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Protocol for the Examination of Specimens From Patients With Tumors of the Peritoneum.

A Basis for Checklists

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
 Diffuse malignant mesothelioma
 Epithelial type
 Sarcomatous type
 Biphasic type
 Undifferentiated
 Rare types(*)

 Serous tumor of borderline malignancy (of low malignant
 potential)([dagger])[1,2]
 Serous carcinoma([double dagger])[3-5]
 Malignant tumors of other mullerian types
 Desmoplastic small round cell tumor
 Soft tissue-type tumors

(*) Rare types include desmoplastic, small cell, lympho-histiocytoid,
and deciduoid types.

([dagger]) 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.

([double dagger]) The Gynecological Oncology Group has adopted the
following criteria for the diagnosis of primary peritoneal
serous carcinoma:

1. 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.

2. 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 x 5 mm in diameter; or (d) tumor less than 5 x 5
mm within the ovarian substance, with or without surface
involvement.

3. 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.

4. 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 ovary[6] and
endometrium[7]).

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

[1.] Bell DA, Scully RE. Serous borderline tumors of the peritoneum. Am J Surg Pathol. 1990;14:230-239.

[2.] Biscotti CV, Hart WR. Peritoneal serous micropapillomatosis of low malignant potential (serous borderline tumors of the peritoneum): a clinicopathologic study of 17 cases. Am J Surg Pathol. 1992;16:467-475.

[3.] Gilks CB, Bell DA, Scully RE. Serous psammocarcinoma of the ovary and peritoneum. Int J Gynecol Pathol. 1990;9:110-121.

[4.] Bloss JD, Liao S, Buller RE, et al. Extraovarian peritoneal serous papillary carcinoma: a case-control retrospective comparison to papillary adenocarcinoma of the ovary. Gynecol Oncol. 1993;50:347-351.

[5.] Piver MS, Jishi MF, Tsukuda Y, Nava G. Primary peritoneal carcinoma after prophylactic oophorectomy in women with a family history of ovarian cancer: a report of the Gilda Radner Familial Ovarian Cancer Registry. Cancer. 1993;71: 2751-2755.

[6.] Scully RE, Henson DE, Nielsen ML, Ruby SG. Practice protocol for the examination of specimens removed from patients with ovarian tumors: a basis for checklists. Arch Pathol Lab Med. 1995;119:1012-1022.

[7.] Silverberg SG. Protocol for the examination of specimens from patients with carcinomas of the endometrium: a basis for checklists. Arch Pathol Lab Med. 1999;123:28-32.

[8.] Goldblum J, Hart WR. Localized and diffuse mesotheliomas of the genital tract and peritoneum in women: a clinicopathologic study of nineteen true mesothelial neoplasms, other than adenomatoid tumors, multicystic mesotheliomas, and localized fibrous tumors. Am J Surg Pathol. 1995;19:1124-1137.

Bibliography

Antman KH, Pass HI, Schiff PB. Benign and malignant mesothelioma. In: DeVita VT Jr, Hellman S, Rosenberg SA, eds. Cancer: Principles and Practice of Oncology. 5th ed. Philadelphia, Pa: JB Lippincott-Raven; 1997:1853-1878.

Battifora H, McCaughey WTE. Tumors of the Serosal Membranes. Washington, DC: Armed Forces Institute of Pathology; 1995. Atlas of Tumor Pathology; 3rd series, fascicle 15.

Russell P, Farnsworth A. Surgical Pathology of the Ovaries. 2nd ed. New York, NY: Churchill Livingstone; 1997.

Scully RE, Young RH, Clement PB. Tumors of the Ovary, Maldeveloped Gonads, Fallopian Tube, and Broad Ligament. Washington, DC: Armed Forces Institute of Pathology; 1998. Atlas of Tumor Pathology; 3rd series, fascicle 23.

Accepted for publication May 2, 2001.

From the James Homer Wright Laboratories, Massachusetts General Hospital, Boston, Mass (Dr Scully); and the Division of Medical Oncology, Columbia-Presbyterian Medical Center, New York, NY (Dr Antman).

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.
COPYRIGHT 2001 College of American Pathologists
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2001 Gale, Cengage Learning. All rights reserved.

Article Details
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Author:Scully, Robert E.; Antman, Karen H.
Publication:Archives of Pathology & Laboratory Medicine
Geographic Code:1USA
Date:Sep 1, 2001
Words:1980
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