Introduction

Histopathology reports on surgical cancer specimens are becoming increasingly complex for many reasons. With closer clinicopathological correlation and the use of novel immunocytochemical and molecular techniques, new entities and classifications of tumour emerge that are linked to prognosis and response to various treatment modalities. Increasingly the surgical oncologist wants tissue biopsy proof of cancer diagnoses so that patients may be recruited to suitable treatment protocols. No longer is it sufficient to simply say what it is—this must now be qualified by assessment of prognostic indicators such as tumour grade, extent of spread, relationship to primary excision margins, lymph node and vascular spread. Accurate classification and information on tumour stage and prognosis requires increased time and detail on surgical pathology dissection and reporting. These necessary but stringent demands are met by diagnostic surgical pathologists with varying degrees of success and standards of reporting. For example, an audit of colorectal cancer pathology reports in one National Health Service region of the United Kingdom showed that only 78% of colonic cancer reports and 47% of rectal cancer reports met previously agreed criteria in providing the prog-nostically important information.

From this has arisen a trend towards set format reports or minimum datasets for the common cancers. In the United Kingdom this is sponsored by the Royal College of Pathologists allied to other interested parties, such as the Association of Clinical Pathologists and the UK Association of Cancer Registries. They do not work in isolation but in cooperation with other bodies specifically active in individual cancer types, e.g. breast cancer: NHS Breast Screening Programme, European Commission Working Group on Breast Screening Pathology and the British Breast Group. These new standards mirror changes in the organization and provision of cancer services in the United Kingdom reflected in the Calman-Hine Report "A Policy Framework for Commissioning Cancer Services". The success of this approach is measured by ongoing dataset revision and second cycle of publication (http://www.rcpath.org/index. asp?pageID=254). Similar standards for pathologists are also set in the United States by the Association of Directors of Anatomic and Surgical Pathology (http://www.panix.com/~adasp/tumor.htm and http://www.panix.com/~adasp/checklist%20page.htm) and published reg ularly in the journal Human Pathology. Parallel initiatives have been published in Archives of Pathology and Laboratory Medicine by the College of American Pathologists (http://www.cap.org/apps/docs/cancer_ protocols/protocols_index.html).

From the pathologist's point of view standard reports act as an important aide-memoire for the inclusion of necessary data and audit shows that quality standards of information increase accordingly. Also, once the pathologist is familiarized with them, such reports are relatively time-efficient to dictate and transcribe. The clinician (surgeon or oncologist) can extract from them the relevant data with ease and cancer registries can be facilitated—supplemented by automated download if the database is suitably computerized.

The approach taken herein is aimed at fostering the use of standard format reports in surgical cancer. The headings used are common to all cancers, and can be preset onto a computer field or, if this is not available, easily memorized, dictated and typed in a listed format. The end product is concise, clear and relevant to patient management. The format is:

1. Gross description Specimen: description Tumour:

Site Size

Appearance Edge

2. Histological type

3. Differentiation/grade

4. Extent of local tumour spread

5. Lymphovascular invasion

6. Lymph nodes

7. Excision margins

8. Other pathology

9. Other malignancy

These criteria are chosen for the following reasons: 1. GROSS DESCRIPTION Specimen

Specimen type; biopsy or resection. Full standard format reports are most relevant to resection specimens although the principles and abridged forms are applicable to biopsies. Sometimes a resection is more conveniently reported as free text, or in standard format but requiring clarification in the further comments section. If dictated as free text, care must be taken to include the standard diagnostic and prognostic parameters. Biopsy reports should at least comment on the following (if the data are available): tumour point of origin, type of cancer, differentiation or grade, extent of mucosal or submucosal spread, adjacent dysplasia or carci noma in situ and involvement of lymphovascular channels. The proportion of tissue involved by tumour can be useful, e.g. prostate cancer. It is important epidemiologically that cancer registries can distinguish between biopsy and resection specimens to avoid duplication of statistical data leading to overestimates of cancer incidence and prevalence. This can be achieved by unique patient identification and careful indexing of SNOMED T (topography) and P (procedure) codes. This also facilitates audit of biopsy and resection-proven cancer numbers and correlation with other techniques such as exfoliative or fine needle aspiration cytology, radiological imaging and serum marker levels (e.g. prostate specific antigen, PSA).

Specimen type also has implications for excision margins and clinical adjuvant treatment and follow-up, e.g. breast-sparing excision biopsy vs. mastectomy, diathermy snare polypectomy vs colonic resection.

Specimen weight and size. This may also be an indicator of the underlying pathology, e.g. primary adrenal cortical lesions >50 g are usually carcinoma rather than adenoma, and abundant vesicular uterine curettings up to 100 g suggest complete hydatidiform mole with subsequent potential for persistent trophoblastic disease and choriocarcinoma.

Tumour

Site

Location of tumour within the mucous membrane or wall can often give clues as to its nature. Mucous membrane lesions are often primary and epithelial or lymphoid in character. Mural lesions may be primary and mesenchymal or, similar to serosal disease, secondary and extrinsic. Site dictates which adjacent tissues are involved by direct spread (e.g. cervix carcinoma-ureter) and can indicate variable tumour differentiation and prognosis within a given structure (e.g. adenocarcinoma of the hilum vs. the distal third of the extrahepatic bile ducts). It can also be used as an audit tool to monitor resection rates as in anterior resection vs. abdominoperineal resection for rectal carcinoma. It can influence the diagnosis, e.g. epiphyseal vs. diaphyseal bone tumours, renal pelvis (transitional cell) carcinoma vs. renal cortical (clear cell) carcinoma. Later-ality (right or left) is obviously extremely important in patient management. Some cancers also have a tendency for multifocal growth, e.g. transitional cell carcinoma of the urinary tract or thyroid papillary carcinoma.

Size

Size influences the diagnosis (gastrointestinal stromal tumours >5 cm are more likely to be malignant) and the prognosis (renal cell carcinoma: <7cm = pT1, >7cm = pT2; sarcoma: prognosis relates to tumour grade, size and adequacy of excision; breast carcinoma: Nottingham Prognostic Index = 0.2 x size (cm) + grade + lymph node stage). Gross measurements should ideally be made on the fresh tissue and checked against the histological slide, allowing for tissue shrinkage with fixation and processing (e.g. to 30% for oesophageal resections). Small measurements are done with a dome magnifier, the stage micrometer or an eyepiece graticule. Guidelines are given (National Health Service Breast Screening Programme) to distinguish between size of invasive tumour from whole size (+ in-situ change) tumour measurements and a radiological performance indicator is the percentage yield of invasive tumours <1 cm in diameter.

Appearance

Luminal and polypoid

— oesophageal spindle cell carcinoma.

— uterine malignant mixed mesodermal tumour (carcinosarcoma).

— multiple lymphomatous polyposis or familial adenomatous polyposis coli.

Nodular

— carcinoid tumour of bronchus.

malignant melanoma.

Sessile/plaque

— early gastrointestinal carcinoma (stomach, oesophagus, colorectum).

— high-grade bladder carcinoma.

Ulcerated

— usual carcinoma morphology.

Fleshy

— malignant lymphoma. Pigmented

— malignant melanoma. Haemorrhagic

— choriocarcinoma (gestational or testicular). Cystic

— ovarian carcinoma.

— renal carcinoma.

— thyroid papillary carcinoma.

— secondary squamous carcinoma of head and neck. Edge

Circumscribed—mucinous carcinoma, medullary carcinoma and phyl-lodes tumour of breast, pancreatic endocrine tumours, some gut cancers. Irregular—infiltrating carcinoma.

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