Prostate, Resection November 2021 CAP Synoptic

Procedure
[checkbox name="variable_1" value="Radical prostatectomy: _____"]
[checkbox name="variable_2" value="Other (specify): ______ "]
[checkbox name="variable_3" value="Not specified "]

Prostate Size
[comment memo="+"][checkbox name="variable_4" value="Prostate Weight in Grams (g): _____ g"]
[comment memo="+"][checkbox name="variable_5" value="Prostate Size in Centimeters (cm): _____ cm"]
[comment memo="+"][checkbox name="variable_6" value="Additional Prostate Dimension in Centimeters (cm): _____ cm"]
[comment memo="+"][checkbox name="variable_7" value="Additional Prostate Dimension in Centimeters (cm): _____ cm"]

TUMOR 

Histologic Type [comment memo="(Note B) (select all that apply)"] 
[checkbox name="variable_8" value="Acinar adenocarcinoma "]
[checkbox name="variable_9" value="Ductal adenocarcinoma "]
[checkbox name="variable_10" value="Small-cell neuroendocrine carcinoma "]
[checkbox name="variable_12" value="Other histologic type not listed (specify): _____ "]
[checkbox name="variable_13" value="Cannot be determined: _____ "]
[comment memo="+"][checkbox name="variable_14" value="Histologic Type Comment: _____ "]

Histologic Grade [comment memo="(Note C)"]
Grade
[checkbox name="variable_15" value="Grade group 1 (Gleason Score 3 + 3 = 6)"]
[checkbox name="variable_16" value="Grade group 2 (Gleason Score 3 + 4 = 7) "]
[checkbox name="variable_17" value="Minor Tertiary Pattern 5 (less than 5%) 
_Not applicable 
_Present "]
[comment memo="+"][checkbox name="variable_18" value="Percentage of Pattern 4 
_Less than or equal to 5%
_6 - 10% 
_11 - 20% 
_21 - 30% 
_31 - 40% 
_Greater than 40% "]
[checkbox name="variable_19" value="Grade group 3 (Gleason Score 4 + 3 = 7) "]
[checkbox name="variable_20" value="Minor Tertiary Pattern 5 (less than 5%)
_Not applicable 
_Present "]
[comment memo="+"][checkbox name="variable_21" value="Percentage of Pattern 4 
_Less than 61% 
_61 - 70% 
_71 - 80% 
_81 - 90% 
_Greater than 90% "]
[checkbox name="variable_22" value="Grade group 4 (Gleason Score 4 + 4 = 8) "]
[checkbox name="variable_23" value="Grade group 4 (Gleason Score 3 + 5 = 8) "]
[checkbox name="variable_24" value="Grade group 4 (Gleason Score 5 + 3 = 8) "]
[checkbox name="variable_25" value="Grade group 5 (Gleason Score 4 + 5 = 9) "]
[checkbox name="variable_26" value="Grade group 5 (Gleason Score 5 + 4 = 9) "]
[checkbox name="variable_27" value="Grade group 5 (Gleason Score 5 + 5 = 10)"]
[checkbox name="variable_28" value="Cannot be assessed: _____ "]
[checkbox name="variable_29" value="Not applicable: _____ "]

[comment memo="+"][checkbox name="variable_30" value="If Gleason Score is Greater Than 7 Specify Percentage of Pattern 4: _____ %"]

[comment memo="+"][checkbox name="variable_31" value="If Gleason Score is Greater Than 7 Specify Percentage of Pattern 5: _____ %"]

 Intraductal Carcinoma (IDC) [comment memo="(Note D)"]
[checkbox name="variable_32" value=" Not identified "]
[checkbox name="variable_33" value=" Present "]
    IDC Incorporated into Grade 
[checkbox name="variable_34" value=" Yes "]
[checkbox name="variable_35" value=" No "]
[checkbox name="variable_36" value=" Cannot be determined "]

[checkbox name="variable_37" value="Cribriform Glands (applicable to Gleason score 7 or 8 cancer only) 
___ Not applicable 
___ Not identified 
___ Present 
___ Cannot be determined (explain): _____ "]

Treatment Effect (select all that apply) 
_[checkbox name="variable_38" value=" No known presurgical therapy "]
[checkbox name="variable_39" value=" Not identified "]
[checkbox name="variable_40" value=" Radiation therapy effect present "]
[checkbox name="variable_41" value=" Hormonal therapy effect present "]
[checkbox name="variable_42" value=" Other therapy effect(s) present (specify): _____ "]
[checkbox name="variable_43" value=" Cannot be determined: _____ "]

 TUMOR QUANTITATION [comment memo="(Note E)"] 
Tumor Quantitation (select all that apply) 
___ Via percentage 
Estimated Percentage of Prostate Involved by Tumor 
_[checkbox name="variable_44" value=" Less than 1% "]
[checkbox name="variable_45" value=" 1 - 5% "]
[checkbox name="variable_46" value=" 6 - 10% "]
[checkbox name="variable_111" value=" 11 - 20% "]
[checkbox name="variable_112" value=" 21 - 30% "]
[checkbox name="variable_113" value=" 31 - 40% "]
[checkbox name="variable_114" value=" 41 - 50% "]
[checkbox name="variable_115" value=" 51 - 60% "]
[checkbox name="variable_116" value=" 61 - 70% "]
[checkbox name="variable_117" value=" 71 - 80% "]
[checkbox name="variable_118" value=" 81 - 90% "]
[checkbox name="variable_119" value=" Greater than 90% "]
[checkbox name="variable_121" value=" Cannot be determined (explain): _____ "]
and / or 
___ Via dimension 
[checkbox name="variable_123" value="Greatest Dimension of Dominant Nodule in Millimeters (mm): _____ mm"]

[comment memo="+"][checkbox name="variable_124" value="Additional Dimension of Dominant Nodule in Millimeters (mm): ____ x ____ mm"]

[comment memo="+"][checkbox name="variable_1" value="Location of Dominant Nodule: _____ "]

 Extraprostatic Extension (EPE) [comment memo="(Note F)"]
[checkbox name="variable_125" value=" Not identified "]
[checkbox name="variable_126" value=" Present, focal "]
[checkbox name="variable_127" value=" Present, nonfocal "]
[checkbox name="variable_128" value=" Cannot be determined: _____ "]
[comment memo="+"]Location of Extraprostatic Extension [comment memo="(select all that apply)"]
_[checkbox name="variable_129" value=" Right apical "]
[checkbox name="variable_130" value=" Right bladder neck "]
[checkbox name="variable_131" value=" Right anterior "]
[checkbox name="variable_132" value=" Right lateral "]
[checkbox name="variable_133" value=" Right posterolateral (neurovascular bundle) "]
[checkbox name="variable_134" value=" Right posterior "]
[checkbox name="variable_135" value=" Left apical "]
[checkbox name="variable_136" value=" Left bladder neck "]
[checkbox name="variable_137" value=" Left anterior "]
[checkbox name="variable_138" value=" Left lateral "]
[checkbox name="variable_139" value=" Left postero-lateral (neurovascular bundle) "]
[checkbox name="variable_140" value=" Left posterior "]
[checkbox name="variable_141" value=" Other (specify): _____ "]
[checkbox name="variable_142" value=" Cannot be determined: _____ "]

 Urinary Bladder Neck Invasion [comment memo="(Note G)"]
[checkbox name="variable_143" value=" Not identified "]
[checkbox name="variable_144" value=" Present "]
[checkbox name="variable_145" value=" Cannot be determined: _____ "]

 Seminal Vesicle Invasion [comment memo="(Note H)"]
[checkbox name="variable_146" value=" Not identified "]
[checkbox name="variable_147" value=" Present, right "]
[checkbox name="variable_148" value=" Present, left "]
[checkbox name="variable_149" value=" Present, bilateral "]
[checkbox name="variable_150" value=" Present, laterality cannot be determined "]
[checkbox name="variable_151" value=" No seminal vesicle present "]

 Lymphovascular Invasion [comment memo="(Note I)"]) 
[checkbox name="variable_152" value=" Not Identified "]
[checkbox name="variable_153" value=" Present "]
[checkbox name="variable_154" value=" Cannot be determined (explain): _____ "]

 +Perineural Invasion [comment memo="(Note J)"] 
[checkbox name="variable_155" value=" Not identified "]
[checkbox name="variable_156" value=" Present: _____ "]

 MARGINS [comment memo="(Note K)"]

Margin Status 
[checkbox name="variable_157" value=" Cannot be assessed: _____ "]
[checkbox name="variable_158" value=" All margins negative for invasive carcinoma "]
[checkbox name="variable_159" value=" Invasive carcinoma present at margin "]
[comment memo="+"][checkbox name="variable_160" value="Linear Length of Margin(s) Involved by Carcinoma "]
[checkbox name="variable_161" value=" Specify exact length in Millimeters (mm): _____ mm"]
[checkbox name="variable_162" value=" Less than 3 mm (limited) "]
[checkbox name="variable_163" value=" Greater than or equal to 3 mm (non-limited) "]
[checkbox name="variable_164" value=" Cannot be determined (explain): _____ "]

[comment memo="+"]Focality of Margin Involvement 
[checkbox name="variable_165" value=" Unifocal "]
[checkbox name="variable_166" value=" Multifocal "]

Margin(s) Involved by Invasive Carcinoma (select all that apply) 
_[checkbox name="variable_167" value=" Right apical "]
[checkbox name="variable_168" value=" Right bladder neck "]
[checkbox name="variable_169" value=" Right anterior "]
[checkbox name="variable_170" value=" Right lateral "]
[checkbox name="variable_171" value=" Right postero-lateral (neurovascular bundle) "]
[checkbox name="variable_172" value=" Right posterior "]
[checkbox name="variable_173" value=" Left apical "]
[checkbox name="variable_174" value=" Left bladder neck "]
[checkbox name="variable_175" value=" Left anterior "]
[checkbox name="variable_176" value=" Left lateral "]
[checkbox name="variable_177" value=" Left postero-lateral (neurovascular bundle) "]
[checkbox name="variable_178" value=" Left posterior "]
[checkbox name="variable_179" value=" Other(s) (specify): _____ "]
[checkbox name="variable_180" value=" Cannot be determined: _____ "]

[comment memo="+"]Margin Involvement by Invasive Carcinoma in Area of Extraprostatic Extension (EPE) 
_[checkbox name="variable_181" value=" Not identified "]
[checkbox name="variable_182" value=" Present
[comment memo="+"]Margin(s) Involved by Invasive Carcinoma in Area of EPE: _____ "]

[comment memo="+"]Gleason Pattern at Margin(s) Involved by Carcinoma (Note K) (select all that apply) 
_[checkbox name="variable_183" value=" Pattern 3 "]
[checkbox name="variable_184" value=" Pattern 4 "]
[checkbox name="variable_185" value=" Pattern 5 "]

[comment memo="+"]Margin Comment: _____ 

REGIONAL LYMPH NODES 

Regional Lymph Node Status 
[checkbox name="variable_186" value=" Not applicable (no regional lymph nodes submitted or found)"] 
[checkbox name="variable_187" value=" Regional lymph nodes present "]
[checkbox name="variable_188" value=" All regional lymph nodes negative for tumor "]
[checkbox name="variable_189" value=" Tumor present in regional lymph node(s) "]
Number of Lymph Nodes with Tumor 
[checkbox name="variable_190" value=" Exact number (specify): _____ "]
[checkbox name="variable_191" value=" At least (specify): _____ "]
[checkbox name="variable_192" value=" Other (specify): _____ "]
[checkbox name="variable_193" value=" Cannot be determined (explain): _____ "]

[comment memo="+"]Nodal Site(s) with Tumor (select all that apply) 
[checkbox name="variable_194" value=" Hypogastric: _____ 
[comment memo="+"]Laterality (select all that apply) 
___ Right 
___ Left 
___ Cannot be determined: _____ "]

[checkbox name="variable_195" value=" Obturator: _____ 
[comment memo="+"]Laterality (select all that apply) 
___ Right 
___ Left 
___ Cannot be determined: _____ "]

[checkbox name="variable_196" value=" Internal iliac: _____ 
[comment memo="+"]Laterality (select all that apply) 
___ Right 
___ Left 
___ Cannot be determined: _____ "]

[checkbox name="variable_197" value=" External iliac: _____ 
[comment memo="+"]Laterality (select all that apply) 
___ Right 
___ Left 
___ Cannot be determined: ________________"]

_[checkbox name="variable_198" value=" Iliac NOS: _____ 
[comment memo="+"]Laterality (select all that apply) 
___ Right 
___ Left 
___ Cannot be determined: _____ "]

[checkbox name="variable_199" value=" Pelvic NOS: _____ 
[comment memo="+"]Laterality (select all that apply) 
___ Right 
___ Left 
___ Cannot be determined: _____ "]

[checkbox name="variable_1200" value=" Lateral sacral: _____ 
[comment memo="+"]Laterality (select all that apply) 
___ Right 
___ Left 
___ Cannot be determined: _____ "]

[checkbox name="variable_1201" value=" Presacral: _____ 
[comment memo="+"]Laterality (select all that apply) 
___ Right 
___ Left 
___ Cannot be determined: _____ "]

[checkbox name="variable_1202" value=" Promontory: _____ 
[comment memo="+"]Laterality (select all that apply) 
___ Right 
___ Left 
___ Cannot be determined: _____ "]

[checkbox name="1" value=" Sacral NOS: _____ 
[comment memo="+"]Laterality (select all that apply) 
___ Right 
___ Left 
___ Cannot be determined: _____ "]
_[checkbox name="2" value=" Other (specify): _____ "]

[checkbox name="3" value="+Size of Largest Nodal Metastatic Deposit 
Specify in Centimeters (cm) 
___ Exact size: _____ cm
___ At least: _____ cm
___ Greater than: _____ cm
___ Less than: _____ cm
___ Other (specify): _____ 
___ Cannot be determined: _____ "]

[comment memo="+"][checkbox name="4" value="+Nodal Site with Largest Metastatic Deposit (specify site): _____ "]

[checkbox name="5" value="Size of Largest Lymph Node with Tumor 
Specify in Centimeters (cm) 
___ Exact size: _____ cm
___ At least: _____ cm
___ Greater than: _____ cm
___ Less than: _____ cm
___ Other (specify): _____ 
___ Cannot be determined: _____ "]

[comment memo="+"][checkbox name="6" value="+Largest Lymph Node with Tumor (specify site): _____ "]

[comment memo="+"][checkbox name="7" value="+Extranodal Extension 
___ Not identified 
___ Present 
___ Cannot be determined: _____"]
 
[checkbox name="8" value=" Other (specify): _____ "]
[checkbox name="9" value=" Cannot be determined (explain): _____ "]

[checkbox name="10" value="Number of Lymph Nodes Examined 
___ Exact number (specify): _____ 
___ At least (specify): _____ 
___ Other (specify): _____ 
___ Cannot be determined (explain): _____ "]

[comment memo="+"][checkbox name="11" value="+Regional Lymph Node Comment: _____ "]

DISTANT METASTASIS 

[checkbox name="12" value="Distant Site(s) Involved, if applicable (select all that apply) 
___ Not applicable 
___ Nonregional lymph node(s): _____ 
___ Bone: _____ 
___ Other (specify): _____ 
___ Cannot be determined: _____ "]

 PATHOLOGIC STAGE CLASSIFICATION (pTNM, AJCC 8th Edition) [comment memo="(Note L)"]
Reporting of pT, pN, and (when applicable) pM categories is based on information available to the pathologist at the time the report is issued. As per the AJCC (Chapter 1, 8th Ed.) it is the managing physician’s responsibility to establish the final pathologic stage based upon all pertinent information, including but potentially not limited to this pathology report. 

TNM Descriptors (select all that apply) 
[checkbox name="13" value=" Not applicable: _____ "]
[checkbox name="14" value=" m (multiple) "]
[checkbox name="15" value=" r (recurrent) "]
[checkbox name="16" value=" y (post-treatment) "]

pT Category# 
# There is no pathologic T1 classification. 
_[checkbox name="17" value=" pT2: Organ confined "]
[checkbox name="18" value="pT3: Extraprostatic extension 
___ pT3a: Extraprostatic extension or microscopic invasion of bladder neck 
___ pT3b: Tumor invades seminal vesicle(s) 
___ pT3 (subcategory cannot be determined) "]
[checkbox name="19" value=" pT4: Tumor is fixed or invades adjacent structures other than seminal vesicles such as external sphincter, rectum, bladder, levator muscles, and / or pelvic wall"] 

pN Category 
[checkbox name="20" value=" pN not assigned (no nodes submitted or found) "]
[checkbox name="21" value=" pN not assigned (cannot be determined based on available pathological information) "]
[checkbox name="23" value=" pN0: No positive regional nodes "]
[checkbox name="24" value=" pN1: Metastasis in regional nodes "]

pM Category (required only if confirmed pathologically)# 
# When more than 1 site of metastasis is present, the most advanced category is used. M1c is most advanced. 
[checkbox name="25" value=" Not applicable - pM cannot be determined from the submitted specimen(s) "]
[checkbox name="26" value="pM1: Distant metastasis "]
[checkbox name="27" value=" pM1a: Nonregional lymph node(s) "]
[checkbox name="28" value=" pM1b: Bone(s) "]
[checkbox name="29" value=" pM1c: Other site(s) with or without bone disease "]
[checkbox name="30" value=" pM1 (subcategory cannot be determined) "]

ADDITIONAL FINDINGS 

[comment memo="+"]+Additional Findings (select all that apply) 
_[checkbox name="31" value=" None identified "]
[checkbox name="32" value=" Atypical intraductal proliferation (AIP) "]
[checkbox name="33" value=" High-grade prostatic intraepithelial neoplasia (PIN): _____ "]
[checkbox name="34" value=" Inflammation (specify type): _____ "]
[checkbox name="35" value=" Atypical adenomatous hyperplasia (adenosis) "]
[checkbox name="36" value=" Nodular prostatic hyperplasia "]
[checkbox name="37" value=" Other (specify): _____ "]

SPECIAL STUDIES 

[comment memo="+"][checkbox name="38" value="+Ancillary Studies 
___ Specify: _____ 
+Testing Performed on Block Number(s): _____ 
___ Not performed "]

COMMENTS 

Comment(s): _____