Bladder--biopsy or TURP for carcinoma

 

 

 

Diagnosis

 

A1           In situ transitional cell carcinoma

A2           Transitional cell carcinoma

A3                           With focal glandular metaplasia

A4                           With focal squamous metaplasia

A5           Papilloma

A6                           With focal transitional cell carcinoma

A7           Squamous cell carcinoma

A8           Adenocarcinoma

A9           Small cell carcinoma

A10         Mixed carcinoma composed of the following types:

 

Histologic Grade

 

All           Well differentiated

A12         Moderately differentiated

A13         Poorly differentiated/undifferentiated

 

Pattern of Growth

 

A14         The pattern of growth is papillary

A15         The pattern of growth is flat

A16         The pattern of growth is papillary and flat

A17         The pattern of growth is nodular

A18         The pattern of growth is papillary and nodular

 

Local Invasion

 

A19         The tumor in noninvasive

A20         The tumor invades into the lamina propria

A21         The tumor invades into the muscularis propria

A22         Presence of muscle invasion cannot be evaluated

A23         The tumor extends into periurethral prostatic ducts

A24         The tumor infiltrates the prostatic stroma

 

Vascular Invasion

 

A25         No vascular invasion is identified

A26         Vascular invasion is present

 

In Situ Carcinoma (for cases also having an invasive component)

 

A27         No in situ carcinoma is identified

A28         In situ carcinoma is also present

 

Non-Neoplastic Mucosa

 

A29         The non-neoplastic mucosa is unremarkable

A30         The non-neoplastic mucosa shows the following abnormality(ies):

A31                         Chronic cystitis

A32                         Granulomatous cystitis

A33                         Ulceration

A34                         Foreign body reaction

A35                         Proliferative cystitis (Brunn's nests, cystitis cystica, cystitis glandularis)

 

 

Bladder-partial or radical cystectomy for carcinoma

 Diagnosis:

 

B1           No residual carcinoma

B2           No residual invasive carcinoma

 

Tumor Type

 

B3           In situ transitional cell carcinoma (pTis) [Use only if there is NOT an invasive component]

B4           Transitional cell carcinoma

B5                           With focal glandular metaplasia

B6                           With focal squamous metaplasia

B7           Papilloma

B8           With focal transitional cell carcinoma

B9           Squamous cell carcinoma

B10         Adenocarcinoma

B11         Small cell carcinoma

B12         Mixed carcinoma composed of the following types:

 

Histologic Grade

 

B13         Well differentiated

B14         Moderately differentiated

B15         Poorly differentiated/undifferentiated

 

Pattern of Growth

 

B16         The pattern of growth is papillary

B17         The pattern of growth is flat

B18         The pattern of growth is papillary and flat

B19         The pattern of growth is nodular

B20         The pattern of growth is papillary and nodular Tumor Multicentricity

B21         No evidence of tumor multicentricity is identified

B22         Multicentric foci of invasive carcinoma are present In Situ Carcinoma (for cases also having an invasive component)

B23         No in situ carcinoma is identified

B24         In situ carcinoma is also present Local Invasion

B25         The tumor in noninvasive (pTa)

B26         The tumor invades into the lamina propria (pTI)

B27         The tumor invades into the superficial half of the muscularis propria (pT2)

B28         The tumor invades into the deep half of the muscularis propria (pT3a)

B29         The tumor invades into the perivesical soft tissues (pT3b)

 

Tumor Extension

 

B30         The tumor does not extend beyond the bladder

B31         The tumor extends beyond the bladder into the following structure(s):

B32                         Right ureter

B33                         Left ureter

B34                         Urethra

B35                         Periurethral prostatic ducts

B36                         Prostatic stroma

B37                         Vagina

 

Vascular Invasion

 

B38         No vascular invasion is identified.

B39         Vascular invasion is present

 

Perineurial Invasion

 

B40         No perineurial invasion is identified

B41         Perineurial invasion is present          

 

Surgical Margins

 

B42         All surgical margins are free from tumor

B43         The following surgical margin(s) is (are) involved by tumor:

B44                         Right ureteral margin

B45                         Left ureteral margin

B46                         Urethral margin

B47                         Perivesical soft tissue margin

B48                         Bladder mucosal margin [for partial cystectomy]

 

Non-Neoplastic Mucosa

 

B49         The non-neoplastic mucosa is unremarkable

B50         The non-neoplastic mucosa shows the following abnormality(ies):

B51                         Chronic cystitis

B52                         Granulomatous cystitis

B53                         Ulceration

B54                         Foreign body reaction

B55                         Proliferative cystitis (Brunn's nests, cystitis cystica, cystitis glandularis)

 

Note: If the prostate shows an independent prostatic adenocarcinoma, stop here and continue with the "Prostate" form

 

Prostate

 

B56         The prostate is unremarkable

B57         The prostate shows nodular hyperplasia

B58         The prostate shows

 

Bladder-partial or radical cystectomy for carcinoma--cont'd

 

Seminal Vesicles

 

B59         The seminal vesicles are unremarkable

B60         The seminal vesicles show

 

Female Genital Organs

 

B61         All the female genital organs are unremarkable

B62         The vagina shows

B63         The cervix shows

B64         The endometrium shows

B65         The myometrium shows

B66         The right fallopian tube shows

B67         The left fallopian tube shows

B68         The right ovary shows

B69         The left ovary shows

B70         All other female genital organs are unremarkable

 

Lymph Nodes

 

B71         The lymph node status is as follows (expressed as the number of metastatic nodes in relation to the total number of nodes examined):

B72                         Right iliac:

B73                         Right internal iliac:

B74                         Right external iliac:

B75                         Left iliac:

B76                         Left internal iliac:

B77                         Left external iliac:

 

Breast--excision in which only benign disease is present

 

Diagnosis

 

C1           No residual in situ or invasive carcinoma

C2           Ductal hyperplasia of mild degree without atypia

C3           Ductal hyperplasia of moderate to florid degree without atypia

C4           Atypical ductal hyperplasia

C5           Lobular hyperplasia without atypia

C6           Atypical lobular hyperplasia

C7           Intraductal papilloma

C8           Sclerosing adenosis

C9           Florid adenosis

C10         Radial scar C11 Cyst(s)

C12         Apocrine metaplasia C13 Fibrosis

C14         Calcification

C15         Atrophy

C16         Duct ectasia

C17         Mastitis

C18         Fibroadenoma

C19         Fibroadenomatoid hyperplasia

C20         Reactive changes at the biopsy site

C21         Radiation changes

 

Lymph Nodes

 

C22         The lymph node status is as follows (expressed as the number of metastatic nodes in relation to the total number of nodes examined):

C23         Level I:

C24         Level II:

C25         Level III:

 

Breast-excision in which only in situ carcinoma is present

 

Diagnosis:

D1           No residual invasive carcinoma

 

Tumor Type

 

D2           Intraductal carcinoma (IDC)

D3           Cribriform type

D4           Solid type

D5           Cribriform and solid type

D6           Papillary type

D7           Micropapillary type

D8           Comedo carcinoma type

D9           With extension into lobules ("lobular cancerization")

 

Distribution

 

D10         The IDC is present as a single tumor focus

D11         The IDC is focal with peripheral extension

D12         The IDC is dispersed Tumor Size

D13         The estimated diameter for the entire IDC is ___ mm

D14         The estimated diameter for the entire IDC is ___ mm

D15         The estimated diameter of the IDC cannot be determined because

 

Calcification

 

D16         No calcification in the IDC is identified

D17         Calcification in the IDC is minimal

D18         Calcification in the IDC is extensive

 

For Mastectomy Only

 

D19         Tumor Location

The IDC is located at the following site(s):

Central / UOQ / UIQ / LOQ / LIQ

 

Tumor Multicentricity

 

D20         No multicentric foci of IDC are identified

D21         Multicentric foci of IDC are present at the following site(s):

Central / UOQ / UIQ / LOQ / LIQ

 

Nipple

 

D22         No nipple involvement by IDC is identified

D23         The IDC involves the large lactiferous ducts

D24         The IDC involves the nipple (Paget disease)

 

Surgical Margins

 

D25         All surgical margins are free from IDC

D26         The IDC is close (within one 40X field) to the following margin(s):

D27         The IDC is present at the following margin(s):

 

Tumor Type

 

D28         Lobular carcinoma in situ (LCIS)

D29                         Classic type (type A)

D30                         Large cell type (type 13)

D31                         With extension into ducts ("pagetoid spread")

 

Distribution

 

D32         The LCIS is present as a single tumor focus

D33         The LCIS is focal with peripheral extension

D34         The LCIS is dispersed

 

Calcification

 

D35         No calcification in the LCIS is identified

D36         Calcification in the LCIS is minimal

D37         Calcification in the LCIS is extensive

 

For Mastectomy Only

 

D38         Tumor Location                                   

The IIDC is located at the following site(s):

Central / UOQ / UIQ / LOQ / LIQ

 

Tumor Multicentricity

 

D39         No multicentric foci of IDC are identified

D40         Multicentric foci of IDC are present at the following sites)

Central / UOQ / UIQ / LOQ

 

Surgical Margins

 

D41         All surgical margins are free from LCIS

D42         The LCIS is close (within one 40X field) to the following margin(s):

D43         The LCIS is present at the following margin(s):

 

 

Breast-excision in which only in situ carcinoma is present-cont'd

 

Non-Neoplastic Breast

 

D44         The non-neoplastic breast is unremarkable

D45         The non-neoplastic breast shows the following abnormality (ies):

D46                         Ductal hyperplasia of mild degree without atypia

D47                         Ductal hyperplasia of moderate to florid degree without atypia

D48                         Atypical ductal hyperplasia

D49                         Lobular hyperplasia

D50                         Atypical lobular hyperplasia

D51                         Intraductal papilloma

D52                         Sclerosing adenosis

D53                         Radial scar

D54                         Apocrine metaplasia D55 Fibrosis

D56                         Calcification

D57                         Duct ectasia

D58                         Mastitis

D59                         Fibroadenoma

D60                         Fibroadenomatoid hyperplasia

D61                         Reactive changes at the biopsy site

D62                         Radiation changes

 

Lymph Nodes

 

D63         The lymph node status is as follows (expressed as the number of metastatic nodes in relation to the total number of nodes examined):

D64         Level I:

D65         Level II:

D66         Level III:

 

Breast-excision in which only invasive carcinoma is present

 

Diagnosis:

 

Tumor Type

 

E1            Invasive ductal carcinoma

E2                            NOS type

E3                            Tubular type

E4                            Cribriform type

E5                            Pure mucinous type

E6                            Mixed mucinous (mucinous and NOS) type

E7                            Papillary type

E8                            Medullary type

E9            Invasive lobular carcinoma

E10                          Classic type

Ell                            Solid type

E12                          Trabecular type

E13                          Alveolar type

E14                          Signet ring type

E15                          Tubulo-alveolar type

E16          Invasive mixed carcinoma:

E17                          Ductal type

E18                          Lobular type

E19          Invasive carcinoma, type undetermined

 

Histologic Grade (for invasive ductal component only)

 

E20          Histologic Grade I/III (well-developed tubules)

E21          Histologic Grade 11/111 (moderate tubule formation)

E22          Histologic Grade III/III (slight or no tubule formation)

 

Nuclear Grade (for invasive ductal component only)

 

E23          Nuclear Grade I/III (slight or no variation in size and.shape)

E24          Nuclear Grade II/111 (moderate variation in size and shape)

E25          Nuclear Grade III/III (marked variation in size and. shape)

 

Tumor Size

 

E26          The largest diameter of the tumor, as measured grossly, is ___ cm

E27          The largest diameter of the tumor, as measured microscopically, is __ mm [use for tumors <_ 1.0 cm]

E28          The largest diameter of the tumor cannot be determined because

 

 

Tumor Necrosis

 

E29          No tumor necrosis is identified

E30          Tumor necrosis is minimal

E31          Tumor necrosis is extensive

E32          Tumor necrosis cannot be evaluated because

 

Tumor Calcification

 

E33          No tumor calcification is identified

E34          Tumor calcification is minimal

E35          Tumor calcification is extensive

 

Vascular Invasion

 

E36          No vascular invasion is identified

E37          Vascular invasion is present

E38          Vascular invasion cannot be evaluated because

 

Peri-neurial Invasion

 

E39          No perineurial invasion is identified

E40          Perineurial invasion is present For Mastectomy Only

 

For Mastectomy Only

 

E41          Tumor Location

The tumor is located at the following site(s):

Central / UOQ / UIQ / LOQ / LIQ

 

Tumor Multicentricity

 

E42          No multicentric foci of IDC are identified

E43          Multicentric foci of invasive tumor  are present at the following site(s):

Central / UOQ / UIQ / LOQ / LIQ

E44          Number

E45          Types

 

Nipple

 

E46          No nipple involvement by invasive carcinoma identified

E47          The nipple is involved by invasive carcinoma

E48          The nipple is involved by Paget disease

 

Skin

 

E49          No skin involvement by carcinoma is identified

E50          The skin is involved by tumor by direct extension

E51          The skin shows tumor emboli in dermal lymph vessels.

E52          The skin shows

 

 

Breast--excision in which only invasive carcinoma is present-cont'd

 

Surgical Margins

E53          All surgical margins are free from tumor

E54          Invasive carcinoma is close (within one 40X field) to the following surgical margin(s):

E55          Invasive carcinoma is present at the following surgical margin(s):

E56          Involvement of surgical margins by invasive carcinoma cannot be determined because

 

Carcinoma In Situ

 

E57          No evidence of either ductal or lobular carcinoma in situ is identified

 

[If there were, you should not have used this form!]

 

Non-Neoplastic Breast

 

E58          The non-neoplastic breast is unremarkable

E59          The non-neoplastic breast shows the following abnormality(ies):

E60          Ductal hyperplasia of mild degree without atypia

E61          Ductal hyperplasia of moderate to florid degree without atypia

E62          Atypical ductal hyperplasia

E63          Lobular hyperplasia

E64          Atypical lobular hyperplasia

E65          Intraductal papilloma

E66          Sclerosing adenosis

E67          Radial scar

E68          Apocrine metaplasia

E69          Fibrosis

E70          Calcification

E71          Duct ectasia

E72          Mastitis

E73          Fibroadenoma

E74          Fibroadenomatoid hyperplasia

E75          Reactive changes at the biopsy site

E76          Radiation changes

 

Lymph Nodes

 

E77          The lymph node status is as follows (expressed as the number of metastatic nodes in relation to the total number of nodes examined):

E78                          Level I:

E79                          Level II:

E80                          Level III:

 

Breast-excision in which both in situ and invasive carcinoma are present

 

Diagnosis:

 

Tumor Type

 

F1            IN SITU AND INVASIVE DUCTAL CARCINOMA

F2            The invasive component is:

F3                            NOS type

F4                            Tubular type

F5                            Cribriform type

F6                            Pure mutinous type

F7                            Mixed mutinous (mutinous and NOS) type

F8                            Papillary type

F9                            Medullary type

F10          The in situ component is:

F11                          Cribriform type

F12                          Solid type

F13                          Cribriform and solid type

F 14                         Papillary type

F15                          Micropapillary type

F16                          Comedo carcinoma type

F17                                          with extension into lobules ("lobular cancerization")

F18          IN SITU AND INVASIVE LOBULAR CARCINOMA

F19          The invasive component is:

F20                          Classical type

F21                          Solid type

F22                          Trabeculartype

F23                          Alveolar type

F24                          Signet ring type

F25                          Tubuao-alveolar type

F26          The in situ component is:

F27                          Classic type (type A)

F28                          Large cell type (type B)

F29          IN SITU LOBULAR AND INVASIVE DUCTAL CARCINOMA

F30                          The in situ lobular component is of  type

F31                          The invasive ductal component is of                                             type

F32          IN SITU DUCTAL AND INVASIVE DUCTAL CARCINOMA

F33                          The in situ ductal component is of   type

F34                          The invasive ductal component is of                                               type

 

Histologic Grade (for invasive ductal component only)

 

F35          Histologic Grade VIII (well-developed tubules)

F36          Histologic Grade II/III (moderate tubule formation)

F37          Histologic Grade III/III (slight or no tubule formation)

 

Nuclear Grade (for invasive ductal component only)

 

F38          Nuclear Grade I/111 (slight or no variation in size and shape)

F39          Nuclear Grade II/III (moderate variation in size and shape)

F40          Nuclear Grade 111/111 (marked variation in size and shape)

 

Percentage of in situ ductal component

 

F41          The in situ carcinoma constitutes <= 25% of the total tumor mass

F42          The in situ carcinoma constitutes > 25% of the total tumor mass

 

Tumor Size

F43          The largest diameter of the tumor, as measured grossly, is ___ cm

F44          The largest diameter of the tumor, as measured microscopically, is ___ mm [use for tumors 5 1.0 cm]

F45          The largest diameter of the tumor cannot be determined because

 

Tumor Necrosis in Invasive Component

 

F46          No tumor necrosis is identified in the invasive component

F47          Tumor necrosis in the invasive component is minimal

F48          Tumor necrosis in the invasive component is extensive

F49          Tumor necrosis in the invasive component cannot be evaluated because

 

Tumor Calcification

 

F50          No tumor calcification is identified in either the in situ or invasive component

F51          No tumor calcification is identified in the in situ component

F52          Tumor calcification in the in situ component is minimal

F53          Tumor calcification in the in situ component is extensive

F54          No tumor calcification is identified in the invasive component

F55          Tumor calcification in the invasive component is minimal

F56          Tumor calcification in the invasive component is extensive

 

Breast-excision in which both in situ and invasive carcinoma are present-cont'd