Minimal Reporting Guidelines for the Treatment of Cancer Patients

Minimal Reporting Guidelines for the  Treatment of Cancer Patients 

As laboratory physicians, our contribution to patient care is knowledge:  this is the starting point from which all informed therapeutic intervention proceeds.  How that knowledge is obtained and communicated is the art and science of our profession.  These minimal diagnostic guidelines are designed  to be used as an aid, not a constraint, in that process.  The guidelines are presented in a specific format out of necessity, but any format that effectively communicates the necessary information in a given pathology  report is valid.  Furthermore, it is accepted that not all of the information specified by these guidelines  may be available at the time of diagnosis.  Specific examples may include estrogen receptor or C-ERB B2  status of breast tumours or adequate information for meaningful pathologic staging.  A lack of this  information should not prevent the timely release of a final diagnosis in any case.  It is assumed that the  pathologist will provide all pertinent information that is available, either at the time of initial diagnosis, or  further along in the course of the patient’s care.

Minimal Reporting Guidelines – Breast Carcinoma

Microscopic Diagnosis  

(Right/Left) Breast, (core biopsy, wire local. biopsy, lumpectomy, mastectomy specimen)  

  a)  Invasive carcinoma, histologic type  

  b)  Greatest linear tumour dimension (define gross or microscopic measurement) of invasive

carcinoma, specify, if multifocal   

  c)  Extent (% of total tumour volume) type and grade, (low, intermed., high) of intraductal

component (w/wo comedonecrosis)  

  d)  Histologic grade of invasive carcinoma (Nottingham modification, Bloom and Richardson)      

      Nuclear grade  -  low = 1

        -  intermediate = 2

        -  high = 3

      Mitotic rate*  -  <4/sq mm = 1 (low)

        -  4-7/sq mm = 2 (intermediate)

        -  >7/sq mm = 3 (high)

      Tubule formation  -  >75% = high = 1

        -  10-75% = intermediate = 2

        -  <10% = low = 3

      Add points for each feature to obtain total score

        3-5 points = well differentiated

        6-7 points = moderately differentiated

        8-9 points = poorly differentiated

  e)  Venous or lymphatic space invasion (identified/not identified); specify if multiple vessels

involved; (specify if dermal lymphatics are involved)

  f)  Surgical Margins (positive/negative, indeterminate; site specific, focal or extensive, closest

approach of invasive/in-situ tumour to margins in mm)

  g)  Lymph node status (x of y lymph nodes positive for metastatic carcinoma, size of largest

metastasis, with/wo extranodal tumour spread).  Note 2002 changes to TNM staging for

microscopic lymph node metastasis.

  h)  Involvement of skin, nipple, or skeletal muscle by invasive carcinoma (present/absent)

  i)  Index microcalcifications present (if seen in specimen radiograph)

  j)  Status of background breast tissue (atypical hyperplasia, benign mass forming lesions)

  k)  Status of estrogen receptors (all invasive CAs)

Status of progesterone receptors (all ER negative tumours)

Status of Her 2-neu expression (all metastatic positive CAs)

Report should indicate tissue block suitable for immunohistochemical prognostic markers. 

Cut off for ER/PR is 5% of tumour cell nuclei staining.  Her2-neu expression should be

reported as negative, equivocal (1+ to 2+), or positive (3+).  All equivocal Her2-neu

immunostaining should be referred for FISH analysis.

  L )  pTNM tumour stage

Minimal Reporting Guidelines – Melanoma

Microscopic Diagnosis

Skin of (site), (biopsy/excision)  

  a)  Positive for invasive malignant melanoma, (histologic type)  

  b)  Clark’s Level 

      II   –  papillary dermis invasion

      III   –  fills papillary dermis, abuts retic. dermis

      IV  –  into reticular dermis

      V   –  into subcutis

  c)  Breslow Depth (mm, from granular layer)

  d)  Ulceration (present/absent)

  e)  Dermal Satellitosis (present/absent)

  f)  Mitotic figures/square mm

  g)  Vascular space invasion (present/absent)

  h)  Margins of excision (positive/negative, closest approach in mm)

  i)  Lymph node status (if applicable)

Minimal Reporting Guidelines – Soft Tissue Sarcoma

Microscopic Diagnosis

Soft tissue of (site), (resection/biopsy)

  a)  Sarcoma type

  b)  Tumour size (3 dimensions)

  c)  Tumour grade (Trojani system)

    Differentiation score – 

      Close resemblance to adult tissue  1

      Tumour type clearly recognized  2

      Undifferentiated sarcoma  3

    Necrosis score –

      None  0

      <50%  1

      >50%  2

     Mitotic score –

      0-9  per 10 hpf  1

      10-19  per 10 hpf  2

      20 or more  per 10 hpf  3

    Total score – 

      2,3  =  Grade 1

      4,5   =  Grade 2

      6,7,8  =  Grade 3

  *  NOTE:  Alveolar and embryonal rhabdomyosarcoma, neuroblastoma, Ewing’s sarcoma

and PNET are, by definition, high grade sarcomas.

  d)  Vascular space invasion (present/absent)

  e)  Surgical resection margin

  i)  positive/<2 cm from margin/>2 cm from margin

  ii)  nearest margin location (sup/inf/med/lat, ant/post)

  iii)  composition of nearest margin (muscle, vessel, fascia, skin, etc.)

  

Minimal Reporting Guidelines – Laryngeal Carcinoma

Microscopic Diagnosis

Larynx, radical resection

  a)  Positive for invasive squamous cell carcinoma (histologic subtype, if applicable)

  b)  Tumour site

  c)  Tumour size

  d)  Tumour grade (well, moderately, poorly differentiated)

  e)  Direct tumour extension (commissure, ventricle, false cords, subglottis)

  f)  Depth of invasion

  g)  Vascular space invasion

  h)  Perineural invasion

  i)  In-situ component (present/absent)

  j)  Surgical margins and distance from margins

  k)  Lymph node status (Site specific:  submandibular; upper jugular; mid jugular; lower jugular;

posterior cervical; juxtathyroid; paratracheal.  Size of largest metastasis and extranodal

tumour spread should be mentioned.)

  l)  pTNM tumour stage

 Minimal Reporting Guidelines – Thyroid Carcinoma

Microscopic Diagnosis

Thyroid, (right/left lobe or total) resection

  a)  Positive for (papillary/follicular/medullary/other) carcinoma

  b)  Tumour location (or locations if multicentric)

  c)  Greatest linear tumour dimension

  d)  Encapsulation (complete/incomplete/absent); w/wo invasion

  e)  Extrathyroidal extension (present/absent, include measurement)

  f)  Vascular space invasion

  g)  Surgical margins (if positive, include measurement)

  h)  Lymph node status (ipsilateral, midline, bilateral, mediastinal)

  i)  Status of non-neoplastic thyroid (thyroiditis, nodular hyperplasia)

  j)  pTNM tumour stage  

Minimal Reporting Guidelines – Lung Carcinoma  

Microscopic Diagnosis  

Lung, (lobectomy, pneumonectomy, side)  

  a)  Histologic tumour type (small cell/non small cell/other)

  b)  Greatest single tumour dimension  

  c)  Location –  <2 cm from bronchial resection margin

      >2 cm from bronchial resection margin  

  d)  Bronchial margin pos/neg  

  e)  Pleural involvement (into visceral pleura, through pleura, extension into chest wall)  

  f)  Lymphangitic spread (present/absent)  

  g)  Direct venous invasion

  h)  Lymph node involvement (Subdivide ipsilateral peribronchial/hilar nodes from

extrapulmonary mediastinal/subcarinal nodes.  Direct extension counts as lymph node

involvement.)

  i)  Lung parenchyma away from tumour

  j)  pTNM tumour stage

    

Minimal Reporting Guidelines – Upper Gastrointestinal and Ileocolic

Microscopic Diagnosis

Esophagus/Stomach/Duodenum/Small Bowel/Colon Resection

  a)  Positive for (well, moderately, poorly) differentiated carcinoma (specify type)

  b)  Longitudinal tumour dimension; polypoid, semicircumferential, circumferential lesion

  c)  Depth of invasion (submucosa, muscularis propria, perivisceral adipose tissue, peritonealized

serosa, extension into adjacent organs) measure the depth of extension beyond the muscularis

propria in mm.

  d)  Surgical margins (proximal, distal, radial; distance to radial margins in mm.)  Direct tumour

extension within 1 mm or a positive lymph node at the radial resection margin is considered a

positive margin.

  e)  Venous space invasion (present/absent)

  f)  Lymph node status *(x of y lymph nodes positive for metastatic carcinoma).  Any mesenteric

tumour deposit with a rounded contour counts as a replaced lymph node.  Stellate deposits are

defined as angiolymphatic tumour spread.

  g)  Perforation (present/absent)

  h)  Status of non-carcinomatous mucosa (Barrett’s mucosa, gastritis, multifocal dysplasia).

  i)  pTNM tumour stage.

* A minimum of 12 lymph nodes are required to accurately predict pNO stage. 

Minimal Reporting Guidelines – Rectum

Microscopic Diagnosis

Rectum, resection

  a)  Positive for (well, moderately, poorly) differentiated adenocarcinoma (if specific subtype,

define).

  b)  Tumour site (anterior, posterior, left, right; above or below peritoneal reflection).

  c)  Longitudinal tumour dimension and fraction of rectal circumference involved by tumour.

  d)  Depth of invasion (submucosa, muscularis propria, perirectal adipose tissue, peritonealized

serosa, adjacent structures).  Measure distance of tumour extension beyond muscularis

propria in mm.

  e)  Surgical margins (proximal, distal, radial).  Measure closest approach of tumour to radial

margin in mm. (Direct tumour extension within 1 mm or a positive lymph node at the radial

margins are defined as a positive margin).

  f)  Completeness of mesorectal excision specimen (essentially complete with minimal

defects/incomplete with exposure of rectal muscularis propria).

  g)  Venous space invasion (present/absent).

  h)  Lymph node status *(x of y lymph nodes positive for metastatic carcinoma).  Any mesenteric

tumour deposit with a rounded contour counts as a replaced lymph node.  Stellate deposits are

defined as angiolymphatic tumour spread.

  i)  Perforation (present/absent).

  j)  Status of noncarcinomatous mucosa (adenomas, CIBD, multifocal dysplasia).

  k)  pTNM tumour stage.

* A minimum of 12 lymph nodes are required to accurately predict pNO stage.

Minimal Reporting Guidelines – Pancreatic/Biliary Carcinoma

Microscopic Diagnosis

Pancreas/common bile duct, total/subtotal resection

  a)  Positive for carcinoma of (tumour site:  common bile duct, ampulla, pancreatic head, etc.)

  b)  Tumour size (significant discrepancies between gross and microscopic estimates are

common.  Unless microscopic growth is confluent, the gross estimate is preferred.)

  c)  Tumour subtype (solid, cystic, papillary, tubular, signet -ring cell, acinic cell, neuroendocrine)

  d)  Tumour grade (well, moderately, poorly differentiated)

  e)  In situ component (present/absent)

  f)  Vascular space invasion (present/absent)

  g)  Perineural invasion (present/absent)

  h)  Direct tumour extension (ie., duodenum, bile ducts, peripancreatic tissue, stomach, spleen,

bowel, large vascular channel)

  i)  Surgical margins:  radial, ductal (if subtotal pancreatectomy or CBD resection)

  j)  Lymph node status:  separate regional (peripancreatic, hepatic artery, peripyloric, celiac,

mesenteric, periaortic) lymph nodes from distant metastases

  k)  Status of non-neoplastic pancreas/bile ducts (pancreatitis, gallstones, sclerosing cholangitis)

  l)  pTNM tumour stage

  

Minimal Reporting Guidelines – Cervical Carcinoma

Microscopic Diagnosis

Cervix, cone excision or Uterus, resection

  a)  Cervical tumour cell type

  b)  Grade of invasive carcinoma

  c)  In situ component (present/absent)

  d)  Depth and breadth of invasive component

  e)  Vascular space invasion (present/absent)

  f)  Extension beyond cervix (parametrium, pelvic wall, vagina, bladder)

  g)  Resection margins (ectocervical, endocervical, deep; with closest approach in mm; define if

mucosal margin is positive for in situ or invasive disease)

  h)  Lymph node status

  i)  FIGO tumour stage

Minimal Reporting Guidelines – Vulva (non-melanoma)

Microscopic Diagnosis

Vulva, (simple/radical) resection

  a)  Vulvar tumour cell type

  b)  Tumour grade (well, moderately, poorly differentiated)

  c)  Depth of invasion and overall tumour size

  d)  Vascular space invasion (present/absent)

  e)  In-situ component (present/absent)

  f)  Extension to extra-vulvar sites (mention if present)

  g)  Surgical margins (peripheral, deep, vaginal; define if positive for in situ or invasive disease).

  h)  Lymph node status

  i)  Status of non-neoplastic mucosa (condyloma)

  j)  FIGO tumour stage

Minimal Reporting Guidelines – Endometrial Carcinoma

Microscopic Diagnosis

Uterus (tubes, ovaries), resection (curettings)

  a)  Positive for (endometrioid, papillary serous, clear cell, etc.) adenocarcinoma

  b)  FIGO tumour grade – 

      1   -  5% or less solid growth

      2   -  6-50% solid growth

      3   -    more than 50% solid growth

    (Morular growth excluded.  High grade nuclei raises tumour grade by 1.  Serous and clear

cell carcinomas are almost always grade 3.)

  c)  Myometrial invasion (none, inner ½ of myometrium, outer ½ of myometrium).  (If possible,

measure maximum depth of invasion and thickness of uninvolved myometrium at this site.)

  d)  Vascular space invasion

  e)  Cervical involvement (absent, noninvasive, invasive)

  f)  Extrauterine spread (bladder, bowel)

  g)  Status of non-carcinomatous endometrium

  h)  Lymph node status (if submitted)

  i)  FIGO tumour stage

Minimal Reporting Guidelines – Ovarian Carcinoma

Microscopic Diagnosis

(Right/left/bilateral/TAHBSO) Ovary, resection

  a)  Positive for (endometrioid, serous, mucinous) adenocarcinoma. 

    (Borderline tumours are reported using the same guidelines.)

  b)  Tumour Grade (Invasive carcinoma only, Silverberg)

    Nuclear score  -  1, 2, 3

    Mitotic score  -  <10  per 10 hpf = 1

        10-24  per 10 hpf = 2

        25 or more  per 10 hpf = 3

    Architecture score  -  glandular  =  1

        papillary  =  2

        solid  =  3

    Total score:     3-5  =  Grade 1

        6-7  =  Grade 2

        8-9  =  Grade 3

  c)  Ovarian surface involvement (present/absent)

  d)  Tumour capsule intact/ruptured

  e)  Tumour involvement unilateral/bilateral 

  f)  Extraovarian spread (define sites of implants, invasive or non-invasive; size of implants

  g)  Status of peritoneal washings (if known)

  h)  Lymph node status (if submitted)

  i)  FIGO tumour stage

Minimal Reporting Guidelines – Penis for Squamous Carcinoma

Microscopic Diagnosis

Penis, resection

  a)  Positive for invasive squamous cell carcinoma

  b)  Tumour site (urethra, foreskin, glans, shaft)

  c)  Tumour grade (well, moderately, poorly differentiated, or verrucous)

  d)  Tumour extension:  subepithelial connective tissue, tunica albuginea, corpus spongiosum,

corpus cavernosum, urethra

  e)  Vascular space invasion (present/absent)

  f)  In situ component (present/absent/extent, multifocal)

  g)  Surgical margins:  urethra, corpora, skin; define if positive for in situ or invasive disease

  h)  Lymph node status

  i)  Status of non-neoplastic epithelium (condyloma, inflammatory process)

  j)  pTNM tumour stage

Minimal Reporting Guidelines – Testis for Germ Cell Tumour

Microscopic Diagnosis

(Right/Left) Testis, radical orchidectomy

  a)  Positive for (germ cell tumour type)

  b)  Tumour size

  c)  Tumour extension (limited to seminiferous tissues, extension into rete testis/tunica

albuginea/epididymis or spermatic cord)

  d)  Vascular space invasion (present/absent, non-seminomatous GCT only)

  e)  Estimated percent of different germ cell components (mixed GCT only)

  f)  Surgical margins (peritesticular, adnexal structures, spermatic cord)

  g)  Status of lymph nodes (if submitted)

  h)  Status of non-neoplastic testis: spermatogenesis, intratubular germ cell neoplasm

  i)  pTNM tumour stage

Minimal Reporting Guidelines – Radical Prostatectomy for Prostatic Carcinoma

Microscopic Diagnosis

Prostate, radical resection

  a)  Positive for prostatic adenocarcinoma

  b)  Gleason primary and secondary grades and total score (omit if treatment effect evident)

  c)  Sites involved (peripheral/transitional zone; single or both lobes; apex, mid or bladder base)

  d)  Greatest single tumour dimension

  e)  Estimated percent of gland involvement

  f)  Tumour extension:  limited to gland, periprostatic fat, seminal vesicles

  g)  Vascular space invasion

  h)  Surgical margins:  peripheral, apex, bladder neck (define:  mm, involvement, type of tissue

involved – capsule/soft tissue)

  i)  Lymph node status (x of y positive, site specific)

  j)  Status of non-malignant prostate (PIN)

  k)  Status of prostatic urothelium (if abnormal)

  l)  pTNM tumour stage

Minimal Reporting Guidelines – Prostate Needle Biopsies

Microscopic Diagnosis

Prostate, needle biopsy (or biopsies xN)

  a)  Positive for prostatic adenocarcinoma

  b)  Gleason primary and secondary grade and score

  c)  Number of and location of cores involved (if multiple at one site)

  d)  Greatest single linear tumour dimension (confluent growth)

  e)  Vascular space invasion (present/not identified)

  f)  Extraprostatic fat involvement (present/not identified)

  g)  High Grade PIN (report if present only)

* NOTE:  Use these same criteria for reporting TUPR specimens.  Substitute number of chips involved

(eg., 4 of 20 chips positive) for linear tumour dimension.  Report prostatic urothelium and

seminal vesicle status, if present.

Gleason Grading (omit if treatment effect evident)

  1)  Single, separate uniform glands closely packed, with definite edge.

  2)  Single, separate uniform glands loosely packed, with irregular edge.

  3)  Single, separate, scattered glands (very small or uniform) or smoothly circumscribed

papillary/cribriform masses.

  4)  Fused glands with ragged infiltration, with or without large pale cells (hypernephroid).

  5)  Solid masses with any necrosis (comedocarcinoma) or anaplastic raggedly infiltrating.

Gleason Score 

  Predominant pattern plus the worst of any additional patterns.

  If only one pattern is seen, the grade is doubled to arrive at score.

  

Minimal Reporting Guidelines – Bladder Carcinoma

Microscopic Diagnosis

Urinary Bladder (transurethral resection/radical cystectomy or cystoprostatectomy)

  a)  Positive for urothelial carcinoma (subtype, invasive/noninvasive)

  b)  Tumour site(s) (single or multifocal)

  c)  Tumour size

  d)  Tumour depth of invasion (lamina propria, submucosa, inner or outer half of muscularis

propria, extravesicle)*

  e)  Involvement of ureters, urethra, prostate or seminal vesicles

  f)  Vascular space invasion (present/absent)

  g)  Histologic grade of invasive component (1,2,3)

  h)  High grade flat carcinoma in situ (present/absent)

  i)  Surgical margins

      i)  ureters

      ii)  urethra

      iii)  perivesical 

      iv)  periprostatic

  j)  Lymph node status (if submitted)

  k)  Prostate Gland (as per prostatectomy guidelines)

  l)  pTNM tumour stage

 * NOTE:  Report should delineate, where possible, invasion into bladder lamina propria versus

submucosa.

  

Minimal Reporting Guidelines – Renal Carcinoma

Microscopic Diagnosis

(Right/Left) Kidney, (segmental, simple, radical) resection

  a)  Positive for renal  cell carcinoma, histologic subtype

  b)  Tumour site(s) (pole, mid region, capsule, multiple)

  c)  Tumour size

  d)  Nuclear grade (Fuhrman)

      Grade 1:  round nuclei: nucleoli visible only at x 400 magnification

      Grade 2:  slightly irregular nuclei; nucleoli visible at x 200 magnification

      Grade 3:  irregular nuclei; nucleoli visible at x 100 magnification

      Grade 4:  enlarged pleomorphic nuclei or giant cells

  e)  Tumour extension (capsular perforation, renal pelvis, adrenal, renal vein, IVC)

  f)  Surgical margins (perinephric, hilar vascular, ureteric)

  g)  Lymph node status (if submitted)

  h)  Status of non-malignant renal tissue

  i)  pTNM tumour stage

GROSS AND MICROSCOPIC NOTES ON PATHOLOGY REPORTING OF EXCISIONAL BREAST BIOPSIES OR MASTECTOMY SPECIMENS

REPORT

  a)  Specimen

·  3 dimensional size and nature of specimen perimeter (ie.,specify if fragmented)

  b)  Invasive carcinoma

    i)  Size in mm

·  re-evaluate maximum exact size of apparent T1 or T2 invasive carcinoma (exclude

size of DCIS if it is major part of tumour nodule) microscopically

·  note critical invasive carcinoma size threshold for node negative cases: <20 mm

versus > 21 mm for chemo, Grade III duct < 10 versus > 10 mm for chemo, and

potentially at 5 and 10 mm thresholds for necessity of node dissection

    ii)  Type

·  duct, lobular, mixed, and other variants

    iii)  Grade

·  I-III/III Nottingham modification of Bloom and Richardson scoring system

·  architecture – tubule; nuclear grade; mitosis

·  record overall average for tubula r differentiation, but highest (even focal) nuclear

grade and mitotic rate; ie., consider grade heterogeneity

    iv)  Single or multifocal 

·  specify details for each focus

    v)  Margin status

·  exact distance in mm (eg., touching inked margin, <1 mm, 1 – 2 mm, 2 – 5 mm, >5

mm or indeterminate)

·  amount of invasive carcinoma at margin (eg., transected, focal microscopic,

number of mm and sections with close/positive margins)

·  exact location of all positive and close (<5 mm) margins composition of margin,

eg., breast parenchyma, fascia, skeletal muscle, skin, etc.

    vi)  Peritumoral lymphatic and vascular invasion

·  record only if definite lymphatic invasion, as may lead to chemotherapy for node

negative T1 carcinoma.

·  comment if lymphatic invasion is extensive (multiple vessels involved)

·  perineural invasion is of lesser importance unless a large nerve is involved near the

margin

·  true peritumoral venous invasion is rare

    

    vii)  Skin or skeletal muscle involvement

    viii)  ER, PR & HER2 (see latter)

  c)  Ductal Carcinoma In-Situ

·  size, grade and distance to closest margins (0 – 10 mm) are important treatment

parameters for cases with DCIS only (re:  Van Nuys Prognostic System)

    i)  Size

·  15, 25, 40 and 50 mm size thresholds for DCIS potentially clinically important.

·  often DCIS size can only be evaluated by summing up thickness of sequentially

submitted blocks

    ii)  Nuclear Grade (I – III) +/- necrosis

    iii)  Type

·  cribriform, solid, micropapillary, other

  d)  ADH, ALH and LCIS

·  Comment about extent

·  Relationship to margin generally not pertinent

·  Differentiate solid DCIS from LCIS at margins

  e)  Lymph Nodes

    i)  Number

·  exact number obtained and number positive

    ii)  Size of positive nodes

·  maximal size of largest metastatic carcinoma deposit (not just size of enlarged

node)

    iii)  Extranodal  soft tissue extension (comment if focal or extensive)

    iv)  Perinodal lymphatic or venous invasion

  

  

RECOMMENDATIONS FOR OPTIMAL HANDLING

OF COLORECTAL CARCINOMA SPECIMENS

GROSS SPECIMEN HANDLING

1)  For rectal resection specimens, identify the peritoneal reflection for orientation.  This well be

located at the anterior superior aspect of the rectum.  Ink all nonperitonealized radial rectal margins. 

For colonic specimens, locate the mesenteric resection margin, where the surgeon’s knife has cut

through the mesentery to remove it from the abdomen, and ink this nonperitonealized surface.

2)  Open and rinse the bowel (starting at the proximal end for rectal specimens, and from both ends for

colonic specimens) but stop when the scissors reach the tumour.  Do not longitudinally transect the

tumour.  Leave the tumour intact and fix the partially opened specimen for 48 hours.

3)  After fixation, slice the bowel through the area of the tumour involvement in radial sections (like a

sausage) at 5 mm intervals.

4)  Examination of these slices should allow measurement of the circumference of the bowel involved

by tumour, gross assessment of the radial margin, and identification of the minimum 12 pericolic or

perirectal lymph nodes.

  HINT:  Reportedly, most of the lymph nodes will be found at the outer edge of the specimen.

5)  Lymph nodes should be submitted for histology in their entirety (bisect them if they are big, but try

to be accurate on the count.  The radial resection margin of a total mesorectal excision should be

sampled in three tissue blocks (one should suffice for the mesenteric root of a colonic specimen) at

the site of closest approach by tumour.  Proximal and distal resection margins only require

sampling if closer than 3 cm to the tumour, in the fixed state.

NOTES ON MICROSCOPIC REPORTING

1)  Radial resection margins and depth of invasion are separate criteria with different clinical

implications.  Extension of a cecal carcinoma to the mesenteric resection margin without extension

to the peritonealized serosal surface is a T3 lesion with residual disease.  Involvement of the serosa

is T4 disease but is considered completely excised.

2)  Tumour at the serosal surface with an inflammatory response is the same as tumour on the serosal

surface (identical clinical implications).

  

3)  If we can’t find 12 lymph nodes, we are obliged to go back to the bottle and look for more.  This

recommendation is based upon validated studies indicating that a minimum of 12 lymph nodes is

required in order to accurately stage a patient as n0.  If less than 12 nodes are examined, and the

pathologist diagnoses the case as negative for node metastasis, there is a significant   chance that

the pathologist is wrong.  However,  if the surgeon has not provided an adequate mesenteric pedicle,

we will not find many nodes.  It is advisable to provide a 1 dimension assessment of the width of

the mesentery, along with the length of the specimen, in the gross description.  This measuresment

is likely to prevent arguments about who’s dissection (the pathologist’s or the surgeon’s) was

inadequate.  Reporting on more than 15 lymph nodes provides no additional information.