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• W4247597818 abstract "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. The College regards the reporting elements in the “Surgical Pathology Cancer Case Summary (Checklist)” 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 checklist 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 these documents.This protocol applies to carcinomas of the intrahepatic bile ducts and mixed hepatocellular-cholangiocarcinoma. Hepatocellular carcinoma, hepatoblastoma, and carcinomas of the perihilar bile ducts are not included. The seventh edition TNM staging system for intrahepatic bile ducts of the American Joint Committee on Cancer and the International Union Against Cancer is recommended.Intrahepatic Bile Ducts: Resection (note A)Select a Single Response Unless Otherwise Indicated*Data elements with asterisks are not required. However, these elements may be clinically important but are not yet validated or regularly used in patient management.Specimen (select all that apply)Procedure (select all that apply)Tumor SizeGreatest dimension: ___ cm*Additional dimensions: ___ × ___ cm___ Cannot be determined (see Comment)Tumor Focality (note B)Histologic Type (note C)Histologic Grade (note D)Tumor Growth Pattern (note E)Microscopic Tumor Extension (select all that apply)Margins (select all that apply) (note F)Hepatic Parenchymal MarginBile Duct MarginOther MarginLymph-Vascular InvasionVenous (Major Vessel) Invasion (V) (invasion of right or left portal vein, 1 or more hepatic veins)Small Vessel Invasion (L)*Perineural InvasionPathologic Staging (pTNM) (note G)TNM Descriptors (required only if applicable) (select all that apply)Primary Tumor (pT)Regional Lymph Nodes (pN) (note H)Distant Metastasis (pM)*Additional Pathologic Findings (select all that apply) (note I)*Ancillary Studies*Clinical History (select all that apply) (note J)*Comment(s): ____________________________________* Data elements with asterisks are not required. However, these elements may be clinically important but are not yet validated or regularly used in patient management.This protocol applies only to hepatic resection specimens containing carcinomas arising in the intrahepatic bile ducts. Hepatocellular carcinomas and carcinomas arising in the perihilar bile ducts are staged using separate TNM systems.1 A separate staging system for intrahepatic cholangiocarcinoma is warranted on the basis of biologic differences in tumor behavior and prognostic factors, such as lack of prognostic impact of tumor size for cholangiocarcinoma compared with hepatocellular carcinoma.1Anatomically, the intrahepatic bile ducts extend from the periphery of the liver to the second-order bile ducts (Figure 1). The perihilar bile ducts extend from the hepatic duct bifurcation to include the extrahepatic biliary tree proximal to the origin of the cystic duct. The distal extrahepatic bile duct extends the junction of the cystic duct–bile duct to the ampulla of Vater.1Sections should be prepared from each major tumor nodule, with representative sampling of smaller nodules if macroscopically different in appearance. For purposes of staging, satellite nodules, multifocal primary cholangiocarcinomas, and intrahepatic metastases are not distinguished and are considered multiple tumors.1 In intrahepatic cholangiocarcinoma, multiple tumor deposits have been associated with poorer survival.2,3The protocol recommends the following modified classification of the World Health Organization.4 In the United States, approximately 30% of the primary malignant tumors of the liver are biliary carcinomas.4CholangiocarcinomaCombined hepatocellular and cholangiocarcinomaBile duct cystadenocarcinomaCombined or mixed hepatocellular-cholangiocarcinoma accounts for less than 5% of primary liver carcinomas5 and should show histologic evidence of both hepatocellular differentiation and bile duct differentiation, such as production of mucin. These tumors generally have a poor prognosis and often arise in the setting of cirrhosis.5,6 Recent studies have found genetic changes similar to those seen in cholangiocarcinoma.7For cholangiocarcinomas, definitive criteria for histologic grading have not been established; however, the following quantitative grading system based on the proportion of gland formation within the tumor is suggested.Three tumor growth patterns of intrahepatic cholangiocarcinoma are described: the mass-forming type, the periductal-infiltrating type, and mixed mass-forming/periductal-infiltrating type. Mass-forming intrahepatic cholangiocarcinoma (60% of cases) forms a well-demarcated nodule growing in a radial pattern and invading the adjacent liver parenchyma (Figure 2). In contrast, the periductal-infiltrating type of cholangiocarcinoma (20% of cases) spreads in a diffuse longitudinal growth pattern along the bile duct. The remaining 20% of cases of intrahepatic cholangiocarcinoma grow in a mixed mass-forming/periductal-infiltrating pattern. Limited analyses suggest that the diffuse periductal-infiltrating type is associated with a poor prognosis.2,8The evaluation of margins for total or partial hepatectomy specimens depends on the method and extent of resection. It is recommended that the surgeon be consulted to determine the critical foci within the margins that require microscopic evaluation. The transection margin of a partial hepatectomy may be large, rendering it impractical for complete examination. In this setting, grossly positive margins should be microscopically confirmed and documented. If the margins are grossly free of tumor, judicious sampling of the cut surface in the region closest to the nearest identified tumor nodule is indicated. In selected cases, adequate random sampling of the cut surface may be sufficient. The histologic examination of the bile ducts at the cut margin is recommended to evaluate the lining epithelium for in situ carcinoma or dysplasia. If the neoplasm is found near the surgical margin, the distance from the margin should be reported. For multiple tumors, the distance from the nearest tumor should be reported.The TNM staging system of the American Joint Committee on Cancer and the International Union Against Cancer applies to all primary carcinomas of the intrahepatic bile ducts and mixed hepatocellular-cholangiocarcinomas.1 It does not apply to hepatic sarcomas or to metastatic tumors of the liver.According to the American Joint Committee on Cancer/International Union Against Cancer convention, the designation “T” refers to a primary tumor that has not been previously treated. The symbol “p” refers to the pathologic classification of the TNM, as opposed to the clinical classification, and is based on gross and microscopic examination. pT entails a resection of the primary tumor or biopsy adequate to evaluate the highest pT category, pN entails removal of nodes adequate to validate lymph node metastasis, and pM implies microscopic examination of distant lesions. Clinical classification (cTNM) is usually carried out by the referring physician before treatment during initial evaluation of the patient or when pathologic classification is not possible.Pathologic staging is usually performed after surgical resection of the primary tumor. Pathologic staging depends on pathologic documentation of the anatomic extent of disease, whether or not the primary tumor has been completely removed. If a biopsied tumor is not resected for any reason (eg, when technically unfeasible) and if the highest T and N categories or the M1 category of the tumor can be confirmed microscopically, the criteria for pathologic classification and staging have been satisfied without total removal of the primary cancer.For identification of special cases of TNM or pTNM classifications, the “m” suffix and “y,” “r,” and “a” prefixes are used. Although they do not affect the stage grouping, they indicate cases needing separate analysis.The “m” suffix indicates the presence of multiple primary tumors in a single site and is recorded in parentheses: pT(m)NM.The “y” prefix indicates those cases in which classification is performed during or after initial multimodality therapy (ie, neoadjuvant chemotherapy, radiation therapy, or both chemotherapy and radiation therapy). The cTNM or pTNM category is identified by a “y” prefix. The ycTNM or ypTNM categorizes the extent of tumor actually present at the time of that examination. The “y” categorization is not an estimate of tumor before multimodality therapy (ie, before initiation of neoadjuvant therapy).The “r” prefix indicates a recurrent tumor when staged after a documented disease-free interval and is identified by the “r” prefix: rTNM.The “a” prefix designates the stage determined at autopsy: aTNM.Intraductal papillary bile duct tumors may be identified in some patients with biliary obstruction and are classified as in situ tumors (Tis).The T classification depends on the number of tumor nodules and the presence or absence of blood vessel invasion.The TNM classification does not discriminate between multiple independent primary tumors, tumor satellite nodules, or intrahepatic metastasis from a single primary carcinoma. Vascular invasion includes either the gross involvement of large vessels or the microscopic involvement of small vessels identified on histologic examination. Major vascular invasion is defined as invasion of the branches of the main portal vein (right or left portal vein) or as invasion of 1 or more of the 3 hepatic veins (right, middle, or left).Direct invasion of adjacent organs, including colon, duodenum, stomach, common bile duct, portal lymph nodes, abdominal wall, and diaphragm, is considered T3 disease, not as metastases.Tumors with periductal growth pattern (diffuse longitudinal growth pattern along the intrahepatic bile ducts on both gross and microscopic examination) or mixed mass-forming and periductal-infiltrating growth pattern are classified as T4.Stage GroupingsLymph-Vascular InvasionLymph-vascular invasion indicates whether microscopic lymph-vascular invasion is identified in the pathology report. Lymph-vascular invasion includes lymphatic invasion, vascular invasion, or lymph-vascular invasion. By the American Joint Committee on Cancer/International Union Against Cancer convention, lymph-vascular invasion does not affect the T category indicating local extent of tumor unless specifically included in the definition of a T category.Lymph node metastases have consistently been identified as an important predictor of outcome for intrahepatic cholangiocarcinoma.1,2,9 Histologic examination of a regional lymphadenectomy specimen usually involves examination of 3 or more lymph nodes.The lymph node involvement pattern for intrahepatic cholangiocarcinomas varies with location in the liver (Figure 3). For biliary carcinomas arising in the right lobe of the liver (segments 5–8), the regional lymph nodes include the hilar (common bile duct, hepatic artery, portal vein, and cystic duct), periduodenal, and peripancreatic lymph nodes. For tumors arising in the left lobe, the regional lymph nodes are the hilar and gastrohepatic lymph nodes. Nodal involvement of the celiac, periaortic, or caval lymph nodes is considered to be distant metastasis (pM1).1Cirrhosis (Ishak score 6) or severe fibrosis (Ishak score 5, marked bridging fibrosis with occasional nodules)10 should be specifically reported because it has an adverse effect on outcome. The presence of underlying disease, such as primary sclerosing cholangitis, should be included in the pathology report.Approximately 10% of intrahepatic cholangiocarcinomas arise in the setting of chronic inflammatory conditions affecting the intrahepatic bile ducts.11 The most common risk factor for intrahepatic cholangiocarcinoma in the United States is biliary cirrhosis, generally in the setting of primary sclerosing cholangitis. In Asian countries, biliary parasites and recurrent pyogenic cholangitis are also etiologic factors. Recent studies suggest that hepatitis C infection, nonalcoholic fatty liver disease, obesity, and smoking are also risk factors for the development of this tumor.12,13The authors have no relevant financial interest in the products or companies described in this article." @default.
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• W4247597818 title "Protocol for the Examination of Specimens From Patients With Carcinoma of the Intrahepatic Bile Ducts" @default.
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