Cervical Cancer Histopathology Reporting Proforma
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1 Cervical Cancer Histopathology Reporting Proforma Mandatory questions (i.e. protocol standards) are in bold (e.g. S1.01). S1.01 Identification Family name Given name(s) Ethnicity Unknown Aboriginal/Torres Strait Islander Other ethnicity: Date of birth DD MM YYYY Date of request Mandatory questions (i.e. protocol standards) are in bold (e.g. S1.01). Requesting doctor - name and contact details DD MM YYYY Patient identifiers e.g. MRN, IHI or NHI (please indicate which) S1.03 Accession number Tumour location New primary or recurrence New primary cancer Details: Distant metastasis Local recurrence Operative procedure Cone biopsy (laser cone or cold knife cone biopsy) Radical trachelectomy Hysterectomy Radical hysterectomy Other Previous treatment Details of prior cancer diagnosis Accompanying specimens Lymph nodes Other Family history Clinical diagnosis Previous biopsy or cytology results Surgeon s opinion on existence of local residual cancer S1.04 Principal clinician Version 1.0 Proforma: Cervical Cancer Structured Reporting Protocol 1st Edition Page 1 of 8
2 G1.01 Other clinical information received TUMOUR 1 G2.03 Tumour location within ectocervix/endocervix plane Macroscopic findings S2.02 Specimen labelled as Tumour location radially (clock-face) S2.03 Orientation markers S2.06 Tumour size length x width G2.01 Specimen external appearance length x width in mucosal surface area G2.04 Tumour appearance S2.04 SPECIMEN MEASUREMENTS Cone bx or radical trachelectomy Length of specimen Length of canal Diameter of ectocervix in 3-9 o clock plane Diameter of ectocervix in 6-12 o clock plane Hysterectomy or radical hysterectomy Uterine dimensions superior to inferior x distance between cornu x anterior to posterior length x width x thickness S2.07 Tumour thickness Record thickness from the tumour surface to deepest point of invasion the total cervical wall thickness in this region S2.08 tumour to resection margin TUMOUR 2 G2.03 Tumour location within ectocervix/endocervix plane G2.02 Description of uterus and accompanying organs/tissues Tumour location radially (clock-face) S2.05 Macroscopically visible tumour Description: S2.06 Tumour size length x width length x width in mucosal surface area Number of visible tumours Version 1.0 Proforma: Cervical Cancer Structured Reporting Protocol 1st Edition Page 2 of 8
3 TUMOUR 2 (cont.) G2.05 Distance between tumours G2.04 Tumour appearance Outermost span of tumours S2.07 Tumour thickness Record thickness from the tumour surface to deepest point of invasion the total cervical wall thickness in this region S2.08 tumour to resection margin S2.09 Macroscopic invasion Vaginal cuff Uterine body Parametrium Other organs or tissues TUMOUR 3 S2.10 Nature and site of blocks G2.03 Tumour location within ectocervix/endocervix plane Tumour location radially (clock-face) S2.06 Tumour size length x width length x width in mucosal surface area G2.04 Tumour appearance S2.07 Tumour thickness Record thickness from the tumour surface to deepest point of invasion the total cervical wall thickness in this region S2.08 tumour to resection margin Version 1.0 Proforma: Cervical Cancer Structured Reporting Protocol 1st Edition Page 3 of 8
4 S2.11 Lymph nodes Not submitted Submitted Site 1 (including laterality) Microscopic findings S3.01 Multiple tumours Number of tumours Total number of nodes TUMOUR 1 S3.02 Histological tumour type (refer p8) Macroscopically does not appear involved Macroscopically appears involved G3.01 Carcinoma subtype (if applicable) Site 2 (including laterality) Total number of nodes Macroscopically does not appear involved Macroscopically appears involved S3.03 Histological tumour grade - adenocarcinoma (if applicable) Well differentiated (grade 1) Moderately differentiated (grade 2) Poorly differentiated (grade 3) G3.02 Histological tumour grade - SCC (if applicable) Site 3 (including laterality) TUMOUR 2 Total number of nodes S3.02 Histological tumour type (refer p8) Macroscopically does not appear involved Macroscopically appears involved G3.01 Carcinoma subtype (if applicable) G2.06 Other macroscopic description S3.03 Histological tumour grade - adenocarcinoma (if applicable) Well differentiated (grade 1) Moderately differentiated (grade 2) Poorly differentiated (grade 3) G3.02 Histological tumour grade - SCC (if applicable) Version 1.0 Proforma: Cervical Cancer Structured Reporting Protocol 1st Edition Page 4 of 8
5 TUMOUR 3 S3.02 Histological tumour type (refer p8) S3.06 Greatest horizontal (transverse) measure of carcinoma G3.01 Carcinoma subtype (if applicable) S3.03 Histological tumour grade - adenocarcinoma (if applicable) Well differentiated (grade 1) Moderately differentiated (grade 2) Poorly differentiated (grade 3) G3.02 Histological tumour grade - SCC (if applicable) G3.05 Second horizontal (transverse) measurement of carcinoma TUMOUR 2 If there are multiple foci of invasion with clearly separate individual points of origin, then separate measurements for S3.06 and G3.05 should be made and each tumour documented as a separate focus. S3.06 Greatest horizontal (transverse) measure of carcinoma G3.05 Second horizontal (transverse) measurement of carcinoma S3.05 Maximum microscopic depth of invasion (most deeply invasive focus) OR TUMOUR 3 S3.06 Greatest horizontal (transverse) measure of carcinoma at least the deepest point of invasion involves a margin Depths of invasion of additional tumours TUMOUR 1 G3.05 Second horizontal (transverse) measurement of carcinoma G3.06 Tumour site(s) TUMOUR 2 TUMOUR 2 OR From to G3.03 Cervical wall thickness (In the maximal area of invasion) S3.07 Associated CIN G3.04 Ulceration S3.08 Associated AIS Version 1.0 Proforma: Cervical Cancer Structured Reporting Protocol 1st Edition Page 5 of 8
6 S3.09 Involvement of other organs Not applicable OR Pelvic wall Vagina - upper two thirds Vagina - lower third Mucosa of bladder Mucosa of rectum Uterine body Other organs or tissues Radical trachelectomy Endocervical (superior) margin Vaginal cuff margin S3.10 Vascular invasion Not identified G3.07 Type of vessel involved Lymphatic Blood vessel G3.08 Number of lymphatic spaces involved Number of vascular spaces involved Radial stromal margin Hysterectomy specimens Inferior margin (vaginal or cervical) S3.11 MARGIN STATUS INVASIVE COMPONENT Radial stromal margin Cone biopsy Endocervical (apical) margin Ectocervical margin S3.12 Margin status - CIN margins Consider G3.09 G3.09 CIN to this margin Radial stromal margin S3.13 Margin status - AIS margins Consider G3.10 Version 1.0 Proforma: Cervical Cancer Structured Reporting Protocol 1st Edition Page 6 of 8
7 G3.10 AIS to this margin G3.12 Largest nodal metastatic deposit S3.14 Parametrium Not applicable G3.11 Nature of parametrial involvement Soft tissue Vascular S3.15 REGIONAL LYMPH NODE STATUS G3.13 Extranodal extension Greatest dimension from capsule G3.14 Additional microscopic coent Site 1 (including laterality) Number of involved nodes Number of involved nodes /Total number of nodes resected at this site Site 2 (including laterality) Ancillary test findings G4.01 Iunohistochemistry Not performed Pending Performed Result Interpretive coent Number of involved nodes Number of involved nodes /Total number of nodes resected at this site Site 3 (including laterality) Other ancillary tests Not performed Pending Performed Number of involved nodes Type of test 1 (eg FISH, cytogenetics) Result Interpretive coent Number of involved nodes /Total number of nodes resected at this site Version 1.0 Proforma: Cervical Cancer Structured Reporting Protocol 1st Edition Page 7 of 8
8 Type of test 2 (eg FISH, cytogenetics) Result Interpretive coent Type of test 3 (eg FISH, cytogenetics) Result Interpretive coent G4.02 HPV typing Synthesis and overview G5.01 Diagnostic suary Includehistological type, differentiation if adenocarcinoma, depth of invasion, tumour size, margin assessment, blood vessel or lymphatic invasion if present, parametrial involvement if present, involvement of other organs if present, number of nodal metastases, total number of lymph nodes present S5.01 Overarching coent Epithelial tumours Squamous tumours and precursors Squamous cell carcinoma, not otherwise specified 8070/3 Keratinizing 8071/3 Non-keratinizing 8072/3 Basaloid 8083/3 Verrucous 8051/3 Warty 8051/3 Papillary 8052/3 Lymphoepithelioma-like 8082/3 Squamotransitional 8120/3 Early invasive (microinvasive) squamous cell carcinoma 8076/3 Squamous intraepithelial neoplasm Cervical intraepithelial neoplasia (CIN) 3 / 8077/2 squamous cell carcinoma in situ 8070/2 Benign squamous cell lesions Condyloma acuminatum Squamous papilloma 8052/0 Fibroepithelial polyp Glandular tumours and precursors Adenocarcinoma 8140/3 Mucinous adenocarcinoma 8480/3 Endocervical 8482/3 Intestinal 8144/3 Signet-ring cell 8490/3 Minimal deviation 8480/3 Villoglandular 8262/3 Endometrioid adenocarcinoma 8380/3 Clear cell adenocarcinoma 8310/3 Serous adenocarcinoma 8441/3 Mesonephric adenocarcinoma 9110/3 Early invasive adenocarcinoma 8140/3 Adenocarcinoma in situ 8140/2 Glandular dysplasia Benign glandular lesions Müllerian papilloma Endocervical polyp Other epithelial tumours Adenosquamous carcinoma 8560/3 Glassy cell carcinoma variant 8015/3 Adenoid cystic carcinoma 8200/3 Adenoid basal carcinoma 8098/3 Neuroendocrine tumours Carcinoid 8240/3 Atypical carcinoid 8249/3 Small cell carcinoma 8041/3 Large cell neuroendocrine carcinoma 8013/3 Undifferentiated carcinoma 8020/3 Mesenchymal tumours and tumour-like conditions Leiomyosarcoma 8890/3 Endometrioid stromal sarcoma, low grade 8931/3 Undifferentiated endocervical sarcoma 8805/3 Sarcoma botryoides 8910/3 Alveolar soft part sarcoma 9581/3 Angiosarcoma 9120/3 Malignant peripheral nerve sheath tumour 9540/3 Leiomyoma 8890/0 Genital rhabdomyoma 8905/0 Postoperative spindle cell nodule Mixed epithelial and mesenchymal tumours Carcinosarcoma (malignant müllerian mixed tumour; metaplastic carcinoma) 8980/3 Adenosarcoma 8933/3 Wilms tumour 8960/3 Adenofibroma 9013/0 Adenomyoma 8932/0 Melanocytic tumours Malignant melanoma 8720/3 Blue naevus 8780/0 WHO histological classification of tumours of the uterine cervix 1 Morphology code of the International Classification of Diseases for Oncology (ICD-O) and the Systematized Nomenclature of Medicine ( Behaviour is coded /0 for benign tumours, /2 for in situ carcinomas and grade 3 intraepithelial neoplasia, /3 for malignant tumours, and /1 for borderline or uncertain behaviour. 2 Intraepithelial neoplasia does not have a generic code in ICD-O. ICD-O codes are only available for lesions categorized as squamous intraepithelial neoplasia grade 3 (e.g. cervical intraepithelial neoplasia 3) = 8077/2, squamous cell carcinoma in situ = 8070/2, glandular intraepithelial neoplasia grade 3 = 8148/2 and adenocarcinoma in situ = 8140/2. Miscellaneous tumours Tumours of germ cell type Yolk sac tumour 9071/3 Dermoid cyst 9084/0 Mature cystic teratoma 9080/0 Lymphoid and haematopoetic tumours Malignant lymphoma (specify type) Leukaemia (specify type) Secondary tumours World Health Organisation. Reproduced with permission. Version 1.0 Proforma: Cervical Cancer Structured Reporting Protocol 1st Edition Page 8 of 8
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