This protocol is intended to assist pathologists in providing clinically useful and relevant information as a result of the examination of surgical specimens. Use of this protocol is intended to be entirely voluntary. If equally valid protocols or similar documents are applicable, the pathologist is, of course, free to follow them. Indeed, the ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of the individual circumstances presented by a specific patient or specimen.
It should be understood that adherence to this protocol will not guarantee a successful result. Nevertheless, pathologists are urged to familiarize themselves with the document. Should a physician choose to deviate from this protocol or similar documents based on the circumstances of a particular patient or specimen, the physician is advised to make a contemporaneous written notation of the reason for the procedure followed.
The College recognizes that this document may be used by hospitals, attorneys, managed care organizations, insurance carriers, and other payers. However, the document was developed solely as a tool to assist pathologists in the diagnostic process by providing information that reflects the state of relevant medical knowledge at the time the protocol was first published. It was not developed for credentialing, litigation, or reimbursement purposes. The College cautions that any uses of the protocol for these purposes involve considerations that are beyond the scope of this document.
PROTOCOL FOR THE EXAMINATION OF SPECIMENS FROM PATIENTS WITH TUMORS OF THE PERITONEUM
I. Cytologic Material
A. Clinical information
1. Patient identification
a. Name
b. Identification number
c. Age (birth date)
d. Gender
e. Location (eg, ward, clinic, office)
2. Responsible physician(s)
3. Date of procedure
4. Clinical information
a. Relevant history
(1) Asbestos exposure
(2) Radiation exposure
(3) Evidence of tumor(s) elsewhere
(4) Prior tumor(s)
(5) Prior operation(s)
b. Relevant findings (eg, radiologic studies, laboratory data)
c. Clinical diagnosis
d. Operative findings (eg, unifocal, multifocal, or diffuse)
e. Type(s) or site(s) of specimen(s)
(1) Ascitic fluid
(2) Peritoneal washings (specify site[s])
(3) Brushings (specify site[s])
(4) Fine-needle aspirate (specify site[s])
(5) Cytology preparation of tissue (touch preparation) (specify site[s])
(6) Other
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)
2. Material submitted for microscopic evaluation (eg, smear; cytocentrifuge, touch, or filter preparation; cell block)
3. Special studies (specify) (eg, cytochemistry, immunocytochemistry)
C. Microscopic examination
1. Adequacy of specimen for evaluation (if unsatisfactory or limited, specify reason)
2. Tumor, if present
a. Histologic type, if possible (note A)
b. Other characteristics (eg, nuclear grade, necrosis) (note B)
3. Additional cytologic findings
4. Results/status of special studies
5. Comments
a. Correlation with intraprocedural consultation
b. Correlation with other specimens, as appropriate
c. Correlation with clinical information, as appropriate
II. Biopsy
A. Clinical information
1. Patient identification
a. Name
b. Identification number
c. Age (birth date)
d. Gender
e. Location (eg, ward, clinic, office)
2. Responsible physician(s)
3. Date of procedure
4. Clinical information
a. Relevant history
(1) Asbestos exposure
(2) Radiation exposure
(3) Evidence of tumor(s) elsewhere
(4) Prior tumor(s)
(5) Prior operation(s)
b. Relevant findings (eg, radiologic studies, laboratory data)
c. Clinical diagnosis
d. Procedure
e. Operative findings (eg, unifocal, multifocal or diffuse)
f. Anatomic site(s) of specimen(s)
B. Macroscopic examination
1. Specimen
a. Unfixed/fixed (specify fixative)
b. Number of pieces
c. Size or size range
d. Descriptive features
2. Submit entire specimen(s) for microscopic evaluation
3. Special studies (specify) (eg, histochemistry, immunohistochemistry, electron microscopy, asbestos fiber count)
C. Microscopic examination
1. Tumor
a. Histologic type (note A)
b. Histologic grade, if appropriate (note B)
c. Other features of possible prognostic or therapeutic significance (eg, invasive, noninvasive)
2. Additional pathologic findings (eg, endosalpingiosis and relation to tumor, if pertinent)
3. Results/status of special studies
4. Comments
a. Correlation with intraprocedural consultation
b. Correlation with other specimens, as appropriate
c. Correlation with clinical information, as appropriate
5. Pathologic stage (note C)
III. Resection
A. Clinical information
1. Patient identification
a. Name
b. Identification number
c. Age (birth date)
d. Gender
e. Location (eg, ward, clinic, office)
2. Responsible physician(s)
3. Date of procedure
4. Clinical information
a. Relevant history
(1) Asbestos exposure
(2) Radiation exposure
(3) Evidence of tumor(s) elsewhere
(4) Prior tumor(s)
(5) Prior operation(s)
b. Relevant findings (eg, radiologic studies, laboratory data)
c. Clinical diagnosis
d. Procedure
e. Operative findings (eg, unifocal, multifocal, or diffuse)
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. Descriptive features
(1) Peritoneal tissue(s)
i. Outer surface (normal, adhesions, roughening, granularity, tumor)
ii. Sectioned surface(s)
iii. Size of tumor(s) if different from size of entire specimen, descriptive features, identification of areas for special study (eg, resection margin[s] if pertinent)
iv. Other lesions
(2) Organ(s) removed
i. Outer surface (normal, adhesions, roughening, granularity, tumor)
ii. Sectioned surface
(a) Tumor(s) dimension(s) and distribution on or within organ, descriptive features, identification of areas for special study (eg, resection margin[s] if pertinent)
(b) Other lesions
2. Tissues submitted for microscopic evaluation
3. Special studies (specify) (eg, histochemistry, immunohistochemistry, electron microscopy, asbestos fiber count)
C. Microscopic examination
1. Tumor
a. Histologic type (note A)
b. Histologic grade, if appropriate (note B)
c. Other features of possible prognostic or therapeutic significance (eg, invasive, noninvasive)
2. Status of resection margins
3. Additional pathologic findings (eg, endosalpingiosis)
4. Results/status of special studies
5. Comments
a. Correlation with intraprocedural consultation
b. Correlation with other specimens, as appropriate
c. Correlation with clinical information, as appropriate
6. Pathologic stage (note C)
EXPLANATORY NOTES
A: Histologic Type.—This protocol refers only to primary tumors of the peritoneum. Secondary tumors, including those causing pseudomyxoma peritonei (usually of appendiceal origin), are not addressed by these guidelines. It is possible, however, that “peritoneal spread” of some ovarian serous borderline tumors may reflect independently primary peritoneal rather than metastatic ovarian neoplasia in some cases.
Classification of Peritoneal Tumors
Benign
Adenomatoid tumor
Benign multicystic mesothelioma (multilocular peritoneal inclusion cyst)
Mesothelial cyst(s) (unilocular) (free or attached)
Well-differentiated papillary mesothelioma
Solitary fibrous tumor (fibrous mesothelioma)
Malignant
* Rare types include desmoplastic, small cell, lymphohistiocytoid, and deciduoid types.
† When this tumor involves the extraovarian peritoneum significantly and the ovarian surface minimally or not at all, it is generally considered to be of peritoneal origin.
‡ The Gynecological Oncology Group has adopted the following criteria for the diagnosis of primary peritoneal serous carcinoma:
Both ovaries are either normal in size or enlarged by a benign process. In the judgment of the surgeon and the pathologist, the bulk of the tumor is on the peritoneum, and the extent of tumor involvement at 1 or more extraovarian sites is greater than that on the surface of or within either ovary.
Microscopic examination of the ovaries reveals (a) no tumor; (b) tumor confined to the surface epithelium with no evidence of cortical invasion; (c) tumor involving the ovarian surface and the underlying cortical stroma but less than 5 × 5 mm in diameter; or (d) tumor less than 5 × 5 mm within the ovarian substance, with or without surface involvement.
The histologic and cytologic characteristics of the tumor are predominantly serous and similar or identical to those of ovarian serous papillary carcinoma of any grade.
If an oophorectomy has been performed in the past, a confident diagnosis of primary peritoneal serous carcinoma requires 1 of the following: (a) a pathology report to document the absence of carcinoma in the ovarian specimen, with review of all the slides if the oophorectomy has been performed within 5 years of the current procedure; (b) if the oophorectomy has been performed more than 5 years before the current procedure, the pathology report of the specimen should be obtained, and the slides should be reviewed if still available. The peritoneal tumor should be interpreted in light of the ovarian findings.
B: Histologic Grade.—There is no established grading system for most peritoneal tumors, but the degree of differentiation is incorporated into the terminology of some of them. Serous and other mullerian-type tumors can be graded according to the criteria used for similar tumors in the female genital tract (see protocols on ovary6 and endometrium7).
C: Staging of Peritoneal Tumors.—There is no widely accepted staging system for peritoneal tumors, but their extent may have prognostic significance. Thus, it is important to determine whether a mesothelioma is unifocal, multifocal, or diffuse,8 and whether there are lymph node or distant metastases. Peritoneal serous carcinomas are generally staged as though they were stage II to stage IV ovarian cancers (see protocol for ovary).6
References
Bibliography
This protocol was developed by the Cancer Committee of the College of American Pathologists and submitted for editorial review and publication. It represents the views of the Cancer Committee and is not the official policy of the College of American Pathologists.
Reprints: See Archives of Pathology & Laboratory Medicine Web site at www.cap.org.