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«Protocol for the Examination of Specimens From Patients With Uveal Melanoma Protocol applies to malignant melanoma of the uvea. Based on AJCC/UICC ...»

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Protocol for the Examination of Specimens From Patients With

Uveal Melanoma

Protocol applies to malignant melanoma of the uvea.

Based on AJCC/UICC TNM, 7th edition

Protocol web posting date: January 2016

Procedures

• Resection (Local Resection, Enucleation, Limited or Complete Exenteration)

Authors

Hans E. Grossniklaus MD, MBA, FCAP*

Departments of Ophthalmology and Pathology, Emory University School of Medicine, Atlanta, Georgia

Paul T. Finger MD

Department of Ophthalmology, The New York Eye Cancer Center, New York, New York J. William Harbour MD Department of Ophthalmology, Washington University School of Medicine, St. Louis, Missouri Tero Kivëla MD Departments of Ophthalmology and Pathology, University of Helsinki, Finland For the Members of the Cancer Committee, College of American Pathologists * Denotes primary author. All other contributing authors are listed alphabetically.

Previous lead contributors: David L. Page, Harry H. Brown, MD Ophthalmic • Uveal Melanoma UvealMelanoma 3.3.0.0 © 2016 College of American Pathologists (CAP). All rights reserved.

The College does not permit reproduction of any substantial portion of these protocols without its written authorization. The College hereby authorizes use of these protocols by physicians and other health care providers in reporting on surgical specimens, in teaching, and in carrying out medical research for nonprofit purposes. This authorization does not extend to reproduction or other use of any substantial portion of these protocols for commercial purposes without the written consent of the College.

The CAP also authorizes physicians and other health care practitioners to make modified versions of the Protocols solely for their individual use in reporting on surgical specimens for individual patients, teaching, and carrying out medical research for non-profit purposes.

The CAP further authorizes the following uses by physicians and other health care practitioners, in reporting on surgical specimens for individual patients, in teaching, and in carrying out medical research for non-profit purposes: (1) Dictation from the original or modified protocols for the purposes of creating a text-based patient record on paper, or in a word processing document; (2) Copying from the original or modified protocols into a text-based patient record on paper, or in a word processing document; (3) The use of a computerized system for items (1) and (2), provided that the protocol data is stored intact as a single text-based document, and is not stored as multiple discrete data fields.

Other than uses (1), (2), and (3) above, the CAP does not authorize any use of the Protocols in electronic medical records systems, pathology informatics systems, cancer registry computer systems, computerized databases, mappings between coding works, or any computerized system without a written license from the CAP.

Any public dissemination of the original or modified protocols is prohibited without a written license from the CAP.

The College of American Pathologists offers these protocols to assist pathologists in providing clinically useful and relevant information when reporting results of surgical specimen examinations of surgical specimens. The College regards the reporting elements in the “Surgical Pathology Cancer Case Summary” portion of the protocols as essential elements of the pathology report. However, the manner in which these elements are reported is at the discretion of each specific pathologist, taking into account clinician preferences, institutional policies, and individual practice.

The College developed these protocols as an educational tool to assist pathologists in the useful reporting of relevant information. It did not issue the protocols for use in litigation, reimbursement, or other contexts.

Nevertheless, the College recognizes that the protocols might be used by hospitals, attorneys, payers, and others.

Indeed, effective January 1, 2004, the Commission on Cancer of the American College of Surgeons mandated the use of the required data elements of the protocols as part of its Cancer Program Standards for Approved Cancer Programs. Therefore, it becomes even more important for pathologists to familiarize themselves with these documents. At the same time, the College cautions that use of the protocols other than for their intended educational purpose may involve additional considerations that are beyond the scope of this document.

The inclusion of a product name or service in a CAP publication should not be construed as an endorsement of such product or service, nor is failure to include the name of a product or service to be construed as disapproval.

–  –  –

CAP Uveal Melanoma Protocol Revision History Version Code The definition of the version code can be found at www.cap.org/cancerprotocols.

Version: UvealMelanoma 3.3.0.0 Summary of Changes The following changes have been made since the October 2013 release.

–  –  –

Surgical Pathology Cancer Case Summary Protocol web posting date: January 2016 UVEAL MELANOMA: Resection (Local Resection, Enucleation, Limited or Complete Exenteration) (Note A) Select a single response unless otherwise indicated.

Procedure ___ Local resection ___ Enucleation ___ Limited exenteration ___ Complete exenteration ___ Other (specify): ____________________________





___ Not specified Specimen Laterality ___ Right ___ Left ___ Unspecified Tumor Site (macroscopic examination/transillumination) (select all that apply) (Note B) ___ Cannot be determined ___ Superotemporal quadrant of globe ___ Superonasal quadrant of globe ___ Inferotemporal quadrant of globe ___ Inferonasal quadrant of globe ___ Between ____ and ____ o’clock ___ Other (specify): ____________________________

Tumor Size After Sectioning (Note C) ___ Cannot be determined Greatest basal diameter: ____ mm + Base at cut edge: ____ mm Greatest height: ____ mm + Height at cut edge: ____ mm Tumor Site After Sectioning (Note D) ___ Cannot be determined ___ Superonasal ___ Inferonasal ___ Superotemporal ___ Inferotemporal + Distance from anterior edge of tumor to limbus at cut edge: ___ mm + Distance of posterior margin of tumor base from edge of optic disc: ___ mm Tumor Involvement of Other Ocular Structures (select all that apply) ___ Cannot be determined ___ Sclera ___ Vortex vein(s) ___ Optic disc ___ Vitreous ___ Choroid ___ Ciliary body

–  –  –

___ Iris ___ Lens ___ Anterior chamber ___ Extrascleral extension (anterior) ___ Extrascleral extension (posterior) ___ Angle/Schlemm’s canal ___ Optic nerve ___ Retina + ___ Cornea Growth Pattern ___ Cannot be determined ___ Solid mass ___ Dome shape ___ Mushroom shape ___ Diffuse (ciliary body ring) ___ Diffuse (flat) Histologic Type (Note E) ___ Spindle cell melanoma (90% spindle cells) ___ Mixed cell melanoma (10% epithelioid cells and 90% spindle cells) ___ Epithelioid cell melanoma (90% epithelioid cells) Microscopic Tumor Extension + Tumor Location + ___ Anterior margin between equator and iris + ___ Anterior margin between disc and equator + ___ Posterior margin between equator and iris + ___ Posterior margin between disc and equator + ___ Cannot be determined + ___ None of above Scleral Involvement ___ Cannot be determined ___ None ___ Extrascleral ___ Intrascleral Margins ___ Cannot be assessed ___ No melanoma at margins ___ Extrascleral extension (for enucleation specimens) ___ Other margin(s) involved (specify): ____________________________

Pathologic Staging (pTNM) (Note F) TNM Descriptors (required only if applicable) (select all that apply) ___ m (multiple primary tumors) ___ r (recurrent) ___ y (posttreatment)

–  –  –

Primary Tumor (pT) Iris ___ pTX: Primary tumor cannot be assessed ___ pT0: No evidence of primary tumor pT1: Tumor limited to the iris ___ pT1a: Tumor limited to the iris not more than 3 clock hours in size ___ pT1b: Tumor limited to the iris more than 3 clock hours in size ___ pT1c: Tumor limited to the iris with secondary glaucoma ___ pT2: Tumor confluent with or extending into the ciliary body, choroid, or both ___ pT2a: Tumor confluent with or extending into the ciliary body, choroid, or both, with secondary glaucoma ___ pT3: Tumor confluent with or extending into the ciliary body, choroid, or both, with scleral extension ___ pT3a: Tumor confluent with or extending into the ciliary body, choroid, or both, with scleral extension and secondary glaucoma pT4: Tumor with extrascleral extension ___ pT4a: Tumor with extrascleral extension less than or equal to 5 mm in diameter ___ pT4b: Tumor with extrascleral extension more than 5 mm in diameter Ciliary Body and Choroid ___ pTX: Primary tumor cannot be assessed ___ pT0: No evidence of primary tumor pT1:Tumor size category 1 ___ pT1a: Tumor size category 1 without ciliary body involvement and extraocular extension ___ pT1b: Tumor size category 1 with ciliary body involvement ___ pT1c: Tumor size category 1 without ciliary body involvement but with extraocular extension less than or equal to 5 mm in diameter ___ pT1d: Tumor size category 1 with ciliary body involvement and extraocular extension less than or equal to 5 mm in diameter pT2:Tumor size category 2 ___ pT2a: Tumor size category 2 without ciliary body involvement and extraocular extension ___ pT2b: Tumor size category 2 with ciliary body involvement ___ pT2c: Tumor size category 2 without ciliary body involvement but with extraocular extension less than or equal to 5 mm in diameter ___ pT2d: Tumor size category 2 with ciliary body involvement and extraocular extension less than or equal to 5 mm in diameter pT3: Tumor size category 3 ___ pT3a: Tumor size category 3 without ciliary body involvement and extraocular extension ___ pT3b: Tumor size category 3 with ciliary body involvement ___ pT3c: Tumor size category 3 without ciliary body involvement but with extraocular extension less than or equal to 5 mm in diameter ___ pT3d: Tumor size category 3 with ciliary body involvement and extraocular extension less than or equal to 5 mm in diameter pT4: Tumor size category 4 ___ pT4a: Tumor size category 4 without ciliary body involvement and extraocular extension ___ pT4b: Tumor size category 4 with ciliary body involvement ___ pT4c: Tumor size category 4 without ciliary body involvement but with extraocular extension less than or equal to 5 mm in diameter ___ pT4d: Tumor size category 4 with ciliary body involvement and extraocular extension less than or equal to 5 mm in diameter ___ pT4e: Any tumor size category with extraocular extension more than 5 mm in diameter Regional Lymph Nodes (pN) ___ pNX: Regional lymph nodes cannot be assessed ___ pN0: No regional lymph node metastasis ___ pN1: Regional lymph node metastasis

–  –  –

Distant Metastasis (pM) (required only if confirmed pathologically in this case) ___ pM1: Distant metastasis ___ pM1a: Largest diameter of the largest metastasis 3 cm or less ___ pM1b: Largest diameter of the largest metastasis 3.1-8.0 cm ___ pM1c: Largest diameter of the largest metastasis 8.1 cm or more Specify sites(s), if known: _________________________________

+ Additional Pathologic Findings (select all that apply) (Note G) + ___ None identified + ___ Mitotic rate (number of mitoses per 40X objective with a field area of 0.152 mm ) (specify): _____ + ___ Extravascular matrix pattern + ___ Vascular invasion (tumor vessels or other vessels) + ___ Degree of pigmentation + ___ Inflammatory cells/tumor infiltrating lymphocytes + ___ Drusen + ___ Retinal detachment + ___ Invasion of Bruch’s membrane + ___ Nevus + ___ Hemorrhage + ___ Neovascularization + ___ Other (specify): ____________________________

+ Comment(s)

–  –  –

Explanatory Notes A. Fixative The minimum recommended fixation time for whole globes with intraocular tumors is 48 hours. The globe should be fixed in an adequate volume of fixative with a 10:1 ratio of fixative volume to specimen volume recommended.

Incisions or windows in the globe are not necessary for adequate penetration of fixative and are not recommended. Injection of fixative into the globe is also not recommended.

B. Orientation The orientation of a globe may be determined by identification of extraocular muscle insertions, the optic nerve, and other landmarks, as illustrated in Figure 1. The terms temporal and nasal are generally used in place of lateral and medial with reference to ocular anatomy.

Figure 1. Anatomic landmarks of the posterior aspect of the globe (right eye).

The position of the inferior oblique muscle relative to the optic nerve is most helpful in orienting the globe. The inferior oblique muscle insertion is located temporal (lateral) to the optic nerve on the sclera, and its fibers travel inferonasally from its insertion. The long posterior ciliary artery is often seen as a blue-gray line in the sclera on either side of the optic nerve and marks the horizontal meridian of the globe.

Reprinted with permission from WB Saunders Company.

–  –  –

D. Sectioning the Globe The globe is generally sectioned in the horizontal or vertical plane, with care to include the pupil and optic nerve in the section to be submitted for microscopic examination. If the mass cannot be included with horizontal or vertical sectioning, the globe is sectioned obliquely to include the tumor, pupil, and optic nerve, as illustrated in Figure 2.

Alternative methods of sectioning have been described.

Figure 2. The most common methods of sectioning a globe.

After transillumination, the tumor base is marked, if possible, and included in the pupil-optic (p-o) nerve section and submitted for processing. If tumor is found in either of the calottes, these may also be submitted for sectioning. The meridian in which the globe was sectioned should be included in the gross description of the pathology report. It is not uncommon to induce an artifactitious retinal detachment while sectioning the globe. This can be minimized by gentle handling and by avoiding a sawing motion with the blade. Reprinted with permission from WB Saunders Company.

–  –  –



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