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Pancreas (Exocrine)

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Pancreas (Exocrine)

Pancreas (Exocrine)

    Protocol applies to all carcinomas

    of the exocrine pancreas.

    Protocol revision date: January 2005 thBased on AJCC/UICC TNM, 6 edition

Procedures

    • Cytology (No Accompanying Checklist)

    • Incisional Biopsy (No Accompanying Checklist)

     Partial Pancreatectomy

    • Pancreaticoduodenectomy (Whipple Resection)

Author

    Carolyn C. Compton, MD, PhD

     Department of Pathology, McGill University, Montreal, Quebec, Canada For the Members of the Cancer Committee, College of American Pathologists

    Previous contributors: Donald E. Henson, MD; Carlos Fernandez-del Castillo, MD; Andrew L. Warshaw, MD; Christopher Willett, MD

Pancreas (Exocrine) • Digestive System CAP Approved

    ? 2005. College of American Pathologists. 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 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 the document. 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.

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CAP Approved Digestive System • Pancreas (Exocrine)

    Summary of Changes to Checklist(s)

    Protocol revision date: January 2005

The following changes have been made to the data elements of the checkist(s) since

    the January 2004 protocol revision.

Resection Checklist

Microscopic

    Regional Lymph Nodes (pN): the subclassification of pN1 into pN1a and pN1b have

    been changed from required to not required, as shown below

    Regional Lymph Nodes (pN)

    ___ pNX: Cannot be assessed

    ___ pN0: No regional lymph node metastasis

    ___ pN1: Regional lymph node metastasis

    *___ N1a: Metastasis in single regional lymph node

    *___ N1b: Metastasis in multiple regional lymph nodes

    Specify: Number examined ___

     Number involved: ___

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Pancreas (Exocrine) • Digestive System CAP Approved

    Surgical Pathology Cancer Case Summary (Checklist)

    Protocol revision date: January 2005

    Applies to invasive carcinomas only thBased on AJCC/UICC TNM, 6 edition

PANCREAS (EXOCRINE): Resection

Patient name:

    Surgical pathology number:

Note: Check 1 response unless otherwise indicated.

MACROSCOPIC

Specimen Type

    ___ Pancreaticoduodenectomy (Whipple resection), partial pancreatectomy ___ Pancreaticoduodenectomy (Whipple resection), total pancreatectomy ___ Pylorus sparing pancreaticoduodenectomy, partial pancreatectomy ___ Pylorus sparing pancreaticoduodenectomy, total pancreatectomy ___ Partial pancreatectomy, pancreatic body

    ___ Partial pancreatectomy, pancreatic tail

    ___ Other (specify): ____________________________

    ___ Not specified

Tumor Site (check all that apply)

    ___ Pancreatic head

    ___ Uncinate process

    ___ Pancreatic body

    ___ Pancreatic tail

    ___ Not specified

Tumor Size

    Greatest dimension: ___ cm

    *Additional dimensions: ___ x ___ cm

    ___ Cannot be determined (see Comment)

*Other Organs Resected

    *___ None

    *___ Spleen

    *___ Gallbladder

    *___ Other(s) (specify): _________________________

    * Data elements with asterisks are not required for accreditation purposes for 4

    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 Digestive System • Pancreas (Exocrine)

    MICROSCOPIC

Histologic Type

    ___ Ductal adenocarcinoma

    ___ Mucinous noncystic carcinoma

    ___ Signet-ring cell carcinoma

    ___ Adenosquamous carcinoma

    ___ Undifferentiated (anaplastic) carcinoma

    ___ Undifferentiated carcinoma with osteoclast-like giant cells ___ Mixed ductal-endocrine carcinoma

    ___ Serous cystadenocarcinoma

    ___ Mucinous cystadenocarcinoma invasive

    ___ Invasive papillary-mucinous carcinoma

    ___ Acinar cell carcinoma

    ___ Acinar cell cystadenocarcinoma

    ___ Mixed acinar-endocrine carcinoma

    ___ Other (specify): ____________________________ ___ Carcinoma, type cannot be determined

Histologic Grade (ductal carcinoma only)

    ___ Not applicable

    ___ GX: Cannot be assessed

    ___ G1: Well differentiated

    ___ G2: Moderately differentiated

    ___ G3: Poorly differentiated

    ___ G4: Undifferentiated

    ___ Other (specify): ____________________________

Pathologic Staging (pTNM)

Primary Tumor (pT)

    ___ pTX: Cannot be assessed

    ___ pT0: No evidence of primary tumor

    ___ pTis: Carcinoma in situ

    ___ pT1: Tumor limited to the pancreas, 2 cm or less in greatest dimension

    ___ pT2: Tumor limited to the pancreas, more than 2 cm in greatest dimension

    ___ pT3: Tumor extends beyond the pancreas but without involvement of the celiac

    axis or the superior mesenteric artery

    ___ pT4: Tumor involves the celiac axis or the superior mesenteric artery

Regional Lymph Nodes (pN)

    ___ pNX: Cannot be assessed

    ___ pN0: No regional lymph node metastasis

    ___ pN1: Regional lymph node metastasis

    *___ N1a: Metastasis in single regional lymph node *___ N1b: Metastasis in multiple regional lymph nodes Specify: Number examined ___

    * Data elements with asterisks are not required for accreditation purposes for 5

    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.

Pancreas (Exocrine) • Digestive System CAP Approved

     Number involved: ___

Distant Metastasis (pM)

    ___ pMX: Cannot be assessed

    ___ pM1: Distant metastasis

     *Specify site(s), if known: ____________________________

Margins (check all that apply)

    ___ Cannot be assessed

    ___ Margins uninvolved by invasive carcinoma

     Distance of invasive carcinoma from closest margin: ___ mm

     *Specify margin (if possible): ____________________________

     ___ Carcinoma in situ absent at ductal margins

     ___ Carcinoma in situ present at common bile duct margin

     ___ Carcinoma in situ present at pancreatic parenchymal margin ___ Margin(s) involved by invasive carcinoma

     ___ Posterior retroperitoneal (radial) margin: posterior surface of pancreas

     ___ Uncinate process margin (non-peritonealized surface of the

    uncinate process)

     ___ Distal pancreatic margin

     ___ Common bile duct margin

     ___ Proximal pancreatic margin

     ___ Other (specify): ____________________________

    *Venous/Lymphatic (Large/Small Vessel) Invasion (V/L) *___ Absent

    *___ Present

    *___ Indeterminate

*Perineural Invasion

    *___ Absent

    *___ Present

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

    *___ Pancreatic intraepithelial neoplasia (highest grade: PanIN ___) *___ Chronic pancreatitis

    *___ Acute pancreatitis

    *___ Other (specify): ____________________________

*Comment(s)

    * Data elements with asterisks are not required for accreditation purposes for 6

    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.

    For Information Only Digestive System • Pancreas (Exocrine)

    Background Documentation

    Protocol revision date: January 2005

    I. Cytologic Material

    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. Clinical history

    (1) jaundice

    (2) pancreatitis

    (3) previous pancreatic or biliary surgery

    (4) pseudocyst drainage

    (5) diabetes mellitus

    b. Clinical findings (eg, endoscopic retrograde cholangiopancreatography

    [ERCP] and/or imaging studies)

    c. Clinical diagnosis

    d. Procedure (eg, brushing, washing, other)

    e. Operative findings

    B. Macroscopic Examination

    1. Specimen

    a. Unfixed/fixed (specify fixative)

    b. Number of slides received, if appropriate

    c. Quantity and appearance of fluid specimen, if appropriate

    d. Other (eg, cytologic preparation from tissue)

    e. Results of intraprocedural consultation 2. Material submitted for microscopic evaluation 3. Special studies (specify) (eg, cytochemistry, immunocytochemistry)

    C. Microscopic Evaluation

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

    2. Tumor, if present (Note A)

    a. Histologic type, if possible (Note B)

    b. Histologic grade, if possible (Note C)

    c. Other features (eg, necrosis)

    3. Additional pathologic findings, if present 4. Results/status of special studies (specify) 5. Comments

    a. Correlation with intraprocedural consultation, as appropriate

    b. Correlations with other specimens, as appropriate

    c. Correlation with clinical information, as appropriate

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    Pancreas (Exocrine) • Digestive System For Information Only

    II. Incisional 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. Clinical history

    (1) jaundice

    (2) pancreatitis

    (3) previous pancreatic or biliary surgery

    (4) pseudocyst drainage

    (5) diabetes mellitus

    b. Clinical findings (eg, ERCP and/or imaging studies)

    c. Procedure (eg, ERCP biopsy, wedge biopsy)

    d. Operative findings

    e. Anatomic site(s) of specimen(s)

    B. Macroscopic Examination

    1. Specimen

    a. Unfixed/fixed (specify fixative)

    b. Number of pieces

    c. Largest dimension of each piece

    d. Results of intraoperative consultation 2. Tissues submitted for microscopic evaluation

    a. Submit entire specimen

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

    3. Special studies (specify) (eg, histochemistry, immunohistochemistry)

    C. Microscopic Evaluation

    1. Tumor (Note A)

    a. Histologic type (Note B)

    b. Histologic grade (Note C)

    c. Invasion

    2. Additional pathologic findings, if present

    a. Pancreatic intraepithelial neoplasia (PanIN) (Note D)

    b. Metaplasia

    c. Pancreatitis

    d. Other(s)

    3. Results/status of special studies (specify) 4. Comments

    a. Correlation with intraoperative consultation, as appropriate

    b. Correlation with other specimens, as appropriate

    c. Correlation with clinical information, as appropriate

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    For Information Only Digestive System • Pancreas (Exocrine)

    III. Partial Pancreatectomy (Distal or Left Pancreatectomy)

    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. Clinical history

    (1) jaundice

    (2) pancreatitis

    (3) previous pancreatic or biliary surgery

    (4) pseudocyst drainage

    (5) diabetes mellitus

    b. Clinical findings (eg, ERCP and/or imaging studies)

    c. Clinical diagnosis

    d. Procedure (eg, distal pancreatectomy, local excision of tumor)

    e. Operative findings

    f. Anatomic site(s) of specimen(s)

    B. Macroscopic Examination

    1. Specimen

    a. Organs/tissues received (specify)

    b. Unfixed/fixed (specify fixative)

    c. Number of pieces

    d. Dimensions

    e. Orientation of specimen, if indicated by surgeon

    f. Results of intraoperative consultation 2. Tumor (Note A)

    a. Location (Note E)

    b. Configuration (Note F)

    c. Dimensions (best estimate) (Note G)

    d. Descriptive features (eg, color, consistency, necrosis, hemorrhage,

    cavitation)

    e. Estimated extent of invasion (Note G)

    f. Distance from margins (Note H)

    (1) proximal

    (2) distal

    (3) radial (retroperitoneal soft tissue margin closest to deepest

    tumor penetration)

    3. Lesions in noncancerous pancreas

    a. Pancreatic duct obstruction

    b. Stones

    c. Pancreatitis

    d. Other(s)

    4. Regional lymph nodes (identify by location, if possible or if specified by surgeon)

    (Note G)

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    Pancreas (Exocrine) • Digestive System For Information Only

    5. Tissues submitted for microscopic evaluation

    a. Carcinoma, including:

    (1) points of deepest penetration of surrounding structures

    (2) interface with adjacent pancreas

    (3) interface with adjacent duodenum, if appropriate

    (4) visceral serosa overlying tumor

    b. Margins (Note H)

    (1) proximal

    (2) distal

    (3) radial (retroperitoneal posterior soft tissue margin closest to deepest

    tumor penetration)

    c. All lymph nodes (Note G)

    (1) specify node(s) when marked by surgeon

    d. Noninvolved pancreas

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

    f. Other tissue(s)/organ(s)

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

    microscopy, DNA analysis [specify type])

    C. Microscopic Evaluation

    1. Tumor (Note A)

    a. Histologic type (Note B)

    b. Histologic grade (Note C)

    c. Extent of invasion (Note G)

    d. Venous/lymphatic vessel invasion (Note I)

    e. Perineural invasion (Note J)

    2. Margins (Note H)

    a. Proximal

    b. Posterior pancreatic surface (deep radial margin)

    c. Distal, if appropriate

    3. Peritoneal surface

    4. Regional lymph nodes (Note G)

    a. Number

    b. Number involved by tumor

    5. Additional pathologic findings, if present

    a. Pancreatic intraepithelial neoplasia (PanIN) (Note D)

    b. Metaplasia

    c. Pancreatitis

    d. Other(s)

    6. Distant metastasis (pM) (specify site)

    7. Results/status of special studies (specify) 8. Comments

    a. Correlation with intraprocedural consultation, as appropriate

    b. Correlation with other specimens, as appropriate

    c. Correlation with clinical information, as appropriate

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