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(Carcinoid Tumors) of the Jejunum and Ileum

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(Carcinoid Tumors) of the Jejunum and Ileum AAPA Macroscopic Examination Guidelines: Utilization of the CAP Cancer Protocols at the Surgical Gross Bench Protocol for the Examination of Specimens from Patients with Neuroendocrine Tumors (Carcinoid Tumors) of the Jejunum and Ileum. This protocol applies to segmental resections and ileocolectomies of well-differentiated neuroendocrine tumors of the jejunum and ileum. This protocol does not apply to well- differentiated tumors of the duodenum and ampulla, poorly differentiated neuroendocrine carcinoma (including small and large cell), other epithelial tumors including mixed neuroendocrine-non-neuroendocrine neoplasms, lymphoma, gastrointestinal stromal tumors, and non-gastrointestinal stromal tumor sarcomas. Based on: AJCC Cancer Staging Manual, Eighth Edition pTNM requirements CAP Cancer Protocol: Jejunum/IleumNET 1.0.0.2 CAP Protocol Web Posting Date: February 2020 AAPA Macroscopic Examination Template Edition 3.0 AAPA Web Posting Date: Revision History: 1st Edition – April 2017 2nd Edition – September 2018 Summary of Changes: This protocol is revised to the 8th edition of the AJCC Cancer Staging Manual and the current version of the CAP Cancer Protocol Jejunum / Ileum NET 1.0.0.2. This is a major revision to the protocol. Extensive changes have been made throughout the document. Procedures Covered in this Protocol: Segmental resections of the jejunum and ileum Ileocolectomy (may include ileum, cecum, appendix, ascending colon) Authors: Molly A. Person, PA(ASCP)CM*, Patrice Brown, PA(ASCP)CM, Lainee Bulawa, PA(ASCP)CM, Heather Gaburo, PA(ASCP)CM, Courtney Hyland, PA(ASCP)CM, Monica Kendall, PA(ASCP)CM, Darryl Kinnear, PA(ASCP)CM, Alysha Martini, PA(ASCP)CM, Dennis Strenk, PA(ASCP)CM, Constance Thorpe, PA(ASCP)CM, Jon Wagner, PA(ASCP)CM *Denotes primary author. All other contributing authors are listed alphabetically. Previous Lead Contributors: Constance Thorpe, PA(ASCP)CM Katie Johnson, PA(ASCP)CM Art Director Jesse McCoy, BFA, MHS, PA(ASCP)CM Photograph Curator: Lainee Bulawa, MS, PA(ASCP)CM Illustrator: Matthew Brownstein Endocrine – Jejunum and Ileum Jejunum/IleumNET 1.0.0.2 Structured Macroscopic Report Jejunum and Ileum Neuroendocrine Tumor Procedure ____ Segmental resection, small intestine ____ Ileocolic resection ____ Other (specify): __________________________________________________________________ ____ Not specified Nature of Specimen Received ____ Fresh +____ Frozen section (intraoperative consultation) ____ Tissue collected for ancillary diagnostic studies, (specify test): ______________________ ____ In fixative Fixative type: __________________________________________________________________ + Cold ischemic time: ____________________________________________________________ + Fixation time (specify if for entire specimen or specific components): _____________________ ____ Other transport media (specify): _____________________________________________________ Specimen Orientation +____ Specimen oriented +____ Oriented by surgeon (specify): _______________________________________________ +____ Oriented based on anatomic landmarks +____ Not oriented Specimen Integrity ____ Intact ____ Disrupted / fragmented: +____ Margin disrupted (specify):__________________________________________________ +____ Tumor disrupted ____ Other (specify): __________________________________________________________________ Ink Key +____ Ink applied (provide anatomic site and color applied): ____________________________________ Overall Dimensions (cm) ___ x ___ x ___ cm Specimen Anatomical Components and Size in Three Dimensions (if applicable, list specimen components) ____ Small intestine: ___ (length) x ___ (diameter) cm ____ Mesentery: ___ x ___ x ___ cm ____ Cecum: ___ (length) x ___ (diameter) cm ____ Appendix: ___ (length) x ___ (diameter) cm ____ Right colon: ___ (length) x ___ (diameter) cm ____ Omentum: ___ x ___ x ___ cm ____ Other (specify): __________________________________________________, ___x ___ x ___ cm Macroscopic Tumor ____ Absent ____ Present Tumor Focality ____ Unifocal ____ Multifocal (specify number of tumors): ___ 2 Endocrine – Jejunum and Ileum Jejunum/IleumNET 1.0.0.2 ____ Indeterminate (explain): ____________________________________________________________ Tumor Site ____ Jejunum ____ Ileum ____ Small intestine, not otherwise specified ____ Other (specify):___________________________________________________________________ Macroscopic Tumor Size Greatest dimension: ____ cm +Additional dimensions: ___ x ___ cm or ranging from ___ - ___ cm ____ Indeterminate (explain): ____________________________________________________________ +Macroscopic Appearance of Tumor +____ Necrotic +____ Color: _________________________________________________________________________ +____ Consistency: ___________________________________________________________________ +____ Well-circumscribed +____ Other:_________________________________________________________________________ Macroscopic Extent of Tumor (involvement of adjacent structures) ____ Confined to mucosa/submucosa ____ Involves muscularis propria ____ Involves visceral peritoneum or adjacent adipose tissue ____ Involves adjacent structures or other organs (specify): ____________________________________ Macroscopic Margin Involvement Note: use this section only if all margins are uninvolved and can be assessed. ____ All margins are uninvolved by macroscopic tumor Margins examined: _____________________________________________________________ Note: Margins may include proximal, distal, radial, or mesenteric, and others. Distance of tumor to closest margin: ___ mm or ___ cm Specify margin: ________________________________________________________________ ____ Margin(s) involved by macroscopic tumor Specify margin(s): ______________________________________________________________ Note: individual margin reporting required if any margins are involved or margin involvement cannot be assessed. Proximal Margin ____ Cannot be assessed ____ Uninvolved by macroscopic tumor ____ Involved by macroscopic tumor Distal Margin ____ Cannot be assessed ____ Uninvolved by macroscopic tumor ____ Involved by macroscopic tumor Radial or Mesenteric Margin ____ Cannot be assessed ____ Uninvolved by macroscopic tumor ____ Involved by macroscopic tumor Other Margin(s) (required only if applicable) 3 Endocrine – Jejunum and Ileum Jejunum/IleumNET 1.0.0.2 Specify margin(s): _____________________________________________________________________ ____ Cannot be assessed ____ Uninvolved by macroscopic tumor ____ Involved by macroscopic tumor Mesenteric Masses ____ Not identified ____ Large mesenteric mass(es) (>2 cm) present + Specify number: ____ + Size: ___ x ___ x ___ cm or Range: ___ - ___ cm +___ Encases superior mesenteric vessels +____ Mesenteric tumor deposit(s) (<2 cm) + Specify number: ____ + Size: ___ x ___ x ___ cm or Range: ___ - ___ cm +___ Encases superior mesenteric vessels ____ Cannot be determined (explain):_____________________________________________________ +Macroscopic Appearance of Uninvolved Tissue / Organ(s) +____ Ischemic changes (e.g., wall attenuation, dusky discoloration, etc.) +____ Small bowel stenosis, lumen narrows to ___ cm over ___ cm length +____ Mesenteric fibrosis +____ Mucosal ulceration +____ Perforation: ___ x ___ x ___ cm; Location:____________________________________________ +____ Other: _________________________________________________________________________ Lymph Node Examination ____ No lymph nodes submitted or identified ____ Number of lymph nodes identified: ___ ____ Number of lymph nodes macroscopically involved: ___ +Size of lymph nodes in three dimensions: ___ x ___ x ___ cm or range in size: ___ - ___ cm ____ Number of lymph nodes cannot be determined (explain): __________________________________ +____ Tissue Submitted for Research (specify, if possible): __________________________________ (+) Data elements preceded by this symbol are optional elements which may be clinically important but are not yet validated or regularly used in patient management. 4 Endocrine – Jejunum and Ileum Jejunum/IleumNET 1.0.0.2 Recommended Block Allocation Key: Small bowel resection: A1: Proximal mucosal margin, (perpendicular or en face) A2: Distal mucosal margin, (perpendicular or en face) A3-A4: Small bowel mass, with deepest invasion A5: Mass to radial margin (if present and applicable, radial margin may be submitted as a separate shave if distant from the mass) A6: Mass and adjacent uninvolved mucosa A7: Mesenteric mass (if present) to mesenteric margin, perpendicular A8: Additional Mesenteric mass (if present) A19-12: Lymph nodes (12 minimum recommended for adequate staging) Note: Often neuroendocrine tumors of the ileum and jejunum will be small (~1 cm) and there may not be sufficient mass to submit 5 cassettes of tumor, as outlined above. This serves as an example representation of structures and relationships to be sampled as primary tumor allows, and if all mentioned structures are present. Ileocolectomy: A1-2: Small bowel mass, with deepest invasion A3: Mass to radial margin (if present and applicable) A4: Mass and adjacent uninvolved mucosa A5: Mass to nearest mucosal margin, perpendicular OR nearest mucosal margin, shave (if far) A6: Mesenteric mass to mesenteric margin, perpendicular A7: Additional mesenteric mass (if present) A8-11: Lymph nodes (12 minimum recommended for adequate staging) A12: Representative uninvolved cecum / ascending colon A13: Appendix (if present) References: 1. Lester SC. Manual of Surgical Pathology, 3rd ed. Philadelphia, PA:
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