Protocol for the examination of specimens from patients with carcinomas of renal tubular origin, exclusive of Wilms tumor and tumors of urothelial origin: a basis for checklists. Cancer Committee, College of American Pathologists

College of American Pathologists Cancer Protocols: From Optimizing Cancer Patient Care to Facilitating Interoperable Reporting and Downstream Data Use

The College of American Pathologists Cancer Protocols have offered guidance to pathologists for standard cancer pathology reporting for more than 35 years. The adoption of computer readable versions of these protocols by electronic health record and laboratory information system (LIS) vendors has provided a mechanism for pathologists to report within their LIS workflow, in addition to enabling standardized structured data capture and reporting to downstream consumers of these data such as the cancer surveillance community. This paper reviews the history of the Cancer Protocols and electronic Cancer Checklists, outlines the current use of these critically important cancer case reporting tools, and examines future directions, including plans to help improve the integration of the Cancer Protocols into clinical, public health, research, and other workflows.

A review of medical terminology standards and structured reporting

Much effort has been invested in standardizing medical terminology for representation of medical knowledge, storage in electronic medical records, retrieval, reuse for evidence-based decision making, and for efficient messaging between users. We only focus on those efforts related to the representation of clinical medical knowledge required for capturing diagnoses and findings from a wide range of general to specialty clinical perspectives (e.g., internists to pathologists). Standardized medical terminology and the usage of structured reporting have been shown to improve the usage of medical information in secondary activities, such as research, public health, and case studies. The impact of standardization and structured reporting is not limited to secondary activities; standardization has been shown to have a direct impact on patient healthcare.

Percentage of high-grade carcinoma as a prognostic indicator in patients with renal cell carcinoma

BACKGROUND

The prognostic value of Fuhrman nuclear grade for patients with renal cell carcinoma has been well-characterized. However, to the authors' knowledge, the prognostic significance of the amount of high-grade renal cell carcinoma has not been previously analyzed.

METHODS

The authors identified 898 consecutive renal cell carcinoma cases treated with nephrectomy between 1989 and 2003. Histopathologic features that were captured based on re-review of all slides included histologic type, pathologic stage, conventional Fuhrman grade, and percentage of Fuhrman grade 3 and 4 carcinoma, as ascertained by visual inspection of histologic slides. The clinical endpoints were metastasis-free survival, cancer-specific survival, and overall survival.

RESULTS

Kaplan-Meier analysis demonstrated that both conventional Fuhrman grading and the percentage of Fuhrman grade 3 and 4 carcinoma were highly correlated with all 3 measures of patient survival (P < .0001). The creation of 3 categories of the percentage of Fuhrman grade 3 and 4 carcinoma (0%, 1-50%, and 51-100%) generated distinctly separate survival curves. On Cox proportional hazards multivariate analysis, TNM stage, tumor size, and the percentage of Fuhrman grade 3 and 4 carcinoma were all found to be significantly associated with all 3 types of patient survival (all P values <.05).

CONCLUSIONS

The determination of the percentage of renal cell carcinoma that is 0%, 1% to 50%, or 51% to 100% high Fuhrman grade 3 and 4 is a simple and powerful measurement of patient outcome after surgery that provides additional prognostic information beyond stage, tumor size, and conventional Fuhrman grade. This prognostic information could be useful in the stratification of patients into prognostic groups for the development of more individualized follow-upschedules and for enrollment into clinical trials.

Intraoperative pathology consultation for kidney and urinary bladder specimens

CONTEXT

Intraoperative pathology consultation for kidney and urinary bladder specimens is relatively infrequent. Scant literature is devoted to this topic.

OBJECTIVE

The clinical indications and diagnostic usefulness and pitfalls of intraoperative pathology consultation of kidney and urinary bladder specimens will be reviewed, based on literature and personally encountered cases.

DATA SOURCES

The indications for intraoperative pathology consultation for renal lesions included (1) surgical margins in partial nephrectomy specimens, (2) solid renal mass in unusual clinical or radiologic settings, (3) synchronous renal and extrarenal masses, (4) cystic renal lesions, (5) ureteral surgical margin for transitional cell carcinoma, (6) multiple renal masses, (7) solid mass in a diffusely cystic kidney, and (8) evaluation of renal injury. The indications for urinary bladder included (1) status of the surgical margins, (2) diagnosis of bladder tumor biopsy, (3) diagnosis of extravesical tumors with vesical extension, (4) diagnosis of extravesical mass, including pelvic lymph nodes encountered during cystectomy, and (5) status of bladder neck margin during radical prostatectomy for cancer. The frequent problematic areas for the kidney included misdiagnosis or incorrect classification of cystic tumors or spindle cell tumors, and confusion of clear cell renal cell carcinoma with inflammatory lesions. The problematic areas for urinary bladder included the differential diagnoses of high-grade dysplasia/carcinoma in situ with reactive changes at the ureteral or urethral surgical margins.

CONCLUSIONS

Distinctive indications and diagnostic pitfalls are recognized for intraoperative consultation of renal or urinary bladder lesions. Awareness of the pertinent problems should improve diagnostic accuracy and facilitate the proper management of these lesions.

An unusual coincidence of multiple synchronous kidney tumors with a metachronous rectal adenocarcinoma

In synchronous surgery specimens (right-sided nephrectomy and left-sided partial nephrectomy), a unique combination of a papillary (chromophil) renal cell carcinoma (4 x 3.7 x 3.5 cm) and a renal oncocytoma (11 x 10 x 9 mm) in the right kidney and a renal carcinoid (2.5 x 2.3 x 1.1 cm) in the resected part of the left kidney has been found. This multiplicity and bilaterality, based on the findings of three distinct histogenetic types of kidney tumors, was accompanied by a metachronous rectal adenocarcinoma discovered 14 months later. After surgery, no radiation or other oncologic therapy was given. At present, our patient is well without any evidence of neoplastic disease three years after primary diagnosis. To the best of our knowledge, this is the first case of a combination of three distinct histogenetic types of synchronous renal tumors associated with a metachronous rectal adenocarcinoma treated with simple surgery. In the absence of cytogenetic studies, the possibility of a the presence of a hereditary renal cancer syndrome must be considered.

Renal sinus involvement in renal cell carcinomas

The renal sinus is the fatty compartment located within the confines of the kidney not delineated from the renal cortex by a fibrous capsule. Because it contains numerous veins and lymphatics, invasion into this compartment may permit dissemination of a tumor otherwise regarded as renal-limited. Thirty-one consecutive renal carcinomas were studied: 22 clear cell renal cell carcinomas (3 multilocular cystic renal cell carcinomas), 4 chromophobe renal carcinomas, and 5 papillary renal carcinomas. The entire interface between the neoplasm and the sinus was embedded. Seventeen carcinomas did not invade the renal sinus and 16 were pT1 or pT2 tumors. Fourteen carcinomas, 13 clear cell renal cell carcinoma and one chromophobe renal carcinoma, invaded the renal sinus fat, and 9 of 14 invaded the lumen of renal sinus veins (all clear cell renal carcinomas). Although 14 of 22 clear cell renal carcinomas appeared to be renal limited pT1 and pT2 cancers, 6 of 14 carcinomas invaded sinus fat and 4 invaded into the lumen of renal sinus veins. Compared with the nine sinus-negative clear cell renal cell carcinomas, the 13 sinus-positive cancers were larger, exhibited more frequent renal capsule and renal vein involvement, and had higher nuclear grades. Renal sinus invasion was most common in clear cell renal cell carcinomas but was uncommon (one in 12) in 3 more indolent renal cell carcinomas: multilocular cystic renal cell carcinoma, chromophobe renal carcinoma, and papillary renal carcinoma. The follow-up period was short (1-17 months), but metastases developed in four of 31 cases. In three cases with metastases, carcinoma had involved the lumen of sinus veins but not the main renal vein, although two of three had also invaded through the renal capsule. This study shows that in carcinomas which appear to be renal limited (pT1/pT2), seven of 23 (30.4%) had invaded sinus fat and four of 23 (17.4%) had invaded sinus veins. We conclude that renal sinus invasion, especially sinus vein invasion, could identify a patient at risk for metastases even in a putative renal limited tumor, and suggest that all cases be examined for this feature. Renal sinus invasion merits further investigation to establish its prognostic importance and possible incorporation into future revisions of the TNM staging system for renal cell carcinomas.

Protocols for the examination of tumors of diverse sites: introduction. Cancer committee of the College of American Pathologists

This issue of the Archives includes previously unpublished protocols for the examination of specimens removed from patients with cancer of diverse sites. We provide a historical context for the development of these protocols and describe the process of development and approval. General information about the structure and content of the protocols is also provided. Cancer protocol development is an important step in the process of standardized cancer reporting. The value of such standardized reporting is discussed.