Protocol for the Examination of Specimens From
Patients With Carcinomas of the Urinary Bladder, Ureter, and Renal Pelvis
Protocol
applies to all carcinomas of the urinary bladder, ureter, and renal pelvis
Procedures
·
Cytology
·
Bladder biopsy,
Transurethral resection of bladder tumor (TURBT) specimen
-
Radical Cystoprostatectomy
-
Pelvic Exenteration
·
Nephroureterectomy
or Ureterectomy
I. Cytologic
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A. Clinical
information
1. Patient identification
a. Name
b. Identification number
c. Age (birth date)
d. Gender
2. Responsible physician(s)
3. Date of procedure
4. Other clinical information
a. Relevant history (Note A)
b. Relevant
findings (e.g., cytoscopic or imaging study[ies])
c. Clinical diagnosis
d. Procedure
(e.g., voided urine, instrument derived urine, washing, fine needle aspirate,
brushings, cytologic preparation from tissue specimen [specify site])
e. Anatomic site/type of specimen
B. Macroscopic
examination
1. Specimen
a. unfixed/in transport medium (specify
type)/fixed (specify type of fixative)
b. Number of slides received
c. Quantity and appearance of fluid specimen
d. Other (e.g., tissue received for cytologic
preparation)
e. Results of intraoperative/intraprocedural
consultation
2. Material
submitted for microscopic evaluation (e.g., smear; cytocentrifuge, filter,
other liquid-based preparations; cell block)
3. Special studies (specify)
C. Microscopic
evaluation
1. Adequacy of specimen (if unsatisfactory for
evaluation, specify reason) (Note B)
2. Tumor,
if present (Note C)
a. Urothelial
(1) histologic type, if possible (Note D)
(2) cytologic grade
b. Non urothelial (see protocol for prostate,
kidney, other)
3. Additional
pathologic findings, if present (specify cause of abnormality, if possible) (Note C)
a. Inflammation
b. Radiation effect(s)
c. Drug effect(s)
4. Results of special studies (specify)
5. Comments
a. Correlation
with intraoperative/ intraprocedural consultation, as appropriate
b. Correlation with other specimens, as
appropriate
c. Correlation with clinical information, as appropriate
II.
Bladder Biopsy, Transurethral Resection of Bladder Tumor (TURBT) specimen
A. Clinical information
1. Patient
identification
a. Name
b. Identification number
c. Age (birth date)
d. Gender
2. Responsible physician(s)
3. Date of procedure
4. Other clinical information
a. Relevant history (Note A)
b. Relevant findings (e.g., cystoscopic or
imaging studies findings)
c. Clinical diagnosis
d. Procedure
(e.g., TURBT, cold cup, electroresection biopsy, tumor removal [specify site])
e. Anatomic site/type of specimen
B. Macroscopic
examination
1. Specimen
a. Unfixed/fixed (specify type of fixative)
b. Number of pieces
c. Greatest
diameter of single specimen
d. Aggregate
volume of multiple fragments
2. Results of intraoperative consultation, if
appropriate
3. Tissue submitted for microscopic evaluation
a. All or selected sample(s) (if selected,
estimate percent submitted)
b. Frozen section tissue fragment(s) (unless
saved for special studies)
4. Special studies (specify)
C. Microscopic
evaluation
1. Specimen
a.
Adequacy of specimen (if unsatisfactory
for evaluation, specify reason)
b. Layers of bladder (specify if present or
absent)
(1) urothelium
(2) lamina
propria (subepithelial connective tissue/submucosa)
(3) muscularis propria
2. Tumor
a. Histologic
type (Note D)
b. Histologic
grade (specify grading system and total number of grades, if applicable) (Note E)
c. Site(s) of involvement (e.g., trigone, dome,
etc)
d. Pattern of growth
(1)
non-invasive (pure)
i.
papillary
ii. flat
CIS (carcinoma in situ)
iii. papillary
and flat CIS
(2) invasive (pure)
(3) mixed, non-invasive and invasive
i.
papillary and invasive
ii.
flat CIS and invasive
iii.
papillary and flat CIS and invasive
(4) indeterminate
e. Extent of invasion (specify invasion of layers listed)
(1) confined to epithelium (Note F)
(2) subepithelial connective tissue including muscularis mucosae (Notes F and G)
(3) muscularis propria (Note F
and G)
(4) prostatic involvement (Note G)
i. urethral mucosa (flat in situ, papillary
non-invasive, or invasive)
ii. restricted to prostatic ducts or acini (in
situ)
iii. prostatic
stromal invasion
iv. multiple
patterns (urethral mucosa, prostatic ducts or acini, stromal)
v. indeterminate:
state reason (e.g., tumor only, cautery artifact, etc)
f. Blood/lymphatic vessel invasion (Note
H)
3. Additional pathologic findings, if present
a. Urothelial
carcinoma in situ (high grade intraurothelial neoplasia) (focal/ multifocal)
b. Urothelial
dysplasia (low grade intraurothelial neoplasia) (focal/multifocal)
c. Inflammation/Regenerative changes
d. Therapy related
e. Thermocoagulation
effect (Note F)
f.
Other(s) (specify), e.g., cystitis cystica
glandularis, keratinizing squamous metaplasia, intestinal metaplasia
4. Results/status of special studies (specify),
e.g., immunohistochemistry
5. Comments
a. Correlation with intraoperative consultation,
as appropriate
b. Correlation with other specimens, as
appropriate
c. Correlation with clinical information, as
appropriate
III. Cystectomy (Partial, Total),
Radical Cystoprostatectomy, Pelvic Exenteration
A.
Clinical information
1. Patient
identification
a. Name
b. Identification number
c. Age (birth date)
d. Gender
2. Responsible physician(s)
3. Date of procedure
4. Other clinical information
a. Relevant history (e.g., previous diagnosis,
previous treatment) (Note A)
b. Relevant
findings (e.g., clinical findings, cystoscopic findings, radiologic studies)
c. Clinical diagnosis
d. Procedure
(1) partial cystectomy
(2) total cystectomy
(3) cystoprostatectomy
(4) pelvic exenteration
(5) lymphadenectomy
e. Operative findings
f. Anatomic sites of specimen
B. Macroscopic
examination
1. Specimen
a. Organ(s)/tissue(s) included
b. Unfixed/fixed (specify type of fixative)
c. Opened/unopened
d. External aspect (documentation of extent of
resection)
e. Size (three dimensions) (specify for partial
cystectomy)
f. Note areas designated by surgeon
g. Results of intraoperative consultation
2. Tumor
a. Location (trigone,
left/right/anterior/posterior wall, dome)
b. Size (three dimensions)
c. Descriptive features (pattern of growth,
gross appearance)
(1) papillary (pure)
(2) solid /nodular, flat, ulcerated
(3) mixed
(4) indeterminate
d. Extent
(depth of bladder wall) of invasion (Note G)
e. Involvement
of adjacent structures if present, i.e., prostate, vagina
f. Relation to specimen margins (Note
I)
3. Other pathologic findings, if present
a. Mucosal
abnormalities
b. Other
4. Ureter/s
5. Margins (as appropriate) (Note
I)
6. Regional lymph nodes
a. Location (all nodes are designated contiguous
unless specified by surgeon)
b. Number
c. Description (describe gross tumors)
7. Separately submitted lymph nodes
a. Location (report as specified by surgeon)
b. Number
c. Description (describe gross tumors)
8. Other submitted tissue
a. Location (as specified by surgeon)
b. Descriptive features
(1) prostate
(2) seminal
vesicles
(3) uterus
(4) vagina
(5) rectum
(6) pelvic
wall
(7) urethra
(8) ureter(s)
(9) other(s) (specify)
9. Sections submitted for microscopic evaluation
(Note I)
a. Tumor
(1) representative
(2) tumor at point of deepest penetration of wall
(3) interface of tumor with adjacent bladder wall
b. Mucosa remote from cancer
c. Areas with additional pathologic findings
d. Margin(s) of resection
e. Ureter(s)
f. Penile/bulbomembranous urethra
g. Prostatic urethra
h. Prostate and seminal vesicles, representative
i. Lymph nodes
j. Pelvic wall
k. Areas designated by surgeon
l. Sections of other submitted tissues
(specify), e.g., vagina, uterus, rectum
m. Frozen section tissue fragment(s) (unless
saved for special studies)
10. Special
studies (specify), e.g., immunohistochemistry, morphometry, DNA analysis
(specify type), and gross photograph (if obtained)
C. Microscopic
evaluation
1. Tumor
a. Histologic type (Note D)
b. Histologic
grade (specify grading scheme and total number of grades if applicable) (Note E)
c. Site(s) (focal/multifocal)
d. Pattern of growth
(1) non-invasive (pure)
i.
papillary
ii. flat
CIS
iii. papillary
and flat CIS
(2) invasive (pure)
(3) mixed, non-invasive and invasive
i.
papillary and invasive
ii. flat
CIS and invasive
iii.
papillary and flat CIS and invasive
(4) indeterminate
e. Extent
of invasion (specify each layer as involved or uninvolved by tumor) (Note
G)
f. Involvement of other tissue(s)/ structure(s)
(Note G)
(1) prostatic urethra (flat
carcinoma in situ, non-invasive papillary, or invasive)
(2) prostate ducts and acini (without stromal
invasion)
(3) prostatic stroma
(4) seminal vesicles
(5) bulbomembranous or penile urethral mucosa
(6) uterus
(7) vagina
(8) rectum
(9) pelvic wall
(10)
abdominal wall
g. Areas marked by surgeon
h. Blood/lymphatic vessel invasion (Note
H)
2. Margins (Note I)
a. Pelvic soft tissue
b. Urethral
c. Ureters
d. Paravesicular soft tissue
3. Additional pathologic findings, if present
a. Urothelial
carcinoma in situ (high grade intraurothelial neoplasia) (focal/ multifocal)
b. Urothelial
dysplasia (low grade intraurothelial neoplasia) (focal/ multifocal)
c. Inflammation/Regenerative
changes
d. Therapy related
e. Other(s)
(specify), e.g., cystitis cystica glandularis, keratinizing squamous
metaplasia, intestinal metaplasia
4. Regional lymph nodes (Note G)
a. Site(s)/ laterality
b. Number
c. Number involved by tumor
d. Extranodal extension
e. Size of metastasis
5. Separately submitted lymph nodes (report as
specified)
a. Total number examined by site and laterality
b. Number
c. Number involved by tumor
d. Extranodal extension
e. Size of metastasis
6. Other submitted organ(s)/tissue(s)
a. Prostate
(1) invaded by bladder tumor
(2) prostatic adenocarcinoma (see Prostate
protocol for details)
(3) other pathologic features (e.g., high grade prostatic
intraepithelial neoplasia, inflammation, hyperplasia)
b. Other(s) (ureter/urethra/seminal
vesicles/vagina/rectum)
(1) invaded by bladder tumor
(2) other tumors
(3) other pathologic features (e.g., inflammation, hyperplasia,
carcinoma in situ)
c. Margins, as appropriate
7. Results/status
of special studies (specify)
8. Comments
a. Correlation with intraoperative consultation,
as appropriate
b. Correlation with other specimens, as
appropriate
c. Correlation with clinical information, as
appropriate
A.
Clinical information
1. Patient
identification
a. Name
b. Identification number
c. Age (birth date)
d. Gender
2. Responsible physician(s)
3. Date of procedure
4. Other clinical information
a. Relevant history (e.g., previous diagnosis,
previous treatment) (Note A)
b. Relevant findings (e.g., radiologic studies)
c. Clinical diagnosis
d. Procedure (specify anatomic site(s))
e. Operative findings
f. Anatomic site(s) of specimen
g. Results of intraoperative consultation
B. MACROSCOPIC
EXAMINATION
1. Specimen
a. Organ(s)/tissue(s) included
b. Unfixed/fixed (specify type of fixative)
c. External aspect (documentation of extent of
resection)
d. Size (three dimensions) (specify if partial nephrectomy)
e. Areas designated by surgeon
f. Result of intraoperative consultation
2. Tumor
a. Location (pelvi-calyceal system, ureter)
b. Size (three dimensions)
c. Description (pattern of growth, gross appearance)
(1) papillary (pure)
(2) solid/ nodule, flat, ulcerated
(3) mixed
(4) indeterminate
d. Extent (depth) of invasion (Note
G)
3. Margins
a. Ureteral
margin (proximal and distal in ureterectomy specimen)
b. Bladder
cuff margin
c. Gerota’s
fascia/perinephric fat margin (in nephrectomy specimen)
d. Hilar
soft tissue
e. Renal
parenchyma (partial nephrectomy)
4. Additional pathologic features, if present
a. Mucosal
abnormalities
b. Other
lesions (including of renal parenchyma)
5. Lymph nodes submitted as part of specimen
a. Location
(all nodes are designated contiguous unless otherwise specified by surgeon)
b. Number
c. Description (specify gross metastasis)
6. Separately submitted lymph nodes
a. Location (report as specified by surgeon)
b. Number
c. Description (specify
gross metastasis)
7. Sections submitted for microscopic evaluation
a.