Uterus for endometrial malignancy
SPR*/
ICCR¡
Macroscopic reporting dictation template
Data element
Response
Fresh tissue received
Procedure
No
Text
S2.07
Ovary (record for both left and right)
S2.08
S2.05
S2.06
S2.09
Fallopian tube (record for both left and right)
Omentum
Peritoneal biopsies; description & dimensions (per site)
Uterus received
Serosal surface
Measurement of uterus
Gross description
Weight of uterus
For each tumour: (if >1 designate accordingly)
Site of tumour (more than one may apply)
Absent
Present
Laterality ______
__x__x__mm
Surface
Normal
Abnormal, describe
Cut surface Normal
Abnormal, describe
Absent
Present
Laterality ______
__x__mm
Describe
Absent
Present __x__x__mm
Proportion of fat replaced by tumour __% (est.)
Describe
__x__x__mm
Intact
Opened
Normal
Abnormal
Describe
__x__x__ mm Midline fundal-serosa to ectocervix x max. intercornual x max. anterior to posterior
Text
__g
S2.11
S2.10
S2.12
S2.12
G2.05
S2.15
S2.15
S2.04
S2.04
G2.06
Tumour dimensions (superior-inferior x transverse x thickness)
Tumour appearance (more than one may apply)
Myometrial invasion
Endometrial thickness
Distance of endometrial tumour from the inferior surgical
margin
Cervical involvement
Distance from the inferior surgical margin
Maximum depth of cervical wall invasion
Other endometrial abnormalities
Thickness of uninvolved cervical wall
Lymph nodes
Per site: Description
Total number of nodes, maximum diameter/range
Other relevant macroscopic information
Block identification key
Yes
If yes, describe any additional tests/ frozen sections/biobanking performed
As stated by the clinician
Anterior endometrium
Fundal endometrium
Left cornual recess
Posterior endometrium
Isthmus
Right cornual recess
__x__x__mm
Thickness = exophytic + endophytic
Exophytic
Endophytic
Haemorrhagic
Necrotic
No
Yes Max. depth of invasion __mm
Thickness of adj. myometrium __mm
__mm
__mm
No
Yes
If tumour is present record the elements listed below
__mm
Distance of cervical tumour to the inferior surgical margin
__mm
No
Yes
Polyp
Other, describe
__mm
Not received
Received
Record number per cassette.
Text (description e.g. macroscopic involvement)
__ (total number of nodes)
__ (total)
__ to __mm (range of maximum diameters)
Text
E.g. any additional orientation; specimen integrity (if disrupted)
Text
Describe nature and site of blocks
SPR*Structured Reporting of Cancer and ICCR¡ International Collaboration On Cancer Reporting Standards (S) & Guidelines (G)
Uterus endometrial malignancy dictation template
Date: 22 October 2015
Version: 1.1