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Textbook of Gyneaecological Oncology (ESGO-ENYGO)Chapter: How to report

a Pathologic Specimen in Gynecologic Oncology – Chapter 57

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 How to Report a Pathology Specimen in
Gynaecologic Oncology?
Ayşe Ayhan, MD, PhD
There is currently no standardized universal guideline for
cut-up and reporting of gynaecological oncology specimens;
however different countries & pathology societies may
have their own guidelines, recommendations or checklists.
Our purpose is not to report/rewrite such guidelines, nor
to prepare an official account to be used in legal action or
reimbursement. We solely will briefly summarize the variables
that we think it should be mentioned in genital tract neoplasm
pathology reports.
• No matter which system they are using, the pathologists
should be aware of the staging details for individual organ
and their impact of alterations on management.
• The report should be comprehensive, but concise and
clear; reflecting the high quality clinico-pathological
knowledge of the pathologist.
• We strongly recommend the inclusion of macroscopic
photograph (fresh, fixed and cut surfaces) along with
matching sketches showing measurements, including
codes for the samples submitted; thus the report and
orientation of the tissues would be clear both to the
pathologist and to any person who at a later time
will need to utilize the report or histological material.
This would avoid subjectivity and eliminates pages of
written information concerning macroscopic description.
Examples for an endometrial cancer, cervix cancer radical
operation and a conization may be seen at Figures 1-3.
• Grading system should be specified, staging (pTNM/
FIGO) with preferably both systems to be mentioned, and
SNOMED/ICD-O coding should be performed.
• Good & full communication between pathologist and
surgical oncologist improves quality of management. The
importance of gynecologic oncology tumor conferences on
the patient management and the role of the pathologist in
the team should be reinforced in every medical unit where
gynecologic oncology operations are being performed (1);
even online tumor conferences are possible and reported
to be feasible, time-saving processes (2).
• Following synoptic guidelines containing required
minimum information that the pathologist should
mention in the report would increase the consistency
in terms of thoroughness, terminology and sequence.
The reader-practicing pathologist and institutions may
follow guidelines from special textbooks (3-8), directly
from Association of Directors of Anatomic and Surgical
344
57
Pathology or from internet-based checklists (9-11). Here
in this report we try to outline our own comprehensive and
compact chart that we created using different sources (3-
11).
• In terms of slide review and consultation, it is mandatory
for the pathologist to review the outside slides of a patient
who is referred to his institution with a microscopic
diagnosis made elsewhere, before starting the therapy.
It is the responsibility of the pathology department of the
referring institution to carefully pack and ship with a copy
of their pathology report. No matter the slides have been
requested by the clinician or the pathology department,
they should be reexamined and a formal report should
be issued, a copy of which should be sent to the referring
pathologist. Neither the clinician nor the pathologist
should object to this practice, it is not instituted to question
their interpretation but rather to ensure uniformity of
diagnosis, grading, nomenclature; allowing comparison
with subsequent material of the same patient, feedback
and education (5).
Vagina
Macroscopical
Specimen submitted / Surgical procedure ± LND
Tumor site (upper / middle / lower third – circumferential /
anterior / posterior / lateral)
Size in two dimensions, macroscopical thickness assessment
Macroscopic extensions
Configuration (exophytic / ulcerative / diffuse / circumferential)
Microscopical
Histological type and grade (grading system should be
indicated).
VAIN3 / SCC (keratinization±, warty, verrucous) / Adenocar-
cinoma (clear cell / endometrioid / mucinous / adenosqua-
mous / mesonephric) / melanoma / sarcoma / others)
Microscopic length and depth of invasion or tumor thickness
in mm
Tumor-stromal interface (blunt vs infiltrative)
Arterial-venous-lymphatic invasion (by HE / elastica-Masson
/ IHC; define D240 - CD31 - CD34 etc) or can not be
assessed
Surrounding VAIN / HPV / adenosis / mesonephric remnant /
hyperplasia
 How to Report a Pathology Specimen in Gynaecologic Oncology? u 345

Figure 1.

Figure 2.

Figure 3.

Figures 1,2,3. Exemplify a cone (Figure 1), a radically resected hysterectomy material for cervix squamous cell carcinoma (Figure 2), and a
hysterectomy+BSO for endometrial carcinoma (Figure 3). In our practice, we include fresh, post-fixed, sectioned and mapped figures along with
our hand-made matching sketches. In consequence, the report and orientation of the tissues should clear both to the pathologist and to any
person who will need to utilize the report or histological material. This practice avoids subjectivity and eliminates pages of written information.
346 u How to Report a Pathology Specimen in Gynaecologic Oncology?
Deep and radial margins
Uninvolved (distance from closest margin) / specify if involved
/ can not be assessed
• Cornerstones: Paravaginal tissues / pelvic wall (specify:
muscle, fascia, neurovascular involvement, bony pelvis)
/ bladder-rectum mucosa / beyond true pelvis (specify if
present)
Pathologic Staging, (pT / pN / p or cM) and FIGO
LN number involved/examined for each region: For tumors
located in upper 2/3 of the vagina (obturator / internal iliac
(hypogastric) / external iliac / pelvic (NOS)
For tumors located in lower 1/3 of the vagina (inguinal /
femoral)
• Paraaortic lymph node metastasis is considered to be M1
disease!
• If tumor also involves cervix or vulva, tumor should be
classified as a primary cervix or vulvar cancer!
Vulva
Vulvar Carcinoma
Macroscopical
Specimen submitted / Surgical procedure (local-wide excision,
partial / total / radical vulvectomy) ± LND
Tumor site (R-L Labia majus/minus/clitoris/perineum/other)
Multifocality
Size in two dimensions (if visible), thickness
Macroscopic extension
Configuration (exophytic/ulcerative/diffuse/circumferential)
Microscopical
Histological type and grade (grading optional, two, three or
four grading system may be used but grading system
should be specified when used).
VIN3 / SCC (keratinization±, basaloid, warty, verrucous) ;
Glandular tumors [Paget / Bartolin – Skene – mammary-
like - other vestibular gland (or NOS)]: (Adenocarcinoma /
Adenoid cystic / Adenosquamous) / small cell / TCC
Microscopic length and depth of invasion (DOI= measurement
from epithelial-stromal junction of the adjacent most
superficial dermal papillae to the deepest point of invasion:
applicable regardless of keratinization or ulceration) or
tumor thickness (if the epithelium is keratinized, from
the bottom of the granular layer to the deepest point of
invasion; if not keratinized, from the surface of the tumor
to the deepest point of invasion) in mm
Tumor-stromal interface (blunt (pushing front), or infiltrating
as finger-like or spray-like)
Arterial-venous-lymphatic invasion (by HE / elastica-Masson
/ IHC; define D240 - CD31 - CD34 etc) or can not be
assessed
Surrounding VIN / HPV / Lichen sclerosis / chronic
granulomatous disease
Deep and radial margins
Uninvolved (distance from closest margin) / specify if involved
(including VIN) / or can not be assessed
Pathologic Staging, (pT / pN / p or cM) and FIGO
• Cornerstones: Greatest dimension 2 cm, stromal invasion
1 mm, lower urethra-vagina-anus involvement / bladder-
rectal-upper urethra involvement.
• It is recommended that the term microinvasive carcinoma
not to be used in reporting vulvar carcinomas as there is
no agreement on the definition.
LN number involved/examined for each region (Femoral and
inguinal) (Specify extranodal extension; metastasis larger
than 5 mm; fixed or ulcerated nodes). Pelvic lymph nodes
and beyond are considered distant metastasis (M1). For TNM
number involved/examined for each region is stated; however
FIGO classifies NX when node number is <6.
Vulvar Malignant Melanoma (additional points from
vulvar carcinoma)
Superficial spreading/nodular/acrolentiginous melanoma
Cell type (epithelioid, spindle, dendritic, nevoid, mixed)
Breslow thickness (from the top of the granular layer – for
mucosa from surface)
Clark anatomic level – if skin is involved
• Cornerstones: Epidermis / papillary dermis / papillary -
reticular interface / reticular dermis / subcutaneous fat) (0
mm / <1mm / 1-2 mm / >2 mm / in fat)
Ulcerations (measures) / Regression / Mitosis per mm2 /
neurotropism
Presence of tumor infiltrating lymphocytes
Surrounding coexisting nevus or precursor lesion and
microscopic satellites (dysplastic - dermal / junctional /
compound nevi)
Presence or absence of vertical growth phase (nests of cells
in the dermis larger than intraepidermal nests; or mitotic
activity)
Cervix
For Biopsy Reports
Lesion histology: HSIL – CIN / Glandular dysplasia / AIS /
Microinvasive suspicion or presence / SCC – keratinized
– nonkeratinized – verrucous variants / Adenocarcinoma
(mucinous – endometrioid – clear cell – serous –
mesonephric / adenosquamous / adenoid cystic / adenoid
basal) / neuroendocrine / undifferentiated. Specify if
grade for SIL can not be given for any reason. Specify if
p16INK4A, MIB-1, ProEx C etc. performed.
LVSI (by HE / elastica-Masson / IHC; define D240 - CD31 -
CD34 etc) or can not be assessed
For Operation Material
Macroscopical
Specimen submitted / Surgical procedure (excision / cold
cone / leep / LLETZ / trachelectomy / hysterectomy /
pelvic exenteration) ± LND, specimen integrity
Tumor site (in quadrants) and / or clockwise
Size in two dimensions if visible
 How to Report a Pathology Specimen in Gynaecologic Oncology? u
Macroscopic extension
Configuration (exophytic / ulcerative / diffuse / circumferential
/ barrel shaped)
Microscopical
Histological type and Grade (grading system should be
indicated):
HSIL-CIN / Glandular dysplasia / AIS / Microinvasive / SCC
– keratinized - nonkeratinized - verrucous variants /
Adenocarcinoma (mucinous – endometrioid – clear cell –
serous - mesonephric / Adenosquamous / Adenoid cystic
/ Adenoid basal) / neuroendocrine / undifferentiated
Early lesions: Microscopic length, depth of invasion
(measurement in mm from the highest epithelial-stromal
interface), tumor thickness (if normal epithelium is not
present adjacent to tumor). Endocervical adenocarcinoma
should be measured from the epithelial stromal interface
to the deepest point of invasion.
Advanced lesions: Depth of invasion (measurement in mm,
residual cervical wall thickness at this area in mm and %
of involvement)
Tumor-stromal interface (blunt or infiltrative as finger-like or
spray-like)
Extent of tumor:
• Cornerstones: If invisible, stromal invasion 3 mm and 5
mm; horizontal spread 7 mm; if visible: 4 cm / pelvic wall-
parametrial involvement / lower 1/3 of vagina / kidney
function / bladder-rectum mucosa involvement (LVI
does not affect stage but presence or abscence must be
mentioned).
Arterial / venous / lymphatic invasion (by HE / elastica
Masson / IHC - define D240 - CD31 - CD34 etc) can not
be assessed
Surrounding associated SIL
Margins: Uninvolved (distance from closest margin) / specify
if involved-including CIN / can not be assessed (endo-
exocervical and deep margins)
Pathologic Staging, (pT / pN / p or cM) and FIGO
LN number involved/examined for each region (parametrial
/ obturator / internal iliac hypogastric) / external iliac /
common iliac / sacral / presacral). For TNM, LN number
involved/examined for each region is stated; however
FIGO classifies NX when node number is <6. Peritoneal
spread, paraaortic and beyond are considered distant
metastasis (M1).
(Leep/cone should be submitted in toto; serially sectioned
for evaluation and should be mapped along with
microscopical results).
Endometrium
For Biopsy Reports
Type of tumor: Endometrioid or non-endometrioid histology
(serous, clear cell, MMMT) should be mentioned. (Specify
if p53, p16INK4A, etc. performed)
Grade for endometrioid histology and variants
347
For Operation Material
Macroscopical
Specimen submitted / Surgical procedure + LND +
omentectomy, specimen integrity
Tumor site (corpus / fundus / cornu / LUS / isthmus / anterior
or posterior wall)
Size in two dimensions if visible
Macroscopic extension
Microscopical
Histological type and Grade (for endometrioid subtypes, and
grading system used).
Endometrioid - variants / mucinous / serous / clear cell / mixed
/ SCC / TCC / undifferentiated / Carcinosarcoma–MMMT
(with description of the components)
Grading: Endometrioid & variants, and mucinous types: by
proportion of non-squamoid solid component (FIGO: 5% /
5-50% / >50%); severe nuclear atypia increase the grade
by one. Adenocarcinomas with squamous metaplasia
should be graded according to the glandular component.
Serous, CCC and MMMT are high grade by definition
(p16INK4A and p53 results diffuse and strong positivity
in serous carcinomas, should be mentioned whenever
performed).
Biphasic juxtaposed (well and poor) tumors (proportion of
each) should be mentioned
Depth of invasion (measurement in mm, myometrial
thickness at this level in mm and % myometrial thickness)
(distinguish adenomyosis involvement)
Invasion pattern (blunt vs infiltrative; finger-like or spraylike)
Arterial / venous / lymphatic invasion (by HE / elastica-
Masson / IHC; define D240 - CD31 - CD34 etc) or can
not be assessed
Associated EIN (or hyperplasia) / p53 signature / Glandular
dysplasia / EIC
Cervical stromal involvement (depth - if present (in mm
and distance from both paracervical and cervicovaginal
resection margin, in mm);
• We prefer submitting cervix as a whole
Margins: uninvolved / involved (specify) / can not be assessed
Extent of tumor:
• Cornerstones: 1/2 myometrial invasion / cervical stromal
– uterine serosal / adnexal-vaginal involvement / LN
metastasis / bladder-bowel mucosa involvement (2008
FIGO no longer uses peritoneal cytology for upstaging IIIA
but should be recorded when present)
Pathologic Staging, (pT / pN / p or cM) and FIGO
Submit entire adnexa if extrauterine disease suspected /
BRCA family history / if serous or high grade histology
LN number involved/examined for each region (pelvic
and paraaortic separately) (obturator / internal iliac
(hypogastric) / external iliac / common iliac / para-aortic
/ presacral / parametrial). For TNM, LN number involved
/examined for each region is stated; however FIGO
classifies NX when node number is <6.
348 u How to Report a Pathology Specimen in Gynaecologic Oncology?
• Surgical-pathologic assessment of regional lymph
nodes is strongly advocated for all patients with corpus
uteri cancer, also recommended by FIGO; although
the therapeutic effect of node dissection has not been
demonstrated by ASTEC and CONSORT studies,
however routine nodal dissection increased the frequency
of patients with positive nodes.
Leiomyosarcoma and Other Mesenchymal Tumors
(Additional Points)
Size, specifying 5 cm or more
Grade, Mitosis per 10 HPF (count at least 50 HPF)
Tumor necrosis (geographic necrosis)
Percent myometrial thickness
Presence of serosal involvement
• Cornerstones: Tumor size 5 cm / beyond uterus / pelvis /
involves adnexa / other pelvic tissues / one or more sites).
• Cornerstones for adenosarcoma: Tumor in endometrium
(endocervical involvement permitted) / 1/2 myometrium /
beyond uterus : involves adnexa / other pelvic tissues /
one or more sites in pelvis / involvement of bladder and
rectum).
Fallopian Tube
Macroscopical
Specimen submitted / Surgical procedure ± LND, specimen
integrity (intact / ruptured / fragmented / other)
Tumor site (RT–LT / isthmus / ampulla / infundibulum / fimbria
/ serosal surface / adherence to ovary / peritoneum /
macroscopic extension)
Size in three dimensions
FT lumen (normal / dilated / occluded)
Microscopical
Histological type (TIC / serous / mucinous / endometrioid /
CCCa / TCC / Squamous / MMMT / metastatic / other
(specify) / can not be assessed)
Grade (two or three tiered grading system may be used but
grading system should be specified in every occasion)
Maximum microscopical dimensions
Depth of invasion (lamina propria / muscularis mucosa /
proper muscle / serosa)
Presence of in situ carcinoma in adjacent mucosa
Involvement of ovary / endometrium / other pelvic structures
(if present)
Arterial / venous / lymphatic invasion (by HE / elastica-
Masson / IHC; define D240 - CD31 - CD34 etc) or can
not be assessed
Associated endometriosis / salpingitis / endosalpingiosis /
p53 signature (indicate p53 IHC)
Pathologic Staging, (pT / pN / p or cM) and FIGO
• Cornerstones: Serosal involvement / ascites - washing
positivity / uterine-ovarian extension / peritoneal implants
- involvement and / or LN involvement / size of peritoneal
metastasis. Inadequate staging biopsies render TX.
LN number involved / examined for each region (common
iliac / external iliac / internal iliac (hypogastric) / obturator
/ para-aortic / inguinal / pelvic (NOS) / para-aortic (NOS).
Adequate evaluation necessitates pelvic and para-aortic
nodes. For TNM, LN number involved / examined for each
region is stated; however FIGO classifies NX when node
number is <6.
We apply SEE-FIM protocol examination for tubal and ovarian
carcinomas (12).
Ovary
a. Borderline epithelial tumors b. Invasive carcinoma
(Exclude metastatic cancers!)
Macroscopical
Specimen submitted / Surgical procedure (Oophorectomy /
Salpingo-Oophorectomy / Subtotal Oophorectomy /
tumor resection in fragments, Hysterectomy + Salpingo-
Oophorectomy) ± LND / capsule integrity for right and left
ovaries
Tumor site (RO – LO / on surface / in parenchyma / other)
Size in three dimensions
Macroscopic extension
Number of sections examined from the tumor (From most
solid-appearing areas, at least 1 cm / max tumor width for
borderline lesions)
Microscopical
Histological type and Grade (grading system should be
indicated).
Serous / Mucinous / Endometrioid / clear cell / TCC / mixed /
undifferentiated / Sex cord-stromal (granulosa-thecoma-
fibroma-Sertoli-unclassified) / germ cell (primitive-
dysgerminoma - yolk sac - embryonal carcinoma -
immature teratoma - percentages if mixed) / Rete ovarii
adenoca /small cell ca (hypercalcemic-pulmonary),
neuroendocrine ca, other (specify)
Presence or absence of surface involvement (location and
type)
Presence or absence (%) of micropapillary-cribriform
architecture (for borderline serous tumors)
Presence or absence of implants (for borderline tumors),
indicate if no biopsy performed.
(location and type: epithelial / desmoplastic; invasive /
noninvasive)
Arterial / venous / lymphatic invasion (by HE / elastica-
Masson / IHC; define D240 - CD31 - CD34 etc) or can
not be assessed
Presence or absence of co-existing benign-borderline
neoplasm
Tumor invasion of other structures (ovary / omentum / uterus
/ FT / peritoneum, etc)
Associated endometriosis (ovarian / extraovarian) /
endosalpingiosis / p53 signature
• Cornerstones: capsule-ovarian surface involvement /
uterus-tube-other pelvic organ extension / peritoneal
washing positivity / peritoneal and/or LN involvement
 How to Report a Pathology Specimen in Gynaecologic Oncology? u
/ size of peritoneal metastasis / distant met including
parenchymal liver-lung-skeletal-supraclavicular-axillary
nodes etc.
Pathologic Staging, (pT / pN / p or cM ) and FIGO
We apply SEE-FIM protocol examination of fallopian tube
for all tubal and ovarian carcinomas (12).
LN number involved/examined for each region (external
iliac / internal iliac (hypogastric) / obturator / common iliac /
para-aortic / inguinal / pelvic (NOS) / para-aortic (NOS).
pN0 necessitates histologic examination of both pelvic
and para-aortic nodes.
For TNM, LN number involved / examined for each region
is stated; however FIGO classifies NX when node number is
<6.
Abbreviations and Notes
TNM Descriptors should be included only if applicable [m
(multiple primary tumors); r (recurrent), y (post-treatment)].
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