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Transcript of CAP Breast Invasive Biopsy Cancer Protocol · Web viewThe aim of this protocol is to improve the...
Reporting Protocol for the Examination of Gross Autopsy of Adult DecedentsVersion: autopsy-adult-20.02Protocol Posting Date: February 2020
Accreditation RequirementsThe use of this protocol is recommended for autopsy but is not required for accreditation purposes.
This protocol may be used for the following procedures:Procedure DescriptionAutopsy Includes routine autopsy for adult decedents
The following should NOT be reported using this protocol:ProcedureForensic autopsyPediatric autopsy
AuthorsJody E. Hooper, MD*, Katie Flickinger, MS, PA (ASCP)CM*
With guidance from the CAP Autopsy and Neuropathology Committees.* Denotes primary author. All other contributing authors are listed alphabetically.
Summary of Changes20.02 – New autopsy reporting protocol
© 2020 College of American Pathologists (CAP). All rights reserved. For Terms of Use please visit www.cap.org/cancerprotocols.
CAP Approved Autopsy-Adult-20.02
Reporting Template
Notes: This case summary may be useful for reporting autopsy findings but is not required for accreditation purposes. (NOTE A)
PATIENT IDENTIFICATION AND CONSENT FOR AUTOPSY
Patient name: ______________________
Consent and patient ID reviewed byDr. ____________________Mr./Ms. ____________________
Two unique patient identifiers reviewedPatient name: ____________________Date of birth: ____________________MRN: ____________________Other: ____________________
___ Type of autopsy___ Complete___ Brain only___ No head___ Chest only___ Abdomen only___ Other: ____________________
Name of consenter: ____________________
Relationship to the deceased: ____________________
PRIOR POSTMORTEM PROCEDURES
___ Organ Donation (select all that apply)___ Corneas___ Skin___ Bone and soft tissue (specify): _______________________ Organs (specify): _______________________ Other (specify): ____________________
___ Funerary Preparation (select all that apply)___ Eye caps___ Jaws wired or sewn closed___ Evidence of embalming (specify): _______________________ Other (specify): ____________________
+ Data elements preceded by this symbol may be of value but are not necessarily routinely reported. 2
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EXTERNAL APPEARANCE
___ General ___ Well-developed___ Other (specify): ____________________
___ Age: _________
___ Race___ Caucasian___ African American___ Hispanic___ Asian___ Other (specify): ____________________
___ Sex___ Male___ Female___ Other (specify): ____________________
Body Weight (kilograms) _____kg
Body Length (centimeters) _____cm
BMI ______Note: use formula weight (kg)/ [height (m)]2
___ Personal effect with or on the body___ No___ Yes (specify): ____________________
___ Toes / fingernails:___ Unremarkable___ Onychomycosis___ Koilonychia___ Splinter hemorrhages___ Cyanotic___ Other (specify): ____________________
___ Skin___ Unremarkable___ Other (specify): ____________________
___ Palpable lymph nodes___ No___ Yes
___ Neck___ Axilla___ Groin ___ Other (specify): ____________________
___ Hair ___ None___ Balding___ Short___ Long
+ Data elements preceded by this symbol may be of value but are not necessarily routinely reported. 3
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___ Other (specify): ____________________
___ Hair color___ Black___ Brown___ Blond___ Grey___ Other (specify): ____________________
___ Eye color___ Brown___ Blue___ Hazel___ Green___ Other (specify): ____________________
Pupil measurement- right (centimeters): _________ cm
Pupil measurement- left (centimeters): _________ cm
___ Sclerae___ Anicteric___ Icteric___ Other (specify): ____________________
___ Ears___ Unremarkable___ Other (specify): ____________________
___ Nose___ Unremarkable___ Other (specify): ____________________
___ Oral cavity___ Good dentition___ Poor dentition___ Dentures___ No teeth___ Exam not performed due to rigor___ Other (specify): ____________________
___ External genitalia___ Normal male___ Normal female___ Other (specify): ____________________
___ Leg circumference 10 cm from medial malleolus___ Right (centimeters): ________ cm___ Left (centimeters): ________ cm
___ Edema___ None___ Peripheral___ Generalized___ Other (specify): ____________________
+ Data elements preceded by this symbol may be of value but are not necessarily routinely reported. 4
CAP Approved Autopsy-Adult-20.02
___ Scars/ incisions___ None___ Present (specify): ____________________
___ Location (specify): ______________ Size (centimeters): ____ cm
___ Evidence of therapy___ None___ Nasogastric tube___ PEG tube___ Endotracheal tube___ Foley catheter___ Other (specify): ____________________
___ Back___ Unremarkable___ Other (specify): ____________________
INCISIONS AND BODY CAVITIES
___ Incision___ Standard Y-shaped___ Biparietal___ Other (specify): ____________________
___ Organs in normal anatomic positions___ Yes___ No___ Other (specify): ____________________
+ Panniculus (centimeters measured at thickest area): ________ cm
___ Peritoneal fluid___ None___ Present (milliliters): __________ ml
___ Serous___ Cloudy___ Serosanguinous___ Sanguinous___ Other (specify): ____________________
___ Peritoneal surfaces___ Smooth___ Adhesions___ Other (specify): ____________________
___ Right pleural cavity___ Smooth___ Adhesions___ Other (specify): ____________________
+ Data elements preceded by this symbol may be of value but are not necessarily routinely reported. 5
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___ Right pleural fluid___ None___ Present (milliliters): __________ ml
___ Serous___ Serosanguinous___ Sanguinous___ Other (specify): ____________________
___ Left pleural cavity___ Smooth___ Adhesions___ Other (specify): ____________________
___ Left pleural fluid___ None___ Present (milliliters): __________ ml
___ Serous___ Serosanguinous___ Sanguinous___ Other (specify): ____________________
CARDIOVASCULAR SYSTEM
___ Heart weight___ (grams): _________ gNote: see reference table by patient weight
___ Pericardium___ Intact___ Adhesions___ No adhesions___ Other (specify): ____________________
___ Pericardial fluid___ None___ Present (milliliters): __________ ml
___ Serous___ Sanguinous___ Other (specify): ____________________
+ ___ Epicardial fat+ ___ Minimal+ ___ Moderate+ ___ Large amount+ ___ Other (specify): ____________________
___ Epicardial surface___ Smooth___ Glistening___ Roughened___ Other (specify): ____________________
+ Data elements preceded by this symbol may be of value but are not necessarily routinely reported. 6
CAP Approved Autopsy-Adult-20.02
___ Coronary ostia___ Normally positioned___ Patent___ Other (specify): ____________________
___ Foramen ovale___ Closed___ Probe patent___ Other (specify): ____________________
___ Coronary arteries follow normal anatomic course___ Yes___ No___ Other (specify): ____________________
___ Coronary circulation___ Right dominant___ Left dominant___ Co- dominant
Atherosclerosis___ Left anterior descending artery (LAD)
___ None___ % stenosis: _____________ Eccentric___ Concentric___ Other (specify): ____________________
___ Left circumflex artery (LCX)___ None___ % stenosis: _____________ Eccentric___ Concentric___ Other (specify): ____________________
___ Right coronary artery (RCA)___ None___ % stenosis: _____________ Eccentric___ Concentric___ Other (specify): ____________________
___ Chamber dilation___ Yes___ No___ Other (specify): ____________________
___ Valve leaflets___ Thin/ delicate___ Other (specify): ____________________
___ Chordae tendinae___ Thin___ Other (specify): ____________________
+ Data elements preceded by this symbol may be of value but are not necessarily routinely reported. 7
CAP Approved Autopsy-Adult-20.02
+ Valve circumferences+ Tricuspid (centimeters): _________ cm
____ Abnormalities (specify): ____________________ Note: Reference range 10.0 – 12.5 cm
+ Pulmonic (centimeters): _________ cm____ Abnormalities (specify): ____________________ Note: Reference range 7.0 – 9.0 cm
+ Mitral (centimeters): _________ cm____ Abnormalities (specify): ____________________ Note: Reference range 8.0 – 10.5 cm
+ Aortic (centimeters): _________ cm____ Abnormalities (specify): ____________________ Note: Reference range 6.0 – 7.5 cm
___ Myocardium___ Firm___ Red-brown___ Other (specify): ____________________
____ Endocardium___ Smooth and thin___ Thickened___ Other (specify): ____________________
Left ventricular free wall (centimeters): _________ cmNote: Reference range less than 1.5 cm
Right ventricular free wall (centimeters): _________ cmNote: Reference range less than 0.5 cm
Septum (centimeters): _________ cmNote: Reference range less than 1.5 cm
___ Pulmonary artery___ Appropriate caliber___ Normal configuration___ Contains embolus___ Other (specify): ____________________
___ Ascending aorta___ Appropriate caliber___ Normal configuration___ Other (specify): ____________________
___ Major arteries arising from aortic arch___ Normal configuration___ Patent___ Other (specify): ____________________
+ Data elements preceded by this symbol may be of value but are not necessarily routinely reported. 8
CAP Approved Autopsy-Adult-20.02
___ Thoracic aorta___ No atherosclerosis___ Mild atherosclerosis___ Moderate atherosclerosis___ Severe atherosclerosis
___ Abdominal aorta___ No atherosclerosis___ Mild atherosclerosis___ Moderate atherosclerosis___ Severe atherosclerosis
___ Venae cavae___ Patent___ Thin- walled___ Thrombi present___ Other (specify): ____________________
RESPIRATORY SYSTEM
___ Epiglottis, larynx, trachea___ No lesions___ Other (specify): ____________________
Right lung weight (grams): _________ gNote: Reference range 360 – 570 g
Left lung weight (grams): _________ gNote: Reference range 325 – 480 g
___ Fixation___ Fixed in distension___ Cut fresh___ Other (specify): ____________________
___ Right lung parenchyma___ Soft and pale red___ Other (specify): ____________________
___ Left lung parenchyma___ Soft and pale red___ Other (specify): ____________________
___ Bronchi___ Patent___ Other (specify): ____________________
___ Bronchial mucosa___ No lesions___ Other (specify): ____________________
+ Data elements preceded by this symbol may be of value but are not necessarily routinely reported. 9
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___ Pulmonary arteries___ No atherosclerosis___ Atherosclerosis___ Pulmonary emboli (specify size and location)___ No pulmonary emboli___ Other (specify): ____________________
DIGESTIVE SYSTEM
+ ___ Tongue+ ___ Papillated+ ___ Smooth+ ___ Other (specify): ____________________
___ Esophagus___ Normal anatomic configuration___ Other (specify): ____________________
___ Esophageal mucosa___ White___ Intact___ Other (specify): ____________________
___ Squamocolumnar junction___ Sharply defined___ Indistinct___ Other (specify): ____________________
___ Stomach___ Empty___ Distended___ Contains partially digested food and liquids___ Other (specify): ____________________
___ Gastric mucosa___ Intact, rugated___ Other (specify): ____________________
___ Appendix___ Present___ Surgically absent___ Other (specify): ____________________
___ Small bowel___ Usual caliber___ Dilated___ Strictured___ Other (specify): ____________________
___ Small bowel serosa___ Tan pink shiny___ Adhesions___ Other (specify): ____________________
+ Data elements preceded by this symbol may be of value but are not necessarily routinely reported. 10
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Small bowel contents (specify): ____________________
___ Small bowel mucosa___ Tan___ No lesions___ Other (specify): ____________________
___ Large bowel___ Usual caliber___ Dilated ___ Stricture___ Other (specify): ____________________
___ Large bowel serosa ___ Tan pink shiny___ Adhesions___ Other (specify): ____________________
Large bowel contents (specify): ____________________
___ Large bowel mucosa___ Tan ___ No lesions___ Polyps___ Diverticula___ Other (specify): ____________________
+ ___ Superior mesenteric artery+ ___ No atherosclerosis+ ___ Degree of atherosclerosis (specify): ____________________+ ___ Other (specify): ____________________
Liver weight (grams): __________ gNote: Reference range 1500 – 1800 g
___ Liver capsule___ Smooth___ Glistening___ Intact___ Other (specify): ____________________
___ Liver parenchyma___ Slightly firm___ Firm___ Soft___ Maroon-brown___ Green tinged___ Yellow orange___ Rusty brown___ Mottled red___ Nodular___ No focal lesions___ Other (specify): ____________________
+ Data elements preceded by this symbol may be of value but are not necessarily routinely reported. 11
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___ Gallbladder___ Present___ Surgically absent___ Other (specify): ____________________
___ Gallbladder wall___ Thin___ Fibrous___ Other (specify): ____________________
___ Gallbladder mucosa___ Velvety___ Green___ Other (specify): ____________________
___ Gallbladder contents___ Dark green mucoid bile___ No calculi___ Calculi___ Other (specify): ____________________
___ Extrahepatic biliary system___ Patent___ Other (specify): ____________________
___ Portal vein___ Patent___ Other (specify): ____________________
___ Hepatic arteries___ Patent___ Other (specify): ____________________
___ Hepatic veins___ Patent___ Other (specify): ____________________
Pancreas dimensions (centimeters): ____ cm x ____ cm x ____ cmNote: Average 23.0 x 4.5 x 3.8 cm
___ Pancreatic parenchyma___ Tan___ Firm and lobulated___ Autolyzed___ Other (specify): ____________________
___ Pancreatic duct___ Patent___ Not probe patent___ Other (specify): ____________________
+ Data elements preceded by this symbol may be of value but are not necessarily routinely reported. 12
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URINARY TRACTNote: Average combined kidney weight 230-440 g
Right kidney weight (grams): __________ g
___ Right kidney cortex___ Thickness (centimeters): ____ cm___ Smooth___ Granular___ Scarred___ Other (specify): ____________________
___ Right kidney parenchyma___ Red-brown___ Clearly demarcated corticomedullary junctions___ Ill-defined corticomedullary junctions___ Other (specify): ____________________
___ Right ureter___ Patent___ Not patent___ Dilated___ Not dilated___ Other (specify): ____________________
Left kidney weight (grams): __________ g
___ Left kidney cortex___ Thickness (centimeters): ____ cm___ Smooth___ Granular___ Scarred___ Other (specify): ____________________
___ Left kidney parenchyma___ Red-brown___ Clearly demarcated corticomedullary junctions___ Ill-defined corticomedullary junctions___ Other (specify): ____________________
___ Left ureter___ Patent___ Not patent___ Dilated___ Not dilated___ Other (specify): ____________________
___ Renal arteries___ Patent___ No atherosclerosis___ Mild atherosclerosis___ Moderate atherosclerosis___ Severe atherosclerosis
+ Data elements preceded by this symbol may be of value but are not necessarily routinely reported. 13
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___ Bladder___ Collapsed___ Volume of urine (milliliters): __________ ml
___ Bladder mucosa___ Intact___ Other (specify): ____________________
MALE REPRODUCTIVE TRACT (if appropriate)
___ Prostate___ Normal size___ Enlarged___ Nodular___ Size (centimeters): ____ cm x ____ cm x ____ cm___ Other (specify): ____________________
___ Testes___ Normal size___ Enlarged___ Other (specify): ____________________
___ Testes cut surface___ Brown parenchyma___ Tubules string in normal manner___ Tubules do not string___ Other (specify): ____________________
FEMALE REPRODUCTIVE TRACT (if appropriate)
___ Uterus___ Present and appropriate size___ Present (comment): _______________________ Surgically absent
___ Right Ovary ___ Size (centimeters): ____ cm x ____ cm x ____ cm___ Not identified___ Other (specify): ____________________
___ Left Ovary ___ Size (centimeters): ____ cm x ____ cm x ____ cm___ Not identified___ Other (specify): ____________________
___ Endometrium ___ Pale___ Red___ Other (specify): ____________________
___ Vagina___ Without lesions___ Other (specify): ____________________
+ Data elements preceded by this symbol may be of value but are not necessarily routinely reported. 14
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___ Cervix___ Without lesions___ Other (specify): ____________________
ENDOCRINE SYSTEM
Right adrenal weight (grams): __________ gNote: Average weight 6 g (trimmed)
Left adrenal weight (grams): __________ gNote: Average weight 6 g (trimmed)
___ Adrenal parenchyma___ Uniform yellow cortices___ Good demarcation from the medullae___ Autolyzed___ Other (specify): ____________________
___ Thyroid___ Weight (grams): __________ g___ Symmetrical___ Red-brown___ Firm___ Nodular___ Other (specify): ____________________Note: Average weight 30 – 70 g
___ Breast tissue contains small amount of white fibrous tissue within yellow fat___ Other (specify): ____________________
LYMPHORETICULAR SYSTEM
Spleen weight (grams): __________ gNote: Average weight 150 – 200 g unless over 80-years-old, then average 100 g
___ Spleen capsule___ Smooth___ Intact___ Other (specify): ____________________
___ Spleen parenchyma___ Dark red___ Other (specify): ____________________
___ Bone marrow___ Dark red___ Hard___ Softer than usual___ Other (specify): ____________________
___ Lymph nodes___ Not enlarged___ Other (specify): ____________________
+ Data elements preceded by this symbol may be of value but are not necessarily routinely reported. 15
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___ Thymus___ Not identified___ Age appropriate fatty replacement___ Present (weigh)___ Other
MUSCULOSKELETAL SYSTEM
___ Diaphragm___ Intact___ Other (specify): ____________________
___ Skeletal muscles___ Red-brown and firm___ Appropriate mass for age/ gender___ Other (specify): ____________________
___Calvarium___ Intact___ Normal thickness___ Other (specify): ____________________
___ Vertebral column___ Normal curvature___ Kyphosis___ Scoliosis___ Other (specify): ____________________
___ Ribs___ Fractures (specify): _______________________ No fractures___ Other (specify): ____________________
___ Vertebral bodies___ No fractures___ Other (specify): ____________________
CENTRAL NERVOUS SYSTEMGross brain observations at time of autopsy. Post-fixation brain cutting observations and tissue sampling will be considered in separate protocol (under development)
Brain weight (grams): __________ gNote: Average weight 1100 – 1600 g
___ Dura___ No lesions___ Epidural hemorrhage___ Subdural hemorrhage___ Removal reveals no bony abnormalities___ Other (specify): ____________________
___ Leptomeninges___ No lesions___ Subarachnoid hemorrhage
+ Data elements preceded by this symbol may be of value but are not necessarily routinely reported. 16
CAP Approved Autopsy-Adult-20.02
___ Opacity or discoloration___ Other (specify): ____________________
___ Cerebral hemispheres___ No lesions___ Asymmetric (specify):_____________________ Atrophy (specify: diffuse, focal, lobar): ______________________ Edema (specify: diffuse, focal): _____________________ Other (specify): ____________________
___ Base of brain___ No lesions___ Uncal herniation
___ Circle of Willis___ Normal___ Atherosclerosis (specify location and severity): ____________________ Aneurysm (specify location and type): _______________* Note: If a ruptured aneurysm is suspected clinically and hemorrhage is present at the base of
the brain, it is advisable to wash away the blood and conduct a thorough search for the aneurysm before fixation of the brain.
___ Other (specify): ______________
___ Cerebellum___ No lesions___ Tonsillar herniation___ Other (specify): ____________________
___ Brainstem___ No lesions___ Other (specify): ____________________
___ Spinal cord___ Length (cm from cut superior to conus): ___________cm___ No lesions___ Other (specify): _______________________ Not submitted
___ Pituitary___ No lesions___ Other (specify): ____________________
+ EYES
+ ___ Eyes+ ___ Submitted+ ___ Not submitted+ ___ Other (specify): ____________________
AUTOPSY PROCEDURES AND ANCILLARY TESTING
___ Approach to autopsy dissection___ Rokitansky
+ Data elements preceded by this symbol may be of value but are not necessarily routinely reported. 17
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___ Virchow___ Other (specify): ____________________
___ Special dissection___ None___ Other (specify): ____________________
___ Tissue retention___ Stock jar___ All organs (until signout)___ Other (specify): ____________________
___ Additional samples taken___ Blood (specify): _______________________ Vitreous___ Tissue (specify): _______________________ Other (specify): ____________________
___ Ancillary testing___ None___ Radiology (specify): _______________________ Blood cultures (specify): _______________________ Tissue cultures (specify): _______________________ Toxicology (specify): _______________________ Other (specify): ____________________
+ Data elements preceded by this symbol may be of value but are not necessarily routinely reported. 18
Background Documentation Autopsy-Adult-20.02
Explanatory Notes
A. IntroductionThe aim of this protocol is to improve the completeness, clarity, and portability of autopsy reporting, while being mindful of the wide range of practice settings in which the data in the report is generated and disseminated. Autopsy reporting has traditionally been entirely in prose, a methodology which complicates real time dictation in many cases, and which does not make data easily retrievable, particularly across institutions.
The protocol is based upon input from past and present members of the CAP Autopsy Committee, CAP Neuropathology Committee, and input from Katie Flickinger, MS, PA(ASCP)CM as well as the references below.
The construction of this protocol does allow for the insertion of sentences where desired and thus combines the best of templating and traditional description. It is recommended that it be used as a paper copy or electronic tool directly in the autopsy suite while a case is being completed, though its use can be adapted as needed at different centers and depending on the information technology environment. Portions of the template may also be used in limited autopsies. Though this template represents the Autopsy Committee’s recommendations for inclusion in an autopsy report, some sections with a plus sign “+” are considered more readily optional in practice and could be omitted.
Not only will the template provide more easily reproducible and extractable data, it may be used as a guide for trainees and pathologists who may only perform a limited number of autopsies in their practice. The committee hopes this is a first step in providing a general framework for more standardized quality autopsy practice.
The content of the protocol represents the consensus opinion of the CAP Autopsy Committee. It was ordered by organ system rather than order of the block dissection in recognition of variations in dissection practices across institutions as well as to create the most intelligible final report. Recognizing that the order of elements may be adjusted by users, it is the Committee’s recommendation that all elements be included in the Gross Description. Microscopic sampling can also be institution dependent, but the Committee recommends broad histologic evaluation for autopsies.
References1. Fyfe-Kirschner B and Miller DK. The future of autopsy reporting: data repository and research support. In:
Hooper and Williamson, editors. Autopsy in the 21st Century: Best Practices and Future Ideas. Switzerland: Springer;2019. 39-56.
2. Wittekind C, Habeck JO, Gradistanac T. Proposals for standardization of autopsy reports. Pathologe 2014;35:182-190. https://doi.org/10.1007/s00292-013-1885-8.
3. Hanzlick R. The autopsy lexicon: suggested headings for autopsy reports. In: Collins K, editor. Autopsy Performance and Reporting. 3rd ed. Chicago: CAP Press;2017. 377-382.
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