorithm Schematic
It is recommended that tissue be fixed with 10% phosphate buffered formalin (4% formaldehyde),pH 7.0. The optimal fixation time is 8 to 48 hours.
Antibodies currently used in Ontario include monoclonal antibody CBll (Novocastra), monoclonal antibody TAB250 (Zymed), polyclonal antibody A0485 (DAKO) and the HercepTest Kit (DAKO). Assays using these antibodies have been optimized and instructions must be followed precisely. Other appropriately validated antibodies may be used.

If immunohistochemical detection of HER2/neu is carried out using more than one antibody then the antibodies should be directed at different epitopes.

If the findings with the second IHC antibody remain equivocal/indeterminate, in-situ hybridization (FISH or chromogenic in-situ hybridization [CISH]) testing is required.

Controls using tissue and, if possible, cell lines demonstrating high, intermediate and low level HER2/neu amplification, should be run in parallel with patient testing. Patient tests must be repeated when the controls are non-conforming. The report should include an estimate of the % positive cells as well as intensity of staining. If the HercepTest kit is used, the recommended scoring system of 0-3+ should be reported as well as the percentage of positive cells.

The target turnaround time from receipt of the tissue block in the laboratory to report should be within one week and not longer than two weeks. The laboratory must confirm indeterminate IHC results using either FISH / CISH or arrange to have such confirmation carried out by a named referral laboratory that has agreed to provide this service.

Approximately 15 to 30% cases may require FISH. The laboratory must document and maintain a record of the number of patient samples processed and the number of positives, negatives and indeterminates. The percent positives should be calculated on a regular basis as one of the quality indicators.

REFERENCES
1. Ellis 10, Bartlett J, Dowsett M et al. Updated recommendations for HER2/neu testing in the UK. J Clin Pathol, 2004;57:233-237.
2. W. HannaF,P O'Malley. Updated recommendations from the HER2/neu consensus
meeting-Toronto, Ontario, September 2001. Current Oncology. 2002; 9 (Suppl. 1): S18-
S19.

Quirke's Method For Dissecting Colorectal Adenocarcinoma

Quirke's Method For Dissecting Colorectal Adenocarcinoma.
This is Philip Quirke's method for assessing colorectal adenocarcinoma as demonstrated for the MRC-CR07 trial participants. The first step is to assess the colon for completeness of mesorectal excision. A grade of 1, 2 or 3 (3 is best) is given.
Gross pathologic assessment of completeness of mesorectal excision (i.e. complete excision of the rectal mesentery or mesorectal fat pad) be reported on all rectal cancers. The purpose of this is to identify those patients who are more likely to recur postop., giving prognostic information and thus affecting followup . There is no doubt that complete mesorectal excision will reduce local recurrence rates (from 30-40% without TME, down to 3.7% with TME (as reported by Heald).

Quirke's graded assessment of completeness of mesorectal excision (MRC trial)
3-Good: Intact mesorectum with only minor irregularities of a smooth mesorectal surface. No defect is deeper then 5 mm. No coning on the specimen. Smooth CRM on slicing.

2-Moderate: moderate bulk to the mesorectum but irregularity of the mesorectal suface. Moderate coning of the specimen towards the distal margin. At no site is the m.propria visible with the exception of the insertion of levator muscles. Moderate irregularity of CRM.

1-Poor: Little bulk to mesorectum with defects down onto m.propria and/or very irregular cirumferential resection margin.

Notes
- Coning refers to the tendency for the surgeon to cut towards the colon and breachthe mesorectal envelope as he goes distal rather than staying outside the mesorectal plane. This gives a tapered conical appearance rather than a bulky distal mesorectal fat pad. This can also lend a ragged appearance to the specimen since the surgeon may realize his mistake and go outside the mesorectum to find the correct plane once again, leaving gashes in what should be a smooth mesorectal surface.
- Is it possible for the entire mesorectum to be removed even though it has a ragged appearance? Yes, but it doesn't matter. Once the mesorectum has been violated the risk for spillage of tumour from lymphatics exists. A ragged specimen without a smooth surface must therefore be a grade 2.

Guidelines for Colo rectal resection: Margins and lymph nodes

Optimization of Pathological Quality Performance in Radical Surgery for Colon and Rectal Cancer: Margins and Lymph Nodes Guideline Recommendations : Cancer Care Ontario,Canada


Question:
What is the recommended approach to processing and reporting the resected specimen, including specimen marking in the operating room, as well as processing and reporting requirements in the pathology laboratory?
Answer:Proximal and Distal Margins
The surgeon should communicate with the pathologist regarding the orientation of the specimen.
Proximal and distal margins should be sampled for histological examination.
The distance of the tumour to the proximal and distal margins should be reported in the fresh state, if possible. Measurement in the fixed state must take into account the fact that shrinkage will have occurred; pinning the fresh specimen to a board, under tension, will produce less shrinkage. If the tumour is close to a margin, the distance between the tumour and the margin of concern should be reported as measured microscopically on the glass slide.
Radial Margins
The surgeon must clearly indicate to the pathologist areas with close contact to other organs or the abdominal wall. The pathologist should be aware of the retroperitoneal margin that exists in certain locations (e.g., proximal ascending colon and descending colon).
The radial margins of the resected specimen should be inked and sectioned.
The radial margin distance must be reported. The radial margin should be reported as positive if tumour is located 1 mm or less from the inked nonperitonealized surface of the specimen.


Margins of Resection: Rectum
Technical Recommendations

Technical recommendations are based on the Expert Panel consensus informed by the technical issues highlighted in four key papers in the field (2-5), as well as pathology studies identified in the recent literature search.


Proximal and Distal Margins
Proximal and distal margins should be sampled for histological examination.
Pathologists should pay close attention to mesorectal soft tissue, in addition to the mucosa, when assessing the distal margin.
Circumferential Radial Margins
All rectal cancer specimens should be assessed grossly by the pathologist using the method developed by Quirke .
The mesorectal tissue that constitutes the CRM, including all non-peritonealized bare areas anteriorly and posteriorly, should be inked. The specimen should be
fixed with the tumour segment unopened 5 cm above and below the proximal and distal edges of the tumour, respectively, and a gauze wick placed into the unopened segment to facilitate fixation. Following at least 48 hours of fixation, the segment with the tumour should be sliced into transverse sections. The relationship of the tumour to the CRM must be carefully assessed.
The CRM distance must be reported. The CRM is positive if the tumour is located 1 mm or less from the margin; this includes tumour cells within a lymph node, vein, or nerve, as well as direct tumour extension.
Note that tumours of the upper rectum have a peritonealized anterior surface and a non-peritonealized posterior radial margin similar to the ascending and descending colon.


Serosal Penetration
Involvement of the serosa by tumour (pT4b) is not equivalent to involvement of the radial margin by tumour (although there are circumstances in which an advanced tumour has penetrated the serosa and is adherent to adjacent soft tissue).
Documentation of serosal involvement by tumour requires careful gross and microscopic examination and may require extensive sampling and/or serial sectioning of sampled tissue blocks.Serosal penetration is defined as occurring when any of the following criteria are met:
Free tumour cells are present on the serosal surface with underlying ulceration.
Tumour is present at the serosal surface with an associated inflammatory reaction, mesothelial hyperplasia, and/or erosion or ulceration.
The tumour is close to, but not at the serosal surface but there is an associated mesothelial inflammatory and/or hyperplastic reaction.


Serosal penetration is an independent prognostic variable and has a strong negative impact on prognosis. The frequency of distant metastasis is greater in cases with perforation of the visceral peritoneum compared to cases with direct invasion of adjacent organs or structures without perforation of the visceral peritoneum, and the median survival time following surgical resection for cure is shorter for patients with pT4b tumours compared to those with pT4a tumours (with or without distant metastasis).


Lymph Node Assessment

Technique of Lymph Node ExaminationTechnical recommendations are based on Expert Panel consensus informed by four key papers in the field (2-5) and pathology studies identified in the recent literature search.
Pericolic fat should be carefully examined using inspection and palpation. For colonic tumours, examination should occur after pericolic fat has been stripped off the colon and after any appropriate sections have been taken to evaluate the radial margin.
In the case of rectal tumours, the cross-sectioned slices are examined for lymph nodes, taking care not to double count lymph nodes that might be present in more than one cross-sectional slice.
All lymph nodes present must be examined histologically. Nodal examination must not stop once 12 nodes have been identified. It is particularly important to find small lymph nodes close to the underlying bowel wall. If less than 12 lymph nodes are
found, consideration should be given to placing the fat into a lymph node highlighting solution.
All grossly negative or equivocal lymph nodes must be submitted in their entirety. However, if a node is grossly positive, partial submission is acceptable.
Number of Lymph Nodes Assessed
Technical Recommendations
Technical recommendations are based on Expert Panel consensus informed by four key papers in the field (2-5) and pathology studies identified in the recent literature search.
The pathology report should indicate the number of positive lymph nodes as well as the total number of nodes assessed.
The number of lymph nodes involved by micrometastases (tumour deposits >0.2 mm but <2.0>

RELATED GUIDELINES
Practice Guideline Report #2-20-2: Laparoscopic Surgery for Cancer of the Colon, September 2005
Practice Guideline Report #2-9: Follow-up of Patients with Curatively Resected Colorectal Cancer, January 2004
Diagnostic Imaging Recommendations Report: Cross-sectional Imaging in Colorectal Cancer, April 2006
Multidisciplinary Care Conference Standards, June 2006
Evidence-Based Series: #2-29: Adjuvant Systemic Chemotherapy for Stage II and III Colon Cancer Following Complete Resection, April 2008
Evidence-Based Series #2-4: Preoperative or Postoperative Therapy for the Management of
Patients with Stage II or III Rectal Cancer [In progress]

Papillary Thyroid Ca Criteria in Cytology

Papillary Thyroid Ca Criteria in Cytology (Kini)

5 criteria "Definite"; 4 criteria "Suspicious"; 3 criteria "Follicular Lesion"

Adequate Specimen: 6 clusters of 10-15 cells

1 Syncytial tissue fragments
2 Enlarge nuclei with fine dusty chromatin
3 Multiple micro and or macro nucleoli
4 Intranuclear inclusions
5 Nuclear grooves

Papillary Thyroid Ca Diagnostic Criteria in Histology

4 Major or (3 Major + 4 Minor required)

Major Criteria
1 Nuclei oval (not rounded)
2 Nuclei crowded, manifesting as lack of polarization in cells lining a follicle and overlapping nuclei
3 Pale chromatin esp. at the edge of the tissue where well-fixed
4 Psammoma bodies

Minor Criteria
1 Abortive papillae
2 Elongated or irregular follicles
3 Dark staining colloid
4 Rarely nuclear pseudo inclusion
5 Multinucleated histiiocytes in lumens of follicles
6 Grooves


Ref:
1 Chan JKC Strict criteria should be applied in the diagnosis of encapsulated follicular variant of papillay thyroid ca. AJCP 2002;117:16-18
2 Balock ZW, LiVolsi VA Follicular-patterned lesions of the thyroid. AJCP{ 2002;117:143-150

Guidelines for Radical Prostatectomy Specimen Handling

Guideline for Optimization of Pathological Quality Performance for Radical Prostatectomy in Prostate Cancer Management:CANCER CARE ONTARIO,CANADA GUIDE LINES.

Pathological Questions

1. What are the recommended procedures for handling the RP specimen in the operating
room and for handling and processing the RP specimen (with or without lymph nodes)
in the pathology lab?
2. What diagnostic and prognostic elements should be included in the pathology report,what format should be used, and what reporting elements should be included?

Answers:

(1)Handling of the Radical Prostatectomy Specimen in the Operating Room

• Frozen section analysis of the radical prostatectomy specimen (RPS) for margin status is not recommended.
• For routine handling, the RPS should be fixed in 10% neutral buffered formalin or other appropriate fixative. The specimen should be put in an appropriately sized container with a minimum formalin/tissue ratio of 10:1 (i.e., 500 cc formalin for a 50 cc prostate).

Pathology Requisition Information
• The surgical specimen should be accompanied by an appropriate pathology requisition
that includes demographic and other identifying information, relevant clinical data (e.g.,serum PSA, DRE findings [T1c versus T2], Gleason score on biopsy), and the history of neoadjuvant therapy (e.g., hormones )

Pathology Report
• The surgical pathology report should include the relevant diagnostic and prognostic information as outlined in the CAP Cancer Protocol for Carcinomas of the Prostate Gland
(2) CCO has recommended as a minimum standard that all mandatory elements on the CAP checklist (Section 2: Appendix 2) be included in the RPS pathology report.
• It is recommended that the diagnostic and prognostic factors be presented as a synopsis as opposed to a narrative or paragraph form. Data from CCO indicates that synopses are more likely to be complete.

Technical Considerations for Handling and Processing the Radical Prostatectomy Specimen in the Pathology Laboratory
• In the Pathology Laboratory, the RPS (with or without lymph nodes) is accessioned in the usual fashion.
• The RPS should be fixed in neutral buffered formalin (minimum 10:1 ratio) for a minimum of 18-24 hours prior to sectioning. A microwave-assisted technique may be used to reduce fixation time.
• The prostate gland should be weighed and measured in three dimensions; seminal vesicles should be measured; accompanying lymph node specimens should also be measured and a record made of the number and size of grossly identified nodes.
• The outer aspects of the RPS should be carefully inked to identify the surgical margins,prior to tissue banking.
• After appropriate fixation and inking, the distal apical segment is transected and then serially sectioned, perpendicular to the inked surface. An en face (shave) technique is to be discouraged at the apex, as this approach can result in false-positive margin interpretation.
• The basal (bladder neck) aspect is commonly doughnut shaped and irregular. It is transected from the main specimen and should also be submitted in a perpendicular fashion to minimize the possibility of a false-positive margin at this location.
• The intervening transverse sections can be either totally or subtotally submitted using regular-sized blocks. The submission protocol should be documented with an appropriate diagramatic or written block legend.
• For subtotal submissions, a systematic approach to include the posterolateral peripheral zone should be used.
• All lymph nodes accompanying the RPS should be submitted for histological analysis. It is not necessary to submit all perinodal fat, although it is often difficult to distinguish between adipose tissue and fatty lymph nodes.
• The full CAP checklist and protocol for RP are available at
http://www.cap.org/apps/docs/cancer_protocols/2006/prostate06_pw.pdf

http://www.cancercare.on.ca/pdf/pebc17-3s.pdf

Synoptic reporting of cancer

Synoptic reporting of cancer:

Research studies during the 1990s revealed a significant amount of variation in the content of cancer-related pathology reports.Although the reports contained similar information, they could not be used toaccurately compare cases, treatment options, or clinical outcomes. Variability was mainly due to dictated free-text that contained transcription errors, insufficient and sometimes omitted clinical data. In response to these findings, the CAP Cancer Committee developed tumor site specific checklists for pathologists to use as a common framework for cancer reporting.

The synoptic section of the report uses standardized content and definitions in a coherent, clinically relevant and consistent way. This format allows the pathologist’s findings to be efficiently and effectively used in patient diagnosis, prognosis, and treatment. The use of standardized reporting has applicability in all areas of medicine to improve patient clinical documentation and to aggregate data across different platforms.Sharing standardized cancer information will help to win the war on cancer by providing comparable tumor data and treatment outcomes that can be used to support initiatives in cancer research and in public health.

What are the Cancer Checklists?
The CAP Cancer Checklists are a set of standardized, evidence-based, “scientifically validated” protocols for the 60 most commonly reported forms of cancer.Checklists are developed by the CAP Cancer Committee, a team of pathology experts and liaisons from other highly recognized cancer organizations. The checklists consist of data elements structured as a set of questions and prospective answers with reference information regarding the intended use and meaning of checklist elements. The cancer checklists are available in doc and pdf file versions on the CAP Web site at www.cap.org , and in an electronic format consistent with existing international standards for incorporation into existing information systems. The CAP cancer checklists form a library of best practices in pathology reporting for cancer specimen data.

About the author of this blog

About the creater of this blog

I am Dr.Prashant Jani,a dynamic and progressive Oncopathologist with more than 13 years of experience.

EDUCATION
2001-2005- FRCPC Anatomic Pathology Residency,University of Toronto, Ontario, Canada.
1994-1997 - M.D.General pathology,University of Pune, India
1987-1994 – M.B.B.S.University of Pune, India

WORK EXPERIENCE

Aug.2005 – Current date

o Anatomic Pathologist, Thunder Bay Regional Health sciences Centre and Northern Ontario Cancer Research Centre, Thunder Bay, Ontario, Canada.
o Assistant Professor, Department of Pathology and Laboratory medicine.Northern Ontario School of Medicine. Ontario, Canada.
o Responsibilities included surgical pathology with large number of oncopathology specimens; cytopathology and autopsy .Thunder Bay Regional health Sciences centre is a teaching hospital with work load of more than 20,000 surgical pathology specimens per year, 3000 cytopathology specimens per year and up to 200 autopsies per year.
o Teaching medical students, nursing students and residents is an integral part of the service.

PREVIOUS APPOINTMENTS:

 03/2001- 05/2005- Resident, Anatomic Pathology, University of Toronto, Canada
 01/1997 – 1/2001-Private Consultant Pathologist, Pune India
 01/1997 –01/2001-Cytopathologist, Care India Medical Society Pune, India.
 06/1997 –02/1998-Cytopathologist, B.J. Medical College, Pune, India.
 01/1994 –12/1997-Blood Transfusion Officer, Red Cross Blood Bank, Pune,India.

PUBLICATIONS AND PRESENTATIONS

1) D-240 expression on luminal surface of pulmonary airspaces in normal developing and adult lung but is lost in conditions associated with intra alveolar infiltrates.
 Poster presentation-Unites states and Canadian Academyof Pathology,2005,San Antanio,USA
2) Aberrant expression of CD4 and CD7 T cell antigens in Atypical B cell –
Chronic Lymphocytic leukemia.
 Poster presentation at American Society of Clinical Pathology, Nov.2005, Chicago,
USA.
 Prashant Jani,Abdel Walkett, and Hong Chang,Am J Hematol.2007 Jan;82(1):73-6.
3) CD 138 expression in Merkel cell carcinoma:A potential diagnostic pitfall in hematological malignancies.
 Poster presentation at Annual meeting of Canadian Association of Pathologist,
June,2006, Toronto, Ontario, Canada.
4) Synchronous adrenocrtical and renal cell carcinoma: A rare association
 Poster presentation at Annual meeting of Canadian Association of Pathologist,June,2006, Toronto, Ontario, Canada.
 Prashant Jani, D.El-demallawy , The Canadian Journal of Urology, 2007 Jan;56(11):933-50.
5) Value of CD 138 in normal and Pathological endometrium
 Poster presentation at Annual meeting of Canadian Association of Pathologist,
June, 2006, Toronto, Ontario, Canada.
6) Application of immunohistochemistry in classification of ovarian tumors
 Poster presentation at American Society of Clinical pathology,Oct.2004 San
Antonio, USA
7) An approach to duodenal biopsies.
 S.Serra,P.Jani J Clin Pathol. 2006 Nov;59(11):1133-50. 2006
8) Massive Bone Marrow Involvement by Alveolar Rhabdomyosarcoma with an Unusual Histologic Pattern and an Unknown Primary Site: A case Report with Morphologic, Immunohistochemical, Ultrastructural, and Cytogenetic Studies
 Prashant Jani, Charles Ye, Nov.2007,Journal of Clinical pathology.

Invited Speaker :

1) Role of Pathologist in management of breast Cancer- Dec.2006
Faculty and Course coordinator,Practicing pathologist association meeting, ,B.J Medical College, University of Pune, Maharashtra, India.
2) Her2/neu and Breast Cancer: May 2008
Faculty , Northern Ontario Cancer Research Foundation meeting Ontario, Canada.
3) Cancer Pathology Course : Jan.2007 and 2008
Faculty Lakehead University,Thunder Bay,Ontario,Canada.
4) Surgical pathology CME –Feb.2009
Course co-ordinator and faculty at B.J.Medical College and Sasson Genreal hospitals, Pune,India

RESEARCH EXPERIENCES:
 2005- 2009 – Thunder bay Regional health Sciences and Northern Ontario School
of Medicine, Ontario, Canada
 2001- 2005 – University of Toronto, Ontario, Canada.

MEMBERSHIP College of American Pathologist (CAP)
 American Society of Clinical Pathology.
 College of Physicians and Surgeons of Canada.
 Ontario Medical Association.(OMA)
 United States and Canadian Academy Of Pathology(USCAP)