Protocol for the Examination of Specimens from Patients with
Tumors of the Lung
Protocol applies to
all carcinomas of the lung.
Procedures:
·
Cytology
·
Biopsy
I. Cytologic
Material back Top Main Page
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. Date
of specimen receipt in pathology laboratory
5. Previous/concurrent
cytology or biopsy specimen
6. Other
clinical information
a. Relevant
history (eg smoking, previous diagnosis, treatment)
b. Relevant findings (eg imaging, PET
scan, operative)
c. Clinical diagnosis
d. Anticipated
clinical stage per imaging studies
e. Procedure
(1) Bronchoscopy
with bronchial washings
(2) Bronchoscopy
with bronchial brushings
(3) Bronchoscopy
with transbronchial cytology
(4) Bronchoscopy
with bronchoalveolar lavage
(5) CT
guided transthoracic needle biopsy
(6) Ultrasound
guided transthoracic needle biopsy
(7) Sputum
cytology
(8) Pleural
fluid
(9) Other
specimen
f. Anatomic site(s) of specimen(s) (eg,
left upper lobe; right pleural space)
B. Macroscopic Examination
1. Specimen
a. Description (eg, bronchial washings,
pleural fluid)
b. Unfixed/fixed (specify fixative)
c. Number of slides received, if
appropriate
d. Quantity
and appearance of fluid specimen, if appropriate
e. Other (eg, cytologic preparation from
tissue)
f.
Material prepared for microscopic evaluation
(eg, smear of fluid, cell block)
g. Results of intraprocedural consultation
2. Special
studies (specify)
C. Microscopic Evaluation
1. Adequacy
of specimen (if unsatisfactory for evaluation, specify reason)
2. Tumor,
if present
a. Histologic type, if possible (Note A)
b. Histologic grade, if possible (Note B)
3. Additional
pathologic findings, if present (specify)
4. Results
of special studies (specify)
5. Comments
a. Correlation
with intraprocedural consultation, as appropriate
b. Correlation with other specimens, as
appropriate
c. Correlation with clinical and
radiological 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. Date
of specimen receipt in pathology laboratory
5. Previous/concurrent
cytology or biopsy specimen
6. Other
clinical information
a. Relevant
history (eg, smoking, previous diagnosis, treatment)
b. Relevant findings (eg, imaging, PET
scan, operative)
c. Clinical diagnosis
d. Anticipated
clinical stage per imaging studies
e.
Procedure (bronchial biopsy, transbronchial
biopsy, mediastinoscopic biopsy)
f. Findings
at bronchoscopy/mediastinoscopy
g. Anatomic
site(s) of specimen(s) (eg, left upper lobe)
B. Macroscopic Examination
1. Specimen
a. Unfixed/fixed (specify fixative)
b. Size (3 dimensions)
c. Descriptive features
2. Tissue
submitted for microscopic evaluation
a. Submit entire specimen
b. Frozen
section tissue fragment(s) (unless saved for special studies)
3. Special
studies (specify)
C. Microscopic Evaluation
1. Tumor,
if present
a. Histologic type (Note A)
b. Histologic grade (Note B)
c. Extent of invasion, as appropriate
d. Bronchus, in situ vs. invasive
e. Vascular invasion
f. Lymphatic
vessel invasion (Note C)
g. Mediastinal lymph node, metastasis, if
present (note extracapsular extension) (Note C)
h. Pleural invasion
i. Other (specify)
2. Additional
pathologic findings, if present
3. Status/results
of special studies (specify)
4. Comment
a. Correlation
with intraprocedural consultation, as appropriate
b. Correlation with other specimens, as
appropriate
c. Correlation with clinical information,
as appropriate
III. Resection back Top Main Page
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. Date
of specimen receipt in pathology laboratory
5. Previous
/ concurrent cytology or biopsy specimen
6. Previous
chemotherapy, radiotherapy, photodynamic therapy
7. Other
clinical information
a. Relevant
history (eg, smoking, previous diagnosis, treatment)
b. Relevant findings (eg, imaging, PET
scan, operative)
c. Clinical diagnosis
d. Anticipated
clinical stage per imaging studies
e. Procedure
(1) major
airway resection (eg, trachea, carina, main
bronchus)
(2) video assisted thoracoscopic surgery
(VATS)
(3) wedge resection (subsegmentectomy)
(4) segmentectomy
i. standard segmentectomy
ii. en bloc with chest wall or other
parietal tissue (eg, diaphragm/pericardium)
(5) lobectomy/bilobectomy
i. sleeve lobectomy
ii. en bloc with chest wall or other
parietal tissue (eg, diaphragm/pericardium)
(6) pneumonectomy
i. standard pneumonectomy
ii. pneumonectomy
with tracheal and carinal resection
iii. complex pneumonectomy (eg,
pleuropneumonectomy, extrapleural pneumonectomy including en bloc resection)
e. Operative findings
f. Anatomic
site(s) of specimen(s) (eg, upper lobe of left lung)
B. Macroscopic Examination
1. Specimen
a. Organs/tissues
received (documentation of extent of resection)
b. Unfixed/fixed (specify fixative)
c. Size of entire specimen (3 dimensions)
d. Weight
e. External aspect
(1) visceral pleura (eg, puckering,
pleuritis)
(2) attached tissue (eg, parietal pleura,
pericardium, diaphragm, chest wall with or without ribs, other)
f. Documentation of areas marked by
surgeon
g. Results of intraoperative consultation
2. Tumor
a. Location
(1) bronchial
i. main
ii. lobar
iii. segmental
(2) peripheral
(3) pleural
b. Size (Note E)
c. Descriptive features
(1) color
(2) shape
(3) circumscription
(4) cavitation
(5) other (eg, necrosis, hemorrhage)
d. Extent of invasion
(1) bronchial involvement
(2) visceral
pleural invasion
(3) interlobar fissure extension, as
appropriate
(4) attached
tissues (depth of invasion, as appropriate)
(5) invasion of pulmonary artery
3. Additional
tumors, if present
a. Describe each possible primary tumor as
above (Note F)
b. Multiple nodules not regarded as
primaries (Note F)
(1) size (range)
(2) number
(3) location
4. Margins
(specify distance from closest approach of tumor)
a. bronchial
b. vascular (pulmonary artery and vein)
c. parietal
pleura, if present
d. resected
parenchymal surfaces
e. attached tissues (see 1.e.2.)
5. Additional
pathologic findings, if present
6. Regional lymph nodes in specimen (all
nodes included in specimen are designated N1 unless otherwise specified by
surgeon) (Note G)
7. Separately submitted N1 or N2 nodes
(report each node station separately, as specified by surgeon) (Note
G)
8. Sections
of tissue for microscopic evaluation (as appropriate)
a. Tumor
b. Tumor and adjacent lung
c. Tumor and wall of bronchus (if arising
in bronchus)
d. Bronchial mucosa proximal to tumor
e. Tumor relation to pleura
f. Required margins
(1) bronchial
(2) vascular (pulmonary artery and vein)
(3) pleura
(4) parenchymal
margin (VATS, wedge, segmentectomy)
g. Additional margins/samples if needed
(1) attached tissue
(2) areas marked by surgeon
h. Non-neoplastic lung
(1) normal
(2) abnormal
i. All lymph nodes
k. Frozen
section tissue fragment(s) (unless saved for special studies)
9. Special
studies (specify)
10. Photography
C. Microscopic Evaluation
1. Tumor
a. Histologic type (Note A)
b. Histologic grade (Note B)
c. Site
(1) bronchus
(2) peripheral lung
(3) pleura
(4) areas marked by surgeon
d. Extent of invasion (Note
D)
(1) bronchial involvement
(2) visceral pleural invasion
(3) attached tissues
g. Perineural
invasion
2. Margins
a. Bronchial
b. Vascular
(1) pulmonary artery
(2) pulmonary vein
c. Parenchymal
d. Pleural/extrapleural
(Note D):
(1) the
visceral pleura is free of involvement
(2) the tumor invades into the visceral pleura, but not through
it
(3) the tumor invades through the visceral pleura
(4) the tumor is in subpleural lymphatics
(5) multifocal pleural involvement
(6) the tumor extends into superficial or deep chest wall
e. Other (eg, attached ribs)
3. Regional
(N1) Lymph nodes included in main specimen (N1) (Notes E and F)
a. Total number examined
b. Number
involved by tumor
c. Size
of the largest metastasis
d. Extracapsular
extension present or absent (Note C)
4. Separately submitted N1 or N2 lymph
nodes (report each node station separately, as specified) (Note G)
a. Total number examined
b. Number
involved by tumor
c. Extracapsular
extension present or absent (Note C)
5. Additional
pathologic findings, if present
6. Results
of special studies (specify)
7. Comments
a. Correlation
with intraoperative consultation, as appropriate
b. Correlation with other specimens, as
appropriate
c. Correlation with clinical information,
as appropriate
EXPLANATORY NOTES
A. Histologic Type back Top Main Page
For consistency in reporting,
the histologic classification published by the World Health Organization (WHO)
for carcinomas of the lung is recommended.(1) This protocol does not preclude
the use of other systems of classification of histologic types.(2)
World Health Organization (WHO) classification of Lung
Neoplasms
1. Epithelial
Tumors
2. Soft
Tissue Tumors
3. Mesothelial
Tumors
4. Miscellaneous
Tumors
5. Lymphoproliferative
Diseases
6. Secondary
Tumors (Metastatic)
7. Unclassified
Tumors
8. Tumor-Like
Lesions
Each category of lung
neoplasms includes a variety of benign and malignant tumors. A detailed list of all these neoplasms is
beyond the scope of this protocol. Most lung neoplasms are malignant epithelial
tumors.
Benign epithelial
tumors of the lung include:
1. Papillomas
Squamous
cell papilloma
Exophytic
Inverted
Glandular
papilloma
Mixed
squamous cell and glandular papilloma
2. Adenomas
Alveolar
adenoma
Papillary
adenoma
Adenomas
of salivary-gland type
Mucous
gland adenoma
Pleomorphic
adenoma
Others
3. Mucinous cystadenoma
4. Others
Preinvasive lesions
include:
1. Squamous
dysplasia
Carcinoma
in situ
2. Atypical
adenomatous hyperplasia
3. Diffuse
idiopathic pulmonary neuroendocrine cell hyperplasia
Malignant epithelial
tumors of the lung include:
1. Squamous
cell carcinoma
Papillary
Clear
cell
Small
cell
Basaloid
2. Small
cell carcinoma
3. Variant
Combined
small cell carcinoma
4. Adenocarcinoma
Acinar
Papillary
Bronchiolo-alveolar
carcinoma
-Non-mucinous
-Mucinous
-Mixed
mucinous and non-mucinous or indeterminate cell type
Solid
adenocarcinoma with mucin
Adenocarcinoma
with mixed subtypes
Variants
-Well-differentiated
fetal adenocarcinoma
-Mucinous
(“colloid”) adenocarcinoma
-Mucinous
cystadenocarcinoma
-Signet-ring
adenocarcinoma
-Clear
cell adenocarcinoma
5. Large cell carcinoma
Variants
-Large
cell neuroendocrine carcinoma
-Combined
large cell neuroendocrine carcinoma
-Basaloid
carcinoma
-Lymphoepithelioma-like
carcinoma
-Clear
cell carcinoma
-Large
cell carcinoma with rhabdoid phenotype
5. Adenosquamous carcinoma
6. Carcinomas with pleomorphic,
sarcomatoid or sarcomatous elements
Carcinomas
with spindle and/or giant cells
Spindle
cell carcinoma
Giant
cell carcinoma
Carcinosarcoma
Pulmonary
blastoma
7. Carcinoid tumor
Typical
carcinoid
Atypical carcinoid
8. Carcinomas of salivary-gland type
Mucoepidermoid
carcinoma
Adenoid
cystic carcinoma
Others
9. Unclassified carcinoma
Soft tissue tumors
include:
1. Localized
fibrous tumor
2. Epithelioid
hemangioendothelioma
3. Pleuropulmonary
blastoma
4. Chondroma
5. Calcifying
fibrous pseudotumor of the pleura
6. Congenital
peribronchial myofibroblastic tumor
7. Diffuse
pulmonary lymphangiomatosis
8. Desmoplastic
round cell tumor
9. Others
Mesothelial tumors
include:
1. Benign
Adenomatoid
tumor
2. Malignant
Epithelioid
mesothelioma
Sarcomatoid
mesothelioma
Desmoplastic
mesothelioma
Biphasic
mesothelioma
Others
Miscellaneous tumors
include:
1. Hamartoma
2. Sclerosing
hemangioma
3. Clear
cell tumor
4. Germ
cell tumors
Teratoma,
mature
Teratoma,
immature
Other
germ cell tumors
5. Thymoma
6. Malignant
melanoma
7. Others
Lymphoproliferative
disorders include:
1. Lymphoid
interstitial pneumonia
2. Nodular
lymphoid hyperplasia
3. Low
grade marginal zone B-cell lymphoma of the mucosa-associated lymphoid tissue
(MALT)
4. Lymphomatoid
granulomatosis