ࡱ>  bjbj <~A ___sss8G |s8dn!!!!!$$$cccccccfHiVc_$$$"$$c!!c&&&$j"!_!ZT &$c&&Pr#U!MXܴsA%CR,sZd08doRi%iX#U#Ui_7U<$$&$$$$$cc&$$$8d$$$$i$$$$$$$$$ :  Dataset for histopathology reporting of mucosal malignancies of the larynx Appendix D Reporting proformas In order to provide flexibility in use, separate reporting proformas are provided for the primary carcinoma and for nodal disease. It is expected that the proformas will be combined if one operation yields tissue from both the primary site and neck dissection, providing one pathological summary and staging. The nodal proforma should be edited appropriately, depending on the type(s) of specimen received (sentinel nodes, left and/or right neck dissections). Contents Dataset for primary laryngeal carcinoma 2 Dataset for lymph node excision specimens 4 Dataset for primary laryngeal carcinoma (page 1) Surname Forenames. Date of birth.. Sex.... Hospital.. Hospital no.. NHS/CHI no.. Date of receipt.. Date of reporting.... Report no... Pathologist. Surgeon.. CLINICAL DATA Type of specimen Incisional biopsy ( Excisional biopsy ( Resection Yes ( No ( If yes, Partial ( Total ( Clinical TNM stage T N M New primary ( Recurrence ( Not known ( Previous radiotherapy Yes ( No ( Not known ( Previous chemotherapy Yes ( No ( Not known ( Primary tumour SiteLarynx. Subsite(s).. Right ( Left ( Midline ( Histological type: squamous cell carcinoma ( Conventional ( Verrucous ( Papillary ( Acantholytic ( Other (specify) . Other malignancy (specify).. . Differentiation Well ( Moderate ( Poor ( Invasive front cohesive ( non-cohesive ( Maximum diameter .(mm) Deep tissue planes involved: paraglottic space Yes ( No ( Pre-epiglottic space Yes ( No ( Cartilage invasion Yes ( No ( If present: Inner table ( Full thickness ( Distance from invasive tumour to mucosal margin ...(mm) deep margin (mm) not applicable ( Vascular invasion Yes ( No ( Nerve invasion Yes ( No ( Severe dysplasia Yes ( No ( If yes: Dysplasia at margin: Yes ( No ( COMMENTS/ADDITIONAL INFORMATION Dataset for primary laryngeal carcinoma (page 2) Surname Forenames. Date of birth..... Sex....... Hospital.. Hospital no..... NHS/CHI no.. Date of receipt.. Date of reporting....... Report no...... Pathologist.... Surgeon.. SUMMARY OF PATHOLOGICAL DATA Tumour site. Tumour type pTNM stage pT... pN. SNOMED codes T M. T M. Resection of primary tumour Clear ( Close ( Involved ( Signature: ...................................................... Date: ....................................... Dataset for lymph node excision specimens (page 1) Surname Forenames. Date of birth..... Sex....... Hospital.. Hospital no..... NHS/CHI no.. Date of receipt.. Date of reporting....... Report no...... Pathologist.... Surgeon.. Sentinel node(s) Levels submittedI ( IIA ( IIB ( III ( IV ( V ( VI ( other (Node levelNo. nodes presentNo. positive nodesECS presentIYes ( No (II (total)Yes ( No ( IIAYes ( No ( IIBYes ( No (IIIYes ( No (IVYes ( No (VYes ( No (VIYes ( No (OtherYes ( No (TotalsYes ( No ( Right neck dissection Levels submittedI ( IIA ( IIB ( III ( IV ( V ( VI ( other (Node levelNo. nodes presentNo. positive nodesECS presentIYes ( No (II (total)Yes ( No ( IIAYes ( No ( IIBYes ( No (IIIYes ( No (IVYes ( No (VYes ( No (VIYes ( No (OtherYes ( No (TotalsYes ( No ( Left neck dissection Levels submittedI ( IIA ( IIB ( III ( IV ( V ( VI ( other (Node levelNo. nodes presentNo. positive nodesECS presentIYes ( No (II (total)Yes ( No ( IIAYes ( No ( IIBYes ( No (IIYes ( No (IIIYes ( No (IVYes ( No (VYes ( No (VIYes ( No (OtherYes ( No (TotalsYes ( No ( Dataset for lymph node excision specimens (page 2) Surname Forenames. Date of birth..... Sex....... Hospital.. Hospital no..... NHS/CHI no.. Date of receipt.. Date of reporting....... Report no...... Pathologist.... Surgeon.. COMMENTS/ADDITIONAL INFORMATION SUMMARY OF PATHOLOGICAL DATA Tumour type ... Tumour site pTNM stage pN. SNOMED codes T M. Signature: ...................................................... Date: .......................................     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