Dataset for thyroid cancer histopathology reports

Appendix C Histopathology reporting proforma for thyroid cancer

Surname……………………… Forenames………………….… Date of birth…………..... Sex.......

Hospital………….……….…… Hospital no……………….….... NHS/CHI no……………..
Date of receipt………….……. Date of reporting………..…..... Report no……………......
Pathologist……….…………... Surgeon………………….…….

CORE DATA ITEMS

Specimen type
Total thyroidectomy 
Left hemithyroidectomy 
Right hemithyroidectomy 
Isthmusectomy 
Biopsy of thyroid 
Biopsy/resection of metastasis  (Define site…………………………………)
Additional specimens, e.g. lymph node dissection  (Specify..……………………………………)

Location of carcinoma
Left lobe  Right lobe  Isthmus  Other  (Specify.......................)
No of tumours .......... Single  Multiple (m)  Bilateral (m) 
Size.......................mm (of largest if multiple)

Cancer type
Papillary carcinoma 
Classical PTC 
FVPTC 
Encapsulated FVPTC 
Non-invasive 
Capsular invasion only 
Vascular (angio)invasion Present  Not identified 
Uncertain  Cannot be assessed 
Non-encapsulated FVPTC 
Diffuse / aggressive / multinodular FVPTC 
Microcarcinoma (pT1a):
Single  Multiple (m)  Bilateral (m) 
Desmoplastic fibrosis or infiltrative growth pattern present 
Incidental finding 
Other PTC variant  (Specify......................................................)
Oncocytic variant Yes  No 
Minority poorly differentiated (not anaplastic) component Yes  No 

Follicular carcinoma 
Minimally invasive 

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 Capsular invasion only 
Vascular (angio)invasion Present  Not identified 
Uncertain  Cannot be assessed 
Widely invasive 
Vascular (angio)invasion Present  Not identified 
Uncertain  Cannot be assessed 
Oncocytic variant Yes  No 
Minority poorly differentiated (not anaplastic) component Yes  No 

Medullary carcinoma 

Poorly differentiated carcinoma (majority (> 50%) of tumour is poorly differentiated) 

Differentiated component identified  (Specify)…………………………....................................

Undifferentiated/anaplastic carcinoma 
Differentiated component identified  (Specify)…………………………....................................

Mixed medullary carcinoma with papillary carcinoma 

Mixed medullary carcinoma with follicular carcinoma 

Angioinvasion / vascular invasion Present  Not identified 

Uncertain  Cannot be assessed 

Extent
Confined to thyroid (intrathyroidal) 
Minimal extrathyroidal extension (seen by microscopy) beyond thyroid capsule into
sternothyroid or perithyroidal soft tissues only (pT3) 
Tumour invades beyond thyroid capsule into subcutaneous soft tissues, larynx, trachea,
oesophagus or recurrent laryngeal nerve; or an anaplastic carcinoma not extending beyond
the thyroid capsule (pT4a) 
Tumour invades beyond thyroid capsule into prevertebral fascia, mediastinal vessels or
encasement of carotid artery, or anaplastic carcinoma extending beyond thyroid capsule (pT4b) 

Excision margins
Free of tumour (R0)  Minimum distance ..........mm
Microscopic tumour at margin (R1) 
Macroscopic tumour at margin (R2) 

Lymph nodes
Total number of lymph nodes identified...................
Level VI lymph nodes  Total number ............ Number positive ........... (pN1a)
Other lymph nodes  (Specify site ................................................................)
Total number ............ Number positive ............ (pN1b)

Distant metastasis
Pathological confirmation (pM1)  (Specify site ................................................................)

Stage pT ………. pN ………. pM ………. R ……….

SNOMED code TB6 M…………….

Signature ……………………………………………………….…. Date……………..………

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