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Ampulla of Vater

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Ampulla of Vater ...

Heart

    Protocol applies to primary malignant

    cardiac tumors.

    Protocol revision date: January 2004

    No AJCC/UICC staging system

Procedures

    • Cytology (No Accompanying Checklist) • Incisional Biopsy

    • Excisional Biopsy

Author

    M. Elizabeth Hammond, MD

    Department of Pathology, LDS Hospital and University of Utah School of

    Medicine, Salt Lake City, Utah

    For the Members of the Cancer Committee, College of American Pathologists

Previous contributors: Robert L. Yowell, MD, PhD; Robert L. Flinner, MD;

    Donald B. Doty, MD

Heart • Thorax CAP Approved

    Surgical Pathology Cancer Case Summary (Checklist)

    Protocol revision date: January 2004

    Applies to malignant cardiac tumors only

    No AJCC/UICC staging system

HEART: Resection

Patient name:

    Surgical pathology number:

Note: Check 1 response unless otherwise indicated.

MACROSCOPIC

Specimen Type

    ___ Excisional biopsy

    ___ Other (specify): ____________________________

    ___ Not specified

Tumor Site (check all that apply)

    ___ Pericardium

    ___ Right ventricle

    ___ Left ventricle

    ___ Right atrium

    ___ Left atrium

    ___ Other (specify): ____________________________

    ___ Not specified

Tumor Size

    ___ Not applicable

    Greatest dimension: ___ cm

    *Additional dimensions: ___ x ___ cm

    ___ Cannot be determined (see Comment)

    * Data elements with asterisks are not required for accreditation purposes for 2

    the Commission on Cancer. These elements may be clinically important,

    but are not yet validated or regularly used in patient management.

    Alternatively, the necessary data may not be available to the pathologist

    at the time of pathologic assessment of this specimen.

CAP Approved Thorax • Heart

    MICROSCOPIC

Histologic Type

    ___ Angiosarcoma

    ___ Malignant fibrous histiocytoma

    ___ Myxosarcoma

    ___ Fibrosarcoma

    ___ Leiomyosarcoma

    ___ Rhabdomyosarcoma

    ___ Osteosarcoma

    ___ Synovial sarcoma

    ___ Malignant schwannoma (malignant peripheral nerve sheath tumor) ___ Malignant mesenchymoma

    ___ Other (specify): ________________________

    ___ Sarcoma, type cannot be determined

Histologic Grade

    ___ Not applicable

    ___ Cannot be determined

    ___ Low-grade

    ___ High-grade

    ___ Other (specify): ____________________________

Extent of Invasion (as appropriate)

    ___ Cannot be determined

    ___ No involvement of adjacent tissue(s)

    ___ Involvement of adjacent tissue(s)

    ___ Other organ involvement (specify): ____________________________

Margins (as appropriate)

    ___ Not applicable

    ___ Cannot be assessed

    ___ Uninvolved by tumor

    ___ Involved by tumor

     Specify site(s), if known: ____________________________

    *Additional Pathologic Findings (check all that apply) *___ None identified

    *___ Benign tumor (specify): ____________________________ *___ Therapy-related changes (specify): ____________________________ *___ Inflammation

    *___ Other (specify): ____________________________

*Comment(s)

* Data elements with asterisks are not required for accreditation purposes for 3

    the Commission on Cancer. These elements may be clinically important, but are not yet validated or regularly used in patient management. Alternatively, the necessary data may not be available to the pathologist

    at the time of pathologic assessment of this specimen.

    Heart • Thorax For Information Only

    Background Documentation

    Protocol revision date: January 2004

    I. Cytologic Material

    (Pericardial Fluid)

    A. Clinical Information

    1. Patient identification

    a. Name

    b. Identification number

    c. Age (birth date)

    d. Sex

    2. Responsible physician(s)

    3. Date of procedure

    4. Other clinical information

    a. Relevant history

    (1) primary cardiovascular disease

    (2) myocarditis

    (3) congenital heart disease

    (4) history of tumor elsewhere

    (5) immunosuppression

    (6) tuberous sclerosis

    (7) previous irradiation

    b. Relevant findings (eg, echocardiographic [ECHO] findings, evidence of

    tumor elsewhere in body)

    c. Clinical diagnosis

    d. Procedure (eg, fine-needle aspiration [FNA] of pericardial fluid)

    e. Anatomic site(s) of specimen (eg, anterior pericardial sac)

    B. Macroscopic Examination

    1. Specimen

    a. Description

    b. Unfixed/fixed (specify fixative)

     c. Number of slides received, if appropriate

    d. Quantity, appearance of fluid specimen, if appropriate

    e. Results of intraprocedural consultation

    2. Material submitted for microscopic evaluation

    3. Results of rapid smear review

    4. Special studies (specify)

    C. Microscopic Evaluation

    1. Adequacy of specimen (if unsatisfactory for evaluation, specify reason)

    2. Tumor (Note A)

    a. Histologic type, if possible

    b. Histologic grade, if possible

    3. Additional pathologic findings, if present

    a. Therapy-related changes

    b. Degenerative changes

    c. Atypical cellular reaction

    d. Inflammation

    e. Other

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    For Information Only Thorax • Heart

    4. Status/results of special studies (specify)

    5. Comments

    a. Correlation with intraprocedural consultation, as appropriate

    b. Correlation with other specimens, as appropriate

    c. Correlation with clinical information, as appropriate

    II. Incisional or Excisional Biopsy

    A. Clinical Information

    1. Patient identification

    a. Name

    b. Identification number

    c. Age (birth date)

    d. Sex

    2. Responsible physician(s)

    3. Date of procedure

    4. Other clinical information

    a. Relevant history

    (1) primary cardiovascular disease

    (2) myocarditis

    (3) congenital heart disease

    (4) history of tumor elsewhere

    (5) immunosuppression

    (6) tuberous sclerosis

    (7) previous irradiation

    b. Relevant findings (eg, ECHO findings, evidence of tumor elsewhere in body)

    c. Clinical diagnosis

    d. Procedure

    e. Operative findings

    f. Anatomic site(s) of specimen (eg, pericardium, left/right ventricle, atrium)

    B. Macroscopic Examination

    1. Specimen

    a. Tissue(s) received

    b. Unfixed/fixed (specify fixative)

    c. Number of fragments

    d. Dimensions

    e. Descriptive features (color/consistency)

    f. Orientation, if designated by surgeon

    g. Results of intraoperative consultation

    2. Tumor

    a. Size (Note B)

    b. Descriptive features (eg, consistency, color, hemorrhage, necrosis)

    c. Extension

    3. Margins, if appropriate

    a. Vascular

    b. Pericardial

    c. Other

    4. Tissue submitted for microscopic evaluation

    a. Tumor (Note C)

    b. Designated areas including those marked adherent to other structures

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Heart • Thorax For Information Only

    c. Margin(s)

    d. Frozen section tissue fragment(s) (unless saved for special studies)

    e. Other (specify)

    5. Special studies (specify) (eg, histochemistry, immunohistochemistry, electron

    microscopy, morphometry, DNA analysis [specify type]) C. Microscopic Evaluation

    1. Tissue(s) present

    2. Tumor

    a. Histologic type(s) (Note D)

    b. Histologic grade (Note E)

    c. Status of designated areas

    d. Extent of invasion (adjacent tissues)

    3. Margins, as appropriate

    4. Additional pathologic findings, if present

    a. Benign tumor

    b. Therapy-related changes

    c. Degenerative changes

    d. Atypical cellular reaction

    e. Inflammation

    f. Other

    5. Results/status of special studies (specify) (Note F)

    6. Comments

    a. Correlation with intraoperative consultation, as appropriate

    b. Correlation with other specimens, as appropriate

    c. Correlation with clinical information, as appropriate

Explanatory Notes

A. Cytologic Findings

    Pericardial effusions are rarely caused by primary cardiac tumors. The most common

    causes of malignant pericardial effusions are metastatic adenocarcinoma from lung or

    breast, malignant melanoma, or extension of malignant mesothelioma into the

    pericardium. The pathologist should evaluate the nature and clinical significance of a

    malignant pericardial effusion by discussing the findings with the clinician, reviewing the

    patient’s medical record, or both. Cellular changes considered to be infective, reactive,

    or degenerative (eg, viral infection, immunotherapy, chemotherapy, or radiation effect)

    should be clearly distinguished from malignant or atypical (potentially malignant)

    cytologic findings. Additional patient history and pertinent clinical findings may be

    helpful in arriving at a definitive diagnosis.

B. Staging

    The greatest diameter of the tumor in centimeters should be recorded. There is no

    published staging system for primary cardiac tumors.

C. Number of Sections

    The number of sections varies with the size of the specimen and the nature of the

    neoplasm. The pathologist should sample areas with diverse gross appearances. In

    addition to tumor evaluation, routine sampling of the non-neoplastic components of the

    specimen should be performed.

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For Information Only Thorax • Heart

D. Histologic Type

    The classification of malignant cardiac tumors as recommended by the Armed Forces 1 Institute of Pathology (AFIP) fascicle on tumors of the heart and great vessels follows.This protocol, however, does not preclude the use of other histologic classifications.

AFIP Classification of Malignant Cardiac Tumors

    Angiosarcoma

    Malignant fibrous histiocytoma

    Myxosarcoma

    Fibrosarcoma

    Leiomyosarcoma

    Rhabdomyosarcoma

    Osteosarcoma

    Synovial sarcoma

    Malignant schwannoma (malignant peripheral nerve sheath tumor)

    Malignant mesenchymoma

    Malignant mesothelioma

    Other

    As with sarcomas in other sites, a variety of histologic patterns may be found. Although not included in the classification, lymphomas also are found in the heart.

E. Histologic Evaluation

    Pathologists should grade the tumor and indicate the grading system used. Most

    malignant tumors of the heart are sarcomas. Necrosis of groups of cells and mitotic

    rates of greater than 5 mitoses per 10 high-power fields have been associated with 1 reduced survival.

F. Special Studies

    Immunohistochemistry can be used to ascertain the histogenesis of a sarcoma or

    substantiate the diagnosis of mesothelioma. Generally speaking, mesotheliomas

    contain cytokeratins, which are usually lacking from sarcomas (see Thoracic

    Mesothelioma protocol). Transmission electron microscopy is also very helpful in the

    distinction of these tumor types. Myxoma, the most common benign tumor, has no

    distinctive immunohistochemical features.

Reference

    1. Burke AP, Renu V. Atlas of Tumor Pathology. Tumors of the Heart and Great

    Vessels. 3rd series. Fascicle 16. Washington, DC: Armed Forces Institute of

    Pathology; 1996.

Bibliography

    Blondeau P. Primary cardiac tumors: French studies of 533 cases. Thorac Cardiovasc

    Surg. 1990;38(suppl 2):192-195. Burke AP, Cowan D, Virmani R. Primary sarcomas of the heart. Cancer. 1992;69:387-

    395.

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Heart • Thorax For Information Only

    Burke AP, Rosado-de-Christenson M, Templeton PA, Virmani R. Cardiac fibroma:

    clinico-pathologic correlates and surgical treatment. J Cardiovasc Surg.

    1994;108:862-870.

    Burke AP, Virmani R. Osteosarcomas of the heart. Am J Surg Pathol. 1991;15:289-295. Dein JR, Frist WH, Stinson EB, et al. Primary cardiac neoplasms: early and late studies

    of surgical treatment in 42 patients. J Thorac Cardiovasc Surg. 1987;93:502-511. Melo J, Ahmad A, Chapman R, Wood J, Starr A. Primary tumors of the heart:

    a rewarding challenge. Am Surg. 1979;45:681-683.

    Miralles A, Bracamonte L, Soncul H, et al. Cardiac tumors: clinical experience and

    surgical results in 74 patients. Ann Thorac Surg. 1991;52:886-895.

    Murphy MC, Sweeny MS, Putnam JB Jr, et al. Surgical treatment of cardiac tumors:

    a 25-year experience. Ann Thorac Surg. 1990;49:612-617.

    Reece IJ, Cooley DA, Frazier OH, Hallman GL, Powers PL, Montero CG. Cardiac

    tumors: clinical spectrum and prognosis of lesions other than classical benign

    myxoma in 20 patients. J Thorac Cardiovasc Surg. 1984;88:439-446. Ryan RE Jr, Obeid AI, Parker FB Jr. Primary cardiac valve tumors. J Heart Valve Dis.

    1995;4:222-226.

    Tazelaar HD, Locke TJ, McGregor CG. Pathology of surgically excised primary cardiac

    tumors. Mayo Clin Proc. 1992;67:957-965.

    Turner A, Batrick N. Primary cardiac sarcomas: a report of three cases and a review of

    the current literature. Int J Cardiol. 1993;40:115-119.

    Verkkala K, Kupari M, Maamies T, et al. Primary cardiac tumors: operative treatment of

    20 patients. J Thorac Cardiovasc Surg. 1989;37:361-364.

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