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Ovary

By Rita Gonzales,2014-05-10 02:50
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Ovary

    Protocol for the Examination of Specimens From Patients With Carcinoma of the Ovary

    Protocol applies to all primary borderline and malignant surface epithelial tumors, and also to germ cell tumors and sex cord-stromal tumors.

Based on AJCC/UICC TNM, 7th edition

    Protocol web posting date: February 1, 2011

Procedures

    • Oophorectomy

    • Salpingo-Oophorectomy

    • Subtotal Resection or Removal of Tumor in Fragments

    • Hysterectomy with Salpingo-Oophorectomy

Authors

    Saeid Movahedi-Lankarani, MD, FCAP*

    Department of Pathology, Abbott Northwestern Hospital, Minneapolis, Minnesota

    Patricia M. Baker, MD

     Pathology Department, Health Sciences Centre, Winnipeg, Canada Blake Gilks, MD

    Vancouver General Hospital, Vancouver, Canada

    Robert A. Soslow, MD

    Memorial Sloan Kettering Cancer Center, New York, New York Esther Oliva, MD, FACP

    Department of Pathology, Massachusetts General Hospital, Boston,

    Massachusetts

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

    * denotes primary author. † denotes senior author. All other contributing authors are listed alphabetically.

    Previous contributors: Robert E. Scully, MD; Philip A. Branton, MD; Donald Earl Henson, MD; Mary L. Nielsen, MD; Stephen G. Ruby, MD; William T. Creasman, MD; Andrew Fried, MD;

    David M. Gershenson, MD; William R. Hart, MD; Richard L. Kempson, MD; David L. Page, MD; Suzanne M. Selvaggi, MD

     Gynecologic • Ovary

    Ovary 3.1.0.0

    ? 2011 College of American Pathologists (CAP). All rights reserved.

    The College does not permit reproduction of any substantial portion of these protocols without its written authorization. The College hereby authorizes use of these protocols by physicians and other health care providers in reporting on surgical specimens, in teaching, and in carrying out medical research for nonprofit purposes. This authorization does not extend to reproduction or other use of any substantial portion of these protocols for commercial purposes without the written consent of the College.

    The CAP also authorizes physicians and other health care practitioners to make modified versions of the Protocols solely for their individual use in reporting on surgical specimens for individual patients, teaching, and carrying out medical research for non-profit purposes. The CAP further authorizes the following uses by physicians and other health care practitioners, in reporting on surgical specimens for individual patients, in teaching, and in carrying out medical research for non-profit purposes: (1) Dictation from the original or modified protocols for the

    purposes of creating a text-based patient record on paper, or in a word processing document; (2) Copying from the original or modified protocols into a text-based patient record on paper, or in a word processing document; (3) The use of a computerized system for items (1) and (2),

    provided that the Protocol data is stored intact as a single text-based document, and is not stored as multiple discrete data fields.

    Other than uses (1), (2), and (3) above, the CAP does not authorize any use of the Protocols in electronic medical records systems, pathology informatics systems, cancer registry computer systems, computerized databases, mappings between coding works, or any computerized system without a written license from CAP. Applications for such a license should be addressed to the SNOMED Terminology Solutions division of the CAP.

    Any public dissemination of the original or modified Protocols is prohibited without a written license from the CAP.

    The College of American Pathologists offers these protocols to assist pathologists in providing clinically useful and relevant information when reporting results of surgical specimen examinations of surgical specimens. The College regards the reporting elements in the “Surgical Pathology Cancer Case Summary (Checklist)” portion of the protocols as essential elements of

    the pathology report. However, the manner in which these elements are reported is at the discretion of each specific pathologist, taking into account clinician preferences, institutional policies, and individual practice.

    The College developed these protocols as an educational tool to assist pathologists in the useful reporting of relevant information. It did not issue the protocols for use in litigation, reimbursement, or other contexts. Nevertheless, the College recognizes that the protocols might be used by hospitals, attorneys, payers, and others. Indeed, effective January 1, 2004, the Commission on Cancer of the American College of Surgeons mandated the use of the checklist elements of the protocols as part of its Cancer Program Standards for Approved Cancer Programs. Therefore, it becomes even more important for pathologists to familiarize themselves with these documents. At the same time, the College cautions that use of the protocols other than for their intended educational purpose may involve additional considerations that are beyond the scope of this document.

    The inclusion of a product name or service in a CAP publication should not be construed as an endorsement of such product or service, nor is failure to include the name of a product or service to be construed as disapproval.

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     Gynecologic • Ovary

    Ovary 3.1.0.0

    CAP Ovary Protocol Revision History

Revision: Ovary 3.1.0.0

Version Code

    The definition of the version code can be found at www.cap.org/cancerprotocols.

Summary of Changes

    The following changes have been made since the October 2009 release.

    Oophorectomy, Salpingo-Oophorectomy, Subtotal Oophorectomy or Removal of Tumor in Fragments, Hysterectomy with Salpingo-Oophorectomy Checklist

Regional Lymph Nodes (pN)

    Specify: Number examined / Number involved, has been changed to:

___ No nodes submitted or found

Number of Lymph Nodes Examined

    Specify: ____

    ___ Number cannot be determined (explain): ______________________

Number of Lymph Nodes Involved

    Specify: ____

    ___ Number cannot be determined (explain): ______________________

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    CAP Approved Gynecologic • Ovary

    Ovary 3.1.0.0

    Surgical Pathology Cancer Case Summary (Checklist)

    Protocol web posting date: February 1, 2011

OVARY: Oophorectomy, Salpingo-Oophorectomy, Subtotal Oophorectomy or

    Removal of Tumor in Fragments, Hysterectomy with Salpingo-

    Oophorectomy

    Note: Applies to ovarian primary tumor. If bilateral tumors of 2 different

    histologic types are present, separate checklists should be used for

    each tumor.

    Select a single response unless otherwise indicated.

    Specimen (select all that apply) (Note A) ___ Right ovary

    ___ Left ovary

    ___ Right fallopian tube

    ___ Left fallopian tube

    ___ Uterus

    ___ Cervix

    ___ Omentum

    ___ Peritoneum

    ___ Other (specify): ___________________________ ___ Not specified

    ___ Cannot be determined

Procedure (select all that apply)

    ___ Right oophorectomy

    ___ Left oophorectomy

    ___ Right salpingo-oophorectomy

    ___ Left salpingo-oophorectomy

    ___ Bilateral salpingo-oophorectomy

    ___ Subtotal right oophorectomy

    ___ Subtotal left oophorectomy

    ___ Supracervical hysterectomy

    ___ Hysterectomy

    ___ Omentectomy

    ___ Peritoneal biopsies

    ___ Other (specify): ____________________________ ___ Not specified

Lymph Node Sampling

    ___ Performed

    ___ Not performed

    ___ Not known

    * Data elements with asterisks are not required. However, these elements may be 4 clinically important but are not yet validated or regularly used in patient management.

    CAP Approved Gynecologic • Ovary

    Ovary 3.1.0.0

    Specimen Integrity (select all that apply) (Note B)

Right Ovary

    ___ Not applicable

    ___ Capsule intact

    ___ Capsule ruptured

    ___ Fragmented

    ___ Other (specify): ____________________________

Left Ovary

    ___ Not applicable

    ___ Capsule intact

    ___ Capsule ruptured

    ___ Fragmented

    ___ Other (specify): ____________________________

Primary Tumor Site (select all that apply) (Notes C, D, and E)

    ____ Right ovary

    ____ Left ovary

    ____ Bilateral ovarian involvement

    ____ Not specified

Ovarian Surface Involvement

    ____Present

    ____Absent

    ____Uncertain/cannot be determined

Tumor Size

    Right Ovary (if applicable)

    Greatest dimension: ___ cm

    *Additional dimensions: ___ x ___ cm

    ___ Cannot be determined (see Comment)

Left Ovary (if applicable)

    Greatest dimension: ___ cm

    *Additional dimensions: ___ x ___ cm

    ___ Cannot be determined (see Comment)

    Histologic Type (select all that apply) (Notes F and G) ___ Serous, borderline tumor

    ___ Serous, carcinoma

    ___ Mucinous, borderline tumor, intestinal type ___ Mucinous, borderline tumor, endocervical type (seromucinous type)

    ___ Mucinous carcinoma

    ___ Endometrioid borderline tumor

    ___ Endometrioid carcinoma

    ___ Clear cell borderline tumor

    * Data elements with asterisks are not required. However, these elements may be 5 clinically important but are not yet validated or regularly used in patient management.

CAP Approved Gynecologic • Ovary

    Ovary 3.1.0.0

    ___ Clear cell carcinoma

    ___ Transitional cell borderline tumor

    ___ Transitional cell carcinoma

    ___ Brenner tumor, malignant type

    ___ Squamous cell carcinoma

    ___ Mixed epithelial borderline tumor (specify types and percentages): _____________

    ___ Mixed epithelial carcinoma (specify types and percentages): __________________

    ___ Undifferentiated carcinoma

    ___ Carcinosarcoma (Malignant müllerian mixed tumor) ___ Granulosa cell tumor

    ___ Other sex cord-stromal tumor (specify type): _____________________________

    ___ Malignant germ cell tumor (specify types and percentages): _________________

    ___ Other(s) (specify): __________________________

Histologic Grade (Note H)

World Health Organization (WHO) Grading System

    (applies to all carcinomas, including serous carcinomas) ___ GX: Cannot be assessed

    ___ G1: Well differentiated

    ___ G2: Moderately differentiated

    ___ G3: Poorly differentiated

    ___ G4: Undifferentiated

Two-Tier Grading System

    (may be applied to serous carcinomas and immature teratomas only) ___ Low grade

    ___ High grade

    ___ Other (specify): _____________________________ ___ Not applicable

Implants (only applies to advanced stage serous/seromucinous borderline tumors)

    (select all that apply) (Note I)

    ___ Not applicable/not sampled

Noninvasive Implant(s)

    ___ Not present

    ___ Present (specify sites): _______________________

     *Type of noninvasive implant(s)

     *___ Epithelial

     *___ Desmoplastic

Invasive Implant(s)

    ___ Not present

    ___ Present (specify sites): _______________________

* Data elements with asterisks are not required. However, these elements may be 6 clinically important but are not yet validated or regularly used in patient management.

    CAP Approved Gynecologic • Ovary

    Ovary 3.1.0.0 Extent of Involvement of Other Tissues/Organs (select all that apply)

    ___ Right ovary

     ___ Involved

     ___ Not involved

     ___ Not applicable

    ___ Left ovary

     ___ Involved

     ___ Not involved

     ___ Not applicable

    ___ Right fallopian tube

     ___ Involved

     ___ Not involved

     ___ Not applicable

    ___ Left fallopian tube

     ___ Involved

     ___ Not involved

     ___ Not applicable

    ___ Omentum

     ___ Involved

     ___ Not involved

     ___ Not applicable

    ___ Uterus

     ___ Involved (specify location: __________________________)

     ___ Not involved

     ___ Not applicable

    ___ Peritoneum

     ___ Involved

     ___ Not involved

     ___ Not applicable

    ___ Other organs/tissues (specify): ____________________________

*Treatment Effect (applicable to carcinomas treated with neoadjuvant therapy)

    *___ No definite or minimal response identified (poor or no response)

    *___ Marked response (minimal residual cancer)

*Lymph-Vascular Invasion (Note J)

    *___ Not identified

    *___ Present

    *___ Indeterminate

    Pathologic Staging (pTNM [FIGO]) (Note K)

TNM Descriptors (required only if applicable) (select all that apply)

    ___ m (multiple primary tumors)

    ___ r (recurrent)

    ___ y (posttreatment)

* Data elements with asterisks are not required. However, these elements may be 7 clinically important but are not yet validated or regularly used in patient management.

CAP Approved Gynecologic • Ovary

    Ovary 3.1.0.0

    Primary Tumor (pT)

    ___ pTX [--]: Cannot be assessed

    ___ pT0 [--]: No evidence of primary tumor

    pT1 [I]: Tumor limited to ovaries (one or both)

    ___ pT1a [IA]: Tumor limited to one ovary; capsule intact, no tumor on ovarian # surface. No malignant cells in ascites or peritoneal washings___ pT1b [IB]: Tumor limited to both ovaries; capsule intact, no tumor on ovarian

    surface. No malignant cells in ascites or peritoneal washings ___ pT1c [IC]: Tumor limited to one or both ovaries with any of the following:

    capsule ruptured, tumor on ovarian surface, malignant cells in ascites

    or peritoneal washings

    pT2 [II]: Tumor involves one or both ovaries with pelvic extension and/or implants ___ pT2a [IIA]: Extension and/or implants on uterus and/or tube(s). No malignant

    cells in ascites or peritoneal washings

    ___ pT2b [IIB]: Extension to other pelvic tissues. No malignant cells in ascites or

    peritoneal washings

    ___ pT2c [IIC]: Pelvic extension and/or implants (T2a or T2b / IIa or IIb) with

    malignant cells in ascites or peritoneal washings

    pT3 and/or N1 [III]: Tumor involves one or both ovaries with confirmed peritoneal

    metastasis outside the pelvis (including liver capsule metastasis

    and/or regional lymph node metastasis [N1])

    ___ pT3a [IIIA]: Microscopic peritoneal metastasis beyond pelvis (no macroscopic

    tumor)

    ___ pT3b [IIIB]: Macroscopic peritoneal metastasis beyond pelvis ;2 cm in greatest

    dimension

    ___ pT3c and/or N1 [IIIC]: Peritoneal metastasis beyond pelvis >2 cm in greatest

    dimension and/or regional lymph node metastasis

    # Nonmalignant ascites is not classified. The presence of ascites does not affect staging unless malignant cells are present.

Regional Lymph Nodes (pN)

    ___ pNX: Cannot be assessed

    ___ pN0: No regional lymph node metastasis

    ___ pN1 [IIIC]: Regional lymph node metastasis

___ No nodes submitted or found

Number of Lymph Nodes Examined

    Specify: ____

    ___ Number cannot be determined (explain): ______________________

Number of Lymph Nodes Involved

    Specify: ____

    ___ Number cannot be determined (explain): ______________________

    * Data elements with asterisks are not required. However, these elements may be 8 clinically important but are not yet validated or regularly used in patient management.

CAP Approved Gynecologic • Ovary

    Ovary 3.1.0.0

    Distant Metastasis (pM)

    ___ Not applicable

    ___ pM1 [IV]: Distant metastases (excludes peritoneal metastasis)

     *Specify site(s), if known: ____________________________ Note: If pleural effusion is present, there must be a positive cytology for a stage IV designation.

    Parenchymal liver metastasis is classified as stage IV disease, whereas liver capsule metastasis

    is classified as stage III disease.

    *Additional Pathologic Findings (select all that apply) (Note L) *___ None identified

    *___ Endometriosis

     *___ Ovarian

     *___ Extraovarian

    *___ Endosalpingiosis

    *___ Other(s)

     *Specify site(s) and type(s): ______________________________

*Ancillary Studies (Note M)

    *Specify: ______________________________

*Clinical History (select all that apply)

    *___ BRCA1/2 family history

    *___ Hereditary breast/ovarian cancer

    *___ Other (specify): _________________________

*Comment(s)

    * Data elements with asterisks are not required. However, these elements may be 9 clinically important but are not yet validated or regularly used in patient management.

Background Documentation Gynecologic • Ovary

    Ovary 3.1.0.0

    Explanatory Notes

A. Suggestions for Sampling for Microscopic Examination

Ovarian Surface Epithelium

    The surface of the ovary should be handled as gently as possible; rubbing or scraping it or allowing it to dry should be avoided. Involvement of the ovarian surface is an important element in staging tumors limited to the ovary, and the presence of surface involvement may influence treatment. Therefore, careful examination of the ovarian surface is crucial. Furthermore, in patients who undergo prophylactic oophorectomy because of a family history of ovarian and/or breast cancer, very small carcinomas centered in the ovarian surface may be present that may be potentially lethal and may 1be missed if the macroscopic inspection is not optimal.

Primary Tumor

    One section for each centimeter of the tumor’s largest dimension is generally recommended, with modification based on the degree of heterogeneity of the tumor #and the difficulty of diagnosis.

    Some sections should include the ovarian surface where it is most closely approached by tumor on gross examination, with the number of sections depending on the degree of suspicion of surface involvement.

    Tumor adhesions, sites of rupture, and resection margins, if pertinent, should be sampled and labeled specifically for microscopic identification.

The ovary and fallopian tube should be submitted in toto in patients with BRCA

    mutations or suspected to be at increased risk of hereditary breast/ovarian cancer, even when grossly normal. This detailed examination results in an approximately 4-fold 2increase in detection of precursor lesions or early, microscopic carcinoma.

    Appropriate handling implies that all ovarian and tubal tissue should be serially 3,4sectioned and submitted. For fallopian tubes, amputate the fimbriated ends and

    section parallel to the long axis of the fallopian tube to maximize the amount of tubal 5 epithelium available for histological examination (SEE-FIM protocol) (Figure 1). The

    remainder of the fallopian tube is submitted as serial cross-sections.

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